HX64119220 RC46 . An2 1 899 A Text-book of the p "Kc^w ^^^^ \%<\% (Eiilumbia lutufraiti; in tltp (Etty of Npui f nrU (HoUrrir of ^Iigatrmua aniJ ^iirgrona WitUxtntt Hibrarg Digitized by the Internet Archive in 2010 with funding from Open Knowledge Commons http://www.archive.org/details/textbookofpractiOOande A TEXT-BOOK Practice of Medicine BY JAMES M. ANDERS, M.D., Ph.D., LL.D. Professor of the Practice of Medicine and of Clinical Medicine in the Medico- Chirurgical College, Philadelphiaj Attending Physician to the Medico- Chirurgical and Samaritan Hospitals, Philadelphia; etc. ILLUSTRATED THIRD EDITION, REVISED. PHILADELPHIA W. B. SAUNDERS 925 Walnut Street 1899 Copyright, 1899, by W. B. SAUNDERS. PRESS OF ELECTROTVPED BY ^ ^ SAUNDERS. PH.LAOA. WESTCOTT 81 THOMSON. PHILADA PREFACE TO THE THIRD EDITION. Ix the second edition of this Avork, issued less than a year ago. it was found unnecessary to make any important alterations. The present issue, however, is the result of careful and thorough revision. Espe- cially was this deemed necessary as relating to the section on Infectious Diseases — a department in which the advance in our knowledge since the publication of the first edition has been considerable. A few new subjects have been introduced — Glandular Fever, Ether- pneumonia, Splenic Anemia, Meralgia Paraesthetica, and Periodic Paral- ysis. The affections that have been substantially rewritten are : The Plao-ue. Malta Fever, Diseases of the Thymus Gland, the Liver Cir- rhoses, and Progressive Spinal Muscular Atrophy. The following articles have been extensively revised : Typhoid Fever, Yellow Fever, Lobar Pneumonia. Dengue, Tuberculosis, Diabetes Mellitus, Gout, Arthritis Deformans, Autumnal Catarrh, the Diseases of the Circula- torv Svstem, more particularly Hypertrophy and Dilatation of the Heart. Arterio-sclerosis, and Thoracic Aneurysm, Pancreatic Hemor- rhage, Jaundice, Acute Peritonitis, Acute Yellow Atrophy, Hematoma of the Dura Mater, and Scleroses of the Brain. These extensive changes have given the author an opportunity, of which he gladly availed himself, to accomplish in many places an im- proved classification of the practical portion of the matter under appro- priate headings. Scarcely subsidiary to clearness and accuracy of delineation in clinical medicine, to meet the needs of the medical student and busy practitioner, is a systematic and convenient arrange- ment of the diagnostic and therapeutic data. The proper classification of knowledge facilitates its acquisition by the student, and conveys to his mind a clearer and more lasting image. The leading symptoms have been more uniformly italicized — a modification that cannot fail to prove helpful to the medical student. The preliminary chapter in the section on Xervous Diseases is new, and deals with the subject of localization and the various methods of investigating nervous affections ; it has thus been brought into closer harmony with the practical character of similar chapters introductory to other divisions of the book. Dr. Joseph Sailer rendered efficient aid in the revision of Part YIIL. Diseases of the Xervous System. 1 2 PREFACE TO THE THIRD EDITION. There has been no appreciable increase in the size of the volume, the numerous additions having been compensated by patient and care- ful condensation of the text. A repagination and an enlarged index were found to be necessary. Six new illustrations have been added. They are microscopic prepa- rations, and Avere derived directly from patients while under observation. They have been introduced to emphasize the fact that the microscope, along with the use of the senses and laboratory investigation, is some- times essential for an absolute diagnosis. I desire to thank numerous correspondents who have kindly volun- teered warm expressions of approval, mingled sometimes with timely suggestions. My thanks are also due Mr. Thomas F. Dagney, of the Editorial Department of W. B. Saunders, Publisher, for his aid in supervising and expediting the work while passing through the press. I venture to hope that by the changes and additions which have been made in carrying out my purpose the practical value of the work has been enhanced, and that the third edition will enjoy the same measure of popularity so generously accorded the previous issues. JAMES M. ANDERS. 1605 Walnut Street, Philadelphia. PREFACE. This work is meant to introduce the student to the present state of our knowledge of the practice of medicine in general and of the diagno- sis, differential diagnosis, and treatment of disease in particular. The historic development of the subjects treated has been either briefly given or intendedly omitted, since this scarcely falls within the scope of a prac- tical treatise on medicine. Although the book as a whole is submitted to the critical judgment of a learned profession, it may be pardonable to emphasize, provisionally, a few features pertaining to the mode of treat- ing the separate subjects, or the arrangement of the material under the latter — to indicate some of the more salient lineaments, so to speak, in the general design. Since in medical schools it is taught from a separate chair, the pathology (special) of the individual affections has almost in- variably been taken up before the etiology ; from this point the student will find the story of each affection a continuous one. The practitioner, however, must ever aim to associate the clinical symptoms with the morbid lesions. Under special etiology the bacteriology has been prominently men- tioned, since we owe to it the rapid progress that is being made in the study of the causation of disease. The differential diagnosis has in many instances been tabulated — an ear-mark that I confidently believe will be found especially helpful. It may be stated that not less than fifty-six diagnostic tables are scattered throughout the woi'k, and that by far the greater number of these are my own? Such formulae have been introduced into the text, and only such, as a more or less extended experience has shown to be possessed of real thera- peutic importance. Whilst these, and all additional points relating to the treatment of the single affections, may serve as guides, particularly to the beginner, I fully appreciate how often the practising physician is 4 PREFACE. placed in a position in which he is compelled to form a therapeutic judgment for himself. Whenever the dosage is stated, the metric equiv- alent is placed in parentheses, the number of grams being stated in round numbers (3j — 4.0; 5j — 32.0) in order to render it of greater practical value. In all instances, hoAvever, in which this would involve an im- portant difference in quantity the exact decimal figures are given. A considerable variation from the usual classification of diseases may be observed, but this is accounted for in the text wherever it occurs. Preference has been given to the modern orthography and termi- nology, not only because it is more euphonious, but also because of its adoption by the standard lexicographers. I have gleaned without stint from medical literature Avith a vieAv to bringing the book up to date, and if I have failed to give full credit in every instance, my grateful acknoAvledgments are here due and are cheerfully made. The chief results of my personal experience and obser- vation, extending over a period of two decades, and derived from both hospital and private practice, will also be found upon these pages. I wish to thank Prof. W. C. Hollopeter, who has written some of the articles upon the diseases of children, as measles, chicken-pox, mumps, whooping-cough, and the acute diarrheas, and Avho has kindly aided in the preparation of those upon diphtheria and scarlatina. My cordial thanks are due also to Dr. C. L. Furbush for kind aid in preparing some of the illustrations, to Doctors Robert N. Willson, Howard S. Anders, and Geo. W. Pfromm for valuable assistance while the work was passing through the press, and to Dr. A. M. Davis for preparing the index. JAMES M. ANDERS. CONTENTS. PART I.— INFECTIOUS DISEASES. PAGE Typhoid Fever 17 Mountain Fever 67 Typhus Fever 67 Eelapsing Fever 73 Malarial Fever 79 Dysentery 97 Catarrhal Dysentery 99 Amebic Dysentery (Tropical Dysentery) 100 Diphtheritic Dysentery . ' lOS Chronic Dysentery 10& Cholera (Epidemic) 109 Yellow Fever _ 11!. Cerebro-spinal Meningitis 124 Lobar Pneumonia 132 Ether Pneumonia 149 Secondary Pneumonia 157 Influenza 158 Dengue 167 The Plague 169 Erysipelas 172 Diphtheria . 179 Septicemia 195 Pyemia 199 Acute Articular Rheumatism 202 Subacute Articular Rheumatism 213 Gonorrheal Arthritis 213 Variola 215 Vaccination 229 Varicella 231 Scarlet Fever 234 Measles 245 Rubella 248 Whooping-cough 251 Parotitis 258 Tuberculosis 260 Tuberculosis of the Lymph-glands 271 Acute Tuberculosis ' 274 General Miliary Tuberculosis 275 Typhoid Form 275 Pulmonary Form 277 Cerebral or Meningeal Form 278 Acute Pneumonic Phthisis 282 Chronic Tuberculosis 285 Fibroid Phthisis 302 Tuberculosis of the Alimentary Tract 304 Tuberculosis of the Serous Membranes 307 Tuberculosis of the Pericardium 308 Tuberculosis of the Peritoneum 309 Tuberculosis of the Liver 311 Tuberculosis of the Genito-urinary System 31 2 Tuberculosis of the Fallopian Tubes, Ovaries, and Uterus 314 Tuberculosis of the Mammary Glands 315 Tuberculosis of the Brain 315 Tuberculosis of the Spinal Cord 315 Tuberculosis of the Heart 315 5 6 CONTENTS. PAGE Tuberculosis of the Arteries and Veins 316 Treatment of Tuberculosis 317 Syphilis 326 Visceral Syphilis 333 Syphilis of the Liver 334 Syphilis of the Alimentary Tract 336 Syphilis of the Lungs 337 Syphilis of the Spleen 338 Syphilis of the Circulatory System 338 Syphilis of the Arteries 339 Syphilis of the Kidneys 339 Syphilis of the Joints 339 Syphilis of the Testicles 340 Leprosy 345 Glanders . 348 Actinomycosis 350 Anthrax 352 Hydrophobia 2p5 Tetanus • 358 Infectious Diseases of I'nknown Etiology 362 Muscular Kheumatism 362 Chronic Articular Kheumatism 365 Weir s Disease 367 Schlammtieber ... 368 Malta Fever • 368 Febricula ^69 Milk-sickness ^iP Miliary Fever • 2^1 Foot-and-mouth Disease . ■ 3r2 Glandular Fever 371 PART II.— CONSTITUTIONAL DISEASES. Diabetes 374 Diabetes Insipidus • 385 Arthritis Deformans 387 Gout 392 Lithemia • 400 Rachitis 402 Scorbutus 407 Infantile Scorbutus ■. . . 411 Purpura 412 Hemophilia 415 Hemorrhagic Diseases of the New-born 418 PART III.— DISEASES OF THE BLOOD AND THE DUCTLESS GLANDS. Anemia 419 The Primary or Essential Anemias 420 Simple or Benign Anemia 420 Chlorosis 421 Progressive Pernicious Anemia 426 The Secondary Anemias 433 Leukocytosis 436 Leukocythemia 437 Pseudo-leukemia 444 Anjemia Infantum Pseudo-leukfemica 449 Splenic Anemia 4oO Chloroma 451 Diseases of the Ductless Glands 451 Diseases of the Supraj-enal Capsules 451 Addison's Disease 451 Diseases of the Thyroid Gland 455 Thyroiditis 455 Goiter 456 Exophthalmic Goiter 458 Myxedema 462 CONTENTS. 7 PART IV.— DISEASES OF THE RESPIRATORY SYSTEM. I. DISEASES OF THE NOSE. PAGE Acute Khinitis _. 467 Chronic Rhinitis 468 Autumnal Catarrh 47] Epistaxis , 472 11. DISEASES OF THE LARYNX. Acute Catarrhal Laryngitis 473 Chronic Laryngitis 475 Spasmodic Laryngitis 477 Tumors of the Larynx 479 Edema of the Larynx 4S0 III. PISEASES OF THE BRONCHI. Catarrhal Bronchitis 480 Acute Bronchitis 481 Chronic Bronchitis 485 Brochiectasis 489 Bronchial Stenosis 492 Asthma 493 Fibrinous Bronchitis 498 IV. DISEASES OF THE LUNQS. •Circulatory Disturbances in the Lungs 500 Congestion of the Lungs 500 Active Hyperemia 500 Passive Hyperemia 501 Pulmonary Edema 502 Hemoptysis 504 Pneumorrhagia 510 Pulmonary Embolism 510 Chronic Interstitial Pneumonia 512 Broncho-pneumonia 514 Pulmonary Atelectasis 521 Emphysema 524 Interlobular Emphysema 524 Vesicular Emphysema 524 Compensating Emphysema 525 Hypertrophic Emphysema . . 525 Senile Emphysema 531 Gangrene of the Lungs 531 Abscess of the Lungs 534 Pneumonokoniosis 535 JSTew Growths of the Lungs 538 Carcinoma of the Lung 538 Sarcoma of the Lung 539 Hydatid Cyst of the Lung 540 V. DISEASES OF THE PLEURA. Pleurisy 541 Acute Plastic Pleurisy 541 Sero-fibrinous Pleurisy 544 Empyema .... 558 Chronic Pleurisy 562 Pneumothorax 564 Ilydrothorax 569 New Growths of the Pleura 570 Diseases of the Mediastinum ' 571 Inflammation of the Mediastinum 571 Tumors of the Mediastinum 572 Diseases of the Thymus Gland 574 Mediastinal Hemorrhage 574 8 CONTENTS. PART V DISEASES OF THE CIRCULATORY 5Y5TEM. I. DISEASES OF THE PERICARDIUM. PAGE Pericajditis • 575 Acute Plastic or Fibrinous Pericarditis 575 Sero-fibrinous Pericarditis 578 Purulent Pericarditis 583 Hemorrhagic Pericarditis 584 Adhesive Pericarditis 58-4 Hvdropericardium 586 Hemopericardium 587 Pneumopericardium 587 II. DISEASES OF THE HEART. Endocarditis 588 Simple Acute Endocarditis 588 Ulcerative Endocarditis • • 592 Chronic Endocarditis 596 Aortic Incompetency 599 Aortic Stenosis 605 Mitral Incompetency 607 Mitral Stenosis 613 Tricuspid Incompetency 617 Tricuspid Stenosis 620 Pulmonary Incompetency 621 Pulmonary Stenosis 622 Combined Forms of Cardiac Diseases 622 Cardiac Thrombosis 636 Hypertrophy of the Heart 638 Dilatation of the Heart 645 Myocarditis 650 Acute Myocarditis 650 Chronic Myocarditis 651 Disease of the Coronary Arteries 655 Degenerations of the Heart . . 656 Fatty Degeneration 656 Fatty Overgrowth 65S Brown Atrophy 659 Calcareous Degeneration 659 Amyloid Degeneration 659 Hyaline Degeneration 659 Cardiac Aneurysm 660 Eupture of the Heart 661 Minor Affections of the Heart 662 ^Tew Growths 662 Parasites 662 Misplacement 663 Floating Heart 663 III. NEUROSES OF THE HEART. Palpitation 663 Tachycardia 665 Brachycardia 667 Arrhythmia 669 Angina Pectoris 671 IV. CONGENITAL AFFECTIONS OF THE HEART. Arrested Development 674 Fetal Endocarditis 675 V. DISEASES OF THE ARTERIES Acute Aortitis 677 Arterial Sclerosis 678 Aneurysm 682 CONTENTS. 9 PAGE Aneurysm of the Thoracic Aorta 683 Aneurysm of the Abdominal Aorta 692 Aneurysm of the Pulmonary Artery 693 Aneurysm of the Coronary Arteries 693 Aneurysm of the Celiac Axis 693 Aneurysm of the Splenic Artery 693 Aneurysm of the Hepatic Artery 693 Aneurysm of the Superior Mesenteric Artery 694 Aneurysm of the Inferior Mesenteric Artery 694 Aneurj'sm of the Eenal Arteries 694 Arterio-venous Aneurysm 694 Congenital Aneurysm 694 PART VI DISEASES OF THE DIGESTIVE SYSTEM. 1. DISEASES OF THE MOUTH. Stomatitis 695 Catarrhal Stomatitis 695 Aphthous Stomatitis 696 Membranous Stomatitis 698 Ulcerative or Fetid Stomatitis 699 Parasitic Stomatitis 701 La Perleche . 703 Gangrenous Stomatitis 703 Mercurial Stomatitis 705 II. DISEASES OF THE TONGUE. Glossitis 706 Acute Glossitis 706 Chronic Superficial Glossitis 707 Glossitis Desiccans 708 Lingual Glossitis 708 Leukoplakia Oris 708 Angina Ludovici 709 III. DISEASES OF THE SALIVARY QLANDS. Hypersecretion 709 Xerostoma 710 Symptomatic Parotitis 710 IV. DISEASES OF THE TONSILS. Acute Tonsillitis 711 Chronic Tonsillitis 717 V. DISEASES OF THE PHARYNX. Pharyngitis 720 Acute Pharyngitis 720 Membranous Pharyngitis 721 Chronic Pharyngitis 722 Acute Infectious Phlegmon of the Throat 723 Retropharyngeal Abscess 724 VI. DISEASES OF THE ESOPHAGUS. Esophagitis 724 Acute Esophagitis • 724 Chronic Esophagitis 726 Ulcer of the Esophagus 726 Carcinoma of the Esophagus 726 Rupture of the Esophagus 728 Neuroses of the Esophagus , 729 Muscular Spasm 729 Paralysis of the Esophagus 729 10 CONTENTS. PAGE Dilatation of the Esophagus 730 Esophageal Diverticulum 731 Stricture of the Esophagus 732 VII. DISEASES OF THE STOMACH. Methods of Diagnosis 735 Examination of the Gastric Functions 735 Physical or External Examination 740 Malposition of the Stomach 743 Gastroptosis 743 Dilatation of the Stomach 744 Inflammatory Diseases of the Stomach 749 Acute Catarrlial Gastritis 749 Toxic Gastritis 752 Diphtheritic Gastritis 753 Acute Suppurative Gastritis 753 Chronic Catarrhal Gastritis 754 Gastric Ulcer 763 Carcinoma of the Stomach 771 Hematemesis 778 Neuroses of the Stomach 779 iS^ervous Dyspepsia 779 Neuroses of Secretion 782 Hyperchlorhydria 782 Neuroses of Motility 784 Increased Peristalsis of the Stomach 784 Diminished Peristalsis of the Stomach 784 Neuroses of Sensation 785 Cardialgia 785 Hyperesthesia of the Stomach 787 Anorexia 787 Hyperoresia 788 VIII. DISEASES OF THE INTESTINES. Methods of Diagnosis 788 Enteroptosis • 791 Intestinal Catarrh 792 Diarrheas of Children 800 Acute Gastro-intestinal Catarrh 800 Celiac Disease 804 Phlegmonous Enteritis 805 Croupous or Diphtheritic Enteritis 805 Cholera Morbus 806 Intestinal Infarction 808 Intestinal fleers 808 Duodenal Ulcer 808 Follicular Ulcers 811 Stercoral Ulcers 81 1 Simple Ulcerative Colitis 811 Solitary Ulcers 812 DitTuse Catarrhal Ulcer 812 Cancerous Ulcer . . 812 Appendicitis 812 Chronic Appendicitis 824 Recurrent Appendicitis 825 Intestinal Obstruction ■ • 828 Carcinoma of the Intestine 835 Habitual Constipation 838 Dilatation of the Colon 842 Neuroses of the Intestine 842 Secretory Disturbances 842 Membranous Enteritis 842 Sensory Disturbances 843 Enteralgia 843 Diminished Intestinal Sensibility 844 CONTENTS. 11 PAGE Disturbances of Motility 845 Nervous Diarrhea 845 Enterospasm 845 Constipation 846 IX. DISEASES OF THE LIVER. Anomalies in Shape and Position 847 Jaundice 848 Catarrhal Jaundice 849 Other Forms of Jaundice 852 Biliary Calculi 853 Chronic Obstruction of the Duct by Gall-stones 856 Obstruction of the Common Duct 856 Obstruction of the Cystic Duct 857 More Remote Effects of Gall-stones 858 Carcinoma of the Bile-ducts 861 Stenosis of the Bile-ducts 862 Icterus Neonatorum 864 Vascular (Circulatory) Affections of the Liver 865 Anemia 865 Hyperemia 865 Acute Hyperemia 865 Passive Hyperemia 866 Diseases of the Portal Vein . 867 Thrombosis and Embolism 867 Suppurative Pylephlebitis 868 Stenosis 870 Affections of the Hepatic Blood-vessels 870 Atrophy and Hypertrophy of the Liver 870 Hepatic Infiltrations and Degenerations 871 Amyloid Infiltration 871 Fatty Infiltration 873 Fatty Degeneration 874 Perihepatitis 875 Acute Perihepatitis 875 Chronic Perihepatitis 877 Abscess of the Liver 878 Acute Yellow Atrophy 883 The Liver in Phosphorus-poisoning 885 Cirrhosis of the Liver 887 Carcinoma of the Liver 895 Other New Growths in the Liver 900 X. DISEASES OF THE SPLEEN. Dislocation of the Spleen 901 Splenic Hyperemia 901 Splenitis 902 Amyloid Degeneration of the Spleen 904 Morbid Growths of the Spleen 904 Rupture of the Spleen 905 XI. DISEASES OF THE PANCREAS. Acute Pancreatitis 905 Hemorrhagic Pancreatitis 905 Suppurative Pancreatitis 907 Gangrenous Pancreatitis 907 Chronic Pancreatitis 908 Pancreatic Hemorrhage 909 Carcinoma of the Pancreas 910 Pancreatic Cyst 912 Pancreatic Calculi 913 12 CONTENTS. XII. DISEASES OF THE PERITONEUM. PAGE Acute Peritonitis 914 Localized or Partial Peritonitis 918 Chronic Peritonitis 923 Ascites 926 New Growths in the Peritoneum 930 Carcinoma of the Peritoneum 930 PART VII.— DISEASES OF THE URINARY 5YSTEM. I. DISEASES OF THE KIDNEY. Mobility of the Kidney 933 Circulatory Disorders of the Kidneys 937 Active Hyperemia 937 Passive Hyperemia 937 Special Pathologic States of the Urine 938 Hematuria 938 Hemoglobinuria 940 Albuminuria 942 Peptonuria and Albumosuria 945 Indicanuria 945 Pvuria 946 Chvluria 947 Chbluria 948 Urobilinuria 949 Glycosuria 949 Acetonuria, Diacetonuria, and Oxybutyria 952 Lithuria 953 Oxaluria 954 Phosphaturia • 955 Leucinuria and Tyrosinnria • • • 956 Cystinuria 956 Various other Conditions 957 The Xephritides - 959 Morphologic Constituents of the Urine in Renal Disease 959 Dropsy of Eenal Disease 961 Uremia 962 Amyloid Kidney 966 Kephrolithiasis 968 Acute Nephritis 974 Chronic Nephritis (Exudative) 981 Chronic Nephritis (Non-exudative) 985 Pyelitis 993 Hydronephrosis 997 Perinephric Abscess 1000 Cystic Kidney 1002 New Growths of the Kidney 1003 II. DISEASES OF THE BLADDER. Cvstitis 1006 Acute Cystitis 1006 Chronic Cystitis 1009 Neoplasms of the Bladder 1011 Vesical Hemorrhage 1011 Neuroses of the Bladder 1012 Irritability of the Bladder 1012 Neuroses of Micturition 1014 PART VIII— DISEASES OF THE NERVOUS SYSTEM. Introduction 1017 CONTENTS. 13 I. DISEASES OF THE PERIPHERAL NERVES. PAGE Neuritis 1028 Beri-beri 1031 Neuromata 1032 Neuralgia - 1033 Neuralgia of the Head 1034 Neuralgia of the Neck and Trunk 1035 Neuralgia of the Extremities 1035 Diseases of the Cranial Nerves 1037 Diseases of the Olfactory Nerve 1037 Diseases of the Ketina, Optic Nerve, and Tract 1038 Diseases of the Motor Nerves of the Eyeball 1043 Diseases of the Fifth Nerve 1047 Diseases of the Seventh or Facial Nerve 1048 Diseases of the Auditory Nerve 1051 Meniere's Disease 105o Diseases of the Glosso-pharyngeal Nerve 1054 Diseases of the Pneumogastric Nerve 1054 Diseases of the Spinal Accessory Nerve 1058 Torticollis 1058 Paralysis of the Spinal Accessory Nerve 1060 Diseases of the Hypoglossal Nerve 1060 Diseases of the Spinal Nerves 1062 Diseases of the Cervical Plexus 1062 Diseases of the Brachial Plexus 1062 Diseases of the Lumbar and Sacral Plexuses 1064 Acute Ascending Paralysis 1065 II. DISEASES OF THE SPINAL CORD AND ITS MENINGES. Diseases of the Meninges 1067 Pachymeningitis - 1067 Leptomeningitis 1068 Acute Leptomeningitis < 1068 Chronic Leptomeningitis 1069 Hemorrhage into the Spinal Meninges 1069 Disturbances of Circulation in the Cord 1070 Hemorrhage into the Spinal Cord 1072 Acute Myelitis 1073 Chronic ^Myelitis 1075 Anterior Poliomyelitis 1077 Essential Paralysis of Children 107 , Acute, Subacute, and Chronic Poliomyelitis in Adults 1079 Abscess of the Spinal Cord 1079 Unilateral Lesion of the Spinal Cord 1080 Locomotor Ataxia 1081 Hereditary Ataxia 1086 Spastic Paraplegia 1087 Primary Lateral Sclerosis 1088 Secondary Spastic Paralysis 1089 Congenital Spastic Paraplegia 1089 Ataxic Paraplegia 1089 Combined System Sclerosis 1090 Eeflex Paraplegia 1091 Intermittent Paraplegia • • • 1091 Multiple Sclerosis 1091 Pseudosclerosis 1094 Bulbar Paralysis 1094 Amyotrophic Lateral Sclerosis 1095 Syringomyelia .... 1097 Compression of the Spinal Cord 1098 Tumors of the Spinal Cord and its Membranes ■. 1100 Lesions of the Conus Terminalis and the Cauda Equina 1103 14 coy TEXTS. III. DISEASES OF THE BRAIN AND ITS MENINGES. PAGE Diseases of the Dura Mater 1104 Diseases of the Pia 1105 Disturbances of Circulation of the Brain 1107 Hyperemia 1107 Anemia 1108 Edema of the Krain • 1108 Embolism and Thrombosis 1109 Vascular Degeneration .... 1112 Inflammation of the Brain 1113 Focal Encephalitis 1113 Diflbse Encephalitis 1114 Cerebral Hemorrhage 1115 Aphasia 1120 Intracranial Growths 1124 Chronic Hydrocephalus 1128 External Hydrocephalus 1128 Internal Hydrocephalus 1128 Sclerosis of the Brain 1130 General Paralysis of the Insane 1131 Cerebral Palsies of Childhood 1133 Acute Delirium 1135 IV. DISEASES OF UNKNOWN PATHOLOGY. Epilepsy 1137 Migraine 1142 Acute Chorea 1144 Huntingdon's Chorea 1147 Rhythmic Chorea 1148 Choreiform Disorders 1148 Paramyoclonus Multiplex 1148 Chorea Electrica 1148 Fibrillary Chorea 1150 Athetosis . . . ; 1150 Habit -spasm 1152 General Tic 1152 Saltatoric Spasm 1154 Chorea Major 1154 Paralysis Agitans 1154 Other Forms of Tremor 1156 Tetany 1156 Infantile Convulsions 1159 Occupation-Neuroses 1161 Periodic Paralysis 1163 Hysteria . . ' 1164 Neurasthenia 1174 Acromegaly 1179 Astasia-abasia 1181 Caisson Disease 1182 V. VASOMOTOR AND TROPHIC DISORDERS. Angioneurotic Edema 1184 Hvdrops Articulorum Intermittens 1185 Raynaud's Disease ^^^2 Progressive Hemiatrophy of the Face 1187 Scleroderma DifTusum 1189 Morphea 1190 Ainhum 1190 Erythromelalgia 1191 Acroparesthesia 1192 Meralgia Para^thetica 1193 CONTENTS. 15 PART IX.— DISEASES OF THE MUSCLES. PAGE Myositis 1]95 Infectious Myositis . . 1195 Progressive Ossifying Myositis 1196 Progressive Spinal Muscular Atrophy 1196 Progressive Neural Muscular Atrophy 1197 Pseudo-hypertrophic Muscular Paralysis 1199 Dystrophia Musculorum Progressiva {Erb) 1200 Dystrophia Musculorum Progressiva (Dejerine-Landouzy) 1202 Hereditary Muscular Paralysis 1203 Arthritic Muscular Atrophy 1203 Muscular Atrophies 1204 Muscular Hypertrophy 1204 Thomsen's Disease 1204 PART X.— THE INTOXICATIONS ; OBESITY ; HEAT=STROKE. The Intoxications 120"? Alcoholism 1207 Ginger and Cologne-water Inebriety 1214 Morphinism 1214 Plumbism 1216 Arsenicism 1219 Mercurialism , 1220 Food-infection and Ptomain-poisoning 1222 Grain- and Vegetable-poisoning 1224 Obesity 1225 Heat-stroke • • • 1230 PART XL— ANIMAL PARASITIC DISEASES. Psorospermiasis 1236 Distomiasis 1237 Nematodes 1-38 Ascariasis 1238 Ankylostomiasis - 1242 Trichiniasis 1243 Filariasis • 1247 Dracontiasis 1249 Other Filariis • 1250 Other and Uncommon Nematodes 1250 Cestodes 1251 Tsenise or Tape-worms 1256 Tsenia Nana 1260 Tffinia Cucumerina 1260 Taenia Flavopunctata 1260 Parasitic Arachnida 1260 Other Parasitic Insects 1261 Pediculosis 1261 Cimex Lectularius 1262 Pulex Irritans 1262 Pulex Penetrans 1262 Ixodes 1263 Dermanyssus Avium et Gallinae 1263 Oulicidfe 1263 Hirudo c . , 1263 Estridffi 1263 Muscidffi 1263 PART I. INFECTIOUS DISEASES. TYPHOID FEVER. {Enteric Fever; Abdominal Typhus; lleo-typhoid ; Kerven Fieber.) Definition. — An acute infectious disease of which the definitive cause is the specific bacillus of Eberth. It is characterized, patholog- ically, by hyperplasia and sloughing of Peyer's patches ; and clinically by its slow, insidious onset, peculiar temperature-curve, swelling of the spleen, rose-colored spots, diarrhea, tympanites, and a liability to cer- tain complications (intestinal hemorrhage, peritonitis, etc.). The disease has an average duration of from three to four weeks. History. — Although known beyond the reach of tradition, typhoid fever was clearly distinguished from typhus at a comparatively recent date. Louis of Paris in 1829 proposed the term typhoide^ but it re- mained for Gerhard of Philadelphia to discriminate typhoid from typhus fever as the result of his own precise clinical observations. His account of the disease was ably corroborated by the writings of E. Hale and James Jackson, Sr. (1838, 1839). Later, Shattuck of Boston and Jenner of London made important contributions to the subject. Shattuck's experiments on typhus and typhoid fevers at the London Fever Hospital in England, and Alfred Stille's studies of the former affection in Dublin and Naples, and of the latter in" Paris, in- creased greatly our knowledge of these diseases. As a result of the labors of the above-mentioned American authors the true nature and identity of typhoid fever were appreciated in America at an earlier day than in either France or Eng-land. Briefly, the decade from 1840 to 1850 witnessed, on the one hand, the overthrow of erroneous notions concerning the similarity of typhoid and typhus fevers, and, on the other, the establishment of their points of dissimilarity. Pathology. — The lesions produced by typhoid fever may conve- niently be divided into two groups : (1) Primary lesions, due to the direct effect of the special bacillus upon the lymph-follicles of the intestines, the mesenteric and other lymph-glands, and the spleen. (2) Secondary lesions, due chiefly to the long-continued fever and to secondary infection, for the occurrence of which the essential lesions of typhoid fever furnish the golden opportunity. (1) The primary morbid changes in the Peyer's patches and solitary glands of the intestines are divided, usually, into four stages : (a) The Stage of Infiltration. — The lymph-follicles become engorged 2 17 18 INFECTIOUS DISEASES. (hyperplasia), particularly Peyer's glands in the ileum and near to the valve, and, to a lesser extent, in the lower part of the jejunum. Fre- quently, the solitary glands in the small intestines, the colon, and rarely the rectum, become similarly infiltrated. In about 33 per cent, of the cases the chief morbid lesions are confined to the large intestines. In mild cases a few Peyer's patches in the lower part of the ileum are alone the seat of infiltration and subsequent changes. The follicles are grayish- white in color, and may project — particularly the patches of Peyer — from 3 to 5 mm. or more. Rarely, the solitary glands, which vary in size from a mustard-seed to a large pea, become very prominent and show a bold attempt at pedunculation. The histologic changes at first consist in a marked dilatation of the capillary blood-vessels, which later are more or less compressed (as a consequence of cell-infiltration), giving to the follicles their whitish, anemic appearance. The cellular elements partake of the nature of lymph-corpuscles. Some of these cells are larger and are epithelioid in character, with ten or more nuclei. The mucosa and muscularis ad- jacent to the glandular structures may be similarly infiltrated. From the eighth to the tenth day the stage of infiltration terminates either in resolution or in necrosis and sloughing. The infiltrated cells may undergo granular or fatty degeneration, followed by absorption. This process — resolution — during its progress produces pitting of the swollen follicles. In consequence of these minute points of necrosis the plaques now present a characteristic reticulated appearance (plaques ci surface reticulee). When resolution occurs, accompanied by destruc- tion of the follicles, small hemorrhages may take place into the glandu- lar structure. These hemorrhages may occasion pigmentary deposits in the follicular depressions, giving rise to the so-called "shaven-beard" appearance. Resolution, however, terminates the stage of medullary infiltration -with comparative infre([uency. Far more frequently the hyperplasia of the lymph-follicles ends in {b) Necrosis or Sloughing. — In all save the milder grades of cell- infiltration the hyperplasia of the lymphatic tissue cannot subside before necrosis occurs. The latter process results partly from com- pression and choking of the blood-vessels by the cell-infiltration, and partly from the direct action of the typhoid bacillus, leading to so-called anemic necrosis. Thus, necrotic crusts (sloughs) are formed, which are gradually separated and cast off. "While not all of the glands of Peyer which are the seat of cellular infiltration undergo subsequent necrosis, as a rule those situated in the lower portion of the ileum do, and show the process in its completest development. The depth to which the necrosis extends is quite variable. It may involve only the most super- ficial layers of the mucosa, or it may extend in depth till it reaches, or even perforates, the outer or serous coat ; but usually this work of destruction does not dip below the submucosa or muscularis. The necrosed portions become detached — a process that proceeds from the periphery toward the center — leaving behind the typhoid ulcer. The stage of necrosis and sloughing begins between the eighth and tenth days, and ends on or about the twenty-first dav. (c) Stage of Ulceration. — The size and shape of the ulcers corre- spond exactly to the necrosed areas in these respects. A single gland TYPHOID FEVER. 19 of Peyer generally presents several ulcers of irregular outline separated by strips of mucous membrane. Rarely, the entire plaque is implicated, in which case a large oval ulcer is the result, and at the lower end of the ileum the ulcers often coalesce until they almost encircle the bowel. The ulcers of the solitary glands assume a rounded form. The character of the floor of the ulcer will vary with the character of the intestinal coat which forms its base, though usually it is clean and smooth. The edges are usually irregular, engorged, soft, and frequently overhanging. In the lower segment of the ileum ulcers may be numerous, whilst in other portions of the gut Peyer's plaques may be merely hyperemic. In about 25 per cent, of the cases the typhoid ulcers are found in the large intestines — i. e. in the cecum and colon. Perforation of the large bowel is exceedingly rare. Exceptionally, the appendix is the seat of ulcer, and in a recent case of my own that came to autopsy per- foration had occurred during the fourth week of the disease. Localized abscesses have been found under these circumstances. Hemorrhage usually results from erosion of a vessel — an accident which is occasioned by the separation of the sloughs — but small bleed- ings may take place from the swollen, hyperemic edges of an ulcer.. Perforation of the bowel occurs in a small percentage of cases (about 6 per cent.). In the majority of instances it is attributed to a perfora- tive necrosis ; hence it is that the sloughs are usually found attached to the orifice. Perforation may also occur after the separation of the necrosed portions during the stage of ulceration. The perforations may be multiple, though they are usually single and rarely exceeding two in number. The small, deep ulcers are more apt to lead to complete per- foration than larger ones, and the site of the orifice is usually some- where in the course of the lower third of the ileum. The lesions of peritonitis are invariably present, and during the stages of necrosis and ulceration a catarrhal state of the mucosa of the small and large intestines exists. The diarrhea Avhich usually accompanies this affection is to be ascribed chiefly to the catarrhal state of the large bowel. ( CO ^~ UJ UJ X (- z UJ > to -.1 1^^=^ 1 r! J :=* UJ UJ 5 I 1- X ; "^Y— UJ UJ $ I 1- u. u. >! UJ UJ 5: I h- q: o Ll. '^iJ >■ 1 =__ -ere:-* ■• Ul UJ Q DC X 1- -«=r t=»^ .^=^ r* — —— UJ Ul $ Q Z o o UJ CD ' , — i^^ ' —^ 1 i ~=- -cr f- -?r UJ Ul u. ^0\p^ 113HN3aHVJ dwil 1 "^ TEMP. CENTIGRADE _ O OV 30 r.. ■f ^ n o^ rr, UJ UJ 5: X (- z UJ > UJ s^ T^ ^ ' ^■T"' '-■. 2,000 000 -T ' 'r^-^ y V-"" ' -' ' 2,000,000 40^ ' 11-'". ' 30% 1,000,000 ■ ■ , ■ ' ■ 1 1 1 1,000 000 201 10,000 10000 8 000 8,000 6,000 6,000 ; 1 . ,.'' , , . . . "^T 1 -""1 "*' 1 _,^rLJ — ^is. — ^^ . ■ . I — ' iT" 1 /' ' 1 4,000 4,000 2.000 2,000 T—. 1 1 ' — TTT— '• ' , , , r , , . . . 1 1 . . ; . 1 . , 1 ■ i I ..III 90f 80^ 78^ 60^ 50;{ 40^ 30^ 20s{ Fig. 4.— Chart illustrating the blood-changes in typhoid fever: upper curve, red corpuscles; middle curve, hemoglobin ; lower curve, white corpuscles. early, owing to the absence of a femoral pulse, before the signs of gan- grene appear, but the condition is highly dangerous. Recovery ensues in perhaps more than half of the cases. The blood presents certain changes, some of Avhich are valuable for diagnostic purposes. In those rare cases in which copious diarrhea or profuse sweats are present the red corpuscles may be relatively increased in number during the febrile period, OAving to loss of water. There is, however, in the majority of instances, little or no decrease in the num- ber of red corpuscles till the end of the second week. They are mark- edly diminished, as a rule, during convalescence. Indeed, the oligo- cythemia may attain to an immoderate degree. In one of Osier's cases the number of red corpuscles was as low as 1,300.000 per c.mm.. but I have personally never found the blood-count under 1.800.000. There is a greater relative decrease in the amount of hemoglobin than in the number of red corpuscles, and the restoration of the hemo- globin in the convalescent period takes place more slowly than that of TYPHOID FEVER. 41 the red corpuscles. The number of white corpuscles remains at or a little below the health standard until late convalescence, when it sinks to a moderate degree — furnishing a count of about 2000 per c.mm. This fact is an important aid in the differentiation of typhoid fever from acute inflammations and infectious (febrile) affections accompanied by exudation, in Avhich leukocytosis is marked, and from all suppurative processes in which the polynuclear neutrophiles are moderately increased. In typhoid fever there is also a relative preponderance of the mono- nuclear forms in addition to the absolute decrease of the leukocytes. The blood-characters in typhoid are shown in the accompanying chart (Fig. 4). (/) Nervous System. — The persistent headache that is almost always present is among the most prominent symptoms during the first week, but it diminishes steadily during the early part of the second, as a rule. It affects the temporal, occipital, and cervical regions, and when the onset is comparatively sudden, pain in the back is also a more or less conspicuous feature during the first few days of the illness. In a small class of cases, however, the effects of the typhoid bacilli or their toxins are manifested solely in the nervous system from the very onset. In such there are violent headaches, retraction of the head, rigidity, pho- tophobia, and muscular twitchings (rarely convulsions) — all of which symptoms indicate meningitis. The diagnosis of meningitis as a com- plication must be made with extreme caution, since, no matter how com- plete the clinical picture may be, the post-mortem examination usu- ally reveals a total absence of meningeal inflammation. It must not be forgotten, however, that meningitis is one of the rarest of the complications of typhoid fever. Vertigo may accompany the head- ache, but it seldom outlasts the latter. Before delirium manifests it- self wakefulness and restlessness at night are very annoying, and later the same symptoms may be observed associated with the delirium. In cases of moderate severity mental dulness, and even actual hebetude, are almost invariably present. Questions are apt to be answered inconsist- ently and in monosyllables, and the patient sleeps poorly, notwithstand- ing the pseudo-somnolent state in which he almost constantly appears. Delirium is frequent in the severer cases. It is, however, not an uncommon event for those of moderate severity to be free from this symptom throughout the attack. It is, as a rule, most marked at night or at some time when the patient is left alone. His delusions may impel him to attempt to leave his bed, but more commonly there is mild or noisy delirium, with more or less restlessness. He may lie somnolent, soliloquizing in a loud whisper (muttering delirium), and this so-called typhomania may gradually give place to actual coma to- ward the close of the middle period of the disease. In not a few cases — mild or severe — coma is developed suddenly, and is often a mortal symptom. Still another unfavorable sign is a picking at the bed-clothes or a grasping at imaginary objects (carphologia). The delirium may assume an hysteric type, the patient usually ex- hibiting the saddest emotions, and if he be an alcoholic he may be seized with delirium tremens. In a case of typhoid fever that I saw recently with Dr. S. W. Morton hysteric delirium developed during convalescence, but did not last more than twenty-four or thirty-six hours. 42 INFECTIOUS DISEASES. The motor nerves also present notable disturbances in association ■with the sopor and the forms of delirium previously described. Slight twitchings of the muscles of the face and extremities are quite common, and when they affect the tendons of the wrist and fingers the term sub- sultiis tendinum is applied. The lips, tongue (especially when pro- truded), lower jaw, and even the extremities, are often in a state of con- stant tremor. During this motor irritability the reflexes are increased, but when profound coma comes on they are either largely diminished or totally abolished. The toxins and chemical secretions of the typhoid bacillus, acting poisonously upon the nervous centers, are undoubtedly the cause of the nervous symptoms in typhoid. y^ervous complications and sequeke may arise. Chief among these is paralysis, which is most probably due to neuritis. The lesion may involve one, tAvo, or more nerves, and in this way we may have either a paralysis of one limb or, more rarely, a true paraplegia. Aphasia may be a sequel, particularly in children. Hemiplegia, due to hemorrhage or a localized encephalitis, may occur either as a complication or sequence of the disease. Following typhoid fever, the patient may ex- hibit evidences of mental enfeeblement, and even insaniti/ where a pre- disposition to this condition has existed; and insanity is relatively more common after this disease than after any others belonging to the same class. I have seen four instances, all of which recovered, while Osier has seen five, four of Avhich ended similarly. It is in most cases, as pointed out by Wood, a confusional insanity, due to exhaustion and impairment of the nutrition of the nerve-centers, while in a smaller contingent it takes the form of a true melancholia. After the conclusion of typhoid, as well as during its course, neuralgia affecting the occipital and other cranial nerves is not infrequent. Great hyperesthesia of the skin and muscles is common during convalescence, attacking the lower extremities by preference (Strlimpell). The so-called " typhoid spine "' (Gibney) has also been observed, and consists in an acute inflammation of one or more vertebrae following typhoid. The chief symptoms are pain in the back and hips of a lancinating character. The point of origin appears to be the small of the back ; thence the pains extend paroxysmally up and along the spine and to the abdomen. They subside gradually, leaving the back weak and painful on attempts at turning in bed, etc. Plantar and other skin-reflexes increase, and the knee-jerks are pre- served. G. E. de Schweinitz has described at length the ocular compli- cations and sequehe of typhoid fever. Affections of the conjunctiva and cornea and retinal hemorrhage are perhaps the most frequent, although optic neuritis and affections of the uveal tract also occur. ((/) The Urinary System. — Urine. — The urine is lessened in quantity and high-colored, with an increased specific gravity up to the arrival of the stage of decline. About this time, and rarely earlier, it grows light in color, larger in quantity than the normal, and the specific gravity is relatively diminished. Both urea and uric acid are increased during the earlier stages, and sometimes throughout the attack, while durinor convalescence both are diminished. On the other hand, the chlorids are diminished during the active stages of the disease and in- creased during its decline. A febrile albuminuria is quite common, but is of no clinical importance. TYPHOID FEVER. 43 Acute nephritis may develop as a complication in the earlier or later course of the disease, and can be recognized to a certainty only by a thorough appreciation of the urinary phenomena. The urine is dimin- ished in quantity, being often scanty, and there may be retention. It contains characteristic morphologic elements (albumin, casts, blood, and epithelium). The development of the typhoid state in this affection is rendered much more probable in the presence of this complication, and, moreover, uremic symptoms often put in an appearance at this juncture, and then the situation is really serious. Acute nephritis may arise at one or other of three different periods, and its significance varies with the time of onset : (a) at the beginning of the fever, when it often obscures the true nature of the malady. This is the nephro-typlioid of the German authors, and will be referred to hereafter [vide infra, Varie- ties) ; (b) in the early part of the fastigium or the second week of the disease. Comino; on at this time — an event which I have observed in two instances — its relation to the typhoid bacillus or its toxin is not definable. It is probable, however, that it is to be ascribed to the local effect of the toxin upon the renal tissues. Both of my own instances proved fatal, and in both an autopsy was refused. Wagner ^ has had 5 cases of recovery in succession, but the high mortality mentioned by Amat — 10 deaths in 12 cases — is the more common experience, (c) Acute neph- ritis may arise as a sequel of typhoid, when, Avith the usual symptoms of acute nephritis, there is almost invariably associated a decided edema. In this category of cases recovery is to be expected. The lymphoma- tous nephritis of Wagner {vide supra, Pathology) is usually without symptoms. Diabetes mellitus is, in extremely rare instances, developed after typhoid. Hematuria has also been observed as an occasional symptom of the hemorrhagic diathesis. The diazo-reaction of Ehrlich is an aid in diagnosis, but, unfortunately, may be present also in acute phthisis, meningitis, measles, and other fevers, but the only reliable change is a rose-red (pink) hue of the foam. To obtain it two solutions {a and b) are needed : We mix 1 part of solu- tion [a), which consists of a 0.5 per cent, solution of sodium nitrite, with 40 parts of solution {b), which consists of 2 grams of sulfanilic acid, 150 c.c. of hydrochloric acid, and 1000 c.c. of distilled water. To this an equal volume of urine is added, and the contents of the test-tube are then thoroughly shaken. A layer of ammonium hydrate is now super- imposed, and at the line of contact a ruby or pink ring develops. More* over, it is present in only about 70 per cent, of the cases. A brownish ring is given by normal urine. There is a post-typhoid, diphtheritic pyelitis in which the pelves and calices of the kidneys are primarily the seat of membranous exudation, and later of erosion and ulceration. The urine generally contains blood and pus. Osier has met with this condition in 3 autopsies, in 1 of which it was associated with extensive membranous inflammation of the bladder. Simple vesical catarrh is a rare complication, except as the result of catheterization for retention. Orchitis and epididymitis as well as ovaritis are occasional sequels. ^ Deutsche Archivfiir klin. Med., Bds. xxv. and xxxvii. 44 INFECTIOUS DISEASES. (Ji) The Joints. — Typhoid, septic and rheumatic arthritis may occa- sionally arise as a complication. The first is usually mon-artkular (par- ticularly in the hip) ; the last two commonly j)oly articular. Keen has collected " in all 84 cases involving the joints." (/) The Bones. — Periostitis, due to injury and muscular strain and often leading to necrosis, is a not very rare sequel of typhoid. The favorite seats are the tibia and ribs, though in a case of my own at the Philadelphia Hospital it affected the os calcis. Osteomyelitis may also occur. Keen has collected 216 cases in which the bones were attacked. (_;) The Muscles. — As in the case of the heart, so the voluntary muscles exhibit hyaline degeneration ; also abscesses, in consequence of secondary infection or of infection with the typhoid bacillus itself. Typhoid' abscesses likewise result from perforations in all portions of the gut. Associated Acute Infectious Diseases. — Malarial fever may be com- bined with typhoid, though the relationship is not a vital one. In an analysis of 2122 cases of malaria typhoid fever was associated in 8.^ Many instances of so-called typho-malarial fever would be shown to be pure typhoid by a careful blood-examination, as the presence of chills, sweats, and an intermittent temperature-curve are sometimes observed in this disease (vide supra). Pseudo-membranous inflammation, as above intimated, may occur in the naso-pharynx, larynx, gall-bladder, and genitals. Measles, scarla- tina, and chicken-^jox have also been known to arise in the course of, or during convalescence from, typhoid fever. Erysipelas is a rare secondary affection coming on either during the height of the affection or (more frequently) after its close. Typhus fever may be associated with typhoid, but is an exceedingly rare occurrence. Clinical Varieties of Typhoid Fever. — These are numerous, and may gi'ow out of peculiarities manifested during the course of the affec- tion, as may be observed not only in different epidemics, but also in the same epidemic. The groups of cases described here have reference par- ticularly to the degree of severity of the type, which vai'ies between the wide limits of extreme mildness on the one hand and extreme severity on the other. The course of the disease may also be modified by the occurrence of one or more of its manifold complications. (1) The Mild or Rudimentary Form (Typhus Laevissimus). — Of this variety many cases occur, and especially among children. The charac- teristic typhoid symptoms are scanty, and at times even entirely wanting. The spleen is almost always enlarged, the roseate spots are sometimes present, Avhile the temperature is moderately elevated and often partakes of the same character as that of true typhoid. The fever, however, may pursue the remittent type. Complications presented by special organs are usually absent, but grave accidents (intestinal hemorrhage, perforation) are not impossible. The diagnosis is always difficult, owing to the feeble development of the characteristic symptoms, and in the total absence of the latter is out of the question ; but the recognition is assured if a causal connec- ^ " The Complications of Malaria," Journal of the American Medical Association, vol. xxiv. p. 919, by the author. TYPHOID FEVER. 45 tion between them and typical cases can be shown to exist, and if the Widal test gives a positive result. (2) The abortive form has a sudden onset, and is often marked by fits of shivering. The characteristic features of the disease (enlarge- ment of the spleen, abdominal symptoms, rose spots, etc.) appear earlier than in the usual type, and soon become quite well marked. The fas- tigium is short, and the temperature, from the seventh to the twelfth day of the illness, declines by a prompt lysis, with profuse sweating. With the rather rapid fall of temperature there is a no less rapid im- provement in every other leading symptom. Convalescence is speedy. (3) The Ambulatory Form (Latent or Walking Typhoid). — The pa- tient continues to walk about, either experiencing but slight disturbance or being unwilling to take to his bed. Such cases do not come under the care of the physician in many instances. Others, on account of debility, anorexia, diarrhea, and other vague symptoms, finally consult their physician, who may discover the presence of all the characteristic features of the disease. A third contingent, belonging to this form, continue to move about, or even to follow their usual vocations, till seized suddenly with profuse intestinal hemorrhage or general difiiise peritonitis following perforation. The likelihood of these grave devel- opments is much greater in the case of persons who go about or travel lono; distances while suiFering from this disease. (4) The afebrile is an exceedingly rare form of the aflfection — in this country at least. Liebermeister, however, has met with a number of cases at Basle, the symptoms being lassitude, depression, headache, neuro-muscular pains, anorexia, slow pulse, furred tongue, constipa- tion or diarrhea, with enlargement of the spleen and roseate spots. These cases are often confined to bed, and there are occasional attempts at evening exacerbations of temperature (100.5° F. — 38° C). Sub- normal temperatures are sometimes associated, but I have seen only two cases that I regarded as belongino; to this form. (5) Severe or Grave Forms. — These may be dependent either wholly or in great part upon the degree of virulence of the typhoid poison. Under these circumstances there will be a profound intoxication of the system, as shown by high temperature, violent nervous symptoms, and great prostration. The grave types may arise in the course of cases of average severity from the development of serious complications. Again, to serious forms belong those cases that begin with the characteristic symptoms of a localized inflammation — e. g. the cerehro-spinal form, in which the nervous symptoms greatly predominate at the onset ; the nephro-typlioid (before all.— Portable bath-tub in use. (see Fig. 5). In obstinate and severe cases the fall may be less than one degree, in Avhich case it is advisable either to prolong the bath to twenty minutes or to reduce still further the temperature of the water. l*rotracted warm baths are highly recommended by Reisse and others when cold baths are badly borne or are unproductive of good results. In light cases the cold bath should be repeated every six or eight hours ; in severe ones, every three or four hours, but more frequently than once in three hours is not advisable, even in the worst cases. TYPHOID FEVER. 59 Sufficient water to immerse the patient to the neck (about 30 gallons — 114 liters) should be used. During the night the patient should be allowed to sleep for six or eight hours if he can do so. As before stated, there are a number of convenient and satisfactory portable tubs in the market, but that devised by Dr. C. L. Furbush of Philadelphia possesses certain leading advantages (Figs. 6, 7). The frame is made of light wood, and when folded is 4 inches (10.156 cm.) in Fig. 7.— Portable bath-tub, folded. depth, 14 inches (35.546 cm.) in width, and 5 feet 10 inches (1.778 m.) in length, so that it can be placed in a closet or beneath a bed. Less than two minutes are required to prepare the bath, which the patient receives while lying in bed. When in use the ends are fastened by brass pins hung on small chains, and these hold the frame in a fixed position. The tub proper is made of double-faced sheeting, reinforced in the middle, so as to resist the greatest amount of pressure. The sides of the sheet have a casing through which is passed a wooden rod 4 feet 4 inches long (1.320 meters), and outside of this a margin of 1^ inches (3.808 cm.) is left for the brass eyelets, through which passes a rubber cord which is covered with woven cotton. This cord, which is attached to the sheet, is held to the frame by special brass fittings along the lower sides of the latter. By the use . of the cord and wooden rods we have an even tension on both sides, combined with ample resistance to withstand the pressure of the water. An ad- justable head-rest fits into the end of the frame. The wooden rod also enables the attendant to roll up the sheet quickly after the bath. Through the bottom of the sheet a 1-inch rubber tube is fitted with a stopper, and by means of this the tub can be emptied much sooner than by a siphon. The frame is covered with ivory-enamel paint, and can be cleansed easily, and the entire Aveight of the outfit is 25 pounds (11.33 kgms.). Brand recommends that the baths be commenced when the tempera- ture in the rectum reaches 102.2° F. (39° C). The height of the tem- perature, per se, is not to be invariably regarded as an absolute indi- cation for the employment of the cold bath, since the facts must be recollected that the essential efi"ect is a stimulation of the nerve-centers Avhich preside over the organic functions, respiration, circulation, etc. Moreover, cold baths exert a marked preventive efi'ect in obviating 60 INFECTIOUS DISEASES. serious symptoms and complications. I continue the baths until the evening temperature remains below 101° F. (38.3° C). The contraindications to the use of baths are — (1) Intestinal hemor- rhage, which is in itself attended with danger and requires absolute quiet for a time (four days), when the baths may be resumed if there is no recurrence. (2) Peritonitis, the occurrence of which always excites suspicion of perforation. Here, again, rest and all that the term im- plies must be procured. (3) Extreme Cardiac Weakness. — The excite- ment in the necessary handling of the patient connected with the bath might prove fxtal, as I have witnessed in one instance. This condi- tion is sometimes met with in cases that come under observation at a late period, and have not been brought under proper treatment from the start, or in cases arising in aged and previously enfeebled subjects (4) Cases that have progressed to an advanced stage (the third week of the disease) should not be immersed. Dangerous and even fatal collapse has been observed to follow cold baths under these circumstances. Substitutes for the Cold Bath. — The prejudice which exists against the cold-bath treatment — at least in America — sometimes proves insur- mountable. Again, there are many physicians Avho do not avail them- selves of the means at command for carrying out hydrotherapy. In consequence of these facts substitutes for the cold and the gradually cooled baths are, unfortunately, quite commonly in vogue. Among them cold sponging of the body of the patient is often resorted to, though it secures for him few and trivial advantages as compared with those of the baths. If this method be employed, the water should be of the temperature of the air of the room or ward. The limbs should be sponged and dried in succession, and then the trunk. Whenever the temperature reaches 102.5° F. (39.1° C.) this measure is to be insti- tuted, each sponging being continued until the desired effect has been produced (a reduction of the temperature of 1^° to 2° F. or 1° C), unless the patient gives signs of uneasiness, when it must be cut short. It may be repeated as often as required. To the water used for the appli- cations e(|ual parts of vinegar or spirits should be added. The efficacy of the cool sponging is greatly enhanced by the simultaneous applica- tion of the ice-cap, either constantly or during alternate hours. If this method fails, as it often does in severe types, the cold pack may form a satisfactory substitute ; and I have found it of great use with children, in whom the reaction after a cold bath is often delayed or imperfect. The patient is placed upon a cot previously prepared by spreading over it a blanket, which is in turn covered with a sheet doubled and Avrung out of water of the required temperature, 70° to 80° F. (21.1°-26.6° C). The sheet and blanket are now wrapped about the patient evenly, and he is left in the pack for a period varying from a half to one hour. Free diaphoresis generally ensues, and this aids in maintaining the fall of temperature. The effect, in most instances, is to reduce the body-heat two degrees or more, and the treatment may be repeated at intervals of three or four hours if needful. The wet sheet alone may surround the patient, and be sprinkled at short intervals with a watering-pot containing water of a temperature of 70° F. (21.1° C). In desperate cases in which cold baths are for adequate reasons out of the question ice-water enemata may be tried. If carefully administered. TYPHOID FEVER. 61 they accomplish a reduction of the temperature sometimes by two or more degrees. Leiter's coils may be applied to the head, chest, or ab- domen, and form the most convenient method of applying cold. Guaiacol has been used for its potent antipyretic eifect by H. G. McCormick and others, from 10 to 30 minims (0.666-2.0) being applied to the skin surface. I have seen its use followed by rigors, hyperpyrexia, etc., but McCormick has adopted the rule of using suffi- cient only to lower the temperature to 100° F. (37.7° C), and has thus avoided all ill effects. (5) Internal Antipyretics. — Internal antipyretics are also effectual agents in combating immoderate temperatures, and certain of them, it must be confessed, have a powerful influence. Moreover, they soothe and moderate the nervous symptoms and act more or less potently as antiseptics. But even the most reliable of this group of medicaments (phenacetin, acetanilid, and antipyrin) are open to the serious objection that they depress cardiac power, and on account of this I do not use them in hospital practice (where the Brand method can be rigidly car- ried out), and very rarely indeed at any time in private practice. When the Brand method cannot be employed, or, as rarely happens, it is ineffective and there is present a high fever with decided nervous symptoms, internal antipyretics are allowable if properly administered. The safest among them is phenacetin, of which 5 grains (0.324) may be given at a dose (preferably about 3 P. M.), and repeated after four hours should the first dose fail of the desired eflect. Acetanilid is more effective than phenacetin, but is not quite so free from injurious action as the latter. It may be prescribed in doses of 2 to 4 grains (0.129— 0.259), to be folloAved by a second dose of equal size in four hours if necessary. The heart is always to be guarded by the use of stimulants when internal antipj^retics are exhibited. (6) Intestinal Antiseptics. — Unquestionably these neither destroy the bacilli nor counteract the ill effects of their toxins, since both become active after they pass beyond the intestinal mucosa; but they are indi- cated in an affection in which extensive intestinal ulceration and moder- ate tympanites are usual manifestations. The bowel antiseptic which I have employed quite extensively, and with uniformly good results, is salol, this drug being broken in the intestinal canal into carbolic and salicylic acids, and being capable of controlling meteorism as nothing else has done in my hands. The dose is 2 to 3 grains (0.1296-0.1944) every three hours, preferably administered in capsule. With it I usu- ally combine quinin in doses of 1 to 2 grains (0.0648-0.1296) each. Henry speaks strongly in favor of thymol, which he prescribes in pill or capsule (gr. iiss-0. 1620) every three or four hours. Wilcox^ urges that chlorin is capable of disinfecting the intestinal tract. Lactoplienin (gr. vij-xv — 0.4536-0.9720 per dose), in starch capsules, up to 1-|- drams (6.0) daily, according to the indications, is highly rec- ommended (Jaksch). Carbolic acid, iodin, and other antiseptic agents have their advocates, but my own experience with them has been limited. Turpentine fulfils in some cases a leading indication. When the tongue is dry and brown, the abdomen distended, the general prostra- 1 Medical News, Feb. 11, 1899. 62 INFECTIOUS DISEASES. tion marked, and often muttering delirium present — symptoms of the typhoid state — the use of this agent, together with alcoholics, consti- tutes the best mode of treatment. Turpentine is best given in a capsule in the form of white turpentine — dose, 3 to 5 grains (0.1944-0. 3240) everv three hours. Its routine administration, however, is to be un- qualifiedly condemned. (7) Curative Inoculations with Cultures of Serum. — The brilliant results obtained from the use of antitoxic serum in diphtheria and certain other affections have led to attempts at curative inoculations in typhoid fever. Though their specific virtue is yet to be demonstrated, it is deemed proper to state the results Avhich have been obtained as concisely as pos- sible. E. Friinkel and Manchot have treated o7 cases of typhoid fever with a sterilized liquid derived from a culture of the bacillus of Eberth in thymus bouillon and heated to 140° F. (60° C). Of this, \ c.cm. was injected deeply into the gluteal region, with favorable results. Hughes and Carter treated a number of cases Avith blood-serum de- rived from convalescent cases, but apart from a decided lowering of temperature the general course of the disease was not perceptibly modi- fied. Wasserman and others have shown that the organs of animals, some inoculated experimentally, some not, contain protective substances. Pursuing this line of investigation, Jez ^ found that he was able to obtain from the organs of animals inoculated with typhoid bacilli sub- stances capable of exercising protective and curative influences upon typhoid infection. The mode of producing the extract was as follows : Guinea-pigs were given, at short intervals, several intraperitoneal injec- tions of bouillon-cultures of typhoid bacilli of progressively increasing virulence. When tolerance Avas established the animal was killed and its thymus gland, spleen, bone-marrow, brain, and spinal cord removed, finely divided, and rubbed up in a mortar Avith a solution consisting of sodium chlorid. alcohol, g-lvcerin, and a small amount of carbolic acid. Subsequently a small amount of pepsin also Avas added advantageously. After standing on ice for tAA^enty-four hours the mixture Avas carefully filtered, a clear, reddish fluid resulting. Avhich did not cause agglutina- tion and sedimentation of typhoid bacilli nor inhibit their groAvth, though exhibiting the fixculty in marked degree of neutralizing typhoid toxin. This anti-typhoid extract Avas employed in the treatment of 18 cases of typhoid fever, being administered by the mouth in doses of from a teaspoonful to a tablespoonful every tAvo hours, subcutaneous injections proving less serviceable. In the cases thus treated the characteristic temperature-curve Avas lost, the pyrexia becoming remittent and soon disappearing ; the pulse declined in frequency and increased in strength, diarrhea ceased, the tongue cleared, the general condition improved, and convalescence speedily set in. Unpleasant secondary eff"ects Avere not observed, even Avhen larger doses of the extract Avere employed. The usual hygienic and dietetic and other precautionary general measures Avere not neglected. (8) Treatment of Individual Symptoms and Complications. — Headache. — Early in typhoid the headache demands relief Absolute rest and cold to the head frequently suffice. Depressant analgesics are to be avoided so far as may be, though it sometimes becomes necessary to ' Wiener med. Wochen., Feb. 18, 1899, p. 345. TYPHOID FEVER. 63 resort to tbem. At such times those least objectionable are to be selected. I have found that a mixture containing sodium bromid (gr. x to xv — 0.6480 to 0.9720) and the deodorized tincture of opium (Tlliij to v — 0.1998 to 0.3330) in each dose, given at intervals of three or four hours, exercises a striking palliative influence. In occasional instances the above mixture fails, and then phenacetin (gr. ij to iij — 0.1296 to 0.1944) may be substituted for the opium in the same combination or separately in capsule. Insomnia. — The cold baths or other measures calculated to relieve the headache often procure for the patient refreshing sleep. It is im- portant not to allow him to go too long without sleep, since this tends to the development of a pronounced " typhoid state " and its concomi- tants. When the agents recommended for the headache fail, I employ morphin hypodermically in small doses (gr. Jg- to -|- — 0.004 to 0.008) during the evening hours, with excellent results, and have yet to wit- ness the unpleasant after-effects or the unfavorable influence upon the secretions that have been described by some authors. Codein, sulfonal, and, more recently trional and chloralamid, have proved useful. Chloral is more certain in its action than the above agents, but I have abandoned its use for the reason that it apparently produced cir- culatory collapse in two instances. Delirium. — Since the introduction of the Brand method delirium rarely calls for special medication. I have observed, in common with others, particularly during the advanced stages, that in cases in which the circulation was feeble and in which typhomania was a prominent feature, the administration of stimulants with a free hand completely dispelled the nervous phenomena. If alcohol fails, ether (TTLx — 0.666 — at a dose) may be given hypodermically, and repeated in one or two hours if necessary. To combine with the arterial some nervous stimu- lant (jnusk, valerian) will be found serviceable, particularly in cases in which the delirium assumes an hysteric type. Of special value in meeting this symptom are the bromids, hyoscyamus, the persistent use of ice to the head, and the other agents suggested for the headache and insomnia. Voyiiiting is rarely troublesome. Its chief cause is the irritation of the gastric mucosa, Avhich may be caused by improper diet or medica- tion. The best measure for the relief of this symptom, after the removal of the cause, is the use of ice, taken in small pieces and swal- lowed. If vomiting occur during the period of development, minute doses of calomel, combined with sodium bicarbonate, may be pre- scribed with good eff"ect. If it occur during the fastigium, the amount of milk taken should be reduced by one half, peptonized, and then diluted, preferably with lime-water. If the patient experience a strong aversion to milk, it must be suspended temporarily and liquid beef- peptonoids or broths substituted. Dry champagne may be administered simultaneously. Excessive irritability of the stomach calls for perfect rest of the organ for a period of not less than twenty-four hours, the patient being meanwhile supported by rectal alimentation and subcu- taneous medication. Diarrhea more than any other single symptom claims special atten- tion. Two to four movements daily do not constitute diarrhea and do Or, Or, 64 ISFECTIOUS DISEASES. not demaml treatment, but if this number of stools be exceeded, the condition should receive consideration. It may be caused by overfeed- ing or by improper food — as shown by the stools, as a rule — in which case regulation of the diet is curative. It is often due to ulcerated and catarrhal lesions of the intestines, and particularly the large bowel, and in such cases re([uires medical interference. Unquestionably, the use of proper intestinal antiseptics and such as possess the property of insolu- bility to a high degree is most valuable. Astringents may be combined with the latter or given separately. The subjoined formulte have yielded better results in my own hands than numerous others which have been tried : I^. Bismuth, salicylat., 3ij(8.0); Betanaphtol, 5j (4.0). M. et ft. capsulae No. xxiv. Sig. One to be taken every three hours. I^. Salol., 7^] (4.0); Bismuth, subgallat., 5ij (8.0). M. et ft. capsulffi Xo. xxiv. Sig. One every two or three hours. I^. Plumbi acetat., gr. xxiv (1.555) ; Ext. opii, gr. iss-ij (0.097-0.1296). M. et ft. pil. No. xij. Sig. One every three or four hours, as required. The last formula may be administered in the form of a suppository, both ingredients being doubled in (quantity. Late in typhoid fever, when the ulcers are fully developed, opium is the remedy par excellence, since it tends to arrest the peristaltic action which keeps up the ctiarrhea and favors the spread of the inflammation to the peritoneum. I have recently observed brilliant results from the use of rectal injections of an astringent solution (tannic acid 1-2 per cent.), alternated with an antiseptic solution (salicylic acid 1-2 per cent.), each given once daily at intervals of twelve hours. Constijmtion, which is often present, and particularly until the mid- dle of the second week, is to be relieved by simple enemata of soapsuds every second day. Calomel may be used in the early stage of dynamic cases. Its employment in this manner may be followed by symptoms of a milder type than are ordinarily encountered. If constipation exists during the third week, accompanied by an oscillating temperature-curve, as rarely occurs, saline laxatives in small but repeated doses may cut short the attack. Tympanites. — This is sometimes a most distressing symptom, and is often associated with marked diarrhea. The claim has been made that if turpentine be administered in suitable doses throughout, both tym- panites and diarrhea are controlled. Turpentine is a good remedy, but only when certain indications exist (vide supra), and it is Avithout the power to influence the general course of the affection. As a remedy for tympanites it is excellent and richly deserves a trial. When em- TYPHOID FEVER. 65 ployed for this symptom alone I prefer to apply it in the form of stupes over the abdomen, although Avhen, as is frequently the case, the gases occupy chiefly the large bowel, turpentine enemata should be given, and, these failing, a long rectal tube should be passed. The meteorism is often increased by the milk taken, and a change of food to meat-juices and albumin-Avater may be tried. Hemorrhages from the bowels demand complete rest. The bowel- movements, if the hemorrhage has been copious, must be allowed to pass into the draw-sheet. The ice-bag (suspended if possible) should be applied to the right iliac region, and ice freely given by the mouth. Opium, to control peristalsis, must be given, and, by preference, hypo- dermically. It may be combined with full doses of the acetate of lead. Cases in which slight oozing appears from time to time require turpen- tine. Ergotin may be used (hypodermically, to be repeated every hour) in severe bleedings. The amount of food should be greatly restricted for about twelve hours. For severe hemorrhages, saline infusion, either by the method of intravenous injection or by hypodermoclysis or entero- clysis, is to be strongly advised. The saline solution not only raises the blood-pressure in the vessels, but it also has a hemostatic action. The proper strength is 7 : 1000, and from 10 c.c. (3 fiuidrams) to one-half liter may be employed if the collapse is marked, and repeated several times in the course of a day. Rectal injections may be somewhat larger. Peritonitis. — When this is due to perforation the patient usually passes quickly beyond hope unless saved by timely surgical interference. Operation offers some hope of cure, and with the progress of convales- cence the chances of recovery from this accident improve. Deaver regards the acute development of pain and generalized abdominal rigidity and tenderness as an urgent indication for immediate celiotomy. Keen's statistics show that between twelve and twenty-four hours after perforation is the most favorable time for operation, this period giving 30 per cent, of recoveries. Rarely, appendicitis supervenes in typhoid fever, and presents nearly the same symptoms as when occur- ring independently. It usually demands prompt removal of the appendix. Peritonitis due to direct extension of the infectious inflammation of the boAvel without perforation often admits of successful treatment. Saline purgatives, at the same time controlling pain by means of small doses of morphin, are the measures to be used. Pneumonia. — Broncho-pneumonia is to be treated m the manner indicated in the section on this aifection. Lobar Pneumonia. — The treatment of that form of pneumonia which occurs in the advanced stage of typhoid will be considered hereafter {vide Secondary Pneumonia). That variety of pneumonia Avhich rarely inaugurates typhoid requires the same treatment, until the true typhoid symptoms arise, as primary adynamic pneumonia {lAde p. 154). The hypostatic conyestion of the bases of the lungs is to be met by heart-stimulants and by changing the position of the patient. Bronchitis. — Xo special measures are necessary when the bronchitis is confined to the larger tubes, as in typical cases, while, if severe and diffuse, its management is identical with that of broncho-pneumonia. Larynyitis. — For this condition, counter-irritation should be tried ; and if this fails, a small blister may be applied below the angle of the QQ INFECTIOUS DISEASES. jaw on either side. For edema of the larvrix scarification and the inhalation of simple or medicated steam are useful measures. Then, should suffocation become imminent, tracheotomy should be performed without dela}-. Operation ''gives a mortality of only 55.5 per cent." (Keen). Bed-sores. — The preventive measures have already been considered, but the smallest bed-sore demands active treatment It is to be kept clean by means of a weak solution of some antiseptic, and may then be dusted with a powder composed of equal parts of boric acid, calomel, and bismuth ; if sluggish, Avith a powder made up of aristol and iodo- form. I have found uuguentum balsami peruviani (1 : 30) to be a valu- able remedy in bed-sores. Should the edges of the ulcer become under- mined, a drainage-tube is sometimes necessary. Thrombosis of the femoral vein is best treated by elevating the part and keeping it at perfect rest. The following ointment may also be applied along the course of the vessel : li. T^ng. ichthyol., Lanolin, da. ,~ij (8.0); Ung. belladonnne, q. s. ad 5J (32.0). Sig. Apply three times daily. After the swellinor has subsided an elastic stockino- should be worn for a couple of months. (9) Management of Convalescence. — Some of the points connected with this subject have already been discussed {diet, time for getting up, etc.). I may add that should a recrudescence occur the patient should be kept at rest in the recumbent posture and a return made to the liquid forms of food. Often a moderate laxative serves a good purpose, particularly if an indiscretion in diet have been committed. The ulcers may not be healed, though the temperature may have been normal for a week or ten days ; hence the patient should not be allowed to stir about for a period of two weeks after the temperature has returned to the normal. At first his movements should be slow ; he may soon, however, be allowed to exercise gently in the open air during seasons of favorable weather. Mental excitement is to be avoided, since it may produce a recrudescence of fever. Occasionally, during convalescence the diarrhea persists, being due to colonic ulceration, and is best treated by restricting the diet to milk and other light forms of albuminous food. The patient must be confined to bed. Medicinal treatment by the oxid of zinc internally and the use of astringent and antiseptic rectal injections, as before indi- cated, usually proves successful. Constipation may be a troublesome symptom in convalescence, and is best relieved by simple enemata. Most patients require tonics. We should begin with a vegetable salt of iron in combination with a simple bitter (such as the infusion of gentian), and later an inorganic salt of iron, with quinin and strychnin, may be resorted to. If there be a predisposition to tuberculosis, cod-liver oil and creasote should be given fir a period of two or three months. Re- lapses are to be treated as primary attacks, and recurrences in the same manner. TYPHUS FEVER. 67 Mountain Fever. {Mountain Sickness.) The term " mountain fever " should be regarded as applicable only to that condition which develops shortly after ascent to a very high alti- tude. There is no definite pathology nor etiology., but the symptoms are attributable to the effects of a rarefied air upon the organic functions (respiration, circulation, etc.). The symptoms are a much quickened pulse, urgent dyspnea, head- ache, vertigo, and at times nausea and vomiting. There is a subfebrile movement, the temperature touching 100° or even 101° F. (38.3° C). Thirst is present and the appetite is lost. Malaise and a sense of ex- haustion on attempting exertion are experienced. Hemoptysis has been noted, but rarely. The effect upon the human economy of high altitude varies with the extent of the differences in individual reserve nerve-force. Rest and acclimatization will almost invariably restore healthy function. Mountain anemia has been described ; it is caused by the anchylo stoma. Different clinical observers have depicted as mountain fever various forms of illness which might have been as properly referred to other Avell-recognized diseases, especially typhoid fever. The lesions of typhoid fever were present in two instances that were necropsied. Woodruff has reported 35 cases at Ft. Custer in which the grouping of symptoms, including the Widal reaction, assured a diagnosis of typhoid fever. Gwyn quite recently recorded a case in which the clinical features of typhoid were present (except the Widal reaction), but cultures from the blood showed a "paracolon" variety of bacillus. Curtin has reported four cases all evincing the signs and symptoms of lobar pneumonia. It must not be forgotten that high altitude may alter the clinical peculiar- ities of the acute infectious diseases. TYPHUS FEVER. {Ship-fever., Camp fever, Jail fever, etc.) Definition. — An acute contagious disease of unknown specific eti- ology. It is characterized frequently by an abrupt invasion, and is marked by rigor, high fever, early nervous symptoms of great promi- nence, a maculo-petechial eruption appearing between the third and fifth days, and a termination by crisis. Historic Note. — This affection has been known from time im- memorial. In 1759 the name typhus., which is at present universally employed, was given to it by Sauvages. In presanitary times it pre- vailed extensively in epidemic and endemic forms, particularly in Ire- land and Russia, and also, though less frequently, in the seaport towns of our owm country. It constituted one of the chief plagues of the olden times, if not the chiefest, and its devastations among the armies were more destructive of human life than even war itself. In 1812 typhus fever first appeared in America in the New England States. Its ravages did not cease until every Eastern State had been visited by the plague, when it totally disappeared. In 1836 it reappeared 68 INFECTIOUS DISEASES. in Philadelphia in virulent form and with deadly effect. It Avas at this period that Gerhard began his careful studies, which resulted in the separation of typhus from typhoid. During the last half century com- paratively few instances of typhus have been met with in this country, though it still appears constantly in certain quarters, abroad (Great Britain, the eastern portion of Germany, Poland, Russia, and some parts of Southern Europe). All isolated cases and small groups of cases that have been observed in very recent times here have been properly attrib- uted to importations from other countries, and chiefly from Ireland. Since the epidemic in 1836 the disease has not gained a foothold on our shores, although in the early part of 1893 it appeared in New York City, and 150 cases resulted. Pathology. — The various viscera present no characteristic lesions. After death the eruption continues to be visible, and often large ecchy- moses are observable on the dependent parts of the body. Certain organs may present pathologic appearances, but they are not constant and are the result of the secondary infection which the typhus invites. The serous membranes — the pericardium in particular, and at times the gastro-intestinal mucosa — are the seat of ecchymoses. There is hyperplasia of the lymph-follicles, but no subsequent ulcera- tion. Hemorrhagic extravasation may also occur into the muscles, the latter being dark and often showing hyaline and granular changes ; the Jieart-nmscle is especially apt to undergo a granular degeneration. The spleen is considerably enlarged, soft (even diffluent at times), and of a dark (frequently bluish) red color. The live?' is somewhat swollen and may be softened, while the kidne>/s not rarely manifest the changes belonging to nephritis. In other instances they are merely congested. In the lungs are found a variety of lesions peculiar to different compli- cating conditions (bronchitis, lobular pneumonia, lobar pneumonia, pul- monary congestion with or without edema), and occasionally j^leurist/ (sero-fibrinous or purulent) may be present. Nervous lesions are con- spicuous by their absence. An effusion, either serous or sero-hemor- rhagic, into the subarachnoid space and the ventricles may be noted, and quite commonly there is cerebral congestion. In rare instances there may be a meningitis. The blood-changes are marked, the color being dark, the fluidity much increased, while the coagulability is greatly diminished ; and the intima of the aorta is frequently blood- stained. Ktiologfy. — The direct cause or special micro-organism connected with the typhus contagion has not, as yet, been isolated, notwithstand- ing the fact that the morphologic and biologic studies of the blood obtained by Brannan and Cheesman from the finger-tips of six patients during the mild epidemic of typhus in 1893 showed the presence of a bacillus that proved pathogenic for rabbits, guinea-pigs, and white mice.^ Lewaschew^ has also detected in the blood of typhus patients a distinctive micro-oro-anism. Further observations, however, with a vicAv to showing the constant presence of these micro-organisms in typhus fever, are necessary to demonstrate that they are the specific cause of the disease. - Annual of the Univerml Medical Sciences, 1893, p. 60, section H. ^ Ibid., p. 61, section H. TYPHUS FEVER. 69 It is a known fact, nevertheless, that when typhus arises in a locality in which it was previously unknown, it is dependent upon a transference of the typhus virus from without, and does not arise spontaneously ; this cannot be too strongly emphasized. The different modes of con- veyance of this poison from one place to another are not known posi- tively, but we can be confident that its source is in a preceding case, and that it may leave the body in the expired air, in the epithelial scales thrown off, and in other excretory or secretory products of the body. The poison is apt to be transmitted by contagion from the patient to others who approach him ; and there is convincing proof that it may be transferred by means of fomites (wearing apparel, articles of furniture, etc.). What its precise gateway into the body is we do not definitely know, except that it is more likely to enter through the respiratory tract (by inhalation) than through the alimentary canal. Predisposing Causes. — The influence of insanitary surroundings upon the spread of this affection is positive and vital. Among special conditions may be mentioned filth, poverty, famine, and overcrowding, and here it may be inferred that typhus is a disease of the lower classes. Broadly speaking, any condition of the system in which the natural vitality and resistance to bacterial invasion are lowered increases sus- ceptibility to the disease, and among additional influences which possess considerable etiologic influence are overwork, intemperance, depressing emotions, etc. Age has no direct influence. Obviously, however, the young and middle-aged furnish a preponderant proportion of cases, owing to the fact that they are more liable to exposure to the virus than during other periods of life. Sex has no positive influence, and the season plays only a minor part. Epidemics may, however, occur rather more often in winter than in the other seasons, since the homes of the pauper popula- tion are not so well ventilated, and hence are less cleanly in winter than during the rest of the year. Clinical History. — Incubation. — This lasts from nine to twelve days. There may be prodromal symptoms during the concluding days (one, two, or more of this period), such as anorexia, general malaise, , etc., but in most instances invasion is sudden. Pre-eruptive Stage. — The early symptoms are either a series of chills or one severe rigor, accompanied by vertigo, tinnitus, headache, muscu- lar pains, profound prostration, and fever. The temperature quickly ascends to a high level, reaching 104° or 105° F. (40° or 40.5° C.') as early as the second or third day. The fever is continuous in type, and in severe cases a serious systemic condition may often be developed. The pulse is accelerated proportionately to the temperature and is of good volume. Bronchitis may be present, the appetite is lost, and the thirst is excessive, while a thick, yellowish-white coating covers the tongue. Vomiting occurs, and may be a prominent symptom. The urine is often scanty, its specific gravity is increased, and it may contain a trace of albumin. The cheeks are flushed and the eyes are injected. Nervous symptoms appear early — in the worst cases at the very onset — and are quite pronounced. At first there may be either mild or active delirium, but soon there is stupor or even actual coma, and the 70 INFECTIOUS DISEASES. face takes on a dull, stupid look. With few exceptions the spleen on palpation is found to be enlarged. Eruptive Stage. — Between the third and fifth days of the invasion the chwacteristic eruption appears icithout an accompanyb\g decline in the temperature. The rash comes out first upon the trunk (chest and abdomen), extending thence over the rest of the skin-surface of the body, but, strangely enough, often sparing the face. The crimson-red maculae are changed in two or three days to a darker hue, becoming hemor- rhao^ic (petechije), and when coalescence occurs Ave have the spotted effect that has caused the name of .^mtted fever to be given to it. This name is also given to cerebro-spinal meningitis, in which the eruption, though it resembles that in typhus fever, does not appear at any given time and is extremely inconstant. Not all of the maculse are converted, but some may remain as rose-spots, and these disappear when pressed upon, while the petechii^ do not. It is chiefly in the milder grades of typhus that the rose-spots fail to become petechial (vide infra). The skin -surface between the spots is sometimes diffusely hyperemic, and the eruption is usually rather abundant, though in well-authenti- cated cases it has been scanty or even wholly missing. Unlike many other eruptive diseases in the stage of eruption, the symptoms of typhus fever assume an aggravated type in typical and severe cases. The tem- perature continues high, often reaching 106° F. (41.1° C.) or even higher, with slight nocturnal remissions. The pulse becomes quite rapid (120-140 or more), feeble, and possibly irregular (often dicrotic), and the respirations increase markedly in frequency. At this time severe bronchitis, leading to hroncho-pneumonia , is apt to occur as a complication. The tongue is brown, fissured, tremulous, and occasion- ally black and rolled up, without power to protrude from the mouth. Sordes form on the teeth and lips. The urine is scanty, high-colored, and often albuminous, and there may be retention from paralysis of the bladder. The nervous disturbance is intense, and may take the form of typho- mania, leading to complete coma or maniacal delirium. The patient often lies with eyes open, staring into space, yet unconscious and in the condition known as coma-vigil. The motor nerves show derangement (tremors, subsultus tendinum, etc.), and carphologia (picking at the bed- clothes) is a common symptom. The decubitus is dorsal, as a rule ; the flushed cheeks gradually become dusky, the face expressionless, and the pupils often contracted. The prostration reaches an extreme degree, and absolute exhaustion often terminates life. As a rule, in favorable cases the end of the febrile period comes by crisis between the fourteenth and seventeenth days of the disease, and the temperature drops in the course of twenty-four or thirty-six hours to normal. Immediately preceding the crisis there is generally a great and sudden rise of the temperature (perturbatio critica), and the decline may be interrupted by slight irregularities or fresh exacerbations. The occurrence of the crisis is marked by rapid improvement in the symp- toms in general. The stupor suddenly gives place to a clear mind (sometimes following a profound sleep), the eruption fades quickly, the facial phenomena disappear in inverse order of their appearance, and the general strength is rapidly recovered. TYPHUS FEVER. 71 Leading Symptoms and Complications. — Course of the Fever. — Al- though the temperature, as stated above, rises rapidly on the first day of the illness, it should be added that the highest grade is usually reached as late as the fifth or sixth day. Maximum temperatures of 105°, 106°, or even 107° F. (40.5°-41.6° C.) are common. Hyperpy- rexia usually heralds a fatal termination, the temperature mounting to 108°, 109° F. (42.7° C), or higher, though in light cases the acme may not exceed 103° F. (39.4° C). During the height of the affection the temperature pursues the continued type (slight morning remissions), with moderate oscillations, till the occurrence of the crisis which has been described. The fall of temperature may occasionally be more gradual, than before indicated, though this is a comparatively rare phe- nomenon. The lungs frequently present complications (vide Pathology), among which the most common are bronchitis, broncho-pneumonia, and hy- postatic congestion. Broncho-pneumonia is especially dangerous, its development often preceding a fatal termination, and it may lead to pulmonary gangrene. If the gangrenous, consolidated areas connect with the pleura, empyema commonly results. Sero-fibrinous pleurisy also may occur as a secondary event, as may lobar pneumonia, and to recognize the latter the local physical signs must be fully appreciated, since the rational symptoms are feebly expressed. The heart in typhus continues to grow progressively w^eaker until, in many cases, a fatal issue is reached. This is manifested by the change in the character of the first sound, which becomes more and more indis- tinct as the case progresses, A systolic murmur (probably of hemic origin) may be audible at the apex. The nervous phenomena have been sufiiciently detailed. Meningitis has been met with, but is very rare as a complication. *Reference has been made to the occurrence of the ordinary febrile albuminuria in this disease, and it remains to be pointed out that Jiemorrliagic nephritis very rarely intervenes. During the febrile period the uric acid and urea increase in quantity, while the chlorids decrease. The digestive tract rarely presents distressing symptoms and compli- cations. Hematemesis is most common, and cancrum oris has been noted occasionally. Cases in which the mouth does not receive proper care are apt to develop parotitis^ which often passes on to suppuration, and septic processes^ causing abscesses in different parts of the body (joints, subcutaneous tissue, etc.), may arise as complicating events. Among the sequelae, neuritis, followed by paralyses, deserves first place, and gangrene of the remote extremities (toes, fingers, etc.) has also been observed. The general course and duration of typhus are variable. There is a mild type whose course is run in from seven to ten days, and in such the crisis occurs soon after the appearance of the eruption, which may not proceed to the petechial stage. In this type the development of serious symptoms or grave complications is the exception. A malignant type, however, also occurs {typhus siderans), and this often proves fatal before the time for the appearance of the rash. Some epidemics are characterized by the relative frequency of light forms, and others by the severer types of the disease. 72 INFECTIOUS DISEASES. Diagnosis. — On the known presence of an epidemic with special causative factors (unhygienic surroundings, exposure to the poison, etc.), and with the course and characteristic symptoms, the diagnosis of typhus fever can be made. Of special value is the eruption — its time of appear- ance (third to fifth day), mode of distribution, petechial character, and peculiar behavior under pressure. The recognition of lighter types, on the one hand, and malignant, on the other, is not possible from the symptoms alone, but it is so from the light afforded by a definite know^- ledge of the existence of an epidemic in the vicinity. Differential Diagnosis. — Typhoid fever is distinguished from this affec- tion by (a) its gradual onset, unaccompanied by severe rigor; (ft) the relatively diminished violence and the later development of the nervous symptoms ; {c) the less intense lumbo-muscular pains ; {d) the less abun- dant eruption, which is non-petechial and appears on the seventh or eighth day ; and (e) the gradual convalescence. Cerehro-spinal meningitis may be distinguished by a more intense headache, by retraction of the head, hyperesthesia, intolerance of sounds, photophobia, palsies of the eye-muscles (strabismus), a greater tendency to convulsions, and. finally, by both the absence of the typhus eruption and the countenance absolutely devoid of expression. Uremia is excluded by the absence of the previous history which it always gives (headache, vomiting, and diarrhea extending over a varia- ble period of time), by the presence in typhus of high temperature and a petechial eruption, and by the absence of edema of the extremities and face. Characteristic urinary phenomena are associated in uremia, and it must not be forgotten that among the rarer complications of typhus is acute hemorrhagic nephritis. In pneumonia the mode of onset is not unlike that of typhus, but the early development of the local physical signs, the absence of the typhus eruption, and the non-epidemic appearance of the disease are points which serve to distinguish the former from the latter disease. Relapses are among the rarest of clinical events, and one attack, as a rule. bestoAvs immunity for life. Prognosis. — To arrive at a correct prognosis it is necessary to con- sider (1) the degree of severity of the particular type from Avhich the patient is suffering, (2) the number and character of the complicating conditions present, or likely to occur if the case be of a severe grade, and (3) any peculiar circumstances connected with the individual, among which his food-supply and his sanitary surroundings are deserving of chief mention. In general terms, typhus fever is a grave disease, but its frequency of occurrence, and also its virulence, have been markedly reduced in consequence of better sanitation. The mortality-rate has been, durinff the last half century, lowered immensely, and is betAveen 10 and 20 per cent, at the present day. Treatment. — This need not be discussed at length, since it em- braces, in the main, the same principles that were evolved in the treat- ment of typhoid fever. Prophylaxis demands thorough disinfection and absolute isolation. A special hospital for contagious diseases is ahvays to be preferred to the best accommodations obtainable in private families. When, however, patients cannot be transferred to special hospital wards and must be RELAPSING FEVER. 73 treated in private houses, the sick-room must be kept clean, well-ven- tilated, and at a temperature ranging from 60° to 65° F. (15.5° to 18.3° C). No one other than the doctor and nurse should be allowed to occupy or even enter the room. The thorough disinfection already described under Typhoid Fever must be enforced with equal care, and the importance of supplying fresh air to typhus patients has been abun- dantly shown by the great reduction in the mortality-rate among those treated in tents as compared with that in the hospital wards. The general management, including the use of stimulants, in this disease does not differ from that advised in typhoid fever, except that a more prompt return to solid food can be made during convalescence than in typhoid. Fresh water should be given freely, and, in view of the blunted sensibilities of the patient, should be offered at regular intervals. Hydrotherapy constitutes the best means at our command for controlling (by virtue of its stimulating effect upon the cardiac and respiratory cen- ters) the temperature and the nervous symptoms, while at the same time it obviates dangerous complications. In addition, the use of antiseptic agents and tonic measures is to be recommended. The fact that typhus is a self-limiting affection, and therefore curable if life can be spared until it has run its usual course, gives those measures that are intended to combat exhaustion high rank in the treatment of this affection. RELAPSING FEVER. [Fehris Recurrens ; Relapsing Typhus.) Definition. — An acute infectious disease caused by the spirillum of Obermeier, and characterized by febrile periods which usually last si^ days, and are separated by afebrile periods of the same duration. Historic Note. — The first accurate account of this affection was published in 1739, though it is known to have prevailed in Europe and Ireland prior to that period. During the next century numerous epi- demic outbreaks, more or less extensive, occurred, and in 1844 the dis- ease made its first appearance in America at the Philadelphia Hospital, being brought by immigrants from Ireland. Subsequently small groups of cases occurred, and were reported by Flint and others, and in 1869 it prevailed considerably in Philadelphia (where it was studied especially by E. Rhoads and William Pepper) and in other large cities of the coun- try. This was the last epidemic appearance of the disease in the United States, though in the years 1885 and 1886 Russia was visited by an epidemic of considerable magnitude. Pathology. — The solid organs of the body present no characteristic anatomic changes, though when death occurs during the febrile period the various viscera (heart, liver, kidneys) are the seat of cloudy swelling, and sometimes of hemorrhagic infarct and extravasation. The spleen shows the most constant alterations, being enlarged, but in size it ex- hibits a great variability. Infarction is frequent, and the lymphoid ele- ment of the bone-marrow often shows hyperplasia. If jaundice has been present during life, it is visible after death. 74 INFECTIOUS DISEASES. Ktiology. — Bacteriology. — In 1873. Obermeier discovered in the blood of patients suflFering from relapsing fever a special organism, the spirillum Ohermeieri, and subsequent investigations by others have fully confirmed his observations with refer- ence to the causal relation of this mi- cro-organism to relapsing fever. The specific agent, or spirocJieta, is a deli- cate filamentous organism of spiral • form and much elongated, its length equalling four to six times the diam- . eter of a red blood-corpuscle (Fig. 8). Examined under the microscope dur- 'S,. y . ing a pyretic period, it is seen to ex- ^ - w*^ . hibit active motion among the blood- ' . - ♦ cells, this motion being spiral and "^ -ii^uj^^gi^sp- following the long axis of the organ- FiG. s.-BaeiUus of relapsing fever (from is™- It is aerobic, and may be dem- human bioodi; xiooo(Gunther). onstratcd in dry blood by staining with anilin colors, but the spii'illum has never been found in other fluids or secretions of the body. It is also apparent in the blood only during the paroxysms, and Dr. Van Dyke Carter's careful studies have shown that by inoculation of the blood containing spirillar organisms or their germs the disease may be conveyed to new or old subjects. Shortly before the crisis the spirilla disappear from the blood, and are. as a rule, absent during the whole of the succeeding apyrexial period, and inoculation now fails to produce the disease. After death they are found in all the organs, but they have not been cultivated successfully on artificial media, and little is known of their life-history. Predisposing Causes. — Age. — The complaint is most common in young adults between fifteen and twenty-five years. Sex. — A larger proportion of males than females is affected. The disease is especially apt to prevail in times of famine, and amid antihygienic surroundings. Mode of Infection. — Tictin's studies indicate that the medium of trans- mission may be through suctorial insects (as bedbugs). Clinical History. — The incubation period ranges in its duration from four to ten days, though sometimes it is even briefer ; and in this stage certain symptoms (malaise, fugitive pains, etc.) may appear. The invasion is quite abrupt, often occurring on awakening in the morning, and commonly the attack is ushered in Avith a severe rigor, though there may be only a repeated slight shivering. The chief accom- panying symptoms are frontal headache, vertigo, severe pains in the loins and*^ limbs, and marked physical prostration. The temperature rises soon, and often rapidly, reaching 105°-106° F. (41.1° C). or higher still, on the first or second day. The skin is dry and pungent, and pre- sents very soon either a "characteristic dirty-yellow color'' or a dis- tinctly bronzed appearance. The cheeks are flushed, the eyes sunken, and profuse perspirations often take place (sometimes alternating Avith chills), in consequence of which sudamina are frequently observed. Other RELAPSING FEVER. 75 forms of eruption have been described, but none that are either constant or characteristic. In certain epidemics herpes lahialis has been very gen- erally noticed. At first the tongue is moist and coated T\'ith a yellowish- white fur, and later it may become brown, dry, and fissured, Avith sordes on the teeth. Ulcerative stomatitis has been observed occasionally, and catarrhal pharyngitis and mild tonsillitis may be evidenced by pain on swallowing and other symptoms. Among the earlier symptoms are ex- cessive thirst, anorexia, nausea, and vomiting. The vomitus may be yellowish-green, green, or even black in color, and consist of bile in varying proportions (rarely, also, blood) and gastric secretions. Con- stipation often precedes invasion, and is apt to continue throughout the attack. The pulse rises rapidly Avith the temperature, though the normal ratio between the two is not maintained. At first the pulse is full and strong, and its beats number from 100 to 140 or more per minute ; but in serious cases it becomes Aveak, irregular, or even intermittent, Avhile at the same time the heart-sounds groAv more and more feeble and indis- tinct. Hemic murmurs may be audible. The nervous derangements are not of a grave character, but the headache persists and is severe throughout, and the patient is restive and sleepless. Delirium is not common, and, though occasionally this symptom assumes a prominence toward the crisis, the intellect remains clear as a rule. The urine pre- sents the ordinary febrile characteristics, and may contain albumin and casts. It also contains bile-pigment Avhen jaundice is present. The respirations are accelerated, and immediately preceding the crisis urgent dyspnea may be developed. The physical signs during the febrile paroxysms are few. The epi- gastric region and the nerve-trunks are tender to the touch, Avhile the skin-surface and certain muscles are often hyperesthetic. Palpation detects a A^ariable degree of enlargement of the spleen and liA^er, and the signs of bronchitis, of lobular pneumonia, and of hypostatic con- gestion of the lungs may be present. The symptoms above detailed persist with slight daily fluctuations of temperature till there occurs a turning-point. The Crisis. — This occurs from the fifth to the seventh day, and rarely as late as the tenth. It is sometimes heralded by a critical rise of temperature, the mercury touching 108° F. (42.2° C), but eA'idenced chiefly by a rapid fall of temperature (within tAvelve hours) to or below the normal, Avith profuse sweating. Coincidently, all other symptoms disappear with marvellous rapidity. The critical sweat may be replaced by diarrhea, intestinal hemorrhage, metrorrhagia, or epistaxis, and then follows a speedy afebrile convalescence, so that after the lapse of a day or two the patient expresses himself as being aa'cII. During the intervals betAveen the paroxysms the skin may exhibit a faintly jaundiced tint; there maybe trivial evening exacerbations of temperature, particularly if complications be present and outlast the fever stage; and the spleen is evidently enlarged. There may be, though rarely, but a single paroxysm. As a rule, at the expiration of the second AAcek there will be a recurrence of all the active symptoms of the primary attack, including the rigor or fits of chilliness and 76 jyFECTIOUS DISEASES. fever. Quite frequently a tliird pyrexial stage takes place, and rarely a fourth or even fifth. The duration of the first relapse is briefer than the primary pyretic stage, and if there be subsequent relapses, each succeeding one is sepa- rated from its predecessor by the usual apyrexial period, but is briefer 12 3 4 5 6 9 10 11 12 13 1-1 15 16 17 18 19 20 Fir« int^nni^wn. First r*lax«* Fkj. 9.— Temperature-curve of relapsing fever. and lighter. Hence, should a fourth or a fifth febrile period occur, it is, as a rule, quite rudimentary. The relative duration and severity of the different febrile periods, their manner of recurrence, and the course of the fever are considerations that can best be appreciated by a glance at the accompanying temperature-chart {vide Fig. 9). Complications. — These are not frequent. At the head of the list stands lobar pneumonia, and next comes broncho-pneumonia, which is always secondary. Other conditions, belonging to the latter class, are septico-pyemic processes, iritis, irido-choroiditis. suppurative parotitis, laryngitis, entero-colitis, and neuritis. In pregnant women abortion may take place. Epistaxis has been noted, and has even proved dan- gerous in some epidemics. Acute hemorrhagic nephritis is a very rare but serious complication when it does occur, and may be dependent upon the primary affection. As the result, most probably, of the very high temperature the heart may become exhausted, and the occurrence of sudden paralysis is not unknown. Clinical Varieties. — The difference in the general course of cases in different epidemics, and even in the same one, is, for the most part, the direct result of the varying degrees of intensity of the infection. Thus verv licrht or even rudimentarv cases occur in which the whole course may be made up of one or two brief febrile periods, and their resemblance to ordinary intermittents may be close. The so-called '* bilious typhoid.'' which is a form of relapsing fever, occupies the other extremity, being of malignant type. It is sometimes characterized by the usual symp- toms of the disease, only greatly intensified ; but more often, perhaps, the condition early merges into a typhoid state, to which are added cer- RELAPSING FEVER. 77 tain grave features and complications (marked icterus, hematemesis and hemorrhages from other outlets of the body, uremia, sudden collapse, etc.). Septic and pyemic processes, including infarctions, are common accompaniments, and the outcome is frequently unfavorable. Diagnosis. — The prevalence of an epidemic in which the cases pre- sent similar symptoms ; the sudden onset ; the course and intensity of the fever with its concomitants ; the termination by crisis on or about the seventh day ; and the peculiar manner of repetition of the fever- attacks after an afebrile period of equal duration, — are points that dis- tinguish relapsing fever from other affections which simulate it more or less closely. Additional symptoms that are of special value for diag- nosis are — enlargement of the spleen and liver, a negative character of the nervous and a prominence of the gastric phenomena, and jaundice. To be able to state that relapsing fever is positively present the spiro- cheta Ohermeieri must be found in the blood, and this is particularly true in the earlier cases of an epidemic, before they have passed through their typical, relapses. To demonstrate the presence of this parasite in the blood during the fever-stage is not a difficult task. A drop of blood obtained from the finger-tip is to be examined microscopi- cally without previous dilution. On account of their size and motility the spirilla can be readily detected, and usually the attention of the ex- aminer is first arrested by the peculiar joggling movements of the red blood-corpuscles. Then the real disturbing agents appear as slender spirals with a snake-like motion. Their identity may be confirmed by staining with anilin colors, and, in exceptional cases, by injecting them into the blood of the monkey, in whom they produce the disease. Differential Diagnosis. — Tyj^lius fever may be mistaken for relapsing fever, since both have the same predisposing causes, both prevail epi- demically, both are characterized by an abrupt onset, with or without prodromes, and by a continued type of fever. On the other hand, cer- tain points of distinction serve to separate them reliably. In relapsing fever the eyes are clear but hollowed, the cheeks are flushed, and there is a dirty-yellow tint of skin ; in typhus the eyes are injected, the pupils contracted, the face wears a stupid, inanimate expression, and there is in addition the characteristic maculo-petechial eruption. In relapsing fever the intellect remains clear, or there may be delirium toward the height of the febrile paroxysm ; in typhus stupor develops early, and later there is coma or coma-vigil, with acute or low-muttering delirium and adynamic symptoms. In the former disease the primary period of fever is briefer than in typhus by a ratio of 7 to 14. Re- lapses are the rule in relapsing fever, and the exception in typhus ; while in the blood of relapsing fever patients may be found the spiril- lum, which is absent in typhus fever. Pel and Ebstein have described a febrile condition which sometimes occurs in pseudo-leukemia and simulates that of relapsing fever ; but it may be distinguished by the absence of the spirilla from the blood, the general enlargement of the lymphatic glands, as well as of the liver and spleen, and the fact that the pyrexia! periods do not tend to grow shorter. Prognosis. — The prognosis of relapsing fever is good, but of " bil- ious typhoid " it is bad indeed. Apart from the type, we must consider, 78 INFECTIOUS DISEASES. in this as in all other acute infectious diseases, the number, character, and frequency of occurrence of the various complications. As stated, these are few, infrequent, and mostly benign. Among those signalizing danger are severe hemorrhages (epistaxis, metrorrhagia, hematemesis, etc.), premature labor, signs of uremia and eyncope, marked jaundice and excessive vomiting, urgent diarrhea, etc. Perhaps the most fre- quent causes of death are pneumonia and acute hemorrhagic nephritis. Individual circumstances exert an influence upon the prognosis, and of those that render it more grave are the want of good nursing, privation, a previously enfeebled system, and old age (the disease being more fatal in elderly than in younger subjects). The duration depends upon the number of paroxysms, since the latter are of definite length. In the majority of cases there is but one relapse, and in this event the disease lasts from eighteen to twenty days. Treatment. — The general management, including the time and use of stimulants, must be based on the same principles as are employed in typhoid fever. The fever, as well as the nervous and other leading symp- toms, is to be opposed by the cold or gradually cooled bath, employed as indicated in the article on the treatment of the latter disease. If, as may happen, there are adequate reasons why balneo-therapeutics cannot be used, then cold spongings, with the ice-cap or the cold pack, may be tried. Internal antipyretics may be reserved for use in cases in which the tem- perature is very high and the above-mentioned means are impracticable. Small doses of phenacetin (gr. ij to v — 0.1296 to 0.3240) or acetanilid (gr. ij to iij — 0.1296 to 0.1944) are to be administered, at the same time guarding the heart, and the signs of collapse must be promptly met by the free yet prudent use of stimulants (strychnin, alcoholics, ammonium, etc.). Vomiting often induces marked debility, and calls for the use of ice or iced champagne and small doses of cocain, morphin, or dilute hydrocyanic acid, preceded by a mercurial laxative. Counter-irritation over the epigastrium is also useful. For the intense muscular pain, restlessness, and sleeplessness nothing is so good as morphin given sub- cutaneously, and Dover's powder may be employed if the pain be of moderate severity. During the intermissions the patient should be kept indoors for ten days or more, lest exposure or sudden exertion predispose him to a relapse. Solid food may now be gradually resumed, and tonics judiciously given. The treatment of relapses differs in no way from that of the first febrile period. MALAETAL FEVER. 79 MALARIAL FEVER. (Chills and Fever; Fever and Ague; Swamp Fever.) Definition. — An infectious, non-contagious disease caused by the hematozoa of Laveran. It is characterized by splenic enlargement, brief febrile attacks which recur periodically, melanemia, and a tend- ency in protracted cases to irregular fever and extreme anemia. The following sub-varieties Avill be discussed: (1.) Intermittent fever ; (II.) Pernicious inter77iittent ; (III.) Remittent fever ; (IV.) Malarial ca- chexia; (V.) Masked inter mittents ; and (VI.) Malarial hematuria. Historic Note. — There are few diseases with which the profes- sion has been acquainted longer than with the more typical forms of malaria, and chief among the earliest known hot-beds of this disease were the city of Rome, the Pontine marshes about the latter, and the swamps along the lower Danube. Except in the extremes of latitude there are few localities in which malaria has not been endemic, with seasonal epidemic outbreaks ; yet it is pretty generally believed that the prevalence of the disease long has been, and still is, diminishing. This view is fully corroborated by my own observations. A similar progressive decrease, with slight annual variations, was noted during a period of five years (from 1885 to 1889) when the cases from four leading hospitals of Philadelphia were considered together. The total number of cases for this space of time Avas 1132. It was also found that a tracing representing the number of cases of malaria ad- mitted into the Pennsylvania Hospital yearly during the period extend- ing from 1853 to 1893, inclusive, showed a similar tendency to decline, though in a somewhat less striking degree. Osier has called attention to the fact that the diagnosis of malaria was much more frequently made before the discovery of the parasite than has since been the case, and that, therefore, early statistics of this disease are apt to be mis- leading. New England, once a region in which the disease was very prevalent, now affords few cases. In the southern portion of the United States, also, the severer forms of malaria prevailed extensively, but a marked tendency to progressive reduction in the number of cases has also been observed here. It must not be forgotten, however, that in some districts of the United States, from Avhich malaria had disappeared, it has re- appeared, while other localities, formerly free from the disease, have become more or less malarious. In foreign lands (England, France, Germany, etc.) the constantly decreasing prevalence and virulence of this disease have been noted by numerous careful observers. Pathology. — The chief and most constant morbid lesions are attributable to the direct effect of the malarial parasites upon the blood. The symptomatic anemia (often quite pronounced) results from the de- struction of red corpuscles, which may be observed in all stages, by the parasites. There is a marked tendency to an accumulation of pigment in the blood and in certain of the internal organs, particularly the spleen and liver. To account for this is the fact mentioned in the de- DESCRIPTION OF PLATES I. and II. tie drawings were made ■with the assistance of the camera lucida from specimens of fi-esh blood. A Winckel microscope, objective \i (oil immersion), ocular 4, was used. Figures 4, 13, 2.3. The lod. 24, and 42 of Plate I. were drawn from fresh blood, without the camera lucida PLATE I. The Par.\site of TerIian Fever. 1. — Normal red corpuscle. 2, 3, 4.— Young hyaline forms. In 4, a corpuscle contains three distinct parasites. •5, 21.— Beginning of piisrmentation. The parasite was observed to form a true ring by the con- fluence of two pseudopodia. During observation the body burst from the corpuscle, which became decolorized and disappeared from view. The parasite became, almost immediately, deformed and motionless, as shown in Fig. 21. 6, 7, S.— Partly developed pigmented forms. 9.— Full-grown body. 10-14. — Seginenting bodies. 1.5. — Form simulating a segmenting body. The significance of these forms, several of which have been observed, was not clear to Drs. Thayer and Hewetson, who had never met with similar bodies in stained specimens so as to be able to study the structure of the individual segments. 16, 17.— Precocious segmentation. 18, 19, 20.— Large swollen and fragmenting extracellular bodies. 22.— Flagellate oody. 23, 24.— Vacuolization. The Parasite of Quartan Fever. i5. — Normal red corpuscle. 26.— Young hyaline form. 27-34.— Gradual development of the intracorpuscular bodies. .3.1.— Full-grown body. The substance of the red corpuscle is no more visible in the fresh specimen. 36-39.— Segmenting bodies. 40.— Large swollen extracellular form. 41.— Flagellate body. 42.— Vacuolization ." PLATE IL The PAR.iSITE OF ^ESTrVO-AUTUMXAL Ff.ver. 1, 2.— >!mall refractive ring-like bodies. ;^-6.— Larger disk-like and ameboid forms. 7. — Ring-like body with a few pigment-granules in a brassy, shrunken corpuscle. 8, 9, 10. l2.—.Simi"lar pigmented bodies. 11. — -Ameboid body with pigment. 13. — Body with a central clump of pigment in a corpuscle, showing a retraction of the hemo- globin-containing substance about the parasite. 14-20. — Larger bodies with central pigment clumps or blocks. 21-24.— Segmentin? bodies from the spleen. Figs. 21-23 represent one body where the entire proce.-s of segmentation wa.s observed. The segments, eighteen in number, were accurately counted before separation, as in Fig. 23. The sudden separation of the segments, occurring as thoueh some retaining membrane were ruptured, was observed. 2.>-3.3.— Crescents and ovoid bodies. Fisrs. 30 and 31 represent one body, which was seen to extrude slowly, and later to withdraw, two rounded protrusions. 34, 35.— Hound bodies. .>6. — " Gemmation." fragmentation. 37. — Vacuolization of a crescent. 38-40.— Flagellation. The figures represent one organism. The blood was taken from the ear at 4.15 p. m. ; at 4.17 the body was as represented in Fig. :>. At 4.27 the flagella appeared; at 4.33 two of the flagella had already broken away from the mother body. 41-45. — Phagocytosis. Traced with the camera lucida. 1 These illustrations are reproduced by permission from the article by Drs. Thayer and Hewet- son in The Johns Hopkins Hospital Reports, vol. v., 1895. <^^ The Parasite of Tertian Fever. Plate I. Vi: \# /Th w^ >-^ ~-^- 1^:*^* "— >1_. ' ■ *--: 20 at m '-7^:''?% ^ ^- v4 ""^ '■■ i^ -C' The Parasite of Quartan Fever. fc3' ■At. ■*.*'" 54- iS? ^ The Parasite of Aestivo Autumnal Feven Plate II. 22 "^ 21 VnS^ ?■■•'•■• MALARIAL FEVER. 81 (4) Rapidly-growing trees also dry the soil by absorbing enormous quantities of water. They are probably efficient, however, only in localities that have no natural subsoil drainage ^ — a condition often met with in malarial districts. In the Roman Campagna extensive experi- ments have been made with the eucalyptus tree, and the results have been remarkable, districts protected in this manner becoming almost entirely free from malaria in a few years. (5) Seasons. — In temperate latitudes most cases are developed in the autumn, the maximal period corresponding with the month of Septem- FiG. 10.— Chart showing the seasonal variations of malarial fever. The line increases in incre- ments of 100. ber, as is shown by the tracing on the accompanying chart (Fig. 10), Avhich is based upon 4841 cases of malaria gathered from the records of the leading Philadelphia hospitals. Authors who state that malaria is more prevalent in the spring and autumn than in summer and winter in temperate regions are probably in error. An inspection of the tracing will convince the most skeptical that the spring, unlike the autumn, is unattended with increased preva- lence of the disease, which is in abeyance not only during the winter, ^ House-plants as Sanitary Agents, by the Author, p. 263. 82 INFECTIOUS DISEASES. but also practically during the spring, although the cases are seen to increase during the latter period. In the tropics the case seems to be different, and tAvo maximum periods — spring and autumn — and two minimum — summer and winter — obtain. Autumn has, however, the greater number of cases. (6) Gravitation. — The malarial poison escapes from the soil into the superjacent strata of air. That it does not rise far above the earth's surface is shown by the fact that persons occupying the upper stories of a house or living on slight elevations are affected with relative infrequency. (7) Race exerts little influence in other lands than our own, but in the United States negroes are less susceptible than are the whites. (8) Sex is without effect when men and women are equally exposed. Cases are, however, vastly more frequent among males because of their increased liability to exposure, and particularly while following certain occupations (agriculture, marsh-draining, etc.). The 5044 cases col- lected by myself gave the numerical proportion of 6 to 1 in favor of males. The Malarial Parasite. — In 1879, Klebs and Tommasi Crudeli isolated a low vegetable organism — the bacillus malariae — and claimed it to be the special agent producing all forms of malaria. The evidence afforded by subsequent experiments of other observers, however, failed to corroborate their investigations, and it remained for Laveran in 1880 to discover the specific parasite in the blood of patients affected with malaria. The announcement of his discovery failed to attract wide- spread attention until 1883, when Marchiafava, Celli, and Golgi pub- lished the results of their confirmatory investigations. Since then the claims of Laveran have been abundantly corroborated by Councilman, Osier, James, Dock, Koplik, and others in the United States, by A'an Dyke Carter in India, and, more recently, by numerous French, Eng- lish, German, and Russian observers. It would seem, therefore, as though the evidence as to the specificity of this organism were almost complete, and, at all events, it has invariably been found to be associated with the different forms of malaria. The malarial parasite belongs to a sub-class of the protozoa known as hematozoa. Of tbe latter, three varieties, corresponding with the three leading clinical forms of the affection, have been distinguished, and the evolution of two of these parasites at least takes place within the red blood-corpuscles. They enter the red cells in the form of small, non-pigmented plasmodia, exhibiting ameboid motion, and then feed upon their host, transforming, at the same time, the hemoglobin of the latter into dark pigment-granules as they develop. When the intra- globular plasmodia have consumed the red blood-corpuscles the granules of pigment accumulate in the center of the parasite, while on its periph- ery the processes of subdivision and sporulation are taking place, forming fresh generations of hematozoa. These young parasites assume the form of minute, more or less spheric, hyaline bodies, which again enter the red blood-corpuscles and start on a new cycle of development. It is probable, as Golgi suggests, that the third variety is not intimately connected with the circulating medium, but that its evolution princi- pally takes place in the internal organs (spleen, bone-marrow, etc.). MALARIAL FEVER. 83 The special varieties of the malarial parasite will be described sepa- rately. (1) The Ameha causing Tertian Intermittent Fever. — This begins its cycle of evolution in the red blood-corpuscle as a small hyaline ameba. Its development is attended with the appearance in its inte- rior of fine, brown, motile granules in the form of pigment, and when matured it about equals the size of a normal red corpuscle. It now assumes a spheric form, the pigment collecting centrally, and sporulation into fifteen to twenty or more segments follows. The tertian parasites are exceedingly numerous in the blood, and pass through the various stages of their life-cycle almost simultaneously, the sporulation of an entire generation occurring within the space of a few hours (Golgi). The occurrence of the malarial paroxysm follows the process of sporulation, which is attended, most probably, with the development of a toxiyi, and the symptoms of the disease may be attributable chiefly to the effects of the latter. The red corpuscle that includes the parasite becomes enlarged and decolorized as the latter (ievelops. The parasite of tertian intermittent runs its cycle in about forty-eight hours. Hence infection by a single generation would result in sporulation every second day, followed by the malarial paroxysm. Quite commonly, infection by two groups of parasites occurs on successive days, and, since each has a definite period of evolution, a daily malarial paroxysm is the result (quotidian intermittent). Multiple infection with this parasite may occur, but with great rarity. (2) The Ameha causing Quartan Fever. — This cannot be distinguished from the tertian parasite at the beginning of its brief career, but later differences are clearly perceptible. Its ameboid movements are more deliberate, and its pigment-granules are coarser, darker, and also less motile than those of the tertian organisms. Unlike the latter, it does not attain the size of the red corpuscles, and during sporulation the seg- ments (five to ten in number) encircle in an orderly way the central pigment-mass or clump, "rosettes " of great beauty thus being formed. The red blood-corpuscle that harbors the quartan parasite contracts upon its destroyer, appears shrivelled, and its color changes at the same time from the normal to a deep greenish or bronzed tint. It sporulates about seventy-two hours after it enters the red corpuscle ; hence, if only one group of parasites be present, febrile attacks occur every fourth day, forming the simple quartan intermittent. On the other hand, double quartan infection results in paroxysms on two successive days, followed by an intermission lasting one day, while triple infection, or the presence of three groups, causes daily paroxysms — the quotidian intermittent. Infection by more than three groups of the quartan parasite may occur, but is very rare. (3) The Ameha causing Estivo-autumnal Fevers. — The cycle of this variety is evolved, chiefly, in certain of the internal viscera, and the microscopic examination of the blood in the various stages of the dis- ease does not give a positive result, as in the tertian and quartan types. The organism invades the red blood-corpuscle, but to what extent is not definitely known. It is a quite small hyaline body, its size at maturity scarcely equalling one-half the dimensions of the red corpuscle, and it accumulates very few fine pigment-granules. The parasite is not to be 84 INFECTIOUS DISEASES. found in the later stages, except in the blood from certain internal vis- cera, such as the spleen, bone-marrow, etc. After the condition has lasted a week or more characteristic oval and crescentic bodies, which are more or less refractive, may be observed in the fresh blood. These so-called "sickle-form bodies" show central rods and clumps of coarse pigment, and are especially connected with this category of malarial fevers. The red corpuscle, at whose expense the parasite develops, as- sumes a brassy hue, frequently becoming shrivelled and sometimes notched. The time occupied by the life-cycle of this parasite is not definitely settled, but it generally varies between the extremes of twenty-four and forty-eight hours. In one of my own cases the febrile paroxysms re- curred every seventy-two hours. For the differences in the period of evolution there is no satisfactory explanation. The transformation of malarial crescents into spheres and flagellate bodies occurs in the mos- quito's stomach, and in ordinary blood-preparations and the leech (Ross). Cilice^ or fiagellce, exhibiting active motion, may grow from all of the before-mentioned varieties, and not infrequently they become detached and float free in the blood-stream. They are most common in blood aspirated from the spleen, but their true significance is not known. The ciliated forms, according to Manson, probably do not exist in the blood inside the body, but develop very shortly after it is drawn, especially in the estivo-autumnal type. Usually the presence of the cilia is only indi- cated by occasional oscillatory movements of the red blood-cells sur- rounding the parasite. Mode of Infection. — The exact manner in which the human subject is infected with the malarial parasite is not understood. It is in no sense a contagious disease. Koch's studies in South Africa indicate that malaria is conveyed by mosquitoes. He found that mosquito-nets aflford effective protection against the disease. Infection is probably not direct from person to person, but the plasmodium has a stage of evolution in the mosquito. Bignami believes that inoculation is the mode by which infection is usually acquired. Certain species of the mosquito may brins: malaria from a distant locality to a non-malarious one. The poiso7i 'prohahly also enters the system through the medium of inhalation, Sut not, perhaps, through the digestive tract. Immunity. — Persons Avho have had malaria are more liable to fresh attacks than before, although they may experience no inconvenience so long as they reside in a non-malarial district. Incubation. — The period of incubation varies in diff'erent cases and according to the different clinical types. Thus it is, on the whole, briefer in the remittent than in the intermittent forms of malarial dis- ease, the time usually ranging from five to twenty or more days. (I.) Intermittent Fever. — Symptoms. — The clinical history pre- sents itself under two heads : {a) the paroxysms, and [h) the manner in which the paroxysms recur. (a) The Paroxysms. — There may be premonitions lasting from one to several days, and most significant, yet not distinctive, are headache, pain in the nape of the neck, yawning, a yellowish complexion, and a slight splenic enlargement. In a large proportion of the cases, how- MALARIAL FEVER. 85 ever, the onset is abrupt. Typical paroxysms present three stages — chill, fever, and sweating. The chill is intense, causing shivering, and often chattering of the teeth. Malaise is marked, the skin is cool and pale, face slightly cyanotic, and limbs painful. This stage usually occurs in the morning hours, though the time of onset is by no means constant ; its duration, also, varies greatly, generally lasting from one to two boui's. The internal temperature rises rapidly ; the pulse is small, rapid, and of high tension. The hot stage succeeds the chill, and, in striking contrast with the first stage, the face wears a decided flush and the skin is burning hot to M E M E M E M E M E M E M E M E M E M E M E M E M E M E M E M E M E \ 1 E TTiovementt Urine Daily Am'l V 1 ( si ^'^ ■»v ^ vi ,'^i,'^ ■»-.\ o ? l^ - ^i'nS; P^ ISr^ , ^^ S^^ — ^ ^ r*V ■ ^^ ^ * r>'* ■ ^ ^i>J ' '^ ; ■^5 > . ^ ."^ v5> o^ cS'^ «'--X -Sxc^ o. y. ^ ^ M5 wr <^ a- ^ ^ •■■v ci- so 0^ ^^ -. _ Q ? ^ , " j_ 1 ^ ,1 1^ o 5 '0 \ ■V , \\ ^^ , M (V ^ ' ,1 ts '•^ •^ \ I i i" i s i* 1 c V ^ 1 '^ , in '^!\ 1 (1 I 1 *i , — / \ >f ■^ 101 ° \ V I ^ 1 r> L :^ ^ ' ^ r~ A i ■^ ^ \ 100° S 1 i 1 1 ."> t 99° V^i 1 -5 --»- ~ — — — p ^ r- — — '— — — p — — — ^- •:_ O 1 ' N* fl' 1 98° -- A I A 3 • v ^ / •^ y ht \l ■^ «,„ 1 \i % 97° \ ■■« I V ^ > 1 1 [ 1 1 Dayo/Dis Pulse. ,. f,:^'^H^ m ^M %> % ^-^^^ ^ ^^ 'M '-% & m ^ho '^^6 m ^6Z^ ^Hi Besp. .. ^H-%i %. (^^ '^ ^H H ■--J.0 'h^ 'hs 'kf ,^ !^fs 'h '■^n ^1?. /^? Date. ,§ r ■' ^^ ^7 ■■ ^/ ' -^2* -41» -40' -39* 38» 37« -360 1-35° Fig. 11.— Temperature-curye in a case of double tertian fever. C. F. C, aged forty-one years. the touch. The temperature continues to rise, but not so rapidly as in- the first stage. Its maximum level, usually from 104° to 106° F. (40° to 41° C), is soon reached, and may either be maintained uniformly for several hours, or the curve may show two small summits if the tempera- ture be recorded frequently (Fig. 11). The pulse is full and bounding,. 86 INFECTIO US DISEASES. except in the rare instances in which acute dilatation of the heart en- sues, when it is quite feeble and sometimes irregular. The length of the second stage exceeds that of the first, being from three to six hours. The temperature generally begins to decline before the close of the febrile stage. When stveating, which soon becomes profuse, sets in, the symptoms of the hot stage are promptly relieved. The temperature falls by crisis, touching the normal level in a few hours ; the decline, however, is less rapid than the rise at the beginning of the paroxysm. The fall may be unbroken by any fresh elevations of temperature, though more often the latter occur, and less frequently defervescence occurs by steps, the tem- perature dropping one or more degrees, and remaining at the new level for a short period (Fig. 12). It again drops about an equal distance, DAY OF DISEASE I. II. III. i 1 HOUR 7 j9]1lil |3|5 7 9 11 1 3 5 7 ' 9 1 1 { 3 i ' : ;■ 11 1 1 3| 5 7 9 111 3 5 ' a 11; 1 ' 3'6 7 9 111 3 r T. 41° 39° •38' 37° Wa','//.7/V/^''/ ■ " ' ' ' '//I'^'A'.'.V;/'/.;'/,', '■ w "^ .1 ui ' S -' , ; ■;,; ', . <;!; 1- ■ 1 _ < ' ^- 'II c ^ 2 7 - ^ 1 1 ; i R - ' 3 - '_ a i^ .1 - ', : ? T •"■ <= \- ' 1 ! _.■ : r 1 ' 1 7 -' ^- 1 \ 1 ; ' ! ■• r^-. - 1 1 ' ■ ■ ■ ■/ 1 1 \ I \ 1 1 / - :-:— 1 I / , 1 1 \ . / VI -- .-- '- . .-L_j 1 \ ' ' ■ / - '1 1 \ / ^-■/ r-.": n J \ / 1 / \ ' 1 i / ■ ^ ^ \ ■ • i 1 i 1 / 1 .^,,^ ' ' \ ; ' 1 ' ' .^ I ; ; : \ /\i N /^ 1 1 1 ' ' ' ' \ r \l / s, / ' X' / N / 1 / ; s. ^ / t\ j ■ ; ; ! \ 1 ; ; ; ' ' ^j.i : ■..: . .: . 1 ' 1 i Fig. 12. — Temperature-curve in a case of tertian intermittent fever (Sahli). and so on until the normal is reached. Usually, following the parox- ysm, the temperature becomes subnormal (about 97° F. ; 36° C). The length of the typical malarial paroxysm ranges, in all save exceptional instances, from eight to twelve hours. (b) The Planner in which the Paroxysms Recur. — The special cha- racteristic of this form of intermittent is the regularity with which the paroxysms recur in cases that are not under treatment. The intermis- sion, or time between two successive paroxysms, is most frequently twenty-four hours (quotidian intermittent fever) ; almost as often it is forty-eight hours (tertian intermittent) ; and less frequently it is sev- enty-two hours (quartan intermittent). If there be two paroxysms on one day — a rare occurrence — the term "double quotidian"' is used to designate the case. Of the above types, as stated in the life-history of the parasite, two only — the tertian and the quartan — have been clearly MALARIAL FEVER. 87 distinguished. The quotidian ague (the most frequent clinical variety) is generally due to double infection by the tertian parasite, and very rarely is it to be attributed to the presence in the blood of three groups of the quartan parasite, resulting in daily sporulation. It sometimes happens that the paroxysms recur a couple of hours later each succes- sive day, when it is called a " retarding " intermittent fever, or they may recur a little earlier, when the term '■'■anticipating'' is employed. Other More or Less Characteristic Symptoms. — Apart from the par- oxysms and the regularity with which they recur, splenic enlargement is almost always present, and hence is of considerable clinical import. After the first paroxysm or two the swelling is usually marked and demonstrable, especially by palpation. The organ can be shown to in- crease in size with each succeeding paroxysm. Tenderness is elicited on pressure, and commonly outlasts the course of the affection for a con- siderable length of time. Moderate enlargement of the liver may be present, but this is neither so significant nor so constant as enlargement of the spleen. Connected with the skin are two symptoms of considerable diagnostic value: (1) ^yellowish-brown discoloration., the so-called "malarial com- plexion," due to the deposition of pigment; and (2) herpes. The latter occurs usually on the prolabia or on the nose, though rarely elsewhere. Other skin-eruptions, as urticaria, purpura, etc., have been described by authors, but they have no real clinical worth. As stated under Pathology, acute dilatation of the heart may develop, attended with the usual physical signs of this condition, but it rarely lasts longer than the brief febrile paroxysm. Murmurs of functional origin may also be heard in the heart during the attack, and the lungs upon auscultation sometimes present the signs of a dry bronchitis. The urine may contain a small amount of albumin, and rarely there is acute nephritis. There is a temporary increase in the amount of urea eliminated, and this may be observed from two to six or eight hours be- fore the chill, so that an approaching paroxysm can be foretold if a quantitative analysis of the urine be made at the proper time (Jaccoud). G-astro-intestinal symptoms may be present, but are not prominent, if we except a diarrhea which is sometimes considerable. Catarrhal jaundice may be observed, but this is limited to the graver forms of intermittent. There is no leukocytosis., but there is a rapid diminution in the num- ber of both red and white corpuscles, proportionate "to the severity and the number of the attacks" (W. W. Johnston). Clinical Varieties. — Besides the typical attacks, mild or rudimentary forms are met with, these either being due to slight infection or appear- ing as the remnant of cases of usual severity after active treatment. The separate stages of the febrile attacks are not well marked, and one or more may be missing ; thus the chill may be absent (dumb ague), and less frequently the sweating stage may fail to appear. In children there is no rigor noticeable. They grow pale, the vis- ible mucous membranes often being slightly livid during the chill, and the paroxysms may be initiated by a convulsion or by other nervous phenomena. (11.) Pernicious Malarial Intermittent. — This truly serious form 88 INFECTIOUS DISEASES. occurs chiefly in highly malarial districts, and rarely also in the wide- spread regions in which the simple variety prevails. Hence in the United States it is encountered most frequently in the Southern and Southwest- ern States. In this form of malaria the parasites of estivo-autumnal fever are constantly associated. The paroxysms do not recur with strict regularity, and the primary paroxysms are rarely pernicious in charac- ter ; but second or subsequent attacks may, in addition to the usual symptoms, present the gravest phenomena. Pathology. — This type of malaria may arise (1) as a fresh infection, and (2) as a reinfection. (1) Infection. — The blood is more or less hydremic, and the blood- disks are in all stages of disintegration. The spleen is considerably swollen, soft, and its parenchyma is turbid and lake-colored, all its tissue elements being more than naturally pigmented, though this may not be macroscopically appreciable. Upon microscopic examination, however, pigment-granules and red corpuscles containing parasites and phagocytes are observed, particularly in the pulp adjacent to the arte- rioles. The liver is enlarged, soft, and turbid, and pigmentation occurs, but it is also microscopic. In the minute vessels phagocytes and para- sites containing pigment are perceptible within the red corpuscles, and numerous small necrotic areas have been observed. The kidneys show microscopic pigmentation, most marked in the vicinity of its blood-sup- ply. Minute areas of cell-death are sometimes seen. The brain may be abnormally colored, assuming in severe cases a chocolate tint, and in mild types a lighter hue. The brain-tissue is often anemic, and more rarely edematous. Occasionally there is congestion. The minute vessels and capillaries are literally blocked with phagocytes and blood- disks more or less disintegrated (containing parasites), and perivascular infiltration and minute hemorrhages may rarely occur, producing a focal lesion. (2) Reinfection. — The blood is often extremely hydremic. The spleen may or may not be much enlarged, and is usually quite firm, with a well-marked pigmentation that is obvious to the naked eye. The liver is, as a rule, increased in size to a moderate extent only, and is some- what indurated, while macroscopically it is seen to be deeply pigmented. The changes presented by the kidneys differ in no essential manner from those of the liver. The microscopic appearances of the liver, spleen, and kidneys, apart from the fact that the amount of pigment present is relatively greater, are entirely analogous to those met with when a fresh infection occurs. Clinical Varieties. — Three varieties merit description : (a) Congestive Chills {Algid Form). — These are accompanied by raging gastro-intestinal symptoms (vomiting, purging, etc.), inducing systemic collapse, which simulates to a nicety the algid stage of cholera. The temperature of the interior of the body is much elevated. True dysenteric symptoms may arise, and in a certain proportion of the cases jaundice, followed by grave nervous symptoms, may be a secondary development. This condition is to be discriminated from yellow fever, with which it has frequently been confounded. The parasites in this affection center in a special manner in the gastro-intestinal mucosa, in the vessels of which they may be seen in unusual numbers, sometimes MALARIAL FEVER. 89 forming distinct thrombi. In the United States this is the most com- mon among the pernicious forms. (b) Hematuric Pernicious Malaria. — In this form the chill is severe and prolonged, and during the hot stage the urine is bloody and scanty, containing considerable albumin, -nith bloody, epithelial and granular casts. Hemorrhages from other outlets of the body (mouth, rectum, vagina, nares, etc.) may also occur, together with larger and smaller cutaneous ecchymoses, and the yellowish-brown malarial complexion is intensified. The mind may remain clear throughout, although the patient is restless and anxious. Urinary suppression may ensue, and uremic toxemia be superadded ; the greatest dangers being cardiac fail- ure, uremia, and delirium (or coma independently of the latter). Death is rarely the direct consequence of excessive loss of blood. (c) Comatose Form. — The chill may be absent. Grave cerebral symptoms, as acute delirium or sudden coma, seize the patient violently. The hot stage is attended with high fever, and if the patient survives the paroxysm, the violent nervous symptoms either disappear suddenly with the appearance of the sweating stage, or may outlast the latter by several hours. Primary paroxysms ra.rely prove fatal, but recurrences bring imminent danger. This dangerous variety is due to an inordinate localization of the malarial parasites in the brain, where they form com- plete thrombi, and induce, as a consequence, pathologic lesions in the adjacent structures. (III.) Remittent or Continued Malarial Fevers (iEstivo- autumnal Fever). — On account of the intensity of the gastro-intes- tinal symptoms this variety is also termed bilious re7nittent fever. Its severity exceeds that of intermittent malarial fever. It prevails for the great part in warm and truly tropical climates, though it is also seen in its milder forms in temperate climates. The estivo-autumnal parasites previously described are the specific cause of the disease. Pathology. — Melanosis of the spleen, liver, and brain is generally observed; on the other hand, in rare instances in which the specific parasite had even been demonstrated during life, the internal organs were found to be non-pigmented on autopsy. The degree of the pig- mentation depends upon the length of time that the patient has been infected, as well as upon the frequency of reinfection. The spleen, if it be a fresh infection, becomes swollen, but is soft ; in protracted cases it become permanently enlarged and firm. On microscopic examination the pigment is seen to be most abundant in the splenic pulp and within and around the splenic veins. The liver is enlarged in like manner. The pigment that is found in the form of granular masses in all the hepatic tissue elements (especially Kupffer's cells, vessels, vessel-walls, and perivascular tissue) gives to the organ a bronzed appearance ("bronze liver "). As in pernicious malaria, so in this afi"ection, the brain, and particu- larly the gray matter, is in long-standing cases of a dark broAvn or almost black color. Here, again, most of the pigment is in and around the arterioles. The latter are often found stuffed with phagocytes and blood-disks which contain pigmented parasites. Punctate hemorrhages may occur in the brain. Other organs and tissues of the body, includ- ing the lymphatic glands and the skin, become more or less deeply pig- 90 lyFECTIOUS DISEASES. merited. The Mood shows marked hydremia, with partly or wholly de- generated red blood-disks in abundance. Symptoms. — There may be prodromal symptoms, such as headache, anorexia, and epigastric oppression, lasting a day or two, but these signs are variable. There may be daily or bi-daily paroxysms of fever which resemble the ordinary quotidian and tertian intermittent forms, with this difference, however, that the febrile paroxysms are of longer duration (twenty hours or more). Both the rise at the onset and the decline at the end of the paroxysm are more gradual than in true intermittent malarial fever, and the initial chill may even be wholly absent. The febrile attacks are often '"anticipating," so that it may happen that the succeeding paroxysm -will begin before the elevated temperature of the preceding touches the normal level, giving rise to a remittent type of fever which often exhibits considerable irregularity. The remissions may become shorter and shorter, producing finally a continued type of curve — continued malarial fever. In typical cases of remittent fever a chill generally occurs at the on- set, but is less severe than in malarial intermittents. Shortly after the chill the temperature rises rapidly, so that in ten or twelve hours it may reach 104° or 105° F. (40.5° C). The puhe is full and accelerated to 100 or 120. and there is rending headache. Nausea and vomiting are common : oppression in the epigastrium is intense, and there is well- marked tenderness in the latter region. The spleen is found to be en- larged on palpation. Ji^ervous symptoms (delirium, coma, etc.) may develop speedily, and rarely a mild bronchitis may also arise. About midnight the remission in the temperature and sweating begin, in consequence of which the headache and gastric symptoms largely disappear. The temperature usually drops to 100° F. (37.7° C.) by the next morning, to be followed by a new exacerbation of fever, which commences about noon of the second day. The same symptoms now repeat themselves. The affection has usually, by this time, reached its acme, and the temperature may have risen to 10(3° F. (41.1° C). Grave nervous symptoms may also have appeared. The urine is dimin- ished in amount, often slightly albuminous, and acute nephritis is ob- served in 4.7 per cent, of the cases (Thayer); while either a slight or marked hepatogenous jaundice may appear. Herpes lahialis is quite common. The nocturnal remission again ensues, and in the mild types or in those brought promptly under suitable treatment the febrile parox- ysms grow briefer, resulting in an intermittent form of fever. The course of light cases is run. usually, within two weeks. In severe types or in neglected cases the separate febrile paroxysms grow longer until the remissions become slight and simulate continued fevers. These are the cases that are distinguished by the same symp- toms as those that mark typhoid fever, save the eruption which is pecu- liar to the latter. The discovery of Laveran is of the highest practical value in this category of cases. The course of the attack, if not prop- erlv treated, generally prolongs itself to three, four, or more weeks, and under these circumstances the salient features of pernicious intermittent may suddenly appear and the disease may terminate life. On the other hand, mild forms, in which the fever is of the continued type, also occur, and these yield promptly to the specific — quinin. MALARIAL FEVER. 91 (IV.) Malarial Cachexia. — This is an exceedingly chronic condi- tion, and is usually a remnant of one of the acute forms, particularly of the ordinary intermittents. When the latter are not properly treated, they are apt to drag on, and finally assume the characteristic features of chronic malarial cachexia. The condition may, however, develop in truly malarial localities without the intervention of primary acute mala- ria. It originates, however, only in truly malarial districts. The symptoms are varied both in character and in intensity. There is fever at intervals, but chills do not occur, and the temperature-curve is typical neither of remittent nor intermittent fever, but may approxi- mate either the one or the other. Again, the fever is sometimes wholly irregular, though its range is not high, and it seldom excels 103° F. (39.4° C). The skin often presents the dirty yellowish-brown com- plexion to a marked degree. The spleen is enormously enlarged and indurated, and hypertrophy with hardening of the liver may also be pronounced. The hlood is profoundly anemic, the count in one of my own cases showing but 1,300,000 red corpuscles per cubic millimeter. Many of the local and general symptoms that remain to be given (including, in part, the fever) are chiefly dependent upon the well- marked anemia. Among general features may be mentioned debility, frequent sweatings, and dropsy. Nervous symptoms may also be notice- able, and chief among these are tremors, neuralgia, palsies, vertigo, wakefulness, and nervous palpitation of the heart. Among the rarest concomitants of this condition is paraplegia. Slight cough and dys- pnea evidence the presence of mild bronchitis ; and anorexia, nausea, diarrhea, and other symptoms mark the presence of chronic gastro- intestinal catarrh. The joints and voluntary muscles may be painful. Hemorrhages from the various mucous surfaces and into the retina are common ; and I have seen one case in which spongy, easily-bleeding gums, with cutaneous ecchymoses and numerous petechise, pointed to the existence of associated scorbutus. Tuberculosis finally developed and carried ofi" the patient. Not only the latter affection, but also chronic dysentery, chronic Bright's disease, and amyloid disease, may develop and prove serious complications. These cases do well, gener- ally, if the patient can be removed permanently from the malarial district and if proper treatment be persistently pursued. In long- standing cases the spleen does not return to its natural dimensions. In all other instances, however, complete recovery may be expected, though it may require months or even years to bring it about. (V.) Masked Intermittent. — This presents itself in much the same forms as chronic malarial cachexia, but with the important difi"erence that there is no fever. This type comprises a long list of conditions, at the head of which stands neuralgia, most frequently involving the supraor- bital branch of the trigeminus. Often a striking periodicity is observed, the painful paroxysms usually beginning in the morning and terminating in the late afternoon hours, the patient's sufFerings increasing steadily in intensity until just before the close of the attack, when they sud- denly abate. Among other nerves implicated with relative frequency are the occipital, the intercostals, and the sciatic. Except the blood- appearances be characteristic or unless the attacks yield promptly to quinin, a certain diagnosis of malarial neuralgia should not be ventured. 92 INFECTIOUS DISEASES. Masked intermittents may assume the forms of paresthesia, anesthesia, convulsions, or paralysis : non-febrile intermittent malaria may also appear under the guise of edema, hemorrhages from the various mucous outlets of the body or into the skin, intestinal flux (diarrhea, dysentery), dyspepsia, etc. But, since these affections may all obey the law of periodicity, caution should be used in pronouncing in favor of malarial infection. Indeed, unless they yield readily to the therapeutic specific, a positive statement had better be withheld. (VI.) Malarial Hematuria and Hemoglobinuria. — I have pre- viously described a hemorrhagic form of pernicious intermittent in many cases of which hematuria is a prominent symptom. Among other gen- eral features are jaundice, prostration, nervous symptoms, and nephritis (Plehn). The blood shows pigmented parasites (forming rosettesj and sometimes crescents and pigmented leukocytes. Boisson ^ in 3 cases of hemoglobinuric fever, occurring in soldiers attacked with malaria in Madagascar, found an enormous reduction in the red corpuscles, reaching 670,000 in 1 case, while 7 out of 10 red cells contained parasites. I have observed several instances of malarial hematuria in the Kensington district of Philadelphia, and find that they are met with wherever the moderate forms of malaria prevail. The symptoms consist of a mild cold stage, a subfebrile temperature to which is added hematuria, or more often hemoglobinuria. The par- oxysms may recur daily, bi-daily. or at longer intervals, and in severe forms the hemoglobinuria may be continuous, with aggravations at def- inite intervals. The diagnosis demands the demonstration of the ma- larial parasites in the blood, and of the hemoglobin in the urine. Tyson recommends Teichmaun's (hemin crystals) test to show the presence of hemoglobin. The earthy phosphates are precipitated, filtered out. and a small portion placed on a glass slide and carefully warmed until com- pletely dry. A minute granule of common salt is carried on the point of a knife to the dried mass and thoroughly mixed with it. Any excess of salt is then removed, the mixture is covered with a thin glass cover, a hair interposed, and a drop or two of glacial acetic acid allowed to pass under. The slide is then carefully warmed until bubbles begin to make their appearance. After cooling, hemin crystals can be seen by the aid of the microscope, and. though often very small and incompletely crystal- lized, are easily recognizable by an amplification of 300 diameters. Chemically they are hydrochlorate of hematin. Complications. — The author's analysis of 1780 cases of malaria showed complications in about 10 per cent. The more common among these were not particularly grave in nature, as may be seen by a glance at the subjoined list, in which they are placed in the order of frequency of occurrence: Enteritis (16), nephritis (14), rheumatism (10), typhoid fever (8), lobar pneumonia (5), jaundice (5), and dysentery (4). The opinion of the profession is, and long has been, divided upon the ques- tion. "Has pneumonia any special connection with malaria?" but, ac- cording to the results of my own collective investigations. lohaj- pneu- monia cannot be regarded as being frequently in association with the latter disease. That it is so rarely, however, cannot be denied, since the diagnosis in two of the cases was confirmed by autopsy. 1 Rev. de 3Ied., May 10, 1896. MALARIAL FEVER. 93 Typhoid fever is a complication of malaria, according to these re- searches, but the relationship between these two leading affections can- not be close. Diagnosis. — (1) Of Intermittents. — This is quite difficult, unless the brief febrile paroxysms, with their characteristic stages and other more or less diagnostic features (enlarged spleen, malarial complexion, and herpes), together with the rigid periodicity of the paroxysms, be present. The diagnosis is assisted by a knowledge of the fact that the patient resides in a malarial district. In cases in which a microscopic examination of the blood cannot be made early a positive diagnosis is rarely possible until after the patient has been observed long enough to ascertain the manner in which the paroxysms recur, in addition to noting the symptoms presented. The only unquestionable method of diagnosis is by means of a microscopic examination of the blood, which will show the tertian or quartan parasite {vide infra). Differential Diagnosis. — Non-malarial affections, exhibiting an inter- mittent form of fever, are often mistaken for malarial intermittents. Of these {a) pyemia is very apt to be thus confounded, owing to the fact that it may present a similar temperature -range. It will be observed, however, that the chills recur at more irregular intervals, and in this disease the more profound prostration and other general features during the intervals between the febrile exacerbations serve to distinguish it from intermittent malarial fevers. The etiologic factors and place of residence are also to be considered. In doubtful instances every effort should be made to examine the blood microscopically, and, if this be im- possible, the therapeutic test will, as a rule, remove the doubt. Leu- kocytosis is common in pyemia and absent in malaria. ih) Acute tuberculosis and, more rarely, incipient chronic tuberculosis may present a febrile movement in no way differing from quotidian intermittent, except that in the former the pyrexia develops in the after- noon, instead of the forenoon, as in the latter. A clear history, the associated local and general symptoms, along with the results of a care- ful physical examination, usually render tuberculosis probable and dis- tinguish it from malarial intermittents. Leukocytosis is common in tuberculosis and is absent in malaria, while in tuberculosis the chills recur despite the use of quinin, and this is not the case in malaria. (c) Ulcerative etidocarditis may exhibit an intermittent pyrexia, but in this affection the history is different, and the associated clinical fea- tures are more numerous and, as a rule, decidedly more grave. In en- deavoring to eliminate a disease of so serious a character as ulcerative endocarditis, when the symptoms are strongly suspicious of the latter a blood-examination should be made without delay. The irregular forms of intermittents are diiBcult in the extreme to diao-nosticate. If, in sus- pected cases of " erratic " malaria, quinin is resisted, we cannot feel cer- tain of our diagnosis unless we obtain the microscopic evidence of the presence of the malarial parasite in the blood. (2) The diagnosis of remittent fever would be easily made if it did not sometimes bear a strong resemblance to typhoid fever. On account of this fact its certain diagnosis demands the detection in the blood of the estivo-autumnal parasite. This, at first, is a small hyaline, motile body with little pigment, but in cases lasting a week or more assumes the oval 94 INFECTIOUS DISEASES. or crescentic shape -with much pigment. In typhoid fever the history points to a more gradual onset, the remissions are less marked, and there is not the epigastric oppression witnessed in remittent fever. Again, typhoid has its characteristic eruption. Remittent fever must not be confounded with typho-malaria, nor with continued thermic fever (Guiteras). Method of Examining the Blood for the Malarial Parasite. — The finger or lobe of the ear is carefully cleansed, and then slightly cut with a sharp lancet. The first drop of blood is wiped away and the sec- ond collected on the center of a clean cover-glass, which is immediately placed upon a clean slide and the blood allowed to spread in a thin film. The examination should be made with an oil-immersion objective. If desirable to preserve the specimen or if impossible to make the micro- scopic examination at once, smears should be prepared by laying another cover upon the first, allowing the blood to spread in a thin layer, and then sliding them apart quickly and drying in the air. The specimen may then be fixed in a mixture of equal parts of alcohol and ether, by heat or one of the other usual methods. The most satisfactory stain is methylene blue. A few drops of a watery solution should be placed upon the cover-glass, allowed to remain about a minute, and washed oif with clean water. The specimen can be examined in water or dried and mounted in Canada balsam. The organisms appear as small blue bodies, often containing pigment. Eosin may be used as a counter-stain. For the crescent and oval forms, which are sometimes diflficult to find, it may be advantageous to allow a drop of blood to dry upon the cover-glass without spreading, fix as before, and then wash with dilute acetic acid; wash thoroughly with Avater and stain as before. The red cells are dis- solved, and only the white cells and the parasites remain upon the slide. Prognosis. — All cases of uncomplicated intermittent fever under prompt and proper treatment will probably recover, though fatalities sometimes occur. It is to be borne distinctly in mind that in certain malarious regions and in certain seasons pernicious types are prevalent, but, since these arise only after one or more preceding mild attacks, they are preventable. Primary per7iicions attacks are moderately dan- gerous, while recurrences are highly so. The mortality-rate in this variety of malaria is between 20 and 25 per cent., and simple intermit- tent fever may, if not checked, suddenly develop into the most malig- nant type and result fatally. In remittent fever a fatal issue may be due to asthenia, particularly when the type is severe and when, following the typhoid state, wrong notions as to treatment prevail. The severity of the infection may be estimated by appreciating the degree of fever and the severity of the nervous symptoms. Suppression of urine, followed by uremic symp- toms, hemorrhages, and intense jaundice, are the chief untoward com- plications. Treatment. — 1. For intermittent malarial fever there is an almost infallible remedy in quinin. "When shall its use be commenced?" is a pertinent question. It would certainly seem highly desirable to check the course of the disease as soon as possible, and especially since trans- mission of the simple intermittents into the pernicious forms may occur if the disease be not arrested. At the present day specific treatment is 3IA LABIAL FEVER. 95 often delayed in order to give full opportunity for making a blood-ex- amination with a view to completing the diagnosis. There is no decided advantage in commencing the use of quinin during the first paroxysm, when the blood may be examined ; but on finding the case to be one of malaria, quinin should be administered after the paroxysm, so as to pre- vent a recurrence. For like reason, if the history at the physician's first visit, combined with the symptoms presented, make the diagnosis of intermittent malaria reasonably certain, and there is no opportunity to examine the blood microscopically, the principal antiperiodic remedy should be commenced at the close of the paroxysm, especially if the patient be living in an infected district. The quinin cures malaria by acting directly upon the intracorpuscu- lar hematozoa. During the paroxysm vfe should aim to make the patient comfortable. He is to remain in bed, is to be well covered, and external heat applied during the cold stage ; and he is to be lightly covered, given cooling drinks and cold spongings during the hot stage. During the apyrexial intervals the patient may leave his bed, pro- vided that he feel strong enough, and, as before intimated, the specific remedy is given during the afebrile period. Certain authors recommend that the entire daily quantity be given at one dose from four to six hours before the succeeding paroxysm is expected, the object being to surcharge the blood at the time when the hematozoa sporulate. Others give the remedy in divided portions, administering the last dose from four to six hours before the next paroxysm is due. It may matter little which of these two methods is pursued, yet my own experience leads- me to favor the divided doses rather than the single large ones. The total amount per day required to cut short the intermittents is from 16 to 20 grains (1.036 to 1.296) in most temperate climates. When this fails more may be given — 24 to 30 grains (1.555-1.944). My own prac- tice has been to administer immediately after the close of the sw^eating stage gr. iv or v (0.259 or 0.324), repeating the same dose a few hours later, and the remaining 8 or 10 grains (0.518 or 0.648) (or one-half the daily dose) six hours before the time for the next paroxysm. I have thus escaped the slight toxic symptoms (tinnitus, deafness, nausea, etc.) which are apt to follow single large doses. The remedy is best given in capsules, followed by a few drops of dilute hydrochloric acid, with a view to dissolving the quinin in the stomach. After the attacks cease to recur quinin should be continued in amounts of 6 to 8 grains (0.388 to 0.518) daily for several day's. If quinin cannot be taken per ns, it may be tried by enema or by suppositories in appropriately large doses. Rectal irritability may thus be produced, yet in very young subjects, who cannot be induced to swallow capsules, I have for a long time administered quinin by suppository. The physiologic effects of the drug can be quickly obtained by administering it hypodermically. Hence, if there be no time for ab- sorption from the stomach (four hours being the shortest period it is safe to allow), the drug should be thus employed. For this purpose the more soluble salts (hydrobromate, etc.) of quinin are to be preferred to the ordinary and more insoluble sulphate, which requires the addition of a mineral acid. 96 INFECTIOUS DISEASES. Many preparations of cinchona other than the salts of quinin may be tried, and among these cinchonin administered in the same manner as the latter is the best substitute. Some contend that the sulphate of quinidin has antiperiodic power, almost equal to quinin. In prolonged cases the salts of quinin and other preparations of cinchona sometimes lose their specific influence, and arsenic is then to be employed, either alone or in combination with the former agents. The dose of the arsenic, beginning with TTLiv (0.266) t. i. d. of Fowler's solution, must be increased until its physiologic effects are produced. Arsenious acid often does even better service than Fowler's solution. So soon as the disease is controlled the dose of arsenic is to be reduced. Administered as above indicated, this remedy is most efficacious in malarial cachexia and masked forms of intermittents ; it may be combined with iron and quinin. In cases of malaria that are resistant to quinin (often the quo- tidian forms), methylene-blue has been found extremely active and ser- viceable. Cardamates believes that it is indicated only when (juinin is contraindicated, as in hemoglobinuria or in pregnancy when abortion is feared. AVhile in charge of the out-patient service of the Episcopal Hospital, Philadelphia, I employed in chronic malarial cachexia, with very satisfactory results, the sulphate of cinchonidin in daily doses of gr. xxx-xl (1.944—2.592). In this class of cases Warburg's tincture (5ss (16.0) three times a day) has been warmly recommended. 2. The Treatment of Pernicious Intermittents. — {a) Prophylaxis. — By treating all ordinary intermittents actively after the first paroxysms the occurrence of pernicious forms can be obviated. Not to pursue this course in seasons and in localities in which these serious types are known to prevail, but to delay for second and third paroxysms in order to be able to study the blood, is criminal. {b) The first pernicious attack must be treated immediately, and there is not a moment to be lost. Hence in all varieties of pernicious inter- mittents quinin should be administered hypodermically until the patient is fully cinchonized — a condition that must then be maintained for sev- eral days. In all varieties stimulants are to be used freely if the heart's action becomes feeble, and the patient is to be well nourished through- out. There are other details, though of relatively minor importance, and they vary with the individual forms. Thus in "congestive chills " external warmth is useful, and morphin combined with atropin should be given hypodermically, this combination tending to allay gastro-intes- tinal symptoms as well as to warm the extremities, and meeting really important indications. Rectal feeding must be resorted to should the stomach refuse to retain nourishment. In the comatose form the ner- vous symptoms are most successfully combated by prompt and energetic antiperiodic treatment, together with vigorous stimulation and feeding, since they are not due to cerebral congestion, but to the intensity of the infectious process. (c) During the apyrexial period every effort must be made to prevent a recurrence of the paroxysm, and to this end the patient must be kept fully cinchonized until the time for the next paroxysm is over, and then be removed from the malarial to a non-malarial district. 3. Treatment of Remittent Fever. — The mode of treatment in this form differs somewhat from that appropriate for intermittents. At the onset DYSENTERY. 97 a mild mercurial is advantageous (calomel gr. \ (0.0162) every hour for three doses), followed by a saline laxative (Rochelle salts, oij ; 8.0). During the febrile exacerbations cool spongings of the body, coupled with the use of the ice-cap, are serviceable. The gastric symptoms demand chipped ice by the mouth or small doses of cocain, and a mus- tard plaster externally. Immediately after the first remission sets in quinin must be exhibited, and large doses are now indicated (gr. xv (0.972), to be repeated at 8 or 9 a. m.). A third and even a fourth dose of the same size may be required. The exacerbations of fever gener- ally yield to this remedy, but if, as rarely happens, they do not, then small doses of pilocarpin (gr. -§■ to -^ ; 0.008 to 0,010) may be adminis- tered hypodermically during the height of the fever. This causes free sweating in many instances, and in consequence renders the remission more marked and more prolonged ; thus, in short, rendering the course of the affection speedily favorable. The heart, however, must be care- fully guarded Avhen this depressing agent is prescribed. A case that has been allowed to run on for one, two, or more weeks is often greatly benefited by the use of Warbui'g's tincture, as before recommended, for several days, when quinin may be re-employed. The patient, especially if the case be protracted, must be vigorously fed, and per rectum if it cannot be accomplished by the mouth. In typical cases, which are promptly controlled by quinin, stimulants are rarely needed, or at least not until the convalescent stage is arrived at. In severe and neglected cases the indications for their employment may be presented early, and they should then be given, the physician con- forming to the same rules as in typhoid and other acute infectious dis- eases. The renal congestion and anuria are to be met bv internal dia- phoretics (pilocarpin, etc.) and by saline laxatives. Most efficacious, perhaps, is a combined hot-water and steam bath. The patient is placed in hot water, and tiien a blanket is put around the neck, its free ends being allowed to extend over the edges of the tub. This may be re- peated, if necessary. 4. Treatment of Malarial Hematuria. — As intimated above, in hem- orrhagic pernicious malaria quinin is absolutely indicated, if there be no uremic features. The use of quinin in moderate doses (gr. xvj — 1.0>36 — daily) successfully relieves the hemoglobinuria occurring in connection with mild forms of malaria, and its subsequent use in smaller doses (gr. iij (0.194) to gr. vj (0.388) daily) will prevent a recurrence. It is claimed by some writers that quinin may produce hematuria (Plehn, Richardson, and others), and also that this remedy is of no value in combating this symptom. The specific remedy should not be abandoned, however, and large quantities, such as might act as an irritant to the renal tissues, are not necessary to effect a cure, except in pernicious forms. DYSENTERY. Definition. — An infectious inflammatory disease of the large intes- tine, characterized anatomically by ulceration of the intestinal mucosa, and clinically by frequent mucous and bloody discharges, tenesmus, 7 98 INFECTIOUS DISEASES. fever and prostration becoming profound, a tendency to abscess-forma- tion in the portal system, to paralysis, and, finally, to pronounced anemia. It is a truly epidemic disease, yet it also occurs constantly in endemic form, and particularly does this occur m temperate climates. Historic Note. — Few diseases have been longer known than dys- entery, of which we have a description by Hippocrates. Galen local- ized the chief seat of the affection in the colon, and in 1626, Sennertus defined its sporadic and epidemic character and some of its leading clini- cal features. To Morgagni belongs the credit of having made the first postmortem anatomic study of the disease. Further and more accu- rate pathologic contributions were made in the earlier part of the present century by Cruveilhier and Rokitansky, and, more recently still, the whole subject of the morbid anatomy of this disease has been care- fully investigated by Virchow, whose results have settled most of the questions connected with the subject. In the United States dysentery has prevailed epidemically upward of a century, the time of greatest prevalence in different districts having been about the middle part of the present century (1847-55). Woodward has given us the only com- plete record of the various outbreaks in this country, and an account of the ravages of dysentery in both armies during the War of the Rebellion is given in his Report, wdiich records 259,071 cases of acute and 28,451 of chronic dysentery. The disease is far less frequent than formerly, owing to the advance made in recent times in sanitary science, in con- sequence of which some of the predisposing conditions have been over- come. Ktiology. — As stated below, there are three distinct clinical types of the affection, each of which has special etiologic factors. A few general considerations, having reference to the causation of the different forms in common, may be adduced here, and, as each variety presents different anatomic lesions in leading particulars, their pathology Avill be considered separately. Among disposing factors, season heads the list, dysentery being most common in the summer and autumn ; great and sudden changes of tem- perature are more potent than equal changes in humidity. Climate has a marked effect, and high temperature must be regarded as a pow- erful agency, since the disease is much more prevalent in warm than in cold climates, though it is met with in epidemic form as far north as Norway, llalarial districts suffer more than non-malarial. This may be due to the fact than an attack of malaria may leave the body of the sufferer more receptive to the specific poison of dysentery, or the ex- ternal conditions which favor the development of the plasmodia may also favor the growth of the dysenteric poison. The latter view gains some support from the well-known fact that water taken from stagnant pools in marshy localities (in which malaria is apt to prevail) may give rise to the symptoms of dysentery. Unhygienic conditions, as shown by the local epidemic outbreaks in jails, barracks, institutions, etc., predis- pose to the affection. Among factors connected with the individual are {(() catarrhal con- ditions of the intestinal tract, particularly if the latter be caused by unripe fruit or other unwholesome forms of food ; [h) Aye. Although no age enjoys immunity against dysentery, most cases are met with in DYSENTERY. 99 adults under thirty-five years. Sex and race are probably without ap- preciable influence. Catarrhal Dysentery. Pathology. — There are two forms : (a) In this the solitary follicles are affected chiefly, and are the seat of hyperplasia, followed by necro- sis, with the formation of small ulcers. This is common in children. (b) Here a purulent inflammation of the entire mucosa, with more or less erosion of the surface and superficial ulceration, exists. In both forms the lesions are mainly confined to the large intestine, though the ileum is sometimes implicated to a lesser extent. Special Ktiology. — The specific bacillus of catarrhal dysentery is not known, but it will probably be shown to be the bacillus coli com- munis, which may become pathogenic Avhen the state of the mucosa of the bowel is altered by sudden changes of temperature, etc. (Arnaud, Maurel). Curtis in a recent outbreak found the bacillus pyocyaneus in every specimen of water used and in intestinal discharges. Clinical History. — There may be prodromes, lasting one or two days, which take the form of a mild gastro-intestinal disorder (anorexia, slight pains in the abdomen, followed by diarrhea). The characteristic symptoms are mild colicky pains in the abdomen, followed by discharges from the bowel, Avhich at first number from three to six daily. Soon they become frequent and are accompanied by straining and tenesmus, and now their number ranges from ten to no less than one hundred or more per day. Indeed, the desire to go to stool may be almost constant, and the rectum is the seat of intense burning sensations during and after each evacuation of the bowel. The character of the discharges varies with the different periods of the affec- tion. During the first thirty-six or forty-eight hours they are feculent (sometimes scybalous masses), rather copious, and intermingled with some mucus and blood. For the next four or five days the stools are scanty, measuring from 2 drams (8.0) to \ ounce (16.0), and are made up of a sero-mucous fluid or of a muco-purulent material with blood. The chief constituents of the stools are mucus, blood, and pus, any one of which may preponderate, thus giving rise to mucous (most frequently), purulent, or bloody stools. Microscopic examination of the usually glairy stools shows red blood-corpuscles, numerous leukocytes, generally large, oval or round epithelioid cells containing fat-globules, vacuoles, and bacteria (espe- cially those of putrefaction). Occasionally the Cercomonas intestinalis is seen (Osier). A few shreds (portions of necrosed mucous membrane) may appear from time to time in the discharges, and particularly in severe forms of the affection. These usually increase in number at the close of the first week, and a little later the discharges become less frequent and the amount of mucus and blood diminishes. The stools are now of a greasy brown or dark-green appearance, fecal matter reappearing in them, and soon they are again fully formed. Othe?' Sym2?toms Referable to the Alimentary Tract. — The tongue has a greasy coating — moist at first, dry later — and at last may become red and glazed. Anorexia is present, with excessive thirst, and vomit- 100 INFECTIOUS DISEASES. ing may rarely occur. A distressing though uncommon symptoiji is hiccough. There will usually be tenderness over the line of the colon, but there is an absence of tympanites, and the abdomen is apt to be flat and somewhat tense. The general symptoms are well marked in the severer types. The patient is much debilitated, sometimes even collapsed, as shown by the small, frequent pulse, cool skin-surface, the rapid wasting, and weak, hoarse voice. The temperature is not much elevated, though it may touch 103° or 104° F. (40° C.) at the outset, and the curve is an irregu- larly remittent one. Diagnosis. — This can easily be made upon the intestinal features and from the character of the stools — frequent, small, slimy (or bloody) discharges, accompanied by distressing tenesmus. Differential Diagnosis. — Symptoms simulating dysentery may appear in the course of certain rectal affections, such as strangulated hemor- rhoids, syphilis, and epithelioma. In these conditions, however, there is a different history and the symptoms of proctitis are usually less acute, while a physical examination of the rectum Avill settle the diagnosis in doubtful cases. Prognosis. — The duration of mild cases is from eight to ten days, and in severe types from three to four weeks. The prognosis varies in different epidemics or according to the type of the affection ; but com- monly this is not aggravated and recovery is generally to be expected. Occasionally, however, the disease is threatening to life. Besides the systemic prostration and collapse above referred to, serious nervous symptoms (great restlessness, delirium followed by coma) may develop and cause a fatal termination. When death occurs it is usually due to exhaustion, and is seen particularly in persons previously enfeebled or in the very young and the aged. Complications influencing the prog- nosis are exceptional (peritonitis and liver-abscess). Amebic Dysentery (Tropical Dysentery). Bacteriology. — This form of dysentery is caused by the amoeba coli or the amoeba dysenterice (Councilman and Lafleur). The amoeba dysenteri^e is a unicellular, motile organism, in size 3 to 7 times the diameter of a red blood-corpuscle (15 to 30 micromillimeters). Its pro- toplasm consists of two zones — an outer colorless (ectosarc) and an inner granular zone (endosarc), with a visible nucleus and one or more vac- uoles. This micro-organism was first described by Lambl (1859), but it remained for Liisch, and especially Kartulis, to show its close associa- tion with dysentery. It is now generally held to be the specific cause of tropical dysentery. The ameba [amoeba coli mitis) is occasionally found in health}'' individuals, and also in other bowel -affections than dysentery (mucous enteritis, simple diarrhea, proctitis due to engorge- ment), and two species are recognized — a virulent and a benign form (Quincke and Roos). The ameba is found not only in the discharges, but also in the pus from the secondary liver- abscesses. Hehir has found the bacillus dysentericus associated with the amoeba coll., and considers it to be pathogenic. He describes it as a short, straight bacillus, usually of a length about equal to one-third the diameter of a DYSENTERY. 101 red blood-corpuscle, with rounded ends, sometimes jointed, rarely curved. Later investigations, however, have not entirely confirmed the claims of this observer. The mode of transference of the ameba is not definitely known, though the principal source of the dysenteric germs is most probably the drink- ing-water. The poison is feebly communicable by contact. Amebic dysentery is not confined to the tropics, but is met with also, though less frequently, throughout Europe and North America. Pathology. — The lesions are almost always situated in the large intestine, although rarelv the ileum is also invaded. The first visible change is a hyperemia of the mucosa, most marked in the descending colon and rectum ; but the changes which produce the characteristic dysenteric ulcer begin with infiltration and swelling of the submucosa, followed by necrosis, which involves the overlying mucosa with its epi- thelium (Kruse and Pasquale). How the amebse reach the submucosa has not yet been observed. The visible infiltration occurs usually in circumscribed areas which are oval or hemispheric in shape, and project above the level of the surrounding mucosa. The submucosa presents a grayish-yellow appearance, and is soon thrown off in the form of a slough. The ulcers take various shapes — chiefly irregular, and less frequently round or oval. Their edges are ragged and undermined, and the floor, which is more or less covered with pultaceous material, is rough or crater-like, and formed by the musculature or the outer serous coat of the intestine. From the manner in which the ulcers are formed it is obvious that cellular infiltration (followed by necrosis) may occupy the sub- mucosa for a greater or less distance beyond the borders of the ulcers. In this way fistulous channels may be produced beneath the mucosa and connect two or more ulcers. Usually this ulcerative process afi'ects only certain portions of the large gut, especially the flexures — hepatic and sigmoid — and the rectum ; but it may be general, and I have seen an instance of this kind. Similar cases are not uncommon in which the ulcers are so numerous as to include almost the entire mucosa of the large intestine. Healing is attended with the development of fibrous tissue along the edges and in the base of the ulcer, and secondary contraction of this new connective tissue is often productive of colonic stricture, w'hich is usually either partial or irregular. The cases that come to autopsy often show diphtheritic inflammation as a secondary or terminal condition. The microscope reveals proliferation of the fixed connective-tissue cells, and the presence of amebse in the walls and the base of the ulcers, in the lymph-spaces, and rarely in the blood-vessels. Pus can only occasionally be detected. The liver may be the seat of prominent lesions. These are {a) ab- scesses, which may be single or multiple, the latter being small, and the former often large. The single or solitary abscess is usually situated near either the upper convex or the lower concave surface, while the ab- scess-cavity is formed in a manner similar to the intestinal ulcers. The area aff"ected is at first infiltrated ; it then becomes necrotic, and finally more or less liquefied. Upon the full development of the first stage the part invaded is a grayish-yellow pultaceous mass, but in the second or 102 INFECTIOUS DISEASES. necrotic stage the abscess contains a yellowish or greenish-yellow, spongy material Avith beginning liquefaction. The contents of the mature abscess consist of a greenish- or reddish-yellow purulent material and of rem- nants of liver-tissue. The walls of the recent abscess are irregular and ragged, those of an old abscess being dense and fibrous, and a section of the abscess-wall shows an inner necrotic zone, a middle zone (in which there is great proliferation of the connective-tissue cells, compression and atrophy of the liver-cells), and an outer zone of intense hyperemia (Osier). The contents of the abscess show either few or many amebae, and only rarely pus. When pus is present it is due to a secondary infection by the pyogenic germs. In what way the amebse gain access to the liver is not definitely known, but it is probable that in multiple abscesses they are propagated along the blood-current, either from the ulcers or from a single primary focus. Cultures are generally sterile. (b) The parenchyma of the liver may be the seat of numerous circum- scribed necrotic spots, which are supposed to be due to the action of the chemical secretions of the amebic. The lungs sometimes show changes similar to those in the liver, which are the result of direct e.xtension of the hepatic abscess through the diaphragm into the lower lobe of the right lung. Clinical History. — The mode of onset is gradual except in a small proportion of the cases, in which it is sudden with Avell-marked symp- toms. When, as generally happens, it is insidious, the initial symptom is often a trivial diarrhea. The affection is then characterized prin- cipally by intermissions and an exacerbating diarrhea, the litjuid stools containing necrotic tissue of a grayish-brown and sometimes yellowish-gray color. The latter are often bloody and mucoid, particu- larly at the outset, and in fully developed cases are fluid. The number of discharges per day is exceedingly variable in different epidemics, and even in individual cases, though in most instances they range from six to eight or ten daily. Microscopic examination of the feces during the exacerbations dis- closes amebaB that are almost invariably endowed with motion, though usually not Avhen the stools have become formed. Tenesmus is not a prominent feature in most cases, and may be entirely absent. Colicky abdominal pains are rare, and nausea and vomiting are equally so. General Symptoms. — The febrile movement is usually present, but it is slight and exhibits marked variations. In certain instances, however, the temperature is below the normal curve throughout the entire or greater part of the course. From the time of onset there is gradual though progressive loss of flesh and strength, and anemia usually be- comes well marked. Complications. — The most common is hrpatic abscess, and second- arv to the latter mav arise abscess of the ricrht lunsr- Authors are not agreed as to the frequency of occurrence of liver-abscess^ in amebic dysentery, but it is certainly comparatively rare in this country, not exceeding, perhaps, 3 per cent, of the cases. Peritonitis may result from perforation of a dysenteric ulcer, causing death. The point of per- ' For the diagnosis of this condition the reader is referred to the section on Hepatic Abscess in the article on Diseases of the Liver. DYSENTERY. 103 foration may, however, be in the rectum, when periproctitis is the result ; or it may be in the cecum, when perityphlitis is the sequel. In tropical or subtropical countries the disease is often complicated with malarial affections, and in malarial regions intermittent and remittent fevers are among the commoner complications. The presence of an intermittent fever is not, however, sufficient to warrant the assumption that malaria complicates dysentery; and in order to show the latter combination we must be able to demonstrate the presence of the p)lasmodium malarice. In pyemia and in suppurative processes generally — conditions sometimes met with in dysentery — the temperature-curve is often distinctly inter- mittent. Typhoid fever is a rare complication. The latter disease can- not be said to coexist with dysentery unless all of the characteristic symptoms are present. Certain cases of dysentery are characterized by the development of the typhoid state., and pyemia and septico-pyemia may appear late. Among special manifestations of the latter are pyle- phlebitis, pericarditis, endocarditis, pleuritis, and rheumatoid pains in the joints. Diagnosis. — The slow course, marked by intermissions and exacer- bations of the bloody fluid stools, the mild general symptoms, apart from emaciation and debility, are salient features, but an assured recognition of the affection demands a microscopic examination of the stools. Cases have been recorded by Councilman and Lafleur in which the diagnosis rested upon amebae being found in the sputa, the latter being complicated Avith pulmonary and hepatic abscesses which discharged through a bronchus, w^hile the intestinal symptoms were negative. Prognosis. — The prognosis is graver than in the catarrhal va- riety, and the mortality-rate in certain epidemics has been frightful, particularly among soldiers in the field (amounting to 70 or even 80 per cent.). In sporadic cases the danger to life is less, the mortality-rate in temperate climates being not over 5 or 6 per cent. The complications which render the prognosis unfavorable are various (peritonitis, hepatic and pulmonary abscess, pyemia secondary to the latter, broncho-pneu- monia, malaria) ; death may be due to hemorrhage or peritonitis, but in a preponderating proportion of the cases to asthenia. A dangerous degree of debility is indicated by great nervous depression ; a cool, clammy skin ; a sunken, pinched facies ; a dry tongue ; a feeble, rapid pulse ; and by restlessness, alternating with marked apathy or low mut- tering delirium. Course and Duration. — The average duration ranges from eight to ten weeks in uncomplicated cases; the disease can, however, be cut short by appropriate treatment. It manifests an innate tendency to pursue a chronic course, interrupted by frequent exacerbations or true relapses, and convalescence occupies a long period of time in conse- quence of the profound anemia and debility that supervene. Diphtheritic Dysentery. This is an intestinal inflammation (usually colonic), accompanied by a croupous, or true, diphtheritic exudation. Two clinical forms are recognized : 104 INFECTIOUS DISEASES. Primary Diphtheritic Dysentery, Tn mild grades of this rare aifection a grayish-yellow, croupous exu- date appears upon the inflamed mucosa, with a necrosis of the epithelial layer that is often limited to the top surface of the folds of the colon. In other instances the diphtheritic infiltration involves all the layers of the bowel, which now becomes greatly enlarged, its mucous membrane being converted into a yellowish-brown, thick, elastic mass, sometimes extendino; alono; the entire length of the large intestine. The changes may be confined to the circumscribed areas, and thick sloughs may be cast oif, leaving behind ulcers of corresponding size and depth. Again, these gross lesions may be limited to certain sections of the large bowel, as the rectum or the flexures of the colon. In protracted cases cylin- ders of pseudo-membrane of considerable length may become separated and evacuated with the stools. Clinical History. — The aifection usually has an acute onset and one characterized by the appearance simultaneously of severe local and general symptoms. There may be an initial chill, and there is fever, which rises rapidly, together with a marked and early appearing pros- tration and delirium. Severe abdominal pains are complained of, and the discharges are apt to be very numerous, containing shreds and large sloughs, or even tubular pieces, of false membrane. When these elements are present in the stools the latter are of a dark-brown color, emitting a fetid odor and generally containing more or less blood and mucus. Tenesmus may be present, and particularly when the rectum is involved. The physical signs are often prominent. The belly in most instances is greatly distended, and on pressure very tender — signs due to the fact that the lesions are situated chiefly in the large bowel, and not, as a rule, to peritonitis. The diagnosis rests upon the intestinal symptoms and the charac- ter of the dejections, associated with a grave general condition suddenly developed in a previously healthy individual. The prognosis is almost wholly unfavorable. Occasionally recov- ery follows, though more frequently the disease takes on a chronic course. Secondary Diphtheritic Dysentery. Here the lesions are similar in kind to those of the primary form, but in the majority of instances of a less intense grade. Rarely they may be both extensive and severe. This variety is met with as a ter- minal condition in not a few acute and chronic diseases ; among the former it is with great relative frequency seen to develop in pneumonia (Bristowe), and less frequently, though in not rare instances, in typhoid fever, according to my own observation. Among chronic affections, upon which this condition may become engrafted, are nephritis, organic disease of the heart, and pulmonary tuberculosis. Clinical History. — No characteristic symptoms attend upon its in- vasion. There may be slight diarrhea — two to four liquid stools daily — but it is not often accompanied by tormina and tenesmus, and the discharges rarely contain any noticeable amount of blood or mucus. DYSENTERY. 105 Very rarely shreds of pseudo-membrane are passed with the stools. Secondary diphtheritic dysentery often induces fatal asthenia. The diagnosis is in most cases merely conjectural. Sequelae. — In all forms a relapse is likely to occur, each attack in- creasing the liability of the patient to subsequent ones. Moreover, in persons who have recovered from acute dysentery we often observe a dis- ordered digestion and irritability of the bowels. Rarely, chronic nephritis follows dysentery. The most interesting sequel, however, is paralysis, which occurs mainly in the form of paraplegia (S. Weir Mitchell). Stricture of the bowel may be a sequel, but it is surprisingly rare. Treatment. — Prophylaxis. — This embraces isolation and a thorough disinfection of the discharges, which contain the specific germ of the disease, as soon as passed. The drinking-water during the epidemic prevalence of dysentery should be thoroughly boiled, and healthy per- sons should avoid the use of improper food, while an unhygienic envi- ronment (overcrowding, etc.) is to be corrected as far as possible. All sufferers from dysentery must be kept in bed, and should occupy a well- aired apartment. The diet should consist of milk and light animal broths during the period of active intestinal symptoms, and in the amebic form of the dis- ease it is well to allow easily digestible solids, as raw oysters, eggs, well- boiled rice, fowl, fish, and the like, in small quantities. During con- valescence a return to the usual dietary is gradually to be made. Stimulants. — With the development of asthenia and cardiac failure stimulants must be employed, as in other acute infectious diseases, and alcoholics may be supplemented by the use of strychnin in cases of extreme debility. Medicinal Treatment. — If scybalous masses be passing still, the treat- ment should be commenced by administering a dose of castor oil or a saline purge, and this may be repeated if necessary. It is well to con- vert dysentery into diarrhea, thus cleansing the bowel thoroughly. Measures tending to deplete the mucosa of the intestine and at the same time inhibit undue peristalsis are most effective, as magnesium sulphate. In the later stages purgatives are attended with baneful effects. Ipecacuanha has long been, and still is, regarded as possessing a specific influence in cases of dysentery. Its administration is usually preceded by a dose of opium (laudanum or morphin) Avhich is given when the stomach has been empty for a few hours. Most authors rec- ommend that large doses — gr. xx to 3j (1.29 to 4.0) — should be admin- istered ; but it is probable that a small dose — gr. -g- to ^ (0.010 to 0.016) every half hour — is quite as effective ; and in children the smaller doses are to be preferred and will be found to be quite efiicacious. Other remedies should also be employed, and among these opium is particularly beneficial in combination with ipecacuanha or in the form of Dover's powder, which contains both agencies. Three chief symptomatic indi- cations are met by the opium — pain, restlessness, and undue peristalsis, — and to obtain the best efi"ects from the opiate it should be adminis- tered in the form of morphin hypodermically. In cases in which tenes- mus is an unusually distressing feature an opium suppository (gr. ij — 0.1296) or laudanum (TTtxxx — 2.0, by enema) exercises a beneficial effect. Bismuth in full doses is useful (3ss-j — 2.0-4.0 every two hours), 106 INFECTIOUS DISEASES. and in cases of sporadic dysentery I have frequently found the follow- ing formula productive of happy effects : I^. Pulv. ipecac, et opii, 3ss (2.0) ; Bismuthi subnitrat., oSS (16.0) ; Salol, 3ss (2.0). M. et ft. chart. No. xij. Sig. One every hour or two. Naphthalin and mercuric chlorid are recommended in highest terms. Bosc and Vedel employed in 4 cases intravenous injections of sodium chlorid, 7 : 1000 being the maximum strength. The injections should be made early, and repeated, so that they Mill develop sustained general reaction and a modification of the general condition which can lead to recovery. Care should be taken as to the (juantity used and the rapidity with which it is injected(| to Bounces each minuteshould not beexceeded). Antiseptic irrigation of the bowel would be, if properly carried out, a curative measure, since by this means we may destroy the amebse, and solutions of numerous antiseptic substances and astringents have been recommended for this purpose. Unfortunately, the bowel is frequently so irritable as to seriously interfere wnth this mode of medication. If, on this account, large injections cannot be given, small ones should be substituted and the quantity gradually increased. Preliminary to their use we may also employ cocain in the form of a suppository, or a small quantity of a solution of cocain (4 per cent.), or a laudanum enema (ntxxx — 2.0, in starch-water), after which a large injection may be toler- ated if administered slowly and the flow be interrupted at brief inter- vals. Among the best agents are silver nitrate (gr. ss-j — 0.032— 0.064 — ad 5J — 32.0), tannic acid (1 to 2 per cent.), salicylic acid (1 to 2 per cent.), and mercuric chlorid (1 : 6000). I have for a number of years been in the habit of employing these astringents and antisep- tic solutions alternately, administering each once daily. The tannic- acid and the salicylic-acid solutions are best borne during the more active stages of the disease. The temperature oi, the water should, at first, range from 100° to 110° F. (37.7°-43.3° C), and subsequently this may be slightly reduced. The patient during the administration of the enemata should assume the dorsal position or that upon the left side, but in either case with the hips Avell elevated, so as to aid the flow by gravitation. In amebic dysentery warm injections of quinin (strength 1 : 1000-1 : 5000) have been used with good eff'ects by some authors, but with directly contrary effects by others. Local means in the form of hot fomentations, light poultices, and turpentine stupes often afford much comfort. The various complications must be met by appropriate treatment, as under other circumstances. Chronic Dysentery. This form of the disease almost always succeeds an acute attack. Very rarely is it chronic from the start, and particularly if it be the amebic variety. Pathology. — In most instances the large intestine is still the seat of DYSENTERY. 107 ulceration. Some of the ulcers show no signs of healing ; in others this process is going on ; while in still others it is completed and puckered cicatrices are presented. The ulcers are deeply pigmented, as is the unulcerated mucosa, which often presents a slate-gray or blackish color. The submucous and muscular coats are hypertrophied, as a rule, with occasional narrowing of the lumen of the bowel, and cystic degeneration of the intestinal glands is sometimes observed. It is to be noted that in a certain, though small, percentage of the cases ulceration does not occur, the mucosa everywhere presenting an uneven, puckered aspect, due to deposits of fibrous tissue. Symptoms and Diagnosis. — Many of the most characteristic fea- tures of the acute form are either but feebly expressed or altogether wanting. This is particularly true of the tormina and tenesmus. Cer- tain elements found in the stools of the acute type (blood, shreds of pseudo- membrane, and tissue) are also rarely present. True dysenteric symp- toms, however, may arise during acute exacerbations, with or without pain or tenesmus ; then from three or four to a dozen or more fluid dejections are passed daily. The latter are often frothy (when starchy articles of food are taken), being composed chiefly of fecal matter and undigested particles of food, with considerable mucus ; and in severe forms blood and pus may be constantly present in the discharges. In many cases the stools are semifluid (pultaceous), and rarely they contain scybala ; or the rather frequent liquid or semifluid discharges may alter- nate with constipation. In such instances the lesions are apt to be situ- ated in the lowest portion of the large intestine. The character of the discharges is much influenced by the sort of food taken ; thus when a mixed dietary is partaken of, they are thin, more frequent, and contain more undigested masses of food. Gaseous distention of the intestines is often an annoying symptom. The physical signs are negative, save for slight tenderness along the line of the colon. Associated symptoms referable to other organs are not Avithout value in the diagnosis. The gastric digestion is poor, the appetite generally impaired (though variable), and the tongue is clean, red, and glazed, presenting the appearance of raw beef. There are progressive emacia- tion and asthenia, Avhich eventually reach an extreme degree. The skin- surface becomes dry, harsh, and cool, the facies grim, the pulse exceed- ingly feeble, the mental faculties greatly weakened in the advanced stage ; and, as in the acute form so in the chronic, death is usually due to asthenia — with this diff"erence, that in the latter the end is reached more slowly. Rarely peritonitis in consequence of perforation of the bowel is the immediate cause of death- Differential DlELgnosis. — The disease is discriminated from chronic diarrhea., often with great difficulty. In chronic dysentery there is the history of an antecedent acute attack, with the appearance from time to time of exacerbating periods when mucus, pus, and often blood are contained in the discharges. The latter are, at the same time, more fre- quent and apt to be accompanied by more or less abdominal pain and tenesmus, and the presence of these features would serve to eliminate chronic diarrhea. From tuberculous ulceration of the intestines it is dis- tinguished by the absence of any history of tuberculosis, family or per- 108 INFECTIOUS DISEASES. sonal, and of tuberculous new growths in other portions of the body, particuhirly the hmors. The complications are the same as in acute dysentery, if we except the greater liability, due to the great and protracted weakness of the patient, to certain serious intervening diseases (chronic nephritis, tuber- culosis, pneumonia). Ulceration of the cornea has frequently been noted. The duration is long, the disease lasting for many months or even several years. Treatment. — This should be directed mainly to the local condition, and should consist in methodic irrigation of the bowel with a view to promoting the healing of the ulcers. Formerly it was sought to accom- plish the latter indication by the use of certain remedies internally, as silver nitrate, balsam of copaiba, bismuth subuitrate, etc.. but the only preparation which I have found useful is the zinc oxid (gr. v-x — 0.324- 0.648) three times daily. The latter preparation is decidedly palliative, sometimes even curative. Intestinal irrigation is to be tried, and various disinfectants and astringent remedies should be alternated as advocated in the acute form. Among individual remedies the silver nitrate (gr. ss-ij — 0.032— 0.129 — ad 5J — 32.0) every second day is doubtless the best. On interven- ing days antiseptic remedies may be used in solution, such as mercuric chlorid (1 : 6000) or salicylic acid (1 to 2 per cent.) ; and of other use- ful agents I may mention tannic acid, alum, acetate of lead, creolin, and quinin sulphate. Prior to the use of any of the above-mentioned enemata the bowels should be well flushed with a large injection of tepid water, so as to remove the fecal and other irritating materials. The same details are to be observed in carrying out this mode of treatment as in the acute forms of dysentery. Gallay^has related the curative effects of large enemata of a solution of crystallized silver nitrate in distilled water, a scruple to a quart (1.296 per liter), to which 20 or 30 drops of laudanum have been added. Amelioration follows the third or fourth washing, but a course of sixty is recommended to secure permanent relief I agree with the late Austin Flint that the lower part of the rectum should be examined with the speculum, and appropriate topical applications made if ulcers in this situation be discovered. The dietetic treatment in chronic dysentery is of the utmost import- ance, and the lightest forms of albuminous foods are to be adhered to strictly, to the exclusion of vegetable substances. Milk is excellent when it can be taken. It is well to examine the stools, and if on microscopic examination curds or numerous fat-globules appear, the amount of milk should be reduced or skim-milk substituted. Other forms of food that are allowable and useful are egg-white, meat-broths or beef-juice, whey, and the like. The patient should wear flannels next the skin, so as to protect against the vicissitudes of weather, and, while open-air exercise is useful, it should be moderate. During inclement weather the patient should remain in-doors. I have known change of climate, with proper regula- tion of the mode of living, to be productive of rather brilliant results. ^ "Radical Cure for Chronic Dysentery of Recurrent Type," British Med. Jownal, No. 1779, p. 276. CHOLERA. . 109 Tonics and alcoholic stimulants are sometimes required to assist the appe- tite, digestion, and systemic strength, and among the most efficacious tonic remedies are iron, strychnin, mineral acids, and arsenic, which may be used in succession. CHOLERA (EPIDEMIC). {Asiatic Cholera ; Cholera Algida, etc.) Definition. — Cholera is an acute, infectious, epidemic disease. Its specific cause is the spirillum of Koch, and its most characteristic symp- toms are copious watery dejections, painful cramps, collapse, and suppres- sion of the excretions. In some localities it is endemic. Historic Note. — During the Middle Ages cholera made deplor- able ravages, chiefly along the belts of the Ganges, and has probably been endemic in India for centuries. Only during the present century, however, has the disease been widely known in Europe and America, and when it has appeared it has always been in the epidemic form. The march of epidemics has been from east to west, and always along the lines of commerce and travel by land or sea, sometimes spreading over the en- tire globe. While interesting, it would not be profitable to the student to detail here the progress of the various epidemics of cholera in Europe and America. It will suffice to state the years in which the chief of these occurred : in 1831-32, in 1835-36, in 1847-49, being brought by immi- grant ships from Europe ; in 1852 in Europe (touching our shores in 1854 and prevailing extensively) ; in 1859 (Europe), in 1866-67 (mild out- breaks in America), in 1869-73 (America in 1873), in 1884 (in Europe), and in 1892-93 (abroad). It is seen that there have been no epidemic visitations in America since 1873, though a few small groups of cases have on several occasions been brought to our shores. Pathologfy. — The body is generally much emaciated, the features sharp and drawn, and the skin of the dependent parts presents a mottled appearance. A post-mortem rise of temperature often occurs. The tis- sues are dry, owing to the draining of the liquids of the body, and hence putrefaction is delayed. The kidneys, liver, and heart, as well as other organs in a less degree, show excessive cloudy swelling and often consid- erable fatty degeneration of the parenchymatous tissues. Rigor mortis comes on directly after death, is persistent, and the muscles often con- tract so as to cause the body to assume various uncommon positions. The Visceral Lesions. — The chief of these are confined to the intestinal canal, and depend greatly upon the period of the disease at which death occurs. In the early stage the serosa of the small bowel is congested, presenting a roseate hue. The muscularis is relaxed. The mucosa is the seat of catarrh, being deeply injected, swollen, at times edematous, and often coated in the early stage with more or less tough mucus. Shortly the coils of intestine are filled with an almost transparent or slightly tur- bid liquid ("rice water"), and, occasionally a small amount of clotted blood is seen in the bowel. The solitary follicles and Peyer's patches are at first swollen, and may later, in rare instances, become ulcerated. De- 110 INFECTIOUS DISEASES. nudation of the epithelial lining — most probably a post-mortem change — is the rule, and large or small ecchyraotic spots are visible in the intestinal mucosa. If the patient has died late in the disease (stage of reaction), patches of false membrane (diphtheritic), sometimes dark-brown in color and fetid, may be found anywhere along the intestinal canal, though chiefly in the large bowel ; and this secondary croupous-diphtheritic pro- cess may attack other mucous surfaces (bile-ducts, vagina, etc.). The bacilli are observed in the mucous membrane of the intestine and in the dejections. The stomach shows changes similar in character to those found in the intestines. At first the mucosa is congested ; then, as the result of trans- udation, it becomes filled with "rice-water" material. Soon the hyper- emic mucosa becomes swollen and ecchymoses appear. At last the organ is empty and collapsed. The esophagus also exhibits about the same changes, though Avith an absence of the characteristic transudation. The spleen, contrary to its condition in other infectious diseases, is small as a rule, though if death occur late it may show some degree of enlargement with softening. The liver presents marked passive hyperemia and cloudy swelling, with minute spots of beginning fatty change. Desquamation of the epithelium of the cystic mucosa may occur and lead to a blocking of the bile-ducts. The kidneys shoAv important lesions, being enlarged from passive con- gestion, especially the cortex, and the capsule being somewhat adherent. They exhibit cloudy swelling and decided coagulation-necrosis. Desqua- mation of the epithelium in the uriniferous tubules is extensive. Micro- scopically, the histologic changes are those of acute nephritis in the cases in Avhich death takes place in the advanced stage. The bladder-changes difter in no way from those of other mucous mem- branes. Its mucosa is congested, ecchymotic, and sometimes the seat of diphtheritic deposit. The ureters and the pelves of the kidneys may also present identical appearances. The Circulatory System. — The pericardium is dry, the parietal layer being covered with an adhesive secretion, while the visceral layer is the seat of more or less ecchymosis. The heart is dry and anemic-looking. The left ventricle is contracted, while the right is often distended with blood and soft clots, the latter sometimes extending to the pulmonary artery and the superior and inferior venne cavfe. Outside of the heart the veins, including the cerebral sinuses, contain most of the blood. The latter is thicker than normal, and its color darker, resembling "the juice of huckleberries ;" its specific gravity, albumin, and corpuscles are all increased, while its saline constituents and coagulability are decreased. Respiratory Organs. — The larynx, trachea, and bronchi are hyperemic, and at first covered with tenacious mucus : later they may present ecchy- moses and diphtheritic processes. When death occurs before the stage of reaction the lungs are bloodless and collapsed, and the mouth of the pulmonary artery may be distended with blood. If life is prolonged until the third stasre. the lungs mav show congestion and edema (particularly at the bases) or pulmonary infarction. The post-mortem of a case in this stage, and especially during convales- cence, may exhibit the lesions of broncho- or lobar pneumonia. CHOLERA. Ill The brain and its membranes may be the seat of hyperemia, except when death takes place at a late period, and then the brain-substance may be more or less bloodless and edematous. Ktiology. — The causes are (a) specific and (b) predisposing. (a) The specific cause is the comma bacillus of Koch, -which is found in the intestinal canal of persons ill of cholera. Recent investigations into the bacteriology of the affection show that almost uniformly the cholera spirillum is associated with certain bacteria, most commonly the bacillus coli communis. It has also been shown pretty clearly that true cholera is a nitrite-'poisoiimg, the result of the growth of the specific spirillum. The comma spirillum is not found in any other disease. Its form is that of a slightly curved rod, and its length about half that of the tubercle bacillus, but it is thicker and sometimes has the form of the letter S (Fig. 13). It is to be classed as a spirocheta, and has been grown successfully on media of various sorts and equally success- fully inoculated upon inferior ani- mals. The organism is found in a variety of positions — in the intes- tine, the dejecta (even quite early), and in great profusion in the pathognomonic rice-water stools. Kemp in his review has shown that the comma bacillus is often absent from the evacuations, and that in these cases the bacterium coli is usu- ally present and sometimes streptococci. He believes, however, that the apparent absence is due to faulty technique. To find it in the vomitus, however, is rare. On the other hand, it may be seen in the stools of well persons during epidemics, displaying virulent proper- ties. Cholera spirilla have been repeatedly found in the outer Avorld, and almost invariably in Avater. C. Frankel during the European epidemic of 1892 studied them in flowing water, and in other epidemic outbreaks they have been found in the water used for drinking-purposes. (b) Predisposing Causes. — (1) Locality. — Near to the sea-coast cholera is more common than in the inland districts or towns, and the frequency of occurrence lessens with increasing altitude, this fact possibly being due to a gradual decrease in soil humidity and porosity. (2) Atmosplieric Temperature. — The spirillum of cholera can only flourish in a warm temperature or in a warm climate ; hence the dis- ease is endemic in certain tropical and subtropical climates only ; and hence we see in temperate latitudes the epidemic prevalence of the dis- ease only, and that during the Avarm season. (3) Seasons. — From Avhat has been stated it may be seen that cholera can have no permanent home except in very Avarm climates in Avhich all the other essential conditions prevail. For equally obvious reasons it is more common in the Avarm than in the cold months, most epidemics, Fig. 13.— Comma bacilli (from the mouth) ; X 1000 (Gunther). 112 INFECTIOUS DISEASES. both in Europe and America, having occurred toward the close of sum- mer and in the early autumn. (4) Age, as a rule, has no decided effect. It should be stated, how- ever, that old people are very prone to the affection. Sex is without perceptible influence. (5) Debilitating Causes. — Whenever the private conditions corre- spond to rigid scientific requirements during epidemic outbreaks cholera becomes less prevalent and also less virulent. On the other hand, the deplorable state of municipal sanitation, individual disregard of proper hygienic rules, nervous depression, intemperance, overcrowd- ing, etc. all predispose markedly to the disease. (6) Mere attacks of intestinal disorder due to improper diet, cold, etc. are potent, and are the sole agencies by means of which the disease is disseminated. Modes of Infection. — The spirilla leave the body with the stools, but the most frequent bearer of cholera-poison is the drinking-water. Natur- ally, the individual susceptibility varies greatly (many persons being even insusceptible), and yet the degree of contamination of the drink- ing-water and the virulence of epidemics are almost strictly proportion- ate. As an illustration, Vienna had enjoyed exemption from cholera for nineteen years — a fact attributed to the excellent quality of the drink- ing-water and to hygienic improvements. In the same city the mor- tality-rate in the more recent epidemics has been small (7 per 1000) for a like reason. On the other hand, in 1872 there occurred in a single commune (Hamburg), which had a polluted water-supply (the Elbe) and no filtration plant, 17,862 cases, with the enormous death-rate of 42.3 per cent. Biernacki demonstrated the presence of spirilla in the spring- water of a house in which 13 cases of cholera occurred. The eholeraic poison may be conveyed with the water used for washing, cooking, and other purposes to other fluids imbibed by man (beer, milk, tea, etc.), and also to food-stuffs taken by him (lettuce, cresses, and other raw vegetables, fruits, meats, bread, butter, etc.). The organisms live and maintain their virulence on these articles of food from four to seven days at least. The infection may reach the esophagus with the water used for washing the mouth or teeth, or that used for washing the utensils, dishes, food-receptacles, etc. Again, the hands, commonly those of laundresses and nurses, may become soiled in the careless handling of bed-linen or garments worn by cholera patients or the stools, and convey the poison to the mouth or lips, to be carried into the stomach along with the drink or food. It is quite possible that flies may transfer the infectious element to food-articles (Simmonds). Cholera is not contagious from mere contact with those ill of the disease. The disease is not acquired by inhalation (Shakespeare), and, since desiccation rapidly kills the spirillum, there is little probability that the latter is wafted by the wind-currents or is air-borne. Nor is ■ there any clinical evidence to shoAv that the poison may enter the sys- tem through the skin-surface. Probably the germs are s/rallowed, and the acid gastric juice may then destroy them if the size of the dose of the poison is not too large, or a sufficient number may pass into the intestinal canal and there manifest pathogenic powers. It is to be borne in mind that after the spirillum reaches the intestine, whether or not an CHOLERA. 113 attack of cholera is the result depends both upon the size of the poison- ous dose and upon the personal degree of immunity. Opposed to the drinking-water theory of this disease is that of Pet- tenkofer, which contends that the spirilla found in the serous evacua- tions of cholera patients must enter an appropriate soil and there under- go further development before becoming truly pathogenic. While soils possessing a certain degree of moisture and perviousness and contami- nated with organic matter favor the growth and multiplication of the specific organism, these telluric conditions are not essential, as is shown by the virulence of the intestinal discharges when swallowed in ample quantity. Pettenkofer also claims that the fully developed poison rises from the subsoil into the lower atmospheric strata as a miasm, especially at the time of the subsidence of the ground-water level in summer. Immunity is not conferred by a previous attack of cholera. Pfeiffer and Marx have proved the existence in the blood-serum of human beings of bactericidal bodies (not a true antitoxin) that cause rapid destruction of the cholera bacilli. To these anti-bodies is ascribed the " Pfeiffer serum reaction," by means of which the vibrios are differentiated from other micro-organisms. Pfeiffer and Marx have also shown that the virus of cholera can be effectively preserved by a 0.5 per cent, solution of car- bolic acid, and that it in no Avay impairs its immunizing properties. Clinical History. — The incubation period varies from a few hours to five days. During this prodromal period the patient is either quite well or (during the latter portion) exhibits certain local symptoms. These are occasionally nausea, a feeling of distress in the abdomen, increased peristalsis which may be visible or palpable, slight pain and tenderness, and either a mild or a decided diarrhea. The discharges are feculent, colored, and semifluid, or more rarely quite fluid, and may be quite copious. These symptoms may all be present, though oftener a few, and rarely a single one, is noted ; moreover, they are not distinctive unless seen during an epidemic and unless the patient have been exposed to the poison. Prostration may be rarely marked and there may be slight muscular cramps. The so-called premonitory diarrhea may ter- minate in recovery at the end of from one to three days ; but if not, it is followed by an attack of true cholera. This has three stages: the stage of serous diarrliea, the algid stage or collapse, and the stage of reaction. (1) Stage of Serous Diarrliea. — The dejections are generally painless, very frequent, odorless, copious, and fluid or watery, and usually present the characteristic " rice-water " appearance. Rarely they are distinctly colored with bile, and in severe cases with blood, and rarely also are they frothy. Suspended in them are numerous small, whitish, mucous flakes ; their reaction is neutral or alkaline, and they contain a small percentage of solid constituents made up largely of albumin and sodium chlorid. The microscope brings to view epithelium, mucus, triple phosphates, and numberless micro-organisms, of which latter the only ones characteristic are the comma bacilli (spirilla) of Koch. In cholera sicca these serous evacuations are absent. Death comes quickly, and post-mortem exami- nation shows the intestine to be filled with rice-water material, which is probably retained because of speedy paralysis of the musculature. G-astric symptoms appear early. Vomiting soon becomes frequent, '&nd at first the vomitus may be bilious ; later it is characteristically 114 INFECTIOUS DISEASES. serous and excessive in amount. Thirst is almost intolerable, anorexia is complete, and the tongue often has a thick coating which early becomes dry. Gastro-intestinal pain is not severe, but a feeling of press- ure or burning in the abdomen is experienced, and occasionally there are griping pains with tenesmus. The physical signs are few. The belly is usually flat and flaccid, though it may be scaphoid and hard, and in some cases palpation detects fluctuation. Painful cramps in the muscles form an early characteristic symptom. They aflFect the voluntary muscles of the legs, calves, and feet, more rarely the arms and hands also. Their duration is momentary, but they recur at intervals, and are due to the local action of the toxins. Owing to the withdrawal of fluid from the lymphatics and blood- vessels the tissues become dry and shrivelled and the blood much thicker. This condition of the blood obviously increases the labor of the heart, which beats rapidly, and there may be at first a distressing palpitation ; but soon the heart grows more and more feeble and venous stasis ensues. The pulse is at first rapid, soft, and small ; it may then be lost at the wrist. The cardiac impulse and heart-sounds may disappear with in- creasing asthenia. The fiicies and general appearance also indicate loss of fluid. The cutaneous surfaces of the face and extremities grow cool : there is rapid general emaciation, which may become most pronounced, and the skin is wrinkled. The complexion assumes a livid or blue-gray tint, while the lips become quite dark. The extremities are cyanotic (the finger-tips in particular), the orbits are deeply sunken, the cheeks hollow, the features intensely pinched, the voice husky and feeble, and there is utter prostra- tion. The surface -temperature drops below the normal, even to 96° or 95° F. (85.5°-35° C), while, per contra, the internal or rectal tempera- ture rises to 102° F. (38.8° C.) or over. The mind may remain clear until the close, but oftener the patient is apathetic, and in grave cases this condition may deepen into stupor or even actual coma. The reflexes are greatly diminished ; restlessness and jactitation may rarely appear. The urine becomes very scanty and is highly concentrated, the stand- ing specimen depositing a heavy sediment. On analysis albumin and casts (chiefly granular) are found. In the serious forms the kidneys fail to eliminate the urea, and there is finally complete anuria. (2) Stage of Algidity or Collapse. — Tlie symptoms which characterize this grave condition are the same as those noted under the latter part of the first stage, only intensified. Asthenia is extreme ; the pulse is miss- ing and the heart beats faintly ; the voice is lost ; respirations are per- ceptibly shallow ; lividity is intense ; the surface ice-cold ; and there is usually stupor or even coma. The excessive serous discharges have given place to mere dribblings from the now relaxed anus. During this stage, which may last a few or many hours, the faint glimmerings of the vital spark are often extinguished. (3) Stage of Reaction. — This sets in promptly, and when reaction fol- lows the first stage directly the case may pursue a favorable course, with return to accustomed health by the end of a week or ten days. The first urine passed is usually albuminous and contains tube-casts and some- times blood-cells. Relapses into the stage of collapse may occur and be repeated ; in many instances, however, this stage is bojh protracted and CHOLERA. 115 dangerous. It is aptly termed cholera typhoid, since a genuine typhoid state of the system "with more or less fever develops. The skin may pre- sent so-called choleraic eruptions (macular, roseolar, erythema, purpura). Recovery may now take place, or a great diversity of local secondary inflammations may supervene (vide Complications). Acute nephritis, which may or may not be an essential part of the process, may arise in this stage and lead either slowly or directly to uremic poisoning, as shown by the projection upon the scene of grave nervous phenomena — headache, vomiting, delirium or coma, and con- vulsions. A fatal result may be looked for. Complications. — In this place are to be enumerated the conditions due to secondary infection, including (commonly) septic and pyemic processes. Diphtheritic inflammations aff"ecting mucous surfaces, but especially the throat, colon, and the external genitals, are among the more common. Bronchitis, pneumonia, and pleurisy may arise, and erysipelas and parotitis are not rare. During convalescence digestive disorders may show themselves, and indiscretions in diet may precipi- tate a relapse. Clinical Types. — {a) " Premonitory Diarrhea." — This type has been outlined in the foregoing discussion, and will not need further description. (b) " Cholerine," in which the symptoms are similar to those of cholera nostras. Many of the symptoms characteristic of true cholera are also present, particularly the cramps and prostration, cold extremities, and scanty albuminous urine. The stools, however, are not, as a rule, typical of the disease, but are feculent in character, as in ordinary cholera mor- bus. The duration is from seven to ten days, subject to relapses. (c) The more typical forms — both moderate and severe — have been described under the Clinical History (supra). {d) The Foudroyant or Asphyxia Form. — This may kill instantly ; more frequently the patient lives for a few hours, with or without vomit- ing and purging. Cholera sicca should be classed with this type. The virulence of the cholera-poison explains the intensity of the symptoms. Differential Diagnosis. — This is diflicult in the absence of an epidemic unless bacteriologic and microscopic tests be made, and yet these alone differentiate a sporadic case. The disease most commonly mistaken for cholera (especially cholerine) is cholera morbus, and the fol- lowing points pertaining to the latter disease will eliminate it : 1. No connection with a previous case, but a frequent history of dietetic impru- dence. 2. Absence of "rice-water" stools, which remain turbid with feces or covered with bile or blood. 3. Presence of colicky pains, but absence of painful tonic cramps of legs and feet. 4. Absence of cyanosis and collapse, as a rule, and of urinary suppression. 5. No cholera spirilla in the stools. Arsenic-poisoning and other forms o^ g astro-enteritis must be discrimi- nated by the history, the character of the stools, the absence of violent muscle-cramps and of the effects of great loss of fluid (cyanosis, shrunken body, profound collapse, etc.). Chemical tests are not to be neglected if the history points to any form of corrosive poisoning. Prognosis. — This is dependent mainly upon the type. Thus " chol- erine " is very rarely fatal, while, on the other hand, the asphyxic form is almost as rarely survived. It is impossible to state the average mortality, 116 INFECTIOUS DISEASES. since it varies with each epidemic, but it has been found to range from 20 to 80 per cent. Many deaths occur during the latter part of the first day or during the algid period ; still more during the stage of reaction, the dangers of the latter period being as follows : asthenia, cholera nephritis with uremia, and the various complications {vide supra). The personal circumstances which render an attack grave are old age, alcohol- ism, previous ill-health, and debility. On the other hand, the death-rate may readily be lowered by prompt and judicious treatment. Treatment. — Prophylaxis. — Prevention is of greater importance than cure, and is easily accomplished as compared with the eradication of the disease. It has been owing in great measure to the efficient quarantine system of the United States that cholera has not gained a foothold on our shores since 1873. Individual Prophylaxis. — In the first place, those nursing the sick can prevent the spread of cholera by prompt and thorough disinfection of the vomitus and stools, as well as of the receptacles containing them and anything that may be soiled by them. The dejecta may be disinfected by pouring upon and mixing with them an equal part of a 5 per cent, solution of carbolic acid or an equal volume of a freshly prepared solution of chlorid of lime. The discharges thus treated must be covered and allowed to stand from fifteen minutes to half an hour, and then emptied into a pit in the earth containing quicklime, with which they should also be covered. It is of the utmost importance to guard against a pollution of the water- supply by these pits. Soiled clothing, linen, etc. should be promptly disinfected, and bedding had better be burned ; none but the attendants should be permitted to enter the sick-room. The dishes used should be disinfected immediately after use or before leaving the sick-chamber. Shakespeare further recommends that the remains of the patient's meals should be disinfected and destroyed. After handling the patient or any- thing that he has soiled the attendants should first disinfect and then carefully wash their hands, these ablutions being performed invariably before eating. After vomiting and after an evacuation of the bowels the mouth and the parts around the anus should be wiped with a cloth wet with a solution (1 : 2000) of mercuric chlorid. If convalescence super- vene, the patient should be kept isolated for a week and the stools should be disinfected during that time. Persons exposed should use boiled milk and water only. Certain forms of food must be avoided, especially salads and unripe fruits ; also alcoholic stimulants. All uncooked food may be pernicious. Such per- sons should lead regular lives, avoiding fatigue, excesses, etc., and in- testinal disturbance must be met speedily by the use of antiseptics, opiates, and astringents. In India, Haffkine^ has used a protective virus with encouraging results. Thus, " of 1735 persons not inoculated in a certain section, 174 took the disease and 118 died, whereas of 500 inoc- ulated but 21 were affected and 19 died." He has made, altogether, 70,000 injections in 40,000 patients without a single accident, and claims that the results have been entirely favorable. Behring and Ransom have also succeeded in obtaining an antitoxic serum. Klein concludes against Haffkine's anticholera inoculations, showing that there is no certainty as to the protection against the specific poison in the intestines, even ^ Munch, med. Wock, Jan. 29, 1895. CHOLERA. Ill though there may be protection against the effect of intracellular poison. Klemperer has produced immunity by using a toxin. Treatment of the Attack. — [a) Premonitory Diarrhea. — When the prodromal period exists it must be quickly combated, and if this were attended to appropriately few cases of cholera would follow. In the instances which are not preceded by premonitory diarrhea opportunity to prevent the attacks does not present itself. In this stage a double indi- cation is presented — "to restrain the development of the bacilli in the intestine and to neutralize the cholera-poison." To meet this Cantani proposes tannic acid by irrigation (enteroclysis). He injects into the in- testine -|- to 2-^ quarts (liters) of water, or infusion of chamomile contain- ing 3iss to 3v (6.0 to 20.0) of tannic acid, gtt. xx to xxx (1.20) of laud- anum, and 3v-xij (20.0-50.0) of gum arable. The temperature of the liquid should be 80°-104° F. (26.6°-40° C), in order not to chill the patient. Injections should be repeated four times a day, and in grave cases after each evacuation.^ To this should be added a regulated liquid diet, with rest and recumbency. For the same purpose acetate of lead and opium, or large doses of bismuth with or without Dover's powder, have been much employed with good results. [h] Stage of Serous Diarrhea. — The chief indication is to restore to the blood the watery elements withdrawn by the diarrhea. Not a moment is to be wasted. Opium, and preferably the salts of morphin, should be administered hypodermically, the dose not being small, but gr. \ to -| (0.0162-0.0216) to be repeated at intervals of about eight hours. To opium given per oram or in the usual way there is a serious objection — namely, its slowness of action. Cantani advocates the injection of an artificial serum {hypodermoclysig) containing 1 dram (4.0) of sodium chlorid and gr. xlvj (3.0) of sodium carbonate per quart (liter) of ster- ilized water warmed up to 104° F. (40° C.) into the subcutaneous con- nective tissue. This solution may be introduced through the cannula of an ordinary aspirator, the fluid flowing by gentle pressure. Shakespeare recommends for hypodermoclysis a fountain syringe with a long flexible tube furnished with a cock ; with another shorter tube, one end attached to the cock, the other having a needle-pointed cannula, a little longer, stronger, and Avith a somewhat wider caliber than the ordinary hypo- dermic needle (Fig, 14). The tube and cannula are first perfectly filled with a fluid, and then the cannula is inserted well in between the skin and deep fascia of the flanks, buttocks, or interscapular region. The fluid should be made to flow slowly, allowing fifteen to twenty minutes for the introduction of one quart. This is preferred to intravenous injec- tion, in which the liquid is diffused slowly. The indications presented by the premonitory stage must be met as above stated. The vomiting is to be relieved by bits of ice, small amounts of brandy and water at brief intervals, cocain, or by lavage. In this stage reme- dies by the mouth should be avoided, since they aggravate the gastric dis- turbance. Heat should be applied externally with a view to assisting the peripheral circulation as well as the reaction, and, on the other hand, to obviate collapse. Warm baths have been recommended for this pur- pose. Stimulants must be used to fulfil the same indications. They are of superior value even to the above-mentioned measures, and are to be ^ Annual of the Universal Medical Sciences, 1893. 118 INFECTIOUS DISEASES. given hypodermically, and either brandy, ammonia, or strychnin may be employed in large doses. (c) Stage of Algidity. — If this develop, the case is desperate. In this stage the folloAving measures and procedures, which have been de- tailed in the treatment of the preceding stage, are to be persevered with : Fig. 14.— 1, fountain syringe ; 2, cock ; 3, attachment for cannula : 4, needle : 5, cannula ; 6, soft- rubber rectal tube, with two lateral openings, one a half inch from the end (not visible), the other two inches from the end. The latter is to be introduced by a combined rotatory and pushing motion to the depth of ten inches in enteroclysis, and the fluid then allowed to enter the colon slowly. enteroclysis and hypodermoclysis, hypodermic stimulation, and the ex- ternal application of heat. Additionally, intravenous injections of fluids have been strongly urged by its champions. For this purpose the fol- lowing standard of saline fluid may be chosen : sodium bicarbonate 1 part, sodium chlorid 6 parts, boiled water 1000 parts. The temperature of the fluid when injected varies according to circumstances from 1001° to 104° F. (38°-40° C), more frequently the latter (Shakespeare). The quantity demanded may be 1 or 2 quarts (liters), and the injec- tion may need to be repeated in from one to three or four hours. Despite the physician's best efforts, patients in this period usually succumb. (d) Stage of Reaction. — During this stage the tannic acid may be replaced by a solution of salt in water (10 or 15 per cent.) for entero- clysis (Cantani), and it may be well to continue hypodermoclysis in some instances. Further than this, the treatment is essentially symptomatic. Food of the blandest sort and in small quantities must be allowed at frequent intervals if we would avoid enteritis and other unfavorable com- plications. Tonic remedies should be given cautiously, and rest and careful nursing insisted upon. Complications must be met in accordance Avith general principles. YELLOW FEVER. 119 YELLOW FEVER. [Febris jiava ; Gelbfieber, Ger.) Definition. — Yellow fever is an acute, highly infectious (but non- contagious) endemic and epidemic disease. It is characterized by a sharp period of invasion, followed by a period of remission, and the latter in turn by a relapse and certain symptoms peculiar to the affection (black vomit, jaundice, suppression of urine). Historic Note. — Yellow fever is endemic only within certain geo- graphic limits, where it also prevails epidemically when the conditions are favorable. According to general belief, it first appeared in 1647 in the Barbadoes (West Indies). Subsequently, it was conveyed along the chan- nels of commerce until it became widely disseminated, and chiefly in sea- port towns. In 1699 an English vessel carrying slaves transported the disease to Mexico from the Atlantic coast of Africa. Guiteras classified the areas of infection thus : (1) The focal zone, in which the disease is never absent, including Havana, Vera Cruz, Rio, and other Spanish- American ports. (2) Perifocal zones, or regions of periodic epidemics, including the ports of the tropical Atlantic coast in America and Africa. (3) The zone of accidental epidemics, between the parallels of 45° N. and 35° S. latitude. Yellow fever was brought to the United States (Boston) in 1693, and since then has invaded in epidemic form numerous sea-coast cities, being carried thence to a number of inland towns. The belief that the disease never originates outside of certain territorial limits was ad- vanced for the first time by the College of Physicians of Philadelphia (1797), and the efiicacy of rigid quarantine regulations in preventing con- veyance of the poison by vessels having yellow-fever cases on board was pointed out by the same organization, Patiiology. — The skin is jaundiced (hepatogenous) and often large or small ecchymotic spots are observed, but neither the internal viscera nor the blood shows characteristic lesions in cases of average intensity. In severe forms congestion, hemorrhage, and degeneration are the changes noted, especially in the liver and the gastro-intestinal mucous membranes. After death the liver is anemic, as a rule, but in the early stages of the disease it is markedly hyperemic. Its color varies, ranging from pale yellow to an orange hue, and punctiform extravasations cause mottling of the surface. Its size varies little from the normal. Parenchymatous de- generation of the hepatic tissue is common, though in places it may be entirely normal. The liver-cells are swollen, containing fat and granular matter with indistinctness or absence of nuclei. The gastro-intestinal mucosa is the seat of numerous minute hemor- rhages, similar spots of extravasation being found on the various serous membi'anes of the body (meninges, pericardium, pleura, etc.). Hemor- rhagic infarctions may be found in the various internal viscera. The lesions of acute catarrh are seen in pronounced form in the gastric mucosa, which may also present erosions. The black-vomit material is found in the stomach, and less frequently also in the smaller intestines, which pre- sent the evidences of acute catarrh of their mucous walls. The spleen is dark and friable, but is not enlarged. The kidneys show the lesions of parenchymatous nephritis, the microscope revealing 120 INFECTIOUS DISEASES. cloudy swelling of the epithelium of the tubules with fatty degeneration, and the tubules themselves being occupied by casts, chiefly granular. The heart-muscle looks pale, and may be the seat of granular and fatty degeneration. The brain and its meninges are hyperemic, and degenera- tive changes have been described in the sympathetic ganglia (Schmidt). The blood is dark, and many of the red corpuscles, having disorganized, set fi-ee hemoglobin, as in malaria. Certain significant lesions of a gen- eral character — such as a fatty degeneration of the walls of the small blood-vessels and the capillaries — have been noted b}'^ competent ob- servers, and these, by allowing filtration of blood-serum through the vessel- walls, may account in great measure for the concentration of the blood. Btiology. — Bacteriology. — .J. Sanarelli has described a specific organ- ism of this disease, and named it the bacillus icteroides. It is a slender rod, from 2 // to 4 /i long, motile and ciliated ; it decolorizes by Gram's method, and grows upon various media at room-temperatures. It has little resistance to moist heat, but strongly resists dry heat, desiccation, and sea-water. This micro-organism is not detectable in all cases, especially in the cadaver, for the reason that in the majority of cases secondary infection with the streptococci and staphylococci occurs. The organism is pathogenic for most lower animals, and produces the symptoms (fever, vomiting, hematemesis) as well as the characteristic lesions of the disease. Among predisjjosing causes, season heads the list. The disease prevails chiefly in summer, being completely arrested by one, or at most two, se- vere frosts. The aff"ection is to a far greater degree under the influence of the temperature than of any other meteorologic element, requiring, as it does, at least 72° F. (22.2° C). The persistence of the disease on board ships is due to the combined presence of humidity, heat, darkness, and lack of air. The poison is more virulent at night than in the day- time; and unhygienic conditions (overcrowding, filthiness, ill-ventila- tion) predispose. Age and race have some degree of influence, children being more liable than adults, males than females, and whites than blacks. Other factors worthy of special mention are — intemperance, fliysical exhaustion, sexual excesses., fear, depressing emotions, etc. The poison may be carried to short distances by currents of air, and may be transferred over any distance h\ fomites — clothing, baggage, letters, and packing-cases being the most frequent carriers. The march of an epi- demic may be interrupted or even completely arrested by apparently trivial agencies — e. g. watercourses, rows or clumps of shrubbery or underbrush, high fences or Avails, and so on. One attack usually bestows permanent immunitg, and natives of an infected district are far less liable to the disease than newcomers. Clinical History. — Incubation Stage. — This varies greatly, ranging from one day to two or even three weeks. During the incubation certain general symptoms may appear, such as languor, headache, anorexia, etc., lasting several days. Invasion Stage. — The onset is abrupt, an initial chill usually occurring, but it is verv seldom severe or prolonged, a reactionary fever following promptly and the temperature rising to 103°, 104°, or even 105° F. (40.5 C). The temperature is apt to be highest at the beginning, and then falls gradually, hyperpyrexia being rare. The chill and fever are YELLOW FEVER. 121 accompanied by headache and pains in the loins and legs, often of great severity, and a little later restlessness, mental confusion, and a delirium that is sometimes violent in character may develop. In the majority of instances, however, the mind remains clear. The pulse is accelerated, but not in proportion to the height of the temperature ; it is full and strong at the start, and may fall while the fever is rising. The face is flushed, with slight icteroid addition. The eyes are suffused and intoler- ant of light. The tongue may or may not be coated, and nausea and vomitino; may occur, the latter beinor one of the most characteristic symptoms of the disease. Associated with these symptoms there are epigastric oppression and burning sensations, with decided tenderness. The vomitus may be blood-streaked or contain chocolate-colored parti- cles, and occasionally unaltered blood is vomited. Constipation is usually present, the stools showing a deficiency of bile. The urine is diminished in amount, dark-colored, and often contains a slight amount of albumin : thi^ eay'Ii/ t?rmsient alhtiminw^ia is a very characteristic symptom. The initial stage may last from six or eight hours to two or three days, or even longer, and is longer in the milder forms of the dis- ease. With the termination of this stage the fever remits and the other symptoms disappear with surprising rapidity, the pulse becoming remark- ably slow. Stage of Remission. — From this moment convalescence may begin and proceed to full recovery without interruption, the happy event being often marked by critical discharges. In most instances, however, the patient presents certain symptoms and signs of ill-health during this period (more or less prostration, epigastric distress with tenderness, mental dulness or even stupor, and a yellowish tint of skin and urine), which lasts from a few to twenty-four hours, when another stage with its more striking symp- toms supervenes. Stage of Secondary Fever or Collapse. — The patient becomes extremely weak, presenting the signs of profound collapse. The surface of the body is cool (extremities often positively cold), the skin in nearly all instances assuming a yellow or bronzed tinge, from which the disease receives its name. The pulse is rapid and compressible, and soon vomiting becomes very distressing. Hemorrhage into the stomach generally occurs, the blood being acted upon by the gastric secretions, and producing the material which is expelled as the characteristic ''black vomit." Occa- sionally unaltered blood may be vomited ; the stools also may be tarry. In the worst cases hemorrhages from other mucous surfaces are common (epistaxis, hematuria, metrorrhagia, etc.), and cutaneous hemorrhages also now occur. In this stage the tongue becomes dry, brown, or even black ; less frequently it is smooth, red, and fissured, and sordes may often be observed on the teeth and lips. In most cases the urine is deficient, containing albumin and casts (with careful centrifugation), and in rare instances there is complete anuria. The latter may precede the development of grave nervous symptoms, as convulsions, or even coma, which may be uremic. In some instances the temperature rises during this period (secondary fever), and in favorable cases terminates by lysis, or it may assume the typhoid form and result fatally. In all cases that pursue a favorable course convalescence is slow and gradual, and may be uninterrupted by 122 INFECTIOUS DISEASES. relapses, but this is an unusual course of affairs. The duration of the en- tire attack (composed of three stages) is variable, though as a rule it covers about one week. Clinical Varieties. — Many different varieties have been described, each characterized by one or more prominent features, but none seem more justifiable than Finlay's^ classification, in which he distinguishes three forms : (1) the acclimation fever, or non-albuminuric yelloiv fever ; (2) the i:)lain albuminunc yelloiv fever ; (3) the melatio-albuniinuric yel- low fever, characterized by the presence of blood or "black vomit" in the stomach or intestines. Diagnosis. — The symptoms that justify a diagnosis in the initial stage, provided an epidemic be prevailing, are the sudden onset, head- ache, severe lumbar pains, peculiar facies and pulse, nausea, and vomit- ing of bile. In the early stage intense capillary congestion of the sur- face of the body is diagnostic and indicative of a severe form of the disease. In the third stage the coexistence of jaundice, the black vomit, and suppression of urine, with evidences of collapse, makes the diag- nosis easy. Serum-diagnosis. — Woodson and P. E. and J J. Archinard have applied the Widal reaction (agglutination-test) in 100 cases, and their conclusions are that the serum-diagnosis of yellow fever is practicable and important, and may be used on the second day. A dilution of 1 : 40, with a time-limit of one hour, is preferable. Pernicious malarial fever has not tiie deep jaundice, the slow pulse, the peculiar temperature-curve, the intense capillary congestion of the surface of the body, the black vomit, the early albuminuria, and the clear mind — all symptoms that mark yellow fever. On the other hand, the organism of Laveran is pathognomonic of pernicious malarial fever, as is the effect of quinin upon the disease. Kemp has made a microscopic, spectroscopic, and chemical study of the black vomit of yellow and malarial fevers, and found that the pigment in each case was derived from the blood, which had been acted upon by the gastric juices. The vomitus in malarial fever, however, contains in addition considerable quantities of bile-pigments and bile-salts, which are wanting in that of yellow fever. Further, in the latter the vomited matter is much more highly acid. Prognosis. — Different epidemics show Avidely different death-rates, and the most potent factor is the particular type of the disease in indi- vidual epidemics. Some have been characterized by the lighter forms of the affection, and in such the death-rate has been low (1 per cent.). In other epidemics the type has been so virulent as to make the mor- tality list high, even to 100 per cent. In general, mild epidemics give a mortality of 5 to 10 per cent., and severer forms one of 30 to 50 per cent. The death-rate is lower in private than in hospital practice. Among the gravest symptoms intense cajnllary congestion, coming on during the first stage, deserves special emphasis. Equally serious, in most cases in which they occur, are suppression of urine, intense jaundice, and uremic toxemia. The black vomit is not as fatal a sign as the symptoms previously mentioned. It has been noted that a larger number of men, proportionately, than ' Edinburgh Medical Journal, Edinburgh. YELLOW FEVER. 123 women and children succumb to the disease, and that it is less fatal among negroes than among- whites. Treatment. — The measures that are employed in yellow fever may be considered under three main heads : (1) Prophylaxis ; (2) general management ; and (3) medicinal measures. (1) Prophylaxis. — The patient must be quarantined, and if the area in a city that is infected be definitely known, it should be shunned by well persons, and particularly if the latter are not acclimated. Persons living in infected localities who have not been immunized by a previous attack had better go elsewhere if such a course be practicable. Every available means to prevent a dissemination of the poison by fomites must be enforced, and most important is the thorough disinfection of all personal belongings, bed- and body-linen, mattresses, clothing, etc. The room occupied by the patient must also receive proper attention. Protective inoculation Avith the serum obtained from a horse or an ox vaccinated with the bacillus icteroides has proved eifectively prophylactic in a severe outbreak in an insanitary prison.^ (2) General Management. — The sufferer from yellow fever must be put to bed at once, and an abundance of fresh air (without exposure to strong drafts) must be supplied. The medicaments and the nourishment are to be administered through a tube or spout-cup, so as to obviate raising the patient's head. Body- and bed-linen should be kept scrupulously clean, being changed frequently, and the patient must not be allowed to leave his bed on any account. The diet should be of the lightest sort and entirely liquid, beginning with peptonized milk, koumiss, or light broths, and in small quantities. (3) Medicinal Measures. — At the outset it is well to gently stimulate the various excretory organs, and mild laxative diaphoretics and diuretics answer this purpose. Hydrotherapy may be employed to maintain the nervous tonicity and reduce the temperature, but when the spontaneous fall of temperature sets in this method must be promptly discontinued. During the first stage the neuralgic pains, which attack principally the head, loins, and nerve-trunks, are to be relieved by morphin given hypo- dermically ; and for the same symptom Bemiss highly recommends quinin by the rectum (gr. xx — 1.296). Intestinal antiseptics may also be used throughout the attack (salol, betanaphtol, etc.). During the stage of renmsion the powers of the system are to be fully maintained by a suitable dietary and by tonics and stimulants if required. In the last stage, supportive measures must not be forgotten, every- thing that aids the vital powers being brought into prompt requisition. Rectal nutrient eiiemata should be employed if marked gastric irrita- bility prohibits feeding by the mouth. Stimulants are demanded, and these should also be administered per rectum if not retained by the stomach, or they may in some measure be administered hypodermically. The stomach is, as a rule, tolerant of iced champagne. If irritability of the stomach be present, ice and hydrocyanic acid may be tried. Sodium bicarbonate (gr. x to xx — 0.648 to 1.296) in Vichy, Apollinaris, or Seltzer water is a most useful remedy, and Stern- berg; has used it in combination with mercuric chlorid with success in the following formula : 1 Philada. Med. Jour., Sept. 18, 1898. 124 INFECTIOUS DISEASES. I^. Sodii bicarb., 3iv(16.0); Hvdrarg. bichlorid., gr. ss. (0.032); Aqu« purjE, Oj (480).— M. Sig. For a severe case tAvo teaspoonfuls every hour, day and night ; for a mild case, every hour by day and every two hours by night ; administer alwavs ice-cohl. Perhaps the chief indication for the use of sodium bicarbonate is the extreme acidity of the various secretions, especially the gastric and renal. Sternberg contends that by fulfilling this indication we prevent in great measure the occurrence of acute nephritis and suppression of the urine. Hemori'hages and other symptoms must be treated by the usual means. During convalescence tonics are to be administered, and the customary diet can gradually be resumed. Serum-therapeutics. — Prof. Sanarelli records favorable results from the use of his antitoxic serum. The fever and the albuminuria quickly disappear, the other symptoms more gradually; but convalescence is well established after the injection of 20 cu. cm. (5 fluidrams) and Uo cu. cm. (2 fluidounces) of the serum respectively. In most cases the serum was injected directly into a vein, but hypodermoclysis will prob- ably give equally happy results. If commenced early, the treatment is less apt to be resisted. The experience of Sanarelli has been confirmed by other observers. In Q'o per cent, of the total number treated a cure was obtained. CEREBRO-SPINAL MENINGITIS. {Spotted Fever ; Cerebrospinal Fever.) Definition. — An infectious disease, caused most probably by the Micrococcus lanceolatus. It is characterized anatomically by inflamma- tion of the meninges of the brain and spinal cord, and clinically by an irregular course, a moderate febrile movement with somewhat character- istic and profound nervous symptoms (excruciating headache, pain in the back and upper part of the spine, contraction of the muscles of the nucha, hyperesthesia, delirium, and ofttimes coma). The disease may occur sporadically or in epidemics, or may even assume pandemic pro- portions. Historic Note. — Cerebro-spinal meningitis was first recognized and described as late as the beginning of the present century (1805) by Viesseux of Geneva. During the next decade numerous limited epi- demics were observed both in Europe and the United States, and subse- quently recurring epidemic and pandemic visitations were noted, though at comparatively long and variable intervals of time. In nearly all the large cities in this country it may be said to have become endemic, and in Philadelphia since 1863 ; yet the affection is, without doubt, becoming less and less prevalent. Pathology. — The cases that prove speedily fatal do not present gross characteristic changes, but by the aid of the microscope leukocytes are discovered immediately around the cerebral vessels, and round cells in the cortex of the brain. In some cases the characteristic evidences of CEREBROSPINAL MENINGITIS. 125 encephalitis are already noticeable. On the other hand, the eases in which death occurs after the disease has been fully developed show the lesions of suppurative inflammation of the meninges of the brain. The arteries, veins, and sinuses are much engorged ; the ventricles are dis- tended Avith liquid, but the pia mater is principally aiFected, its vessels being greatly enlarged, and a more or less copious sero-fibrinous or sero- purulent exudate occurring into the meshes of its network. The longer the duration of the case the more purulent is the exudation. The ven- tricles of the brain are filled with a similar exudation, and red blood- globules may be present at an advanced stage. The color of the exu- date is at first almost clear (being composed of serum) ; it then changes to a milky turbidity, to a pale yellow, and, lastly, takes on a greenish- yellow color (" leek-green "). The subarachnoid space may be occupied by a uniform layer composed of fibrin and pus, which exhibits the great- est thickness alons; the lono^itudinal fissure. The brain-matter is congested, and sometimes softened in spots, and on section the gray matter may present punctate extravasations. AVhen resolution occurs recovery may be complete, but more frequently the pia mater remains thickened. The exudation may follow the auditory and optic nerves along their lymph-sheaths, and pus has been found in the internal ear as well as in the chambers of the eye. The membranes of the spinal cord manifest lesions identical with those of the brain. They are vascular engorgements, followed by sero- fibrinous, and later still by sero-purulent, exudation beneath the arach- noid. The changes are more marked on the posterior than the anterior surface of the cord, and the exudate increases in amount in passing from above downward, in severe cases sometimes assuming the form of a sheath which completely surrounds the cord throughout its entire length. The pia mater is congested, and may be thickened, shaggy, and in places adherent to the cord, of which the gray matter may be the seat of serous infiltration, and rarely of softening. Barker describes certain changes that occur in the nerve-cells and the ventral horns of the nucleus dorsalis (Clarkii) of the spinal cord in epidemic cerebro-spinal meningitis. The lungs may exhibit the changes peculiar to bronchitis or pneu- monia. In the heart endocarditis may be noted, though rarely, and both the pleura and the pericardium may show inflammatory lesions and con- tain a serous or sero-purulent exudation. I have noted one malignant case in which hemorrhages into the serous membranes and into the skin had taken place. The spleen may be moderately enlai'ged, the increase in size and the degree of fever being proportional, and the liver is hyper- emic. The kidneys are congested, and bacterial forms have been found associated in the latter with the lesions of acute nephritis and hemor- rhage — conditions of which they were most probably the cause. Ktiology. — Bacteriology. — It is claimed that the micrococcus lance- olatus is the specific cause of cerebro-spinal meningitis. Flexner and Bai'ker found the micrococcus uniformly present in all cases in an epi- demic which occurred at Lonacoming, a mining town in Maryland.^ Other bacteria are, however, constantly found associated (streptococcus pyogenes, ^ Annual of the Universal Medical Sciences, 1895, vol. ii. A-65. 126 INFECTIOUS DISEASES. staphylococcus aureus, etc.). Councilman concludes that the epidemic form is due to the meningococcus intracellularis, discovered by Weich- selbaum in 1887, and believes that it is a distinct organism. Welch, however, suggests that the meningococcus and the pneumococcus are possibly varieties of the same bacterium. It is possible that the former is not the sole specific cause of this disease, but that the pneumococcus, and possibly other organisms, may also produce it. Predisposing Causes. — (1) Age. — Most cases occur in children and young adults, though no age enjoys perfect immunity. (2) Climate. — The disease is unknown in tropical climates, but has oc- curred in all parts of the temperate zone, and is most prevalent in the more northerly portions of the latter. (3) Season is not an important factor, though the disease prevails largely in cold weather. (4) Unhygienic Influences. — Those who live under unfavorable sanitary influences are especially liable, and hence the disease often appears in ill-ventilated and overcrowded habitations — among the poorer classes, among soldiers crowded together in barracks, and among prisoners. Pro- longed marching, and excessive physical or mental exertion, may heighten the susceptibility to the disease. In certain epidemics the disease has raged exclusively in villages. Modes of Conveyance. — Precisely how the contagion is transferred from an infected person to a healthy one is not known, but the disease is probably not contagious. There is evidence to show that the poison may be conveyed hj fomites, though this seems to be limited to the cases fur- nishing intensely virulent poison. The organism, owing to its feeble vitality, probably could not lead a saprophytic existence. As to the manner in which the virus gains entrance to the system, our knoAvledge is imperfect also. Clinical History. — The period of incubation is brief, though un- known. The prodromal symptoms are variable in different epidemics, and may even be absent when the invasion is sudden, a patient in vigor- ous health often being stricken down as though by a blow. In some rapidly fatal cases there is a short prodromal period, during which the patient complains of lassitude, headache, rachialgia, muscle- and joint- pains, and sometimes nausea and vomiting. In ordinary forms the pro- dromes may last from a few hours to a week or more, and the patient's complaint may be limited to cervical and occipital pains lasting a day or two ; then, without any initial chill, the invasion-period supervenes. In milder, and usually in sporadic, cases the symptoms consist chiefly of languor and debility, headache, pain in the back and limbs, vertigo, vomiting, and sometimes diarrhea. Most cases begin abruptly, between noon and midnight. The most distinctive and violent features are chill (often severe), fever of a moder- ate grade, a full and somewhat accelerated pulse, raging headache, and vomiting. In children the ushering-in symptom may be a convulsion. These symptoms are followed soon by pain in the back and cervical portion of the spine — an early and characteristic symptom. Attempts at flexion or rotation of the head increase the pain in the neck, and in like manner movements of the body augment the spinal pains. Later, the muscles in the cervical region contract, at the same time becoming rigid. CEREBROSPINAL MENINGITIS. 127 and produce the condition of opisthotonos. The patient may be unable to swallow on account of the excruciating pain which the act is apt to excite. The teynperature is but moderately elevated. In a certain percentage of the cases it rapidly rises to 104° or 105° F. (40.5° C), but soon falls to 102° or 103° F. (38.8° or 39.4° C), at which level it is maintained with irregular undulations until defervescence, which takes place by lysis. In fatal cases death is preceded by a sudden great elevation of temperature to 108° and even 110° F. (43.3° C). There may be a rapid fall of tem- perature, followed by collapse. In the very young the thermometric range is lower than in adults. The pulse is but slightly accelerated, if at all, in the early stages of the disease. Later, in twenty-four to thirty-six hours, it may in severe cases leap to 120 or even 140, its chief characteristic being the variability in its rate. In the early stage it is of good volume and tension ; later, it may be soft and compressible, and when a fatal termination is impend- ing it becomes small and feeble. - The respirations, as a rule, increase in frequency and are sometimes quite irregular ; but marked dyspnea, with slowing of the respirations, may be observed during the advanced stage, being due to pressure ex- erted by the exudation upon the respiratory center. Cheyne-Stokes breathing and sighing respirations may be present. Nervous Symptoms. — The headache is racking and often persistent, though it is subject to remissions ; and is intensified by light and sounds, being so violent as to cause the patient to groan even while profoundly comatose. There is vertigo in nearly all instances. The pain referred to the spine may be general or limited to either the lumbar or cervical region (rarely the dorsal), and the general myalgic pains are often in- tense, especially in the extremities and the abdominal region. With the cephalalgia and abdominal pain may be associated vomiting. Hyper- esthesia is a prominent symptom, the gentlest touch being extremely painful ; anesthesia may also be noted, though less frequently, and usually follows the hyperesthesia. Any voluntary muscular movements, however, excite pain. In some cases delirium appears early, and in others rather late, while in the worst types death often occurs before de- lirium develops. On the other hand, in a small percentage of cases this symptom is absent throughout the entire course, and always its character and intensity exhibit a remarkable variety. It may be mild or it may take the form merely of incoherent answers to questions. Active delirium, however, is common and is accompanied by hallucinations, during which the patient shouts loudly, and, unless restrained, gets out of bed. This form of delirium occurs in paroxysms that are most apt to appear at night, and in the female it is sometimes hilarious or hysteric. An erotic tendency, with priapism or seminal emissions, has rarely been ob- served in males. The " maudlin " delirium of the drunkard is sometimes seen, but sooner or later somnolence appears and may deepen quickly into coma, the latter symptom perhaps being temporary, though more often it continues until recovery or death. As before stated, vomiting is common, though it may appear late in the disease ; it is doubtless of cerebral origin. Symptoms of motor irritation are among the prominent phenomena of 128 INFECTIOUS DISEASES. the disease, twitching of single muscles or groups of muscles often being seen, and occasionally muscular tremors. Muscular contraction is an almost constant feature. After a few days a tonic spasm of the muscles of the extremities sets in, as the result of wliich the arms are bent upon the chest, the forearm upon the arm, and the thumb upon the palm ; the thigh is also flexed on the abdomen and the leg on the thigh. The opis- thotonos previously alluded to may be followed by trismus, Avhich can be considered a mortal symptom. Convulsions do not occur in adults, but are common in children ; occasionally, however, there are paralysis, especi- ally of the muscles of the face, and paretic hemiplegia. Organs of Special Sense. — Photoj^hobia is a prominent symptom, and the condition of the pupils is very variable. They may be dilated or contracted (more frequently the former) or remain normal ; and in the majority of cases they are unequal in size and react poorly to light. These pupillary changes may come on early or late. Strabismus is fre- quent, being usually temporary, though it may recur several times during the attack. Rarely it is permanent. Conjunctivitis of moderate inten- sity and keratitis may occur, the former being more frequent than the latter, however : and ptosis is almost always present. Intense purulent irido-choroiditis sometimes occurs ; either temporary or permanent blind- ness is met with, and, much more rarely, nystagmus is noted. Among optical sequelae are cataract and atrophy of the eyeball. Deafness is by no means an infrequent symptom, there being an early intolerance of sound and a marked tinnitus aurium. Later, suppurative inflammation of the middle ear, followed by rupture of the tympanum and otorrhea, may occur. The internal ear may be similarly involved, and in such cases the gait may become uncertain from implication of the semicircular canals. The deafness may after recovery be found to be permanent, though, as a rule, it is incomplete. Cutaneous symptoms appear, some of which possess considerable diag- nostic worth. Pallor and lividity of the skin and visible mucous mem- branes often characterize the period of invasion, and shortly after the onset herpes facialis appears in more than half the cases. This symptom is significant for diagnosis. The separate lesions are extensive, and often coalescence of two or more is witnessed. Herpes facialis belongs in a peculiar sense to cerebro-spinal meningitis — herpes labialis to malaria, and less frequently to pneumonia and meningitis. A petechial eruption is common, and has been most fre([uently met with in the early epidemics, and more frequently in America than in Europe. To this symptom the disease owes the name, long since given to it, of "spotted fever." It may, however, be absent, and when present it is sometimes limited to a small superficial area, though more frequently it is diflTuse. At first the eruption may be bright-red (erythematous), later becoming darker, or it may be distinctly petechial from the start ; purpuric spots of considerable size and sometimes large ecchymoses may appear, but these are most common in the more malignant types. Other forms of eruption are also seen (sudamina, urticaria, ecthyma, erythema, erysipelas, etc.), but are devoid of diagnostic value. Gangrene of the skin is occasionally noticed, and in some cases bed-sores are liable to arise ; but there is no fixed time for the skin-lesions of cerebro-spinal fever to appear, and their duration is exceedinirlv variable. CEREBROSPINAL MENINGITIS. 129 Of gastro-intestinal symptoms vomiting is the most common. It usu- ally lasts only for a brief period at the onset, though it may recur later at longer or shorter intervals, and is of nervous origin. The appetite may be good, but in many cases it is soon lost, the tongue, in a large pro- portion of the instances, being only slightly coated. In cases assuming the adynamic or typhoid ' type the tongue is apt to become dry and of a brown color, with the formation of sordes. Under these circumstances the abdomen is tympanitic and the bowels relaxed, and diarrhea may be urgent, resisting all efforts aimed at its relief. Retraction of the belly is common, and constipation instead of diarrhea is the general rule ; the spleen may often be felt a little distance below the costal margin. Renal symptoms are not prominent, though the amount of urine passed is often above the normal despite the febrile movement. It may be below, though rarely, while in still other cases it is found to be about normal ; and retention on the one hand and incontinence on the other have been observed. Albuminuria is sometimes met with, and sugar has been detected in the urine in rare instances. Complications. — Many of these have already been mentioned in the portrayal of the symptoms, particularly those taking the form of destructive inflammations of the eye and ear and the paralyses of the cranial nerves. The purulent inflammations of the serous sacs which were referred to in discussing the pathology (pleurisy and pericarditis) are among the frequently associated conditions, and secondary bron- chitis is also common. Pneumonia (lobar and lobular) is a frequent and much-dreaded com- plication. Atelectasis may occur. Hemorrhagic nephritis, usually of mild type, may appear as a com- plication. Special and Atypical Forms. — (1) Mild or Rudimentary. — In this type the characteristic signs are either undeveloped or wanting, and the diagnosis is possible only during the prevalence of epidemics, which furnish typical cases. The symptoms vary and are indefinite, but per- haps the most constant and significant are severe headache, languor, ver- tigo, nausea, and occasionally vomiting. Fever and contraction of cervi- cal muscles are absent, as a rule. The duration of rudimentary cerebro- spinal fever is brief, the more noticeable symptoms rarely exceeding three or four days. (2) The Abortive Form. — Here the initial symptoms are severe, but after two or three days they rapidly subside, leaving the patient conva- lescent. The disease is cut short by the acquisition of immunity, and not as the result of medical interference. (3) Intermittent Form. — In this variety the symptoms, however in- tense, remit or almost wholly intermit every day or second day ; these re- missions are followed by a decided exacerbation or recurrence of the dis- tressing features of the disease. Intermissions may occur at the begin- ning of a case, though more often they occur at an advanced stage and tend to prolong its course. There is not observed the strict periodicity that is seen in malaria, and neither is the temperature-curve typical of the latter disease nor are the malarial organisms found in the blood. (4) Typhoid Form. — In a certain though small proportion of the cases 130 INFECTIOUS DISEASES. the special features are characteristic of the " typhoid state," but their course is more protracted than is usual. (5) Fulminant or Apoplectic Form. — The symptoms characterizing this most malignant type of the affection are rather inconstant. There may be severe chill, loss of consciousness, followed by deep coma and death, the whole course occupying the space of a few hours only. I saw two such cases in the same family : the first, a girl of five years, was stricken at 2 p. M. and died at 9 p. m. ; the other, a boy of seven years, was taken ill on the following day about the same hour, and died at 10 p. m. Other instances pursue a somewhat slower course, though manifesting the most striking malignancy. These begin with intense chills, violent head- ache, vomiting, early stupor, great prostration, contraction of muscles of the neck, moderate fever, and a feeble, progressively slowing pulse until it sometimes reaches 50 or even 40 beats per minute. The eruption, when it appears, takes the form of purpura. This form is most apt to be met with early in an epidemic, and with few exceptions proves fatal. Diagnosis. — The most important symptoms for diagnosis are the abrupt onset ; intense pains (cervico-occipital and lumbar) ; prostration ; vomiting ; vertigo ; somnolence, alternating with local or general tonic or clonic convulsions ; delirium (often sportive in type) ; tonic contraction of the muscles of the neck, extending to the back ; marked hyperes- thesia ; a slow, followed by a more rapid though variable, pulse ; irregu- lar temperature-curve ; and certain eruptions (petechial, herpetic). Lumbar Puncture. — The most accurate method of diagnosticating this disease is by lumbar puncture. A wire should be inserted into the needle, and if the fluid does not flow upon its withdrawal, the dura mater has probably not been penetrated. The fluid obtained is to be examined not only macroscopically, but also microscopically and bacteriologically. Differential Diagnosis. — The disease, especially the sporadic form, is apt to be confounded with certain other affections. (1) Tubercular Meningitis. — In this affection there is usually a tuber- culous history — either personal or family — with prodromes extending over many days (occasional vomiting, unnatural peevishness, constipation). The invasion-period lacks the sudden onset of meningitis. There is greater re- traction of the abdomen than in the latter disease, while the arching of the neck, the general myalgic pains, and the hyperesthesia are less ; the her- petic and petechial eruptions are rare in tuberculous and common in cerebro- spinal meningitis ; while Cheyne-Stokes breathing and the well-marked changes of pulse belong peculiarly to the tubercular form. By the aid of the ophthalmoscope choroidal tubercles may sometimes be detected. (2) Pneumonia. — This affection may be complicated with a meningitis that affects chiefly the cerebral cortex. Hence, while there will be motor spasm (more or less localized) and tremors, there will also be less retrac- tion of the head and less myalgic pain than in cerebro-spinal meningitis. Again, pneumonia precedes the development of the meningeal symptoms. (3) Typhoid Fever. — The cerebral type of this affection may simulate closely meningitis. In both may be observed fever, delirium, somno- lence, retraction of the neck, spasm, tremor, and profound prostration. The mode of onset, however, is different, being slower in typhoid and unaccompanied by vomiting, muscular spasm, or hyperesthesia. In typhoid there is also the characteristic mental dulness ; the fever is CEREBROSPINAL MENINGITIS. 131 higher, "with a typical fever-curve ; the roseate eruption is characteristic, and there is greater enlargement of the spleen. Sequelae. — The leading sequelae are permanent blindness (due to optic neuritis with atrophy) and deafness, which sometimes terminates in deaf-mutism ; and in many cases headache outlasts the disease for months. Chronic hydrocephalus and mental enfeeblement are not rare sequels (Ziemssen). Various local paralyses are observed, probably due to cer- tain peripheral lesions (neuritis and perineuritis). Immunity. — Permanent immunity is rarely conferred by the occur- rence of cerebro-spinal meningitis, relapses being common, and second (recurrent) attacks having been occasionally observed. Duration and Prognosis.^In very mild forms the duration is from one to four or five days. The most malignant type runs an even shorter course, when, as is the rule, it terminates fatally. If recovery ensues, it is after a long, serious, and protean illness. The abortive form is neces- sarily of brief duration. In the ordinary type convalescence usually sets in at the end of one or two w'eeks, but a slow convalescence, hindered by numerous complications and sequelae, is the rule. Apart from the fulminant form, Avhich nearly ahvays proves fatal, the severity of the infection may be appreciated by noting the degree of fever and the intensity of the nervous symptoms, especially the vomiting, coma, headache, opisthotonos, character of the respirations, etc. Comijlications may likewise aifect the prognosis, pneumonia, and suppurative inflamma- tions of the pleura or pericardium, rendering it particularly grave. Cir- cumstances connected Avith the individual are also potent, and particu- larly the age. In children under two years the disease is very fatal, this period giving the highest mortality-rate ; between two and five and after thirty years it is a more serious disease than during young adult life. The death-rate of cerebro-spinal fever varies greatly in different epidemics, ranging from 25 per cent, in the mildest to 80 per cent, in the severest. Treatment. — (1) G-eneral Management. — The patient should be iso- lated, and the sick-room must be quiet and somewhat dark. All excite- ment is to be avoided ; the patient must not be allowed to leave his bed until convalescence is firmly established ; and the rules for preventing the spread of infectious diseases are to be strictly enforced. The diet should be composed of nutritious liquids, such as milk and animal broths, etc., and as soon as convalescence begins the dietary should be increased by the addition of semisolid substances (rice, eggs, milk- toast, etc.), and, finally, the more easily digestible solids. The period of convalescence may be much abridged by systematic feeding. Medicinal Treatment. — Many and widely various modes of treatment have been recommended by as many difi"erent authors, but in my opinion it is best to treat individual cases according to the special indications pre- sented. ' I regard it as extremely improbable that any case of this affec- tion has been benefited by venesection. Cold or gradually cooled baths are of great value, and warm baths will prove highly beneficial by les- sening the tendency to tonic spasm of the muscles. Among medicinal agents narcotics are the most useful. Morphin hypodermically affords prompt relief from intense headache, myalgic pains, muscular contraction, and other nervous symptoms. If the res- pirations be irregular, atropin may be combined with the opiate ; and if 132 INFECTIOUS DISEASES. the heart threatens to fail, strychnin may be administered. In young chiklren Ave must rely upon the bromids rather than the opiates. In older children we may employ opium if we do so cautiously, and I have f)und the deodorized tincture of opium and paregoric to be the best preparations. For the tonic contraction of the muscles, especially when associated with violent cerebral symptoms, cannabis indica should be tried. Con- vulsions call for warm baths or ether-inhalations. Mercury has been, and still is, firmly advocated by certain authors, and, cerebro-spinal men- ingitis being an infectious disease, this drug may be given for its anti- septic virtue (mercuric chlorid gr. 2V (0.002) every four hours to an adult ; calomel, gr. 72"!^ (0-005-0.004) every four hours to children). Belladonna and ergot have been employed to diminish the congestion of the cerebro-spinal capillaries. They should be administered in the early stages. Antipyrin, acetanilid, and phenacetin are objectionable, since they depress the circulation. Stimulants are required if signs of heart-exhaustion appear. They may be freely exhibited in accordance with the customary rules. After effusion of the exudate has taken place the narcotics are to be replaced by agents that promote absorption, as potassium iodid. The local means are also important. When tub-baths are not available, cold should be used locally, since it is both of value and very grateful to the patient. An ice-bag is to be put on the head, and, if possible, long ice-bags placed along the spine. In rare cases of sthenic type we may employ small blisters at the nape of the neck or over the mastoids : these should be applied early, though they are also useful during the stage of eifusion. In the usual form of the disease it is better to apply the thermo-cautery lightly over the mastoid region. If the patient be not too much enfeebled, we may abstract a small amount of blood by means of leeches or by a few wet cups placed behind the ears. Convalescence is prolonged, and requires to be diligently and judi- ciously treated. We must rely upon the generally accepted tonics — iron, cod-liver oil, arsenic, and strychnin ; the potassium iodid and the mer- cury also being continued for their influence in promoting the absorp- tion of the exudate. Special attention is, however, to be paid to the hygienic management of this period. An abundance of fresh air, sun- shine, and easily assimilable food must be furnished at all hazards, and electricity and massage, judiciously employed, will hasten recovery. LOBAR PNEUMONIA. {Croupous or Fibrinous Pneumonia ; Pneumonitis; Lung Fever.) Definition. — An acute infectious disease caused by the 3Iicrococcus laneeolatus, which produces a specific inflammation of the parenchyma of the lung and marked constitutional disturbances — chill, extreme prostra- tion, and fever which terminates by crisis. There are different forms of lobar pneumonia, classified according to their clinical or pathologic pecu- LOBAR PNEUMONIA. 133 liarities, as j^rimary lobar pneumonia, secondary lobar pneumonia, and lobar pneumonia with the formation of new connective tissue, etc. I shall describe the third form separately (p. 510). Pathology. — Usually the lesions are confined to the whole of one lobe : less frequently to the whole of one lung, and rarely to parts of both lungs. From Jurgensen's analysis of 6666 cases the following statement, showing the different situations of the lesions and their relative frequency, was taken : Right lung, about 54 per cent. ; left lung, about 38 per cent. ; and both lungs, about 8 per cent. In the right lung the lower lobe was involved in 22 per cent., the upper in 12 per cent., the middle in nearly 2 per cent., and the whole lung in about 9 per cent. In the left lung the lower lobe was involved in about 23 per cent., the upper in about 7 per cent., and the whole lung in about 8 per cent. Both lungs were implicated in 8 per cent. The lesions of pneumonia are those of three stages : {a) Stage of con- gestion or engorgement ; {h) Red hepatization (consolidation) ; and (c) Gray hepatization. (a) Stage of Engorgement. — The part or parts implicated are of a dark- red color, and firmer to the feel, but less resilient and crepitant, than normal. The cut section drips a blood-stained serum, and dark blood exudes from the distended capillaries. The air-cells do not collapse, though they are not solid, since excised pieces float ; but the weight of the lung-tissue is much increased and the air-sacs are distended with the corpuscular exudate. Collapsed portions may be observed which may readily be insufilated from the bronchus, and areas of extravasation may occasionally be noted near the pulmonary pleura. On microscopic examination the alveolar epithelium is seen to be swollen, the capillaries greatly distended, and the air-cells filled Avith alveolar epithelial cells, red corpuscles, and a few leukocytes. Similar elements occupy the small bronchi. (h) Red Hepatization. — The affected tissue is solid, airless, and firm, resembling, as the term indicates, liver-tissue. It is reddish brown (ma- hogany) in color, presenting a dry, mottled appearance, and when, as is usual, an entire lobe is involved, it is more voluminous than normal and its surface is often furrowed by the impress of the ribs. Being airless, the affected portion does not crepitate, and its weight and specific gravity are increased. It cannot be inflated ; is extremely friable, and its lace- rated surface presents a finely granular aspect, this latter appearance being due to the minute plugs of inflammatory matter (fibrin) which fill the air-spaces. The air-passages and small bronchi are distended with similar material, and granular masses can be removed from the air-cells of a cut or lacerated surface by carefully scraping the latter. If death takes place during this stage, the ante-mortem, dry, inflammatory exudate soon softens, and may flow from the cut section as a grumous, viscid fluid ; the consolidated tissue sinks rapidly in water. The pulmonary pleura is covered with a fine sheet of fibrin, and in cases complicated by marked pleurisy the fibrinous, inflammatory exudate forms a thick coating upon the pleural membrane, and the sac may contain liquid effusion. Microscopic examination shoAvs the air-spaces filled with clotted fibrin, in whose meshes are held red blood-corpuscles, pus-cells, and changed alveolar epithelium. The interlobular connective tissue may be infiltrated 134 INFECTIOUS DISEASES. with leukocytes and fibrillated fibrin, but the blood-vessels in the walls of the alveoli remain pervious. The pneumococci (micrococci lanceolati), less fre([uently also streptococci and staphylococci, are detectable. (c) Gray Hepatization. — In this stage the fibrinous exudation becomes decolorized, the surface at first resembling granite in color, and later appearing uniformly gray. Associated with this change, and following it, there is fatty and granular degeneration of the inflammatory exudate, in consequence of which the latter becomes moist and soft. The exudate loses its granular character, while at the same time the friability of the lung-tissue is further increased, and from the surface of the cut section there flows usually a grayish-white or yellowish-white purulent liquid. Not less than one-half of the fatal cases die in the early part of this stage. The pleura that invests the involved tissue is usually covered with a fine fibrinous exudation. Microscopic examination shows the air-cells stuff"ed with leukocytes, while the other histologic elements (fibrin, red blood-cells, etc.) have disappeared; and the full development of gray hepatization marks the beginning of resolution, though the latter process may in reality begin with the commencement of the former. The exudate is now softened into a liquid material, with disintegration of cellular elements, and is absorbed by the lymphatics. Resolution usually corresponds in time with the occurrence of the crisis, though it may begin later. Again, the pro- cess may be much prolonged. Among unfavorable terminations are — (1) Purulent Infiltration. — Here the lung-tissue becomes very soft, fri- able, and is bathed in purulent material ; and microscopic observation shows the pus-cells densely infiltrating the interalveolar tissue and filling the air-spaces as well. This impairs the nutrition of the lung-tissue, and may thus cause rupture of the septa, producing (2) Abscess. — This is to be attributed to subsequent infection by streptococci, and hence is a complicating lesion. The abscesses vary in size within the widest limits, most frequently being situated near the base of the lung, and may occupy the periphery and rupture into the pleural sac, causing pyo-pneumothorax. In most instances the abscess-cavity has a fistulous connection with a bronchus, but occasionally the abscesses become encapsulated in fibrous tissue, their contents undergoing first caseous, and then calcareous, degeneration. Rarely they open into the pericardium, and still more seldom externally. They may be small and multiple, in which case they sometimes coalesce, forming large abscesses. (3) Gangrene may rarely follow, but is due to a specific cause, and hence does not belong peculiarly to the pneumonic process. (4) Induration. — A. Frankel states that in a few instances (about 1 per cent.) pneumonia ends in induration, and is found upon section to be smooth and its tissue resistant. The surface of the cut section sometimes shows a peculiar transparency, with characteristic yellow specks, due to the collection of cells which have become fatty. Microscopically, the alveoli are seen to be blocked up by connective tissue resembling polypi and containing vessels. By its structure it re- calls the process of organization in a thrombus, and is probably due to secondary infection. It may also be observed after broncho-pneumonia. Changes in Other Viscera. — The heart often appears pale and is flabby, but upon microscopic examination the muscular cell-fibers of the organ LOBAR PNEUMONIA. 135 are not found to be degenerated, except in rare and usually protracted cases. The cardiac chambers, particularly the right, are distended Avith firm, tough clots, which are usually removable en masse from the great vessels in the form of arboreal casts. The blood tends to coagulate, owing to the fact that its fibrinous elements are vastly increased. Pericarditis occurs in about 5 per cent, of the cases, and is relatively more frequent in left-sided or double pneumonia. Endocarditis is more common, especially the ulcerative form, which was present in 11 out of 100 autopsies (Osier). With malignant endocarditis the lesions of men- ingitis are often combined, but as a separate complication meningitis is rarely encountered. The spleen is congested, moderately enlarged, and softened, and the liver is likewise hyperemic and somewhat swollen. In the Tcidneys are found the lesions of parenchymatous inflammation, and with remarkable frequency also those of chronic interstitial inflammation. A catarrhal state of the gastro-intestinal mucosa (often with jaundice) is common; and a frequent complicating change is croupous inflammation of the colon. A true diphtheritic colitis, however, occurs but seldom. il^tiology. — Bacteriology. — The generally accepted specific cause of pneumonia is the Micrococcus lanceolatus of Frankel. It is a lance- shaped (slightly elliptic) coccus, united in pairs (a fact to which it owes its name of diplococcus), and is preseiTt occasionally in the nose. Eu- stachian tubes, and larynx of healthy individuals. Netter found it in 20 per cent, of the specimens of buccal secretion taken from well persons, and to the presence of this germ is to be ascribed the form of septicemia induced in animals by inoculation with saliva. It is present in about 90 per cent, of all instances of pneumonia, and in persons who have had the disease it is detectable for many months or even years. It is gen- erally present in pure culture, but may be associated with pyogenic organ- isms. It is probable that Friedlander's bacillus and other micro-organ- isms (Eberth's bacillus, streptococcus of erysipelas) may also have the power to cause the disease ; and Wassermann ^ suggests that specific forms of pneumonia may coexist in the same individual, as, for example, lobar pneumonia and influenzal pneumonia. The micrococcus lariceo- latus (Fig. 15) can be readily demonstrated in the sputum by treating a cover-slip preparation " Avith glacial acetic acid, and then, after Avashing ofi" the acid, dropping on anilin oil and gentian-violet, which is to be poured off" and renewed tAvo or three times." The Pneumococcus in Other Diseases. — It has been found in pure culture in pleuritis (including empyema), pericarditis, meningitis, peri- tonitis, endocarditis, synovitis, broncho-pneumonia (principally in adults), acute abscess, and other conditions. The mode of Infection is probably by inhalation. The first and chief eflects of the germ are local — in the lung, though it may reach more distant portions of the body. To the widespread distribution of the pneumococcus is due, in part, the septicemic process sometimes observed. It may cause toxic features and speedy death Avithout consolidation of lung-tissue. Usually, then, the disease is a local one at the start, but soon the toxins of the micrococcus lanceolatus become diS"used through- out the system, producing a general disturbance. Secondary infection ^ Deutsche medicinische Wochenschrift, Leipzig, Nov. 23, 1893. 136 INFECTIOUS DISEASES. with other specific organisms (streptococci, staphylococci, etc.) commonly occurs in the various organs of the body. Predisposing Causes. — (1) Endemic Influence. — That endemics of pneu- monia, often of serious type, may occur in solitary buildings (barracks, tenement-houses, institutions, etc.) cannot be successfully denied, and here the disease appears to make for itself, rarely, a permanent home. We may attribute these outbreaks to defects in the local sanitary con- ditions. (2) Epidemic Influence. — From time to time pneumonia prevails exten- sively, and appears to spread throughout a considerable percentage of the entire population of urban and rural districts. It may also originate in the endemic form in tenement-houses and institutions, and increase in its scope until it assumes an epidemic character. The epidemic form of Fig. 15.— Diplococcus pneumonire, from the heart's blood of a rabbit ; X 1000 (Frankel and Pfeiffer). pneumonia is at times confined to private homes (house epidemics), and in the winter of 1894 I saw, with Dr. W. K. Mattern of Philadelphia, 3 cases develop in rapid succession in one family. A Sister of Charity, after nursing two of the patients faithfully for a period of ten days, was also attacked and died of the disease. It is possible that the house-epi- demic form may spread by contagion. An instructive epidemic is reported by W. B. Rodman, who states that 118 cases of pneumonia, with 25 deaths, occurred in a prison population of 735. B. Robinson ' insists upon his view that pneumonia is contagious. (3) Geographic Distribution. — Pneumonia may be said to be an al- most universally distributed aifection. It prevails, however, more exten- sively in certain countries than in others, and occurs more frequently in » Lancet, April 16, 1898. LOBAR PNEUMONIA. 137 certain sections of the same country than in others. Thus, Delafield^ points out the fact (based on the eighth and ninth census reports) that in the United States the disease is of more frequent occurrence in the South than in the North. Climate, per se, does not, however, exercise a notable influence. (4) Season. — Of 5905 cases collected by Seitz in Munich, 36.8 per cent, occurred in the spring, 32 per cent, in winter, 15.7 per cent, in autumn, and 15.3 per cent, in the summer. The period of maximum frequency of the affection in temperate climates is usually from the begin- ning of February to May, inclusive, and the next most frequent period is from December until February. In London most cases appear between the end of March and the end of June (Herringhan). The period of greatest frequency will be found to correspond in time with the period of the greatest vicissitudes of temperature and humidity, though it cannot be affirmed positively that there is an essential connection between the latter condition and pneumonia. (5) " Catching cold " is often followed by pneumonia, but frequently there is no such history. In this condition the mucosa of the respiratory passages is so altered as to become more susceptible to infection with the pneumococcus, and hence the so-called "cold" is a predisposing cause. Such facts as these also explain why pneumonia occurs with undue fre- quency in persons following certain occupations exposing them to those external influences that are apt to excite " cold." (6) Traumatism. — Following injuries, especially of the chest, pneu- monia occurs quite frequently. Contusions of the thorax by lowering the vital power and resistance of the tissues probably produce the same local effects as taking "cold." (7) Age. — Lobar pneumonia is common at all periods of life, and during the first two years of life lobar pneumonia is quite frequent. Be- tween two and twenty years of age there is less liability, and between twenty and forty it is again increased ; while from forty to sixty years susceptibility again diminishes. After the latter period it augments rapidly. (8) Sex. — Males are, on the w^hole, more frequently attacked than females, the discrepancy in the relative number of cases being greatest from the twentieth to the fiftieth years of age, and being due to the dif- ferent degrees of liability to exposure in the two sexes. (9) Unhygienic Surroundings. — The disease is more frequent among the lower than the higher classes — a fact due to the improved hygienic environment of the latter, since, doubtless, anything that will lower the vital energy will serve as a predisposing factor. (10) Circumstances connected with Individuals. — The alcoholic is espe- cially prone to this disease, any or all habits that tend to depress the ner- vous system acting as predisposing causes. Certain chronic diseases may exert an influence (chronic Bright's disease, organic heart-affections, car- cinoma, diabetes, etc.) ; but, contrary to what is observed in other acute infectious diseases (typhoid fever in particular), susceptibility is not so great among immigrants and new-comers as among the natives and the older residents. ^ " Diseases of the Langs," American Text-Book of the Theory and Practice of Medicine, Pepper, vol. ii. p. 540. 138 IXFECTIOUS DISEASES. (11) Prior Attacks. — One attack undoubtedly leaves the system more susceptible to the disease, so that repeated attacks may occur in the same individual. And yet "while it is true that persons have had nu- merous attacks — ten or more — this predisposing influence has probably been overestimated by most Avriters. Immunity. — The results of the investigations of Behring and Kitasato Avith the blood-serum of animals Avhich had been immunized against tetanus and diphtheria led Drs. G. and F. Klemperer to experiment upon the lower animals with Frankel's diplococcus. They found that the rabbit could be rendered immune by intravenous or subcutaneous injections of large amounts of the fluid bouillon-cultures or of the glycerin-extract. From 10 to 20 c.c. of serum taken from a non-receptive animal were injected into the veins of an animal that was suffering from typical pneumonia (artificially produced), whereupon the symptoms subsided rapidly and the animal entered upon a speedy recovery. The same serum, used in a similar manner upon healthy receptive animals, rendered them non-recep- tive. The important truth that the serum of the blood of patients dur- ing convalescence from pneumonia contains an antitoxin which, when injected into the venous system of infected animals, is found potent to cut short the disease, has also been demonstrated by these observers. They have employed the blood-serum of pneumonic patients after the crisis, injecting it into other patients before the crisis with a view to inducing the latter, and success has attended their efforts in 6 cases. The question of serum-therapy for this important affection in man is not finally cleared up, and is still beset with diflficulties ; but that the pneumococcus engenders a virus — pneumotoxin — which produces eleva- tion of temperature, etc. has been clearly demonstrated by the Klemperer brothers. Again, that this substance, acting upon the albuminous ele- ments of the body, generates an antipneumotoxin Avhich circulates in the blood and neutralizes the pneumotoxins as they are formed, inducing the crisis, has also been clearly proved. Antipneumotoxin, however, has not as yet been isolated. Clinical History. — Prodromes are rare, and when present consist merely of a slight general indisposition, lasting a day or more. Rarely, there is cough, thoracic oppression, and slight chest-pains (simple bron- chitis), that may or may not be connected with the pneumonic process. When this is the case, however, the invasion may be marked by sudden, great thoracic oppression or by a gi-adual development of the local and general symptoms. Usually the invasion is very abrupt, and marked by a severe rigor, which has a duration of from half an hour to an hour, during which period the patient feels most uncomfortable, and is, indeed, very ill. The initial chill may occur at any hour of the day or night, the fever rising immediately and rapidly, and the temperature often mounting to 104° F. (-10° C.) or even higher in the course of a few hours. The skin becomes harsh and dry, the face flushed, and the cheek on the side affected often shows a circumscribed deep-red spot. Prostration is pro- nounced, and headache and other nervous disturbances (restlessness, de- lirium) accompany and follow the ushering-in symptoms. The thoracie symptoms follow closely upon the termination of the chill. Inspiration, particularly if deep, causes a stabbing pain in the LOBAR PNEUMONIA. 139 affected side; the respirations are hurried, somewhat jerking and shallow (panting), while the pain persists, and later dyspnea may become marked, with accelerated breathing. Cough sets in early, and is dry and pain- ful during the first day or even longer, and may be attended with expec- toration, Avhich generally pi"esents a characteristic rusty or blood-stained apjjearance. The physical signs rarely appear before the end of the first day, and sometimes as late as the third (central pneumonia) ; in the latter form the local symptoms, as cough, dyspnea, and sometimes pain, are either wanting or feebly expressed during the first three or four days, and the clinical picture is composed of the general features only. Anorexia is usually complete ; thirst is excessive, and there may be vomiting at the onset, the bowels being generally constipated, though diarrhea may not infrequently be present. The patient in most instances lies upon the affected side until the pain has in great part subsided, and then he is apt to assume the dorsal position, exposing to full view an anxious countenance, with a characteristic flush upon the cheek, while the alae nasi are seen to dilate forcibly during inspiration. Very frequently herjjes on the lips or nose appears about this time, and forms a valuable diagnostic symptom. The nocturnal remissions are slight, the temperature being of the continued type, and the fever con- tinues high— 104° to 105° F. (40.5° C.)— for from five to ten days, and generally terminates by crisis. The pulse is somewhat quickened, but the jjulse-respiration ratio is not maintained. The other general features last until the crisis occurs, or even increase in severity, but do not out- last this period ; many of the local symptoms, however, and particularly pain, are greatly improved before the crisis is reached. As will be seen hereafter, the general course of pneumonia is modi- fied by a variety of interfering conditions that have relation to compli- cations, individual circumstances, severity of the type, etc. In the in- stances in which the crisis is reached convalescence is rapidly established. The crisis may be accompanied by special symptoms, as copious sweat- ing or diarrhea. Leading Symptoms in Detail. — Local or Respiratory Symptoms. — In- creased frequency of the respirations is a characteristic symptom, the rate varying from 40 to 60 per minute in adults, and in children from 60 to 90 or more. It is panting in character, particularly when pneumonia occurs in old subjects, and both inspiration and expiration are brief, though sometimes separated by a rather long pause. Expiration is usually accompanied by an audible " grunt," indicating great oppression, and while actual dyspnea is a frequent symptom, it may be absent or as the case progresses may become either increased or greatly diminished according to the severity of the type. The chief causes of the rapid and labored breathing are the involve- ment of a large portion of the lung, associated general bronchitis, peri- carditis or extensive pleurisy, cardiac failure, collateral congestion with edema, fever, and the intense pain in the side. The pulse-respiration ratio is disturbed, the relation now being 1 to 2, or even 1 to 1.5, instead of 1 to 4, as in health (see Fig. 16). Pain in the affected side is in most cases developed within a few hours after the initial chill, and after lasting tAvo or three days gradually dis- appears. It is stabbing in character, and usually referred to the region 140 ISFECTIOUS DISEASES. immediately below the nipple or to the axilla, and rarely to other points (abdomen, flank). In most instances it is not severe until greatly in- tensified by the cough, which always aggravates this symptom, as does deep inspiration. The pain is due to implication of the pleura covering the intlamed lung, and may be entirely absent, especially in the aged and those showing marked toxemia. The coughs like the chest-pain and respiration, is somewhat charac- teristic, being frequent, short, dry, and voluntarily repressed, because it is attended with increased suffering. Yet there are cases that run their entire course without cough, and this especially in the aged and in drunkards. The Sputum. — At first mucoid and frothy, it soon becomes of a cha- racteristic rusty color. It consists of a frothy, fluid mucus containing an abundance of small viscid masses of a yellowish- or reddish-brown color, from admixture of blood. The chief peculiarity of the sputum in fully developed cases is its viscidity and tenacity, often adhering to the receptacle even though the latter be inverted ; owing to its adhesive quality it is ejected from the mouth with considerable difficulty by the patient. About the time of the crisis the sputum usually becomes more abundant, distinctly purulent, and its expulsion ea.sy, but rarely it may be absent after the crisis. In severe types of the disease it may, at the outset, consist largely of pure blood, and in adynamic forms it is often thinner and darker in color (prune-Juice). There are cases in which there is an abundance of muco-purulent expectoration when extensive associated bronchitis occurs, and, on the other hand, instances are met with in which nothing is expectorated save a little light-colored mucus. In old persons or in those previously enfeebled there may be no expec- toration whatsoever. The amount is therefore exceedingly variable, not only in different cases, but also in different stages of the affection. Under the microscope the sputum is seen to contain red blood-cor- puscles, alveolar epithelium, the Micrococcus lanceolatus (usually with other micro-organisms), pus-corpuscles, and small fibrinous casts. General Features. — The Fever. — As I have already stated, the fever rises rapidly during the initial chill, so that in eight to twelve hours the temperature reaches 104° or 10.5 "^ F. (40.5° C). It then remains high until the crisis, pursuing the continued type, with nocturnal remissions amounting to a degree or over, while the daily fluctuations correspond with the normal, except that they are now somewhat exaggerated. In children the rigor is almost always replaced by convulsions. The tem- perature has a lower average range in persons previously debilitated, in old people, and in drunkards, than in healthy adults and children. During the febrile period there may be observed a ])ronounced fall of temperature — pseudo-crisis — but the temperature again rises to its former height. This may occur quite early, though more often it precedes the true crisis by a day or two ; and rarely it may take place repeatedly, and the temperature-curve bear a strong resemblance to the remittent or even the intermittent type, regardless of any malarial infection. The temperature may be unusually high. 106" F. (41.1° C.) or even 107° F. (41.6° C), these striking elevations sometimes immediately preceding the crisis (perturhatio critica) ; but this does not belong particularly to pneumonia. It is especially characteristic of pneumonia, hoAvever, that — _- _ ^ < > < D > 3 ^^ s 5 5 i i" s i = i S ! ^ p. M. TEMP. 108 107 106 105 104 103 102 101 100 99 NORMAL 98 97 > 2 f- 1 1 11 i * " fj^ j . » ~- 'T~"~»v ~~-<--_ ;: 's _""' : ___" " :r ^ : : ::::":!:=- ::: - \/-. 1 ■ ' ~~ *- E ^>^ ' - . ~ - .^ » " >- - ■ ^^ ~ ;; " ^"Z _ - - _- _-_!: -_ - :::::::::: : :: ^_ _._ _ ,_^ - : : A^ - -- .■=--:- •' _ 5:^ 1 . '=:. '- = "^ ' - - s K ~ ~ = » * J^ '■-. ^ ' "■ " " __ :-:::::::::::::::::_fer:::^:::::::::::::! :: :::::::: » '- - . . , . , , . , , s ... . ~ ?■ ::::::___:::: :.s___:::_:::_::::.:^.^ s : : : ^::::. Vi^... X-- x§:..> ,.-! " ::: ::::"::::::::::5':::^:":::::::::::::=e::::::: ::: ^ <^ _ _ — ^^ .^^ . - -_^^ - - 3 3I-_^ - _ !l-""3I _::..:: ::: %---- ,-^-:: - ::::: :Ji"'' :::=:::::::::::::::::::::: ^ < _::::::: : i.—/- 1:2 QJ _: :::::::_: H;^_( j^= 5 i^. _ ,::=- .. ___ - ^d:2^^ -<^^ ~ — -• — ' '~- '- = •<^ '~-- ~'^ 0; ""~ -- ^>-^ ' = ; " r" 1~-. "~---- ~~~~- n>^ ~ '" '; '~ ; =• = ^ ,-■'. — " ^ ^!::::::: ::>:::::::::"::::::::: - - ::::___ : ":_:_ __ :q:___-.,--j£: ^^ ■-. "->-. To :£ ) - ^2 - __ - -^ :::: : :C--^--i ,-^ - - ^ -- --" '■ >;-- c = '"" - X 5 _----■' "'v ■X ! _:: "'V. : _,;^ .0 "~: ."^^.Kv." Z't~ ~ I : : : z : > _: -^'^i >_:::._-> ^__ - <: --7 - — - .__... * X :: : 'i^:::: ::::. : ___:__.=., 5 ^i. 3 _ ".x C -- - -^ - ±=-_,:5 \ = 142 INFECTIOUS DISEASES. the fever terminates by crisis : hence a mere glance at the temperature- chart may serve to complete the diagnosis in doubtful cases (see page 141). The crisis may occur anywhere from the end of the third to the fourteenth day, but in the majority of instances it is on the seventh or the ninth. The temperature usually falls during the night, and the drop is accompanied by copious perspiration, so that by the following morn- ing the thermometer is found to register at the normal, or more often a subnormal, point (96-95° F. — 35° C). This fall in temperature may also be interrupted by fresh though slight exacerbations. The duration of the period of decline is usually from eight to twelve hours. It may be much shorter, but more often is much longer, just as when the decline takes place by lysis. The latter mode of termination is usually due to some complication, and when the high fever persists for an indefinite period (twelfth to fourteenth day or longer), it is usu- ally owing to delayed resolution. Circulatory Symptoms. — Most important is it to study the condition of the heart and pulse in cases of pneumonia. The average pulse-rate in typical cases is about 100 to 108 per minute, and when it exceeds 120 there is just cause for alarm. The rate may be increased either suddenly or gradually, but in any event augmented frequency implies danger, since it is a certain indication of failure of heart-power. The latter may be due to the influence of the poison secreted by the diplo- cocci, to previous organic disease of the heart, or to some complicating condition (pericarditis, collateral edema), and the period of greatest liability is in the advanced stage of the disease. At first the pulse is small ; a little later full and bounding, although the latter character of the pulse may be associated with low tension (Van Santvoord). In extensive consolidation the pulse is apt to become small, due to the fact that a les- sened amount of blood reaches the left ventricle and systemic circulation. Dicrotism may be noticeable, and an irregularity in the volume and rhythm of the pulse may be observed ; it is an unpropitious sign. In the aged and the weakly, a feeble, frequent pulse may be present. The heart-sounds are clear, and owing to increased tension in the pulmonary vessels the pulmonary second sound is accentuated. This is the state of things throughout in favorable cases. With failure of the right ventricle (a not rare eventj there arise the signs of dilatation of this chamber (extension of cardiac dulness to the right, epigastric impulse, a low systolic murmur, shortening of the diastole, or fetal heart- sounds, signs of venous stasis, and indistinctness of the pulmonary sec- ond soundj. The strength of the right ventricle, upon which so much depends in pneumonia, is indicated by the character of the pulmonic second sound. A soft. loAv-pitched murmur is sometimes audible in the mitral and pulmonary zones. The hlood- appearances are somewhat characteristic. The researches of Lache^ show that leukocytosis is of some value in determining be- tween the crisis and pseudo-crisis, continuing in spite of the fall of tem- perature, etc. in pseudo-crisis, while it disappears with the true crisis. Stienon - finds that in the febrile stage the polynuclear forms predom- inate, but as soon as these diminish the eosinophiles begin to increase. » Berliner klin. Woch., 1893, Xos. 36 and 37. » La Presse mid., .July 13, 1895. LOBAR PNEUMONIA. 143 The red corpuscles and hemoglobin remain little changed during the course of the disease, but show a marked decrease almost immediately after the actual crisis.^ The prognostic significance of absence of leu- kocytosis would seem to be considerable, as this symptom serves to dis- tinguish pneumonia from influenza, in uncomplicated cases of Avhich it does not occur. The blood-plates are also increased in number (Hayem), Da Costa has collected 6 cases of phlegmasia alba dolens in pneumonia. Cerebral Symptoms. — Headache sets in early and may be a prominent and persistent feature. In many cases, and particularly in children, the disease is ushered in by convulsions, this symptom occurring more often in the apical than in the basilar form of pneumonia. Delirium may come on during the acme of the disease (rarely, it may start as an acute mania), and may assume a maniacal form, but oftener in my experience conscious- ness has been retained. In the drunkard delirium tremens usually de- velops, and may anticipate the symptoms referable to the lungs ; and I fully agree with Osier in stating that it should be an invariable rule, if fever be present, to examine the lungs in delirium tremens. These cases may often be appropriately termed "walking pneumonia," since they go about until excitement gives way to a coma that deepens into death. In adynamic forms a low, muttering delirium is frequent and is sometimes accompanied with more or less coma. In the so-called cerebral pneumonia the nervous phenomena are quite pronounced, and simulate closely cases of cortical meningitis. It is often associated Avith excessively high fever, except in the aged, when the cerebral symptoms are also well marked, but the fever is moderate. Most authors contend that apical pneumonias are apt to assume the cerebral type, but, according to my own experience, this dictum is cor- rect as relating to children only. Most authors also state that double pneumonias are characterized frequently by severe cerebral symptoms, yet I have seen instances in the adult without unusual nervous phenomena. The Cutaneous Symptoms. — As stated before, herpes is common and its diagnostic importance is considerable. Naso-labial herpes is but little less frequent in this disease than in malaria, being present in about one- third of the cases. It usually comes out from the second to the fifth day of the disease, and rarely may appear upon the cheek, lobe of the ear, the genitals, forearm, or upon the mucosa of the tongue. Sweats are not common during the height of the disease, but usually accom- pany defervescence, when they may be copious. The deep-red circum- scribed spot upon one cheek {inaliogany flush), usually on the side of the affected lung, has already been mentioned. Urticaria has been ob- served, though rarely. Digestive System. — The mucous membrane of the mouth is dry, the tongue has a coating of a yellowish-white color, becoming dry and brown in cases representing a low form, and anorexia and thirst are present. Vomiting is not uncommon at the outset, and may be repeated, while constipation is the general rule and diarrhea the frequent exception. The above symptoms spring from the marked fever. Splenic enlarge- ment of slight degree can usually be detected on palpation, but the liver is not perceptibly increased in size. ^ Sadler, Fortschritte der Medicin, 1892 ; Leichtenstein, Ueber der Hdmoglobin-gehalt des Blute.-; etc., Leipzig, 1892. 144 INFECTIOUS DISEASES. Urinary Symptoms. — The urine is febrile, diminished in amount, and higrh-colored, the urea and uric acid beincr crreatlv in excess. On the other hand, the chlorids are. according to the older authors, either diminished in amount or absent during the febrile stage, presumably for the reason that they pass into the inflamed lung-tissue. They are not, however, constantly absent, and sometimes they are not even lessened, in pneumonia ; moreover, their disappearance is not peculiar to this dis- ease. The above-mentioned facts justify t^vo important inferences: (1) The absence of chlorids is a symptom of little diagnostic value : and (2) their reappearance in the urine toward the close of pneumonia is of small prognostic worth. Slight (febrile) albuminuria is common. Physical Signs. — Stage of Congestion. — The density of the lung is increased, but the involved tissue is not consolidated and the pleura is not yet covered with fibrin. Inspection. — The movements of the affected side (especially if the base be involved) are defective, the degree of expansion being much diminished. In double pneumonia the costal type of breathing, com- bined with a vigorous play of the abdominal muscles, is observed. Palpation. — There is a slight increase in the tactile fremitus over the congested area. Percussion. — The note may be normal, though more often it is briefer, higher-pitched, or even distinctly tympanitic. Auscultation. — The breath-sounds are weak, and sometimes become broncho-vesicular upon deep inspiration, while over the unaffected lung- tissue they are exaggerated. If, as often happens, inflammatory prod- ucts due to associated bronchitis occupy the small bronchi, subcrepitant rales may be audible. The crepitant rale, however, is rarely heard until the close of the first stage or until fibrin coats the pleural sur- faces, and I cannot agree with the view of certain authorities who claim that this rale is produced in the air-cells and finer bronchi. Stage of Consolidation. — Inspection. — There is little or no expansive motion of the chest over the affected area, while upon the unaffected side it is increased. The volume of the thorax on the diseased side is increased, as shown by mensuration, but the intercostal depressions are not effaced. Palpation renders clearly perceptible the defect or absence of expan- sion. Vocal fremitus is usually much increased, though in exceptional instances it is diminished or absent — a circumstance which can, as a rule, though not invariably, be attributed to an associated pleurisy with more or less effusion. Frequently a friction-rub is felt before complete consolidation is established. Percussion. — Varying degrees of dulness are obtained in this stage, and before the lung-tissue becomes thoroughly solidified the note may have a tympanitic quality. After complete consolidation there is usu- ally marked or absolute dulness posteriorly, while the note may be more or less tympanitic anteriorly, where the vibrations are more apt to reach the air in the larger bronchi. A sense of resistance is offered to the pleximeter-finger. but not to the same degree as in the case of a pleurisy with effusion. When the latter condition is associated the percussion- note will be flat. Deadness is less marked in old people in whose ribs senile changes have taken plac0, which render them more resonant, or in LOBAR PNEUMONIA. 145 cases in which the consolidated areas occupy the central portions of the lung. Above the solidified part Skodaic resonance is usually obtainable. Auscultation. — Bronchial or tubular breathing is heard, as a rule, over the solidified lung, but it may be absent in consequence of the plugging of the large bronchi with exudate (so-called massive pneu- monia). Bronchophony is usually obtainable over the portion of the lung afi"ected, though this may also be absent, and for the same reason as in the case of the bronchial breathing : it sometimes takes the form of egophony. Subcrepitant rales, due to associated bronchitis, are sometimes heard, and the crepitant rale at the end of inspiration, sup- posedly very characteristic, is best heard at the beginning of consolida- tion, when the pleura receives its coat of fibrin and while the lung is yet capable of sufiicient movement to produce fine pleural friction. A distinct friction-rub may also be heard occasionally. Stage of Gray Hepatization. — With beginning resolution the solid con- tents of the air-cells liquefy and are removed, so that air now re-enters the air-cells and permits a consequent increase in the movement of the lung. Inspection. — The normal expansile movement of the affected side gradually returns. Palpation. — Tactile fremitus progressively diminishes. Percussion. — The dull or tympanitic quality of the note is gradually lost, though the fact must be emphasized that the abnormalities in the note vanish more sloAvly than the other abnormal physical signs. Some degree of deadness often remains long after recovery is apparently com- plete. Auscultation. — With increased movement of the lung there may be a reappearance of the crepitant rale, due to interplay of the pleural sur- faces, and the softened exudate in the air-cells gives rise to subcrepitant rales, heard both on inspiration and expiration, with coarser rales over the bronchi. Bronchial breathing gradually gives place to broncho- vesicular, and the latter in turn to normal breathing. Complications. — Doubtless many of these are due to the primary infection by diplococci. Pleurisy is, of necessity, associated in all instances in which the con- solidation reaches the pleura. It is to be looked upon as a direct result of the pneumonic process, since in a great proportion of cases examined the presence of the diplococci has been demonstrated. Cases are met with, however, in which the truly pneumonic symptoms are overshadowed by the intensity of the pleuritis, and to these the term p)leuro-p)neumonia has been applied. In this form there is often a copious eifusion which is exceedingly rich in fibrin — a circumstance which distinguishes it from other forms of acute pleurisy. There may be the ordinary grade of pleurisy on the side affected by the pneumonia, and a severe grade on the opposite side, and when effusion occurs under the latter exceptional conditions it is apt to be purulent. Indeed, empyema has of late been shown to be a frequent complication of pneumonia, but, as far as my own observation goes, it would appear to rank as a sequel rather than a complication, coming on as it usually does several days after the crisis. Its development is accompanied by replacement of ordinary dulness by flatness with great resistance, and by the disappearance of rales and breath-sounds, normal and abnormal. Other characteristic features of 10 146 INFECTIOUS DISEASES. empyema are present, but in tlie event of doubt surrounding the diag- nosis the needle should be introduced. There is a prompt rise of fever, the temperature leaping to 103° or 104° F. (40° C.) quickly, after which it is decidedly remittent in type, but there are no hectic chills. Fistulous connection with a bronchus, however, and the establishment of empyema necessitatis are common events in this form of the disease, and may be preceded by diurnal chills, sweats, etc. The occurrence of septic phenomena is a certain indication of second- ary infection by streptococci. The pus is absorbed very rarely, and more frequently becomes encysted. I saw one instance in which the effusion measured 8 liters, while ordinarily the amount ranges from 2 to 5 liters. Removal of the effusion by aspiration is promptly followed by the disappearance of the fever, but reaccumulation generally occurs, with another rise of temperature. Finally, if defervescence takes place by lysis or if the '' critical " decline is absent, a residual purulent or sero-fibrinous effusion may be considered as the likely cause. This latter complication is attended by a paroxysmal cough which is excited by movement, and is not usually accompanied by expectoration, Avhile the temperature rises, though not so high as when the effusion is purulent. It remains to be pointed out that rarely also there is a primary empyema, due to the pneumococcus. Acute general bronchitis may pre-exist or may arise as a complication, and often proves formidable, intensifying the fever and increasing the dyspnea, the tendency to heart-failure, and the cyanosis. The expec- toration of mucus is freer than in uncomplicated pneumonia, and over the bronchi moist rales intermingled with sibilant and sonorous rales are audible. Pericarditis. — This is one of the most important complicating affec- tions. It results from a direct extension of the adjacent pleuritis, and hence is more common in left- than in right-sided pneumonia, and chil- dren are more prone to it than adults. Although generally of the plas- tic variety, it is not infrequently sero-fibrinous. and rarely the effusion is purulent. The diagnosis can be made in the same way as when other conditions attend its development, but it may be readily overlooked by the careless observer. I would say, however, that the occurrence of in- creased dyspnea, with or without precordial pain, sliould serve as a signal and lead to a physical examination. Endocarditis. — This is far more frequent than pericarditis, and par- ticularly in the ulcerative form. Out of 209 cases of malignant endocar- ditis collected by Osier. 54 cases occurred in pneumonia, and my experi- ence fully agrees with his statement as to its comparative frequency in this affection. There are no reliable symptomatic indications of this condition, and of those symptoms that do appear the physical signs are least trustworthy. Frequently murmurs are entirely absent : and, on the other hand, the presence of a murmur, even though it be loud and harsh, is by no means diagnostic of the complication. Some claim that a rough diastolic murmur is quite significant ; this has not, however, been present in any of my cases. The development of septic manifestations, especially irregular fever, chills, and sweats, renders the case highly suspi- cious, and when in addition there arises distinct evidence of embolic proc- LOBAR PNEUMONIA. 147 esses the diagnosis becomes highly probable. If, now, the symptoms of men- ingitis supervene, little cloubt remains as to the character of the complica- tions, since meningitis and endocarditis are often combined in pneumonia, Netter, Weichselbaum, and Bignami have shown by microscopic examination and cultivation that acute endocarditis may be caused di- rectly by the diplococcus of pneumonia, and, from the presence of this bacillus in the right ventricle, that it is far commoner than the forms due to other causes.^ Chronic Endocarditis. — This predisposes to acute endocarditis, both simple and ulcerative, but, indej^endently of the acute form, pneumonia arising in the course of chronic endocarditis is apt to be attended by cardiac failure, with venous stasis as the consequence. The murmurs of chronic valvular disease often disappear with the development of pneumonia. Cardiac clots (ante-mortem) may form, but are rare. They result from weakness of the ventricular wall, especially in the right heart ; and are most apt to arise, therefore, in cases in which the death-agony is much prolonged. Venous thrombosis is rarely seen, and embolism of the larger arteries is a rare complication. Cerebral embolism, causing aphasia and even hemiplegia, has been observed, but seldom. Acute purulent meningitis is a comparatively rare but very grave com- plication. It is often related etiologically to pneumonia, and its symp- toms are not clearly defined ; particularly is this true when it develops during the invasion^period and the basilar meninges are not involved. Hence its diagnosis is often impossible. The presence of intense and per- sistent headache, rigidity of the nucha, wild delirium, followed by stupor deep- ening into profound coma, affords a basis for a probable diagnosis. Its fre- quent association with ulcerative endocarditis has been pointed out above. Peripheral neuritis is among the rare complications of this disease. Parotitis is also sometimes seen, and may cause a fatal termination of the case. I have seen two instances, however, in which this was a com- plication, and both ended in recovery. It is thought to be associated usually with endocarditis, but not in my own cases. Arthritis. — This may closely simulate rheumatism at the start. It soon, however, takes the form of a purulent arthritis, and may be associated with other suppurative inflammations (meningitis, endocarditis). The pneumococci have been found in the affected articulation.- Rheumatism may be rarely associated also, particularly in children. G-astro-intestinal Complications. — Croupous gasii'itis may rarely inter- vene, but croupous colitis is a more frequent concomitant, giving rise to tympanites and marked diarrhea, and it may prove a serious condition. Peritonitis occurs, but with great rarity. Jaundice may be observed in all types of the affection, though, on the whole, it is more frequent in serious than in mild forms of the disease. It is rarely intense, and has no symptoms as a rule ; it is most probably an obstructive (hepatogenous) jaundice. I have observed cases in which the evidence of a certain degree of obstruction was unmistakable. N. V. P^trov has reported 13 cases complicated with icterus, and in all observed local lesions (mainly catarrhal) of the duodenum and the biliary canals. ^ Praciitionei', London, Aug., 1894. ^ Bernheim, La 3Iedecine moderne, Paris, Feb. 21, 1894. 148 INFECTIOUS DISEASES. Acute nephritis, generally of a mild grade, is a rare sequel or compli- cation, and its recognition is entirely dependent upon the discovery of albumin and casts in the urine. Clinical Varieties and Anomalous Types. — (1) Typhoid Pneu- monia. — This relates to an adynamic, serious type of the disease "with typhoid symptoms, and not to typhoid fever. It is often secondary to low fevers, to septicemia, diabetes, and chronic nephritis, and is also the vai'i- ety met with in drunkards and in persons previously enfeebled. The onset is somewhat gradual. The physical signs may be ill defined, but the general features are always striking and characteristic. Prostration is extreme ; there are delirium and often stupor ; the temperature may or may not be high ; while the respirations and pulse are almost always fre- quent. The skin is dry, and may show a dusky tint or slight jaundice. The tongue is dry, often brown, and vomiting is common; the sputa may be rusty or decidedly hemorrhagic. Splenic enlargement is often clearly perceptible. When recovery ensues convalescence is tedious. (2) Epidemic Pneumonia. — Tliis is often of malignant type. The symptoms exhibit noticeable variations, according to the special etiology and to different epidemics. The pneumonias of epidemic iiijiuenza are complicated with or preceded by general bronchitis. " The heart-power often becomes exhausted early, and then follow congestion and edema of the lungs. The physical signs are often slight. In epidemic forms of pneumonia still other complications may be pronounced (cerebral, intesti- nal, etc.). In so-called " larval pnetimonia " the general symptoms are mild and the local signs ill defined. The epidemic outbreaks that occur in institutions, tenement-houses, jails, etc. belong to this variety. (3) Latent Pneumonia. — To this class belong central pneumonias {vide General Symptomatology). In these instances the sputum is to be stained and examined microscopically, when the pneumococcus will be found. When pneumonia arises in the course of emphysema a physical examination often gives negative results, the dilated air-cells not being filled with the exudate : hence dulness is less marked, and tubular breath- ing is often absent. The sputum is gummous and rusty, as a rule. Be- fore the crisis occurs consolidation usually advances to the periphery. (4) Migratory Pneumonia. — By this is meant an extension of the spe- cific inflammation to other parts of the lungs. Such extension may pre- vent the occurrence of the usual crisis, and often occasions an exacerbation of the general pneumonic features. (5) Bilious Pneumonia (^'■3Ialarial Pneumonia'''). — When lobar pneu- monia occurs in persons who are subjects of malarial poisoning, the initial chill is prolonged and the fever paroxysmal or remittent. Jaundice and vomiting are common. (G) In children, the first symptom is often a convulsion. Cerebral symptoms (delirium, stupor, coma) may appear early. The upper lobes of the lungs are frequently involved. Unless the objective indications be examined for, the disease is frequently overlooked. The characteristic sputum is rarely seen in juvenile pneumonia. (7) In old persons pneumonia runs a peculiar course and is danger- ous. The initial chill is often absent or replaced by moments of chilliness. There may be nausea and vomiting. Prostration is pi'ofound ; there is fever, but it does not range high and is apt to be irregular. Nervous LOBAR PNEUMONIA. 149 phenomena, sometimes prominent, are not uncommon, but the local symp- toms (cough, expectoration, and pain) are mild or "wholly absent. The area of lung-tissue implicated is often insignificant ; when physical signs are present there are usually dulness on percussion (with a tympanitic quality), tubular breathing, and a few subcrepitant rales. This affection, as it occurs in old people, is a most deceptive one, the cases generally ending fatally after an illness of an apparently mild degree of intensity. (8) Ether-pneumonia. — Opinions are divided as to the frequency of occurrence of pneumonia after ether-narcosis. The aggregate number of cases from all sources (57,842) gives a percentage of 0.07. My own statistics, embracing 12,842 cases, give a percentage of 0.23.^ Among the principal causes are — (a) Season. According to my inves- tigations, over 80 per cent, of the cases occur during the winter and spring months. The patient is sometimes cai'ried from a heated operating-theatre through a cold corridor to a room or ward with a lower temperature, (h) " Catching cold," or exposure, as may obtain during protracted opera- tions, {c) Bronchitis, coryza, or other morbid state of the respiratory mucosa at the time of anesthesia, {d) Dried secretions or incrustations of foreign matter that are loosened by the ether and drawn downward into the lungs, particularly if the head be not kept comparatively low and turned from time to time, (e) Abdominal operations give the highest percentage of cases of ether-pneumonia, and my studies show that this is partly due to the more protracted etherization, thus rendering the bronchi more susceptible. Moreover, coughing excites great pain, and hence is restrained, with retention of the bronchial secretions. The clinical features are aptly compared with those of secondary pneu- monia {vide p. 157). The diagnosis rests principally upon the typical physical signs. Owing to the extreme latency of the condition, and the danger that the symptoms may be regarded as being septic in nature, I would emphasize the importance of a physical examination of the thorax upon the sudden accession of fever ^ particularly if associated with thoracic pam, however slight, following an operation. Relapses. — These are among the rarest of events, and are usually rudi- mentary. Recurrences are ordinary, hoAvever, second, third, fourth, and even more attacks occurring in the same individual. Course and Duration. — In cases that recover the febrile stage lasts from three to thirty or more days. In most instances, however, deferves- cence occurs on the seventh or ninth day, and resolution is completed about one week later, making the total duration from twelve days to two or three weeks. Convalescence may be delayed when complications out- last the primary disease or when sequelae arise, and fatal cases are apt to terminate on the seventh, eighth, or tenth day of the disease. The course of pneumonia is often greatly modified by complications. Termination. — (a) Delayed Resolution. — The process of resolution may not begin until the fourth, sixth, or even tenth week. Usually deferves- cence by crisis has taken place long before the physical signs indicate resolution ; the fever may, however, fall by lysis. When resolution occurs it may lead to complete restoration of the functional and anatomic entirety of the lung-tissue, or very rarely proliferation of the interstitial connective tissue may arise during the period of postponed resolution, producing iV) ^ "Ether-pneumonia," University Med. Mag., August, 1898. 150 INFECTIOUS DISEASES. clironic interstitial pneumonia, (e) Abscess and (c?) gangrene are also sequelae. For their clinical description, vide Diseases of the Lung. T. A. Bowes and H. M. Fischer each give notes of a case of gangrene that recovered. Diagnosis. — The diagnosis is determined by special local and gen- eral symptoms, together with the physical signs. Of these, the abrupt onset Avith rigor, the course of the fever with termination by crisis, the stabbing chest-pains, the dyspnea, the peculiar type of breathing, the abnormal pulse-respiration ratio, the cough, the rusty expectoration, atid the signs of lobar consolidation, are the most characteristic. Repeated physical examinations of the chest will often detect consolidation, though local symptoms are entirely wanting. Again, when in the course of cer- FiG. 17 -Lobar pneumonia : 1, unaffected area (upper lobe) ; 2, consolidated area (middle lobe) ; 3, resolving area (lower lobe) ; 4, heart in normal position. tain chronic affections (cancer. Bricrht's disease, diabetes, and organic affections of the heart) fever is developed, physical exploration of the thorax is imperatively demanded. Differential Diagnosis. — This relates to (a) acute pneumonic phthisis, (J) pneumo-tj^phoid, (c) meningitis, {d^ broncho-pneumonia, (e) acute pleurisy with effusion. («) Primary Lobar Pxeumoxia. There may have been prior attacks. AcrTE P.NEUMON'IC PhTHI-SIS. Inherited predisposition or previous tu- berculous disease. LOB A R PNE UMONIA . 151 (a) Primary Lobar Pneumonia. Sudden, with severe rigor and rapid rise of temperature. Fever of continued type, terminating by crisis. No drenching sweats, except at time of crisis. Herpes common. Not much emaciation. Pulse-respiration ratio considerably dis- turbed. Sputum rusty-colored, viscid, and sticky : contains pneumococcus. Acute Pneumonic Phthisis. Generally more gradual — repeated fits of chilliness (rarely severe rigor), often following exposure or "cold.'" Fever of remittent type, often becoming intermittent, without crisis. Drenching sweats present and oft re- peated. Absent. Rapid emaciation. Less so. Sputum may be blood-tinged: is more purulent and copious, and contains nu- merous bacilli and vellow elastic tissue. Fig. 18. — Acute pneumonic phthisis, posterior view : I, cavity ; 2 and 3, consolidation ; 4, infiltra- tion ; the white spots indicate rales. Duration of febrile stage shorter. Duration longer. Physical signs, as a rule, first referable First referable to apex, to base of lung. Usually limited to one lobe or the lower Usually extension from apex to base, portion of one lung. Signs of consolidation, followed by reso- lution. Sisns of consolidation, followed bv cavity- Apex of healthy side not involved. Prognosis not hopeless. Tuberculous disease of other organs does not follow as a rule. apex. Apex of opposite side generally in- vaded. Hopeless. Often does. 152 INFECTIOUS DISEASES. (^^) Tr/pJioid jmeumonia must be diagnosed from pneumo-typhoid, and the blood in the two conditions may be of service in the discrimination. Leukocytosis usually exists in pneumonia, and there is hypoleukocytosis in typhoid ; but this fact is only of value when there is marked increase or decrease of the leukocytes, since figures about normal may occur in either condition. Widal's test will be a decided aid. His assertion that a drop of blood from a patient with typhoid, added to a pure culture of tj^phoid bacilli, causes the cessation of the motion of the bacilli and their collection in clumps, and that this does not occur with blood from other diseases, is, I think, satisfactorily proved. (e) Meningitis is sometimes mistaken for pneumonia, and particularly when the latter occurs in children. The initial symptom of pneumonia in the very young is often a convulsion ; whereas, though in meningitis this symptom is not uncommon, it is more apt to manifest itself later. When headache occurs in pneumonia it is frontal. It is almost invari- ably complained of in meningitis, but is occipital, and is associated with rigidity of the cervical muscles. Before the occurrence of pressure- symptoms in the latter disease the patient is very restless and morose ; his reflexes are exaggerated and there is marked hyperesthesia. The temperature-range is lower, more irregular, and there is no crisis, while the pulse is more variable and often irregular in meningitis. In pneu- monia with latent local symptoms the pulse-respiration ratio is greatly altered and the type of respiration peculiar (vide ante). The important rule, to examine for the physical signs in doubtful cases, must not be neglected, and if the subject be young the apex region in particular. The differential diagnosis between pneumonia and broncho-pneumonia and pleurisy with effusion will be found on pages 517 and 551. Prognosis. — The mortality from pneumonia in hospitals averages about 25 per cent. It is less in private practice — about 15 per cent. The death-rate, however, is greatly modified by the type of the indi- vidual epidemic, and by so many conditions and incidents that a pre- cise statement as to the percentage of fatal cases cannot be ventured. The above mortality-rates have been based upon all of the accessible- statistics at my command. Wells collected 223,730 cases, which gave a mortality of 18.1 per cent. The elements that enter into a correct prognosis are in the main identical with those in other acute infectious diseases, and concern (1) the severity of the type of infection, (2) the presence or absence of complications, and (3) circumstances peculiar to the individual. (1) Severity of the Type of Infection. — In sthenic cases this is shown by (a) the temperature-range, {/>) the degree of heart-power, (c) the in- tensity of the nervous symptoms, and to some extent by (d) the size of the area of lung-induration. It has been demonstrated, experimentally, that the absence of leukocytosis is indicative of a grave type.' In case the diplococcus be found in the blood, the prognosis must be considered very grave, as it has never been found there during life, except in cases that are in themselves very grave or seriously complicated. A continu- ance of marked leukocytosis with a drop in temperature would point to a pseudo-crisis, (a) TIte Temperature-range. — A continued high tem- ^ Von Jaksch and Tchistowitsch, Annual of the Universal Med. Sciences, vol. i., 1893. LOBAR PXEUMOXIA. 153 perature, as, for example, 105° F. (40.5° C), on two or three consecu- tive days without material remissions, is ominous, [b) The Degree of Heart-poiver. — A steadily rising pulse-rate after the fifth day indicates real danger, since it points indisputably to gradual cardiac failure. The same thing is shown by a diminution in the intensity of the second pul- monary sound, particularly the giving out of the right ventricle. (':■) The Intensity of the Nervous Symptoms. — Active delirium is not favor- able at any stage, and is particularly unfavorable if it develop early. When it assumes the form of delirium tremens the case has usually passed beyond the hope of recovery, (d) The Size of the Area of Lung- induration. — I have observed that extension of the consolidation at an advanced stage belongs to serious types. The same may be said of double basic pneumonias. Typhoid pneumonia, being of asthenic type, gives an unfavorable prognosis, not-withstanding an absence of high temperature and of exten- sive inflammation of the lung-tissue. (2) Presence or Absence of Complications. — Cases in which there is involvement of a single lobe or two lobes, if it occur on the right side and without complications, generally terminate in recovery. In nearly one-half of the instances complications occur, and these greatly increase the death-rate. Among the most common is pleurisy, which, unless accompanied by considerable effusion, does not add fresh danger ; when pleurisy attacks the unaffected side, however, it does. Empyema, fol- lowing pneumonia, generally terminates in recovery unless secondary septic phenomena appear. Extensive hronchitis is a most perilous com- plication in my judgment. Pericarditis decreases the chances for re- covery, but by no means to the same extent as endocarditis. Qardiac clots may form, but usually the patient is already moribund. Abscess of the lung and gangrene form highly unfavorable complications. Con- gestion and edema of the uninvaded portions of the lungs render the outlook bad, and these, together with cyanosis, are apt to be dependent upon failure of the right heart. Acute meningitis is exceedingly grave. Fenwick, as the result of an analysis of 10,000 cases, found that the quantity of albumin in the urine is of considerable prognostic value. G astro-intestinal complications occurring at the outset are unpropitious. (3) Circumstances connected with the Individual. — Of these age heads the list, and after the twentieth year the mortality increases progres- sively until the seventh decade. It has been claimed that nine-tenths of the deaths after the seventy-fifth year are from lobar pneumonia. Under the twentieth year, according to the analysis of 708 cases at St. Thomas's Hospital by Hadden, H. W. G. Mackenzie, and W. W. Ord, the mortality is 3.7 per cent. Sex has little influence, though the disease is believed by some to be more fatal in females than in males. The alcoholic rarely escapes death. Course. — In common with other clinicians, I have been impressed with the increased proportion of cases showing an irregular course, and I ascribe this change, in part at least, to influenza. 3Iodes of Death. — Death is commonly due to heart-failure, which results from two causes : (1) overwork, as when an extensive area of lung-tissue is involved ; and (2) the direct effect of the pneumotoxin upon the heart. The complications mentioned may prove fatal, however, and 154 INFECTIOUS DISEASES. in one of my own cases thrombosis of the coronary artery killed the patient. This may be a not uncommon terminal condition. Treatment.— General Management. — The patient should occupy a well-aired apartment, which should be maintained at a temperature of 65° F. (18.3° C), except in pneumonias occurring in the very young, when it should be several degrees higher. The patient should not be allowed to leave his bed for at least one week after the occurrence of the crisis; and as pneumonia is a self-limited affection, the principal object is to support the powers of life until the crisis is passed. To this end notldng contributes so much as proper fcedintj. The diet should be light, chiefly liquid, but of the most nutritious sort. Alimentation should be especially vigorous Avhen there is the slightest tendency to increasing debility. 3Iilk should constitute the chief article of diet; meat-broths or meat-juices, egg-white, and light farinaceous sub- stances may also be allowe'j years, 8.88 ; 65 'and over, 38.55 (Wm. L. Eodman). When death occurs it is due to exhaustion. The mortality-rate is low, as shown by the results of my own collective investigations into the subject.^ I found the general average death-rate to be 5.6 per cent., while in cases from private practice it was 4 per cent. In persons over seventy years it was 46 per cent. The traumatic cases gave a mortality of 14.5 per cent. Treatment. — The treatment of erysipelas falls naturally into three subdivisions : (1) Dietetic ; (2) Constitutional ; (3) Local. (1) Dietetic. — Proper attention to the diet is of the first importance. It must be generous and composed of highly nutritious articles, and if the temperature be high, only li(iuid forms of nourishment should be admin- ' Journrd of the Am/>rirnn Medical A.taodntion, July 22, 1S93. ^"Points in the Etiology and Clinical History of Erysipelas," by the Author: Journal of the Am. Med. Assoc., July 22, 1893. ^ Loc. cit., p. 3. ERYSIPELAS. 177 istered in definite quantities and at regular, brief intervals. Rectal alimentation should be resorted to if the stomach rejects a suitable diet- ary, and I feel confident of the fact that liberal feeding is of greater service to the patient than any of the recognized forms of medicinal treatment. Lack of attention to the patient's diet during the primary attack tends to increase the frequency of relapse. In persons over fifty years of age, and in those in whom the vital processes have been lowered on account of previous chronic diseases, correct alimentation is of para- mount importance, often abridging the otherwise much protracted course of the aiFection. (2) Constitutional Treatment. — When, despite an appropriate diet, the pulse becomes very rapid and feeble, the heart's first sound indistinct, and the tongue dry or brown, indications for the use of stimulants are present and must be heeded. When needful, the alcoholics may be given with a comparatively free hand, 12 to 16 ounces (360.0-480.0) of whiskey daily in divided portions. Strychnin gives prompt results, and may be used in association with the alcoholics. In marked gastric irritability champagne is to be preferred. The tincture of the chlorid of iron was first extensively used in this disease by English authorities, and was formerly regarded by most clin- icians as a truly specific remedy. In 74 cases of erysipelas which were treated by this remedy alone, the average quantity being 1 dram (4.0) daily in divided doses, in the Pennsylvania Hospital by Drs. Lewis, DaCosta, Longstreth, Meigs, and others, the death-rate was 4 per cent.^ Other preparations of iron, however, are equally efiicacious. Quinin is a valu- able remedy in erysipelas, and during the past twelve years I have em- ployed it in not less than 30 cases, confining its use to instances in which the temperature touched 103° F. (39.4° C), and, with a single exception, in uncomplicated cases (22 in number) the nocturnal remissions were de- cidedly greater. In every instance iron in some form was administered simultaneously. J. M. DaCosta first used pilocarpin in erysipelas at the Pennsylvania Hospital. His experience showed that when given hypo- dermically (gr. -J— 0.010) in the very early stage, and repeated three or four times at intervals of two or three hours, it often aborted the attack. If we except this use of the drug, it is only in cases attended with high temperature with slight morning falls that pilocarpin should be employed ; and the condition of the pulse and heart can be relied upon as a guide to its administration. Whether or not the favorable results from the use of pilocarpin are to be ascribed to a property possessed by it of stimulating phagocytic action is not yet clear. Numerous antiseptic remedies have been recommended. Antistreptococcic Serum. — Andre, Robinson, Cox, and others have reported instances of its successful use. The serum is injected subcutane- ously ; its influence endures over several days, but it is important that the injections are repeated at forty-eight hour intervals. Marmorek's serum (care being taken that it is not too old) is to be preferred, and it is prob- able that it has immunizing power as well as a specific action as a prophy- lactic and curative agent. Certain sipnptoms demand internal medication. When the fever, as sometimes happens, is alarmingly high, its reduction must be accom- ^ "The Treatment of Erysipelas," by the Author: Therapeutic Gazette, July 16, 1894. 12 178 INFECTIOUS DISEASES. plished, and the best method is by means of cold spongings combined with the ice-cap, or cold or gradually cooled baths. The happy eflFects of this agent — cold — are manifold. Guaiacol has recently been em- ployed for the purpose of reducing the temperature, and found highly efficacious. The tendency to spontaneous remission of fever in this dis- ease must, however, be steadily borne in mind. For marked nervous jyhenomena, such as pain, sleeplessness, and active delirium, hyoscin hydrobromate (gr. y^ — 0.0006) has been tried hypodermically in numerous cases at the Medico-Chirurgical, Pennsyl- vania, and Philadelphia hospitals, and has given promise of being a valuable remedy. It should not be employed when the heart-power is found to be deficient, and to fulfil the same indications we may utilize the following: Sodium bromid, gr. v (0.324) every two hours, or gr. xx-xxx (1.296-1.944) at night; morphin, gr. ^ (0.008), and chloral, gr. X (0.648), in combination every half hour for three doses : potas- sium bromid, gr. x (0.648), and tincture of cannabis indica, T([x (0.666), in combination at bed-time; atropin, gr. gL. (0.0008), and morphin, gr. I (0.0108), hypodermically. The treatment of the various complieations must be conducted in accordance with general principles applicable to each. (3) Local measures have always held a prominent place in the treat- ment of erysipelas. The list of agents that have been used topically is long and embraces all classes of therapeutic substances. In the paper previousl}" cited it is stated that in the three series of cases (247) that were treated at the Pennsylvania Hospital, together with a fcAv collected from other sources, no less than fifty difi'erent remedies and preparations had been employed locally. Among those most frequently used Avere elm (37 cases) ; iead-water and laudanum (20 cases) ; carbolic acid (1 to 40), injected subcutaneously (18 cases); zinc oxid (14 cases) ; mercuric- chlorid solution (14 cases) ; ichthyol ointment with lanolin (8 cases), etc. Many of these preparations Avere prescribed for their effect in excluding the air — a leading indication. This I am in the habit of meeting by the use of carbolized vaselin or cool carbolized oil. A knowledge of the microbic nature of erysipelas has led to the local application of numerous antiseptic remedies, and it is along this line that the greatest advances in the treatment of the disease are to be ex- pected. Mention has been made of the method of injecting carbolic acid. Here the aim is to check the spread of the inflammatory process l)y inserting the needle at numerous points just beyond the inflamed border. The method (introduced by Heuter) has been much practised by Henry at the Philadelphia Hospital, and more recently by Osier at the Johns Hopkins Hospital, and is especially applicable in erysipelas mio-rans. In the statistics before given a solution of mercuric chlo- rid (1 : 4000) Avas used locally in 14 instances, to Avhich I can add the results of 12 others at the Medico-Chirurgical Hospital and in private practice. In nearly all of the cases it Avas employed in the foi'm of a lotion over the inflamed surface. In a fcAv it Avas injected beneath the skin, as in the case of the carbolic acid. More recently it has been recommended to scarify the affected part and follow Avith the application of a solution of mercuric chlorid. In view of the fact that the strep- tococcus is found chiefly in the more superficial channels of the corium, DIPHTHERIA. 179 it follows that it may be attacked directly by the mercuric-chlorid solution when the latter is used after scarification ; and this method of treatment is at once most promising and rational. In 8 in- stances (3 of AA'hich have been previously reported) it was attended with brilliant results, limiting the spread and allaying the severity of the local inflammation. DIPHTHERIA. [DipMheritis ; Angina Maligna ; Croup.) Definition. — An acute, contagious disease caused by the Klebs- Loffler bacillus, and characterized, anatomically, by a croupous-diph- theritic inflammation of the mucous membrane of the pharynx and upper air-passages. Clinically, it is characterized by irregular fever, prostration, and, frequently, albuminuria ; also by the secondary devel- opment of toxemia, and often of croupous laryngitis or cardiac failure. It is often followed by peculiar paralyses. In large municipalities it behaves endemically, and from time to time epidemically. Pseudo-diphtheria. — There are forms of inflammation occurring most frequently in the pharynx and adjacent air-passages (and also in many other parts of the body) that are attended Avith the formation of a pseudo-membrane, and are not caused by the Klebs-Loffler bacillus. These cases have been studied exhaustively by Prudden and others, who have usually found the streptococcus to be the specific cause of infection. The latter ,'^ however, has been found occasionally in the pharynx of healthy children and in the inflamed mucous surfaces met with in ery- sipelas and measles. "Pseudo-diphtheria," so called, is very common in scarlatina. Patliology. — The true diphtheritic inflammation has for its chief pathologic peculiarity the production of a fibrinous exudate. When the inflammation is superficial and of a mild grade, a croupous mem- brane is produced which can be easily removed from the mucosa, which it covers. Its formation is accompanied by a necrotic process that does not extend below, but practically replaces the epithelial layer of the mucous membrane. In the severer types of the affection, however, the fibrinous membrane infiltrates all the layers of the mucosa, which undergoes necrosis more or less nearly complete. In the severest forms the submucous layer may also become necrotic. It is to be borne in mind that the production of the fibrinous exudate in croup or diph- theria is always preceded by coagulation-necrosis of the epithelium. The mucous membrane surrounding the exudate is hyperemic, more or less edematous, and the seat of muco-purulent secretions. The Pseudo-membrane. — Its composition comprises fibrin, pus, disin- tegrated leukocytes, flakes of necrosed epithelium, bacilli, and some- times red blood-corpuscles. The fibrin has two main sources: (a) "The fibrinogen of the inflammatory matter," which transudes through the capillary Avails ; and {h) Disintegrated, migratory leukocytes, which form branching fibrillie. Weigert holds that the inflammatory exuda- 180 INFECTIOUS DISEASES. tion is coagulated by a ferment derived from the disintegrated leuko- cytes. The Klebs-Lciffler bacilli are found, chiefly and in varying relative numbers, in the meshes of the fibrillae, but also in the granular fibrin and on the adjacent mucous membrane. Frequently other micro-organ- isms are associated (streptococci, staphylococci, etc.). The membrane presents a grayish-white color, and, if croupous in character, can, as before mentioned, easily be removed. When the mucosa is deeply involved the membrane is thicker, firmer, and more adherent, so that its removal entire cannot be effected 'without great difiiculty, and without, as a rule, injui'y to the surface, as shown by bleeding, etc. The character of the pseudo-membrane is affected by the nature of the underlying structure ; thus in the pharynx it is firmer and less easily separable than in the larynx and trachea, where a distinct basement membrane is found (Flexner). As the membrane becomes older its color is apt to grow darker, becoming yellow or even dark brown. It sometimes becomes gangrenous, and softens or disintegrates, with the production of a very offensive brownish, semi-liquid excretion. The advancing edge of the false membrane is usually thin. On the other hand, when the process has become arrested the edge is apt to look raised or Avrinkled, and later it may be distinctly curled up. The membrane may extend downward into the ramifications of the bronchi. In such cases there is apt to be a lobular pneumonia, and this latter condition may occur without extension of the membrane. Occasionally there is a lobar pneumonia. A generalized bronchitis ex- tending to the smaller bronchi is common from the irritation of aspi- rated substances. In rare cases the membrane has spread into the esophagus and even into the stomach. After separation of a croupous membrane repair consists merely in a restoration of the epithelial layer — a process which is initiated by the fragments of epithelium that remain along the edges of the diseased area, and proceeds centrally. On the other hand, in true diphtheria, with necrosis more or less nearly complete of the mucosa and even the submueosa, sloughing occurs, and the missing structures are replaced by cicatricial tissues. The Heart. — The muscular structure and the nervous mechanism suffer most. The histologic changes may be of the parenchymatous va- riety, but only in mild instances ; whereas in severer cases fatty degen- eration is conspicuous. In still other cases the chief pathologic charac- teristic is an interstitial myocarditis, and rarely the lesions of peri- carditis and endocarditis have been noted. The heart is by no means always involved. The spleen is commonly enlarged, though not to an excessive degree. The blood is dark, its coagulability is greatly diminished, and Canon and Froseh have in a few cases found the bacilli in the blood of those dying of diphtheria. The red corpuscles are somewhat decreased in number during the course of the disease, while the white corpuscles are increased. Bouchut and Dulinsay consider the grade of leukocytosis of prognostic value, and claim that it varies directly with the severity. Grawitz has determined in numerous cases a higher specific gravity of the blood during diphtheria. The lymphatic glands of the neck become swollen as DIPHTHERIA. 181 a rule, and are often greatly enlarged, but tliey show little tendency to suppurate. In pronouncedly septic cases in which a mixed infection is found by culture a good deal of tumefaction of the neck occurs, this sometimes even obliterating the normal contour from jaw to clavicle. The Kidneys. — The kidneys show degenerative changes, the usual kidney-lesion being a hyperemic swelling with edema of the interstitial tissues, and often hemorrhagic spots in the cortex. Sometimes there is a marked glomerulo-nephritis. and more rarely a diffuse granular degen- eration of the epithelium. Minute areas of necrosis have been observed in the internal organs, in which fibrin has been found deposited (Oertel). Welch and Flexner have produced, by artificial inoculation upon guinea- pigs, kittens, and rabbits, foci of cell-death in the lymph-glands through- out the body, in the spleen, liver, lungs, heart, and intestinal mucosa. When the dose is small and the animal lives several weeks, the paralysis which belongs to the disease may develop. The nerves, in cases of paralysis, have shown parenchymatous and interstitial inflammatory lesions. In paralysis of throat-muscles {i. e. those near the locality of the pseudo-membranous inflammation) the latter show also round-cell infiltration and fatty degeneration of the fibers. Ktiology. — True diphtheria is caused by the Klebs-Loffler bacillus, and all cases of supposed diphtheria in which the bacillus is absent are to be regarded as non-diphtheritic. The etiologic is, therefore, quite different from the pathologic significance of this term. Recent researches have removed all doubt as to the specific nature of the Klebs-Loffier bacillus. Bacteriology. — The bacillus diphtherise nearly equals in length that of the bacillus tuberculosis, and is twice the diameter of the latter. It has rounded extremities, which are also frequently bulbous, giving it the appearance of a dumb-bell. At times one end only is clubbed, or, more rarely, one or both ends appear pointed. The bacilli are immobile, do not form spores, and stain readily, the best agent being alkaline methyl-blue. Their manner -of taking the stain is important. The bacilli show alternatincr se£!;ments of darker and lighter stained areas, and often minute dots showing a most intense and deep staining. They grow on most culture-media, but for clinical purposes Lofiler's blood- serum is important (3 parts blood-serum and 1 part neutral or slightly alkaline nutritive bouillon, containing 1 per cent, of glucose). Inocu- lated on this, they outgrow all other organisms that may be present, and within eight hours or less show numerous spots, one-half to one millimeter in diameter, which have a dull surface and a dense white or somewhat yellowish color. There are usually present also smaller points which have different appearances and which are colonies of other organisms. The former are the colonies of the bacillus diphtherise, and from these microscopic preparations and (by further cultivation) pure cultures can be obtained. The bacilli are semi-anaerobic, and thrive at the temper- ature of the human body; a temperature of 122°-136.5° F. (50^- 58° C.) causes their destruction in ten minutes. Pseudo-diphtheria Bacillus or Bacillus Xerosis. — From many cases, often showing no lesions, an organism may be obtained that is identical in appearance, manner of culture, growth, etc. with the bacillus diphtheriae, 182 INFECTIOUS DISEASES. but inoculation with it causes no lesions. The works of Abbott, Roux, Yersin, and others seem to show that this is an attenuated form of the true bacillus, and varying grades of pathogenicity may be found between the two. The distinction from the pathogenic bacillus can only be made by determining the lack of infection after inoculation. Site of Infection. — In the human family the seat of election of the bacillus diphtherige is usually the faucial mucosa, and less frequently other raucous surfaces and abraded skin. The bacilli do not penetrate the mucosa, and hence do not find their way into the lymphatic or cir- culatory system, but remain at or very near the site of the local changes. The Toxins. — Toxins are absorbed from the diseased spots by the lymphatics and blood-vessels, and produce the general phenomena in un- complicated cases. They have been isolated from artificial cultivations of the microbe, and when inoculated the chief ptomain of the Klebs- Lofl^ler bacillus so modifies the solids and liquids of the body as to render the subject immune (Behring). Another, however, if employed in like manner, produces dangerous and even fatal symptoms (convulsions, paralysis, etc.). It is certain that the bacillus can maintain an existence for months outside of the body, though its usual habitat is unknown unless it be the organic constituents of the superficial soil. The virulence of its products is modified by many individual conditions, and chief among these is a healthy and intact condition of the mucous membranes, which greatly reduces the susceptibility to the disease. Associated Microbes. — With the Klebs-Loffler bacillus are frequently found other microbes, especially streptococci and staphylococci. These pass beyond the site of local infection, reaching the internal viscera and other structures, and, as will be seen hereafter, give rise to the serious septic element of the disease. Modes of Infection. — When the bacillus leaves the body of the sick it is contained in particles or shreds of the diphtheritic membrane, or in the expired air. Infection may then occur (a) By direct contact with the shreds of membrane thrown off — e.g. when the latter are ejected by coughing and lodge upon the conjunctivae or faucial mucosa of bystand- ers. Under this category come the cases in Avhich the deadly poison is transferred to the physician and attendants, with resulting infection, from the sucking of tracheotomy-tubes, {h) Bij inhaling the air sur- rounding the patient (contagion). Infection by contagion, however, does not extend beyond a radius of a few feet from the patient, (c) A very leading manner of conveyance of the bacillus from the sick to the healthy is by fomites. The contagion adheres tenaciously to a great variety of objects (toys, clothing, library books, letters, slates and drinking-cups in the public schools, etc.), and in this way the germs of diphtheria have been transferred over great distances and have given rise to the disease long after. The latter fact renders it diflScult to trace certain cases to previous ones, to which they invariably owe their origin, (d) Sewer gas, per se, is to be regarded as non-pathogenic, or at least so far as this affection is concerned (Laws). It may, however, become a carrier of diphtheritic poison, (e) I regard it as highly probable that the disease may be communicated by domestic animals (fowls, cats, etc.). DIPHTHERIA. 183 As to the exact conditions under which infection occurs, our know- ledge is as yet incomplete. We know definitely the usual point of local infection in man, and also that a catarrhal mucosa or an open lesion of a mucous surface invites infection. It is not certain, however, that even a slight lesion of the mucous surface is essential to infection, though it is very questionable whether the diphtheritic germs ever find lodgement in the perfectly healthy mucosa. Some writers claim still that the Klebs-Loffler bacillus may enter the blood through the respiratory system and give rise to primary constitutional symptoms, the local manifestations in the throat being secondary. I have met with a single instance that would lend support to this view. Predisposing Factors. — (1) Age. — This is the most important factor, diphtheria being, in the main, a disease of childhood. Most cases occur between the second and seventh years, while the receptivity diminishes rapidly after the tenth year. Instances have, however, been observed up to the fiftieth or even the sixtieth year. During the first year of life also it is rare. (2) Sex. — This is without appreciable influence. (3) Season. — Cases are more numerous in winter and spring than at other seasons. (4) Climate. — Diphtheria is met with less frequently in tropical than in temperate and cold climates. Humidity favors the propagation of the diphtheria germ, and hence damp cellars also promote the spread of the disease. (5) Unhygienic Conclitiojis. — Unfavorable sanitary sur- roundings tend to lower vitality, thus increasing the susceptibility to the specific virus. Most epidemic outbreaks have held more or less intimate relationship with decomposing organic matter, defective drainage and sewage, cesspools, etc., though it is to be especially remembered that the disease often prevails in sparsely-settled rural districts. Immunity. — A single attack does not confer perfect immunity. Second and third attacks not infrequently occur in the same individual. Symptoms. — Incubation. — The duration of this period is from two to seven or ten days, and in a small percentage of the cases it may be longer. In virulent epidemics and when the disease is produced experi- mentally the incubation-stage is short — from twelve hours to two or three days. The prodromal indications of diphtheria are not strikingly characteristic. They may either be acute in character or very mild ; but usually the child will complain of feeling weary and indisposed to play, of being chilly and cold, and of pain in the head, back, and limbs. In young children the onset of diphtheria, as in other infectious diseases, may be marked by convulsions. There is nothing in this early stage of the disease to distinguish it from many of the other affections of children, such as simple pharyngitis or tonsillitis. There may be some fever, not very high — an elevation of one or two degrees at most. The child may often complain of discomfort in swallowing, and on examination the fauces will be found to be reddened, and in a short time the exudate will be found on the tonsils or soft palate. This is the usual type of simple ton- sillar diphtheria. Pharyngeal Diphtheria. — The symptoms are usually slower of develop- ment than in tonsillitis. The child is sluggish, looks heavy-eyed, languid, and pale for several days. The fever may not rise above 101° or 102° F. (38.8° C). On examining the throat, however, it is found to be swollen and red, and if lividity is more pronounced than the swelling, 184 INFECTIOUS DISEASES. it suggests the true nature of the disease. The membrane begins on the tonsils in the form of small patches of yellow exudate, scarcely distinguishable from the thick, cheesy plugs of inspissated dead epi- thelium and secretion which issue from the mouths of the follicles of the tonsils during the course of acute or chronic tonsillitis. The mem- brane spreads from the tonsils to the soft palate and half arches within a few days, and it may also appear on the pharyngeal wall. During this stage the throat may become much swollen and the tonsils greatly enlarged, frequently meeting in the median line. The glands immedi- ately beneath the angle of the lower jaw on one or usually both sides become hard, painful, and slightly enlarged ; the swelling of these glands is not usually great in mild forms, although their presence, in association with the forefjoincr symptoms, is an infallible indication of the disease. The child, as a rule, shows grave constitutional symptoms for a few days, and loses its appetite. The temjyerature is not charac- teristic, as a rule not being high, and the pulse is rapid and weak, being out of proportion to the general indications of the disease. In mild cases the symptoms abate by the end of the first week, and the pseudo- membrane separates, leaving a red. inflamed surface behind. The child is prostrated for a number of weeks, and in about 20 per cent, of all mild cases the toxic effects of the disease may show themselves in the form of a neuritis, with its accompanying paralysis. Variations in Manifestation. — Diphtheria may exhibit a number of variations as regards the seat of attack and the severity of the poison- ing. In some epidemics the Klebs-Lriffler bacillus seems to be more active and more numerous, or perhaps more virulent, than in others. The severity of the attack does not seem to depend on the amount of the pseudo-membrane, but rather, according to Rotch, upon three fac- tors : (1) the virulence of the bacteria ; < 2) the local resistance ; and (3) the general resistance. While false membrane is most frequently seen on the tonsils, spreading gradually to the soft palate and uvula, the mucous membrane of any part of the body (lips, tongue, conjunctivae, vulva, or glans penis) may be the seat of the growth. 3Ialignant Diphtheria. — The symptoms are severe from the com- mencement. There are one or at most two days of slight illness, and' then alarming symptoms manifest themselves, cardiac failure possibly setting in without a specially severe local lesion. Vomiting and high fever, resembling the onset of scarlet fever, may initiate the attack ; and within a few hours we may find extensive swelling at the angles of the jaws, with a feeling of stony hardness, a very off'ensive. bloody dis- charge coming from the nostrils, accompanied with diJEculty in opening the mouth. If the throat is examined, there will be found extensive swelling of the tonsils, even to meeting, the uvula and soft palate being edematous and covered with much sloughy-looking membrane. The temperature in severe cases soon reaches a point between 103° and 104° F. (40° C), while the heart-beats become exceeding feeble. In a day or two the cellulitis extends, the face becomes edematous, the skin pits all over the face, neck, sternum, and chest- walls. The patient soon becomes drowsy, cyanotic, and occasionally an erythematous rash appears about the face, neck, and chest, while a purpuric rash is not in- frequent in malignant cases. Death occurs in such cases within one DIPHTHERIA. 185 week from toxic poisoning. Malignant cases of diphtheria resemble verj closely malignant scarlet fever, though the pulse in scarlet fever will be of assistance in the absence of the characteristic rash. Nasal Diphtheria. — In all severe cases of pharyngeal diphtheria the inflammatory process is likely to extend to the nasal mucous membrane. In some cases the nasal mucous membrane is found to be the first in- volved, and it may spread to the tonsils, but in these cases the exudate will be found to involve the back of the soft palate and pharynx as well. In many cases of nasal diphtheria no membrane may be found during life ; there may be only a purulent discharge with blood, the presence of which in the nasal passage obstructs breathing, giving rise to a bubbling sound, and rendering sleep troublesome and noisy. Many cases have also been reported of formation of pseudo-membrane in the nose with mild general symptoms (often insignificant),, and from which bacilli identical with diphtheria bacilli were obtained by culture, the bacilli often persisting for months. Sometimes the cases have recurring mild attacks of pseudo-membranous inflammation of the nose, while the bacilli may be constantly present. It is probable that these cases may give rise to in- fections of like nature, and even of true diphtheria. In nasal diph- theria the symptoms are quite as severe as in faucial diphtheria, and in cases in which the soft palate, tonsils, and nasal mucous membrane are involved the general symptoms, the depression, and also the albuminuria, are well marked. In all cases of coryza with fever Ave should be guarded as to opinion, especially if an epidemic of diphtheria is prevalent at the time. The diphtheritic inflammation may spread from the nose to the conjunctivae, with the formation of a false membrane, and much purulent discharge may escape from the eyes, the lids of which may be greatly swollen. In this place it is well to remember that in measles we some- times have a form of membranous exudation occurring on the nasal mucous membrane and as a primary disease — " rhinitis fibrinosis " — which is not always diphtheria. This disorder runs a favorable course, the membrane being less adherent than in diphtheria. Ravenel has collected 77 cases, and in 33 out of 41 cases examined bacteriologically the Klebs- Loffler bacillus was found. Constitutional symptoms were either slight or wanting. Wound-diphtheria. — The bacillus will not live on normal skin, but when the skin is cut or bruised, as after blistering or an eczematous condition, and when a moist, raw surface is present, the bacillus freely flourishes. Granulations aJso form a favorable soil. The diphtheritic germs may be introduced into the system during an operation, such as an excision of the tonsils, or even a vaginal examination ; and in new-born infants the granulating surface left after sloughing of the cord may be- come the seat of diphtheritic inflammation. Laryngeal Diphtheria or Memhrayious Croup. — In many cases the Klebs-Loffler bacillus produces its influence first on the mucous mem- brane of the larynx, and in these cases the mucous membrane of the nose and pharynx may never give evidence of a false membrane. In laryngeal cases the first symptom is a cough of a harsh, metallic, ringing character, and never to be forgotten when once heard. The temperature may be slightly above normal, or even, in many cases, normal. The toxic absorption is slight, on account of the locality afi"ected, and the 186 INFECTIOUS DISEASES. constitutional symptoms are usually mild. The local symptoms, however, are very alarming, as they are the results of laryngeal obstruction, there being marked dyspnea with retraction of the intercostal and supraclavic- ular spaces, and later of the epigastrium and lower chest. These are associated with an increasing cyanosis. The child is soon very restless, is forced to sit up to breathe, and for the same reason bends forward with its head thrown back. In these extreme cases, unless relief is soon gained, the child dies of suffocation. In many instances a slower form of suffoca- tion may result from the extension of the membrane downAvard to the bronchi. Complications. — Local complications may be mentioned, as when we have hemorrhage from the nose and throat in the more severe ulcera- tive cases. Skin-rashes are not unusual, especially the diffuse erythema. Sometimes urtieca'ia will be noticed, and in severe forms purpura will mark the skin. Broncho-jjneumonia is the most serious pulmonary complication of diphtheria. It is not produced by the Klebs-Loffler bacillus, but by pyogenic cocci which have been taken in during respiration. Broncho- pneumonia is frequent, and most usually terminates laryngeal cases that have been operated upon. Albuminuria is really a part of the disease, and can scarcely be re- garded as a complication. It is the most constant symptom, and is almost as certain in establishing a diagnosis of true diphtheria as a bac- teriologic examination. It is met with in both mild and severe cases, and the greater the amount of albumin the more severe the case. When acute nephritis complicates diphtheria it is usually not accompanied by edema or anasarca. Dysphagia may, by its constant existence throughout the disease, pro- duce a profound impression on the general nutrition. Involvement of the conjunctivee is a rare but grave complication. Otitis media occurs frequently, and may be a troublesome complica- tion as well as a sequel. The most frequent sequelae are anemia, chronic naso-pharyngeal catarrh, peripheral neuritis and its associated paralysis. Anemia may so prolong convalescence that the child will frequently be exposed to some intercurrent disorder. The chronic naso-pharyngeal catarrh may be so marked as to offer a favorable ground for new diph- theritic invasion. Neuritis and paralysis will not be noticed until the third or fourth week, the paralysis usually being first seen when the child attempts to swallow, and the food, especially if liquid, is regurgitated through the nose. This is due to a paralysis of the muscles of the soft palate, which will also be noticeable owing to a peculiar alteration of the voice. The paralysis may take a general form, such as is seen in mul- tiple neuritis, the lower extremities being affected and the knee-jerk absent. It is frequently quite extensive ; it may extend to the external ocular muscles and cause squint, to the ciliary muscles and cause dimness of vision from unequal accommodation, or to the muscles of the trunk in general, producing widespread paralysis. The child, unable to hold any- thing, may stagger about as if intoxicated, so much so as to suggest the existence of a cerebral tumor. The disturbance of vision and the ab- sence of the patellar tendon reflex has in adults led to a mistaken diag- DIPHTHERIA. 187 nosis of locomotor ataxia. Loss of taste, deafness, and a disturbance of sensation are not infrequent. Thus, paralysis is to diphtheria what dropsy is to scarlet fever — a proof positive of the disease. To make one step more, in many sudden deaths occurring in early diphtheria we must recognize paralysis of the heart outside of all toxic influence, and the fact that in cases of sudden death, which are by no means uncommon during the disease, we have some sudden disturbance of the vagus brought about by means of its cardiac branches. The prognosis in all cases of post-diphtheritic paralysis is quite favor- able. Myocardial weakness tends to supervene as a sequel. It is evi- denced by the sudden accession of pallor, nausea, sometimes by vomit- ing, and also by weak heart-sounds and a feeble, broken, irregular pulse, etc. Diagnosis. — The diagnosis of a pharyngeal diphtheria (the usual typical form) is not difiicult if an epidemic be prevailing. The false membrane on the fauces and the presence of albumin in the urine give us a practically certain diagnosis. From follicular tonsillitis we diifer- entiate diphtheria by the seat of the membrane, that of the former being in the tonsils, while diphtheritic membrane is over the tonsils and over the soft palate. Moreover, in follicular tonsillitis the fever is high, the onset is sudden, and it is most usually associated with gastric disturbance. Albuminuria is generally present in diphtheria, while it is present in fol- licular tonsillitis in exceptional cases only. The histories of the two cases are quite different. A mild case of diphtheria in a house may be fol- lowed by a malignant one. Moreover, mild cases may not present albu- minuria, and fail to show the presence of albumin until later in the disease. In many cases clinical distinctions will entirely fail us, it being uncertain whether or not the case is one of mild diphtheria. The only unequivocal evidence of the disease is the finding of the Klebs-Lbfiler bacillus in the membrane. In many instances of so- called diphtheroid lesions the membrane is only formed by strepto- coccus pyogenes {inemhranous angina), and these cases are sometimes of an intense grade. Croiqjous or memhranous angina may offer some difficulty ; yet in this disease there is no tendency to spread to the nasal mucous membrane or to the larynx ; there is a diminished glandular enlargement ; there is no albumin, and the onset is more sudden. Diphtheria frequently is associated with a rash, rendering it difficult to distinguish the condition from scarlet fever ; but in diphtheria the rash is more truly an erythema, while in scarlet fever it consists of slightly raised points between which there may be an erythematous condition. The glandular swelling and sloughy condition of the throat, however, closely resemble diphtheria, and a positive diagnosis without a bacteri- ologic examination is often impossible. An immediate recognition of the disease is often possible from a smear-preparation of the exudate from the throat (see Fig. 19), the Klebs-Loffler bacilli being present in sufficient numbers to be readily distinguished by the microscopist. Park, who has had a rare experience with this affection, makes the following statement : " The examination by a competent bacteriologist of the bacterial growth in the blood-serum tube, which has been properly inoculated and kept fourteen hours at the body-temperature, can be thoroughly relied upon in 188 INFECTIOUS DISEASES. cases in which there is a visible membrane in the tnroat if the culture is made during the period in which the membrane is forming, and no anti- septic, especially no mercurial solution, has lately been applied. In cases in which the disease is confined to the larynx or bronchi, surprisingly accurate results can be obtained from cultures, and although, in a certain Fig. 19.— 1, A tube of blood-serum ; 2, a sterilized cotton swab in test-tube. Rub the swab gentlj' but freely against the visible exudate, and without laying it down, after withdrawing the cotton plug from the culture-tube, insert it into the latter, and rub that portion which has touclied the exudate gently but thoroughly over the surface of the blood-serum with- out breaking its surface. Now replace the swab in its own tube, plug both tubes, and place them in the box provided by the health officials. This is to be sent to the bacteriologic expert. In laryngeal diphtheria the swab is to be passed far back and rubbed freely against the mucous membrane of the pharynx and tonsils. proportion of cases, no diphtheria bacilli will be found in the first, yet they will be abundantly present in later cultures. We believe, therefore, that absolute reliance for a diagnosis cannot be placed upon a single cul- ture from the pharynx in purely laryngeal cases." When a bacteriologic examination cannot be made the practitioner must regard as suspicious all forms of throat-affections in children, and carry out measures of isola- tion and disinfection. In this way alone can serious errors be avoided. Mistakes do not usually occur in a more pronounced membranous sore throat, but in the lighter types, many of which are in reality due to the Klebs-Loffler bacillus (Osier). Prognosis. — Diphtheria is at the same time the most prevalent and most fatal of all the diseases with which the general practitioner has to deal. The mortality is enormous (30 to 40 per cent.), though it differs widely in different epidemics, and the most fatal variety is unquestion- ably the laryngeal. In laryngeal diphtheria the mortality may be as high as 75 per cent., and the younger the child the more unfavorable the prognosis, the strong and healthy seeming to share the same fate as the weakly. Of especially unfavorable prognosis are those cases that show large quantities of albumin in the urine, general adenitis, cervical glandular enlargement, excessive nasal discharge, a necrotic state of the throat, vomiting, and partial or complete suppression of the urine. Al- though the temperature in diphtheria is never very high, yet a sudden fall of temperature to subnormal and an irregular pulse, or bradycardia, are also a bad augury. Recovery from a severe attack in which there are extreme depression and much albumin is unusual, especially in a child under six years of age, though recovery takes place frequently in what would be regarded as hopeless cases. The results of Morse's ex- tensive observations are opposed to those of Bouchut and Dulinsay, who claim that the degree of leukocytosis is of prognostic value (see p. 180). The cases of neuritis invariably recover. A child who has had diph- DIPHTHERIA. 189 theria once is most likely to contract it again, and if he recovers is liable to suffer from its effects for years. The causes of death in diphtheria, in their order, are as follows: membranous croup or laryngeal diphtheria ; septic infection, Avhich may be a slow death ; sudden heart-failure — paralysis of the heart ; broncho-pneumonia, following tracheotomy or occurring during con- valescence. Treatment. — Prophylaxis. — The best preventive measures against diphtheria are a clean nose and mouth. Insist upon a careful toilet of the nose in all children. The slightest appearance of a coryza must be overcome at once by the use of a mild antiseptic wash ; all accumulations of crusts, dust, dried blood, etc. should be removed from the nose twice daily, especially in children attending school or during the prevalence of an epidemic. The child should be early taught to employ a small anti- septic gargle as a daily routine, using a weak solution of hydrogen dioxid, listerin, or even a mild dilution of alcohol. The teeth should be care- fully cleaned daily, and all decaying teeth should be filled or removed. If it is true, as one authority claims, that over two hundred different spe- cies of bacteria find a happy home in the oral cavity, this fact should make all parents attentive to the proper physiologic condition of the mouths of their children. All cases of sore throat should be examined for the Klebs-Loffler bacil- lus, and, if it is found, the individual should be isolated ; and all cases of diphtheria should be kept isolated until the membrane has disap- peared from the nose and throat. This is especially true in schools and asylums. Moreover, the throats of all persons exposed to this disease, and of those caring for diphtheritic patients, should be frequently ex- amined for the Klebs-Loffler bacillus, and if it be found the person should receive immunizing doses of antitoxin. The fact that the Klebs-Loffler bacilli when found in healthy throats may not be active is no argument against isolation, because it is well known that if the same germs were to find such favorable soil as a broken or catarrhal membrane they would rapidly develop. The seed being there, the soil only requires prepara- tion for its reception. An unrecognized feature in the prophylactic treatment of the disease is seen in the uncertain period of convalescence. It frequently hap- pens that long after all membrane has disappeared active bacilli may still cling to the throat. This condition may continue from two to six months, and even longer in deeply fissured tonsils ; and the disease may be communicated by such throats in the act of kissing young children or adults with sensitive throats or with a broken mucous membrane of the mouth. For this reason the indiscriminate kissing of young children on the lips should be interdicted by the physician. Sufficient importance has not been been given to the milder cases of diphtheria as to their isolation and disinfection, and this fact explains the occurrence of many house-epidemics. Treatment of the Attack. — The treatment falls very naturally under sev- eral departments: {a) the hygienic measures to limit the diffusion of the dis- ease ; {h) the local management of the throat to destroy early the toxic germs ; {c) medication to antagonize the effect of the toxins, and event- ually to overcome the complications and sequelse. 190 INFECTIOUS DISEASES. (a) Hygienic Treatment. — The patient should be in a room well ex- posed to sunlight and fresh air, as diphtheritic germs grow well in poorly- lighted and damp chambers. No stationary washstand should be allowed in the room, and Goodhart well says that many cases seem to have their origin in the proximity to foul-smelling drains. The physician should never consent to be responsible for the recovery of a patient in a room in which there is a washstand with its uncertain connection with the main sewer. If possible, the patient should use two connecting rooms, one during the day and the other at night, so that one while not in use may be thoroughly aired and disinfected. Even in mild cases the patient should be kept in bed throughout the attack, and in more severe cases also for some time during convalescence. This is especially important when there have been symptoms of cardiac depression during the acute stage. The general comfort of the patient is enhanced by two daily sponge baths of tepid salt-water or of alcohol and water. Feeding. — Nursing infants may be fed on breast-milk obtained by a breast-pump, but should not be placed at the mother's breast (Holt). The feedings should be regular, yet lighter in quality and quantity than in health, remembering the tendency to vomit in all acute febrile aifec- tions, and the fact that gastric disturbance is closely associated with diph- theria. The rule must be, less solids and more fluids than in health. Milk in some form being our main dependence, it should usually be diluted, and for young children partially if not wholly peptonized. The greatest difficulty comes in the latter part of the disease, when the child is septic and most likely has a strong objection to be disturbed. At this time vomiting is most easily provoked, and swallowing is rendered very difficult on account of the swelling and pain. We must not neglect the feeding even if it does cause discomfort, and here forced feeding by means of gavage is most valuable. Gavage is more desirable and likely to be more successful with children under three years than rectal alimen- tation. In older children, who object to the tube through the mouth, it may be passed through the nose with very little difficulty, and gavage by this route, even in intubated cases, will be extremely satisfactory. Con- centrated broths, meat-juice, and even milk-punch or raw eggs, may be given in this way. (ft) Medicinal.: — Alcohol no longer holds a debatable ground in the treat- ment of diphtheria : it is the most powerful drug in our possession to off- set the ravages of the disease on the nervous centers and for the control of the circulation. Stimulation should be commenced as soon as there is a reasonable certainty as to the correctness of the diagnosis, and by com- mencing early with whiskey or brandy we may prevent the depressing effects of the poison of diphtheria as seen in the pulse and general con- dition of the child. The indications for alcohol are marked prostration, feeble pulse, and a Aveak first sound of the heart. The quantity must be adjusted to the age and gastric condition of the child, and usually one ounce (32.0) of good whiskey or brandy, w^ell diluted, in twenty-four hours is sufficient for a child four years old. In very bad cases five or six times this quantity may be given, the only limit being the tolerance of the stomach. As a rule, the stimulant should be mingled with the food, as the child may rebel against taking both food and stimulant. Strychnin stands next to alcohol in importance in the treatment of DIPHTHERIA. 191 diphtheria, and usually it is given in too small doses. For a child four years old gr. -^ (0.0021) may be given every six to eight hours, and may be administered in little tablets by the mouth or hypodermically. Digitalis does not hold an important place in the heart-weakness of diphtheria, and yet it is strongly indicated on theoretic grounds. Clinic- ally, it has been found to have an unfavorable action on the stomach before its good influence can be had on the heart itself. The same may be said of camphor and ammonium carbonate. The aromatic spirits of ammonia is valuable for rapid effects in syncopal attacks. In cases of threatened heart-paralysis occurring late in the disease Holt has found nothing so valuable as morphm employed hypodermically, the drug being given in full doses and repeated every two hours, keeping the child under its influence for some days. Internal medication should be avoided until absolutely necessary, and such symptoms as vomiting or diarrhea are to be met with sufiicient treat- ment only for their control. ((?) Local Treatment. — For the direct attack upon the membrane in the throat nearly all the remedies of the Pharmacopeia have been used. Garg- ling, swabbing, painting, spraying, and washing the throat out, all have their advocates, and every physician has his favorite remedy or combi- nation. And, as all adult pharyngeal diphtheria tends to recovery, it would seem reasonable that this form of treatment should not be neglected ; yet since the acceptance of the antitoxin treatment medical opinion has suffered a decided change, especially as to the importance of local meas- ures. The very best local application for pharyngeal or nasal diphtheria consists of hydrogen dioxid, diluted one-sixth, and used both as a gargle and spray as most convenient ; this is usually suSicient in the early stage. The tincture of iron and glycerin is a valuable local remedy applied by means of a swab. The object of local treatment is a more thorough cleanliness — the prevention of systemic absorption of the ptomains. Hence a carefid toilet of the nose and throat is important in pre- venting the spread of the disease. This part of the work is more easily directed than accomplished, especially in rebellious children, and we have frequently felt that new lesions were created in the mucous membrane of the nose and throat by an undue ardor in making applica- tions. To avoid new lesions the spray alone should be used, and for the nose boric-acid solutions or hydrogen dioxid, 1 : 10, will be most service- able. In this work the utmost tact and kindness must be maintained, for it is truly pitiable to force a struggling child, endangering the strength to accomplish so little. Warm, weak solutions, most thoroughly applied by means of the fountain syringe, will be better than the more frequent use of the hand-syringe. In older children who will use it a gargle of boric acid, listerin, or Dobell's solution, well diluted, may be used to keep the nose and mouth clean. In laryngeal diphtheria the child should inhale an atmosphere laden with the vapor of slaking lime, or, whenever practicable, an atmosphere saturated with Lofiler's solution (menthol 10 grams, dissolved in sufficient toluol to make 36 c.c, liq. ferri sesquichlorid, 4 c.c, absolute alcohol. 60 c.c). J. Cordin warmly recommends mercurial fumigation for the relief of laryngeal stenosis. The development of the signs of actual stenosis, as shown by stridulous breathing, cyanosis, etc., furnishes an 192 ISFECTIO US DISEASES. indication for either intubation or tracheotomy. According to my observations, the results of intubation have been quite favorable, and I would strongly recommend a trial of this procedure before resorting to tracheotomy (see temperature-chart, Fig. 20). 1 2 3 4 6 6 7 r. 9 10 11 1. 13 14 15 16 17 18 19 20 M E M|E E M E M { E M 1 £ M 1 E '.■ 1 E V E M E M , E E M E V. E M E M E M E M E M E V. iE 106" 105° 104° 103° 102° 101° 100° 99° 98° 97° t 1 -, UJ 1 - ^ ir. i (T 1 1 i m = o- J 3 . — Li- 1 1 i ' 1 ' K L_/ : i m n - -/- / [ — f A / ^ 1 /' '-\ / /' ( / f ( :/ 1 / , / ) ■1 \ \ / -4 J- 1 I V- J_ V i \/ \>" sf V' / > 1 / ( /! 1 1 , / ; , / /J 1 \ Ij / r \| j / \^ "V^*^ 1 / fl / I A V 1 ji\ \, / ' 1 ^ V -J V- A — - / ^ 1 \/ V 1 V \ r \f\ \ 1 1 \f\ V 1 1 1 1 .1 1 1 1 1 1 1 _ 1 1 Fig. 20.— Temperature-chart of a case of diphtheria. (rZ) External Applications. — External applications to the throat have no effect on the course of the disease. They are useful, however, in relieving the pain and the swelling in the lymph-glands. Careful massage of the neck with camphorated oil, as hot as the skin will tolerate, is very sooth- ing ; and soap liniment may be used in the same way, or if much pain e.xists chloroform liniment may be substituted. Poulticing for the relief of pain is not desirable, as it seems to favor suppuration. In older chil- dren the ice-bag has been used w4th good effect, and it soon brings grate- ful relief from the tension and subdues inflammation. All manipulations about the child, however, should be carried on as gently as possible, so that its rest may not be disturbed. Serum-therapy; the Antitoxin Treatment. — This has now passed be- yond the stage of uncertainty and experimentation, and must be regarded as one of the most positive advances made in practical medicine. Its utility rests upon the discovery that animals may be rendered immune to diphtheria, and that the blood of an animal so treated, when introduced into another animal, protects the latter from infection by the diphtheria bacilli. The studies of Behring. Roux, Kitasato, and others have demon- strated that the use of the blood-serum of the lower animals, artificially rendered immune against diphtheria, has a powerful healing influence upon diphtheria that has been contagiously or spontaneously accjuired by man. These experiments Avere first published in December, 1890. The principle was first shown to be true of tetanus, and, late in 1892, Behring further showed that the blood of an immunized animal had the power DIPHTHERIA. 193 both of protecting and of curing susceptible animals which had been in- oculated either with the toxins or the bacilli of diphtheria. In preparing the blood-serum it is very desirable, of course, to have a uniform strength or standard. One-tenth of one cubic centimeter of what Behring calls his normal serum will counteract ten times the minimum of diphtheria poison, fatal for a guinea-pig weighing three hundred grams. One cu- bic centimeter of this normal serum he calls an antitoxin unit. The serum prepared by his method is labelled in three strengths. No. I. is sixty times the strength of the normal serum ; No. II. is one hundred times as strong ; and No. III. is one hundred and forty times as strong. To a child of two years or over not less than 800 or 1000 units should be administered at the first dose ; hence solution No. I. is rarely employed at the present day. Should a favorable result not be attained, then, on the following day, 1500 to 2000 units should be administered, and a third dose after a similar interval if necessary. The latter dose should be em- ployed at the outset in very severe cases and in those not seen until they are far advanced. The sites to be selected for injection are various. In very young children either the buttock or thigh is to be preferred, while in older children the flanks or subscapular spaces may be chosen as well. The injections should be made deeply into the subcutaneous cellular tissue. In fortunate cases the influence of the serum soon becomes apparent. Within twenty-four hours the faucial swelling diminishes, the membrane exfoliates, the temperature falls, the pulse becomes slower and stronger, and the general condition of the patient quickly improves. In cases of moderate severity and when injections are employed early the improve- ment in the throat and the constitutional symptoms is very decided ; and the earlier the case comes under treatment the better are the results. There are, however, many cases of great severity in which the antitoxin has been used early, and yet has not shown any benefit. A danger in serum-therapy may be the development of local abscesses, which, if full antiseptic precautions be taken, must be rare indeed. I have escaped them altogether. Certain skin-eruptions have been observed after injections, mostly urticarial, though sometimes scarlatiniform. The latter form has given rise to apprehensions of scarlatina. Widerhofer had one case which was isolated as measles, but never developed any symptoms other than the suggestive eruption. Rarely, joint-pains and swellings, with general prostration, supervene. Two fatal cases have been reported — one ^ that of a healthy boy five years old, the result of an injection of Behring's fresh serum as a preventive, dying within five minutes ; the other occurred in Berlin.^ For establishing immunity in subjects exposed to infection the injec- tion of 60 units (1 cubic centimeter of the No. I. serum) affords pro- tection. In order to arrest the development of the disease durino* the period of incubation 100 units (1 cubic centimeter of No. II. serum) is probably sufficient. A large number of preparations are on the market, many of which are good, yet great caution must be exercised in their selection. The use and value of antitoxin in private practice are best shown in ^ Journal of the American Medical Association, April 4, 1896. 2 Medical Neivs, April 18, 1896. 13 194 INFECTIOUS DISEASES. the following summary of the report of the American Pediatric Society's investigation of the subject: 1. The report includes returns from 615 physicians. Of this number more than 600 have pronounced themselves as strongly in favor of the serum-treatment, the great majority being enthusiastic in their advo- cacy. 2. The cases included have been drawn from localities widely sepa- rated from each other, so that any peculiarity of local conditions to which the favorable reports might be ascribed must be excluded. 3. The report includes the record of every case returned, except those in which the evidence of diphtheria was clearly questionable. It will be noted that doubtful cases that recovered have been excluded, while doubtful cases that were fatal have been included. 4. No new cases of sudden death immediately after injection have been returned. 5. The number of cases injected reasonably early, and in which the serum appeared not to influence the progress of the disease, was but 19, these beino' made up of 9 cases of somewhat doubtful diagnosis, 4 cases of diphtheria complicating measles, and 3 malignant cases in Avhich the progress was so rapid that they had passed beyond any reasonable pros- pect of recovery before the serum was used. In 2 of these the serum was of uncertain strength and of doubtful value. 6. The number of cases in which the patients appeared to have been made worse by serum was 3, and among these there is only 1 case in which the result may be fairly attributed to the injection. 7. The general mortality in the 5794 cases reported was 12.3 per cent., and, excluding all cases moribund at the time of the injection or dying within twenty-four hours, it was 8.8 per cent. 8. The most striking improvement was seen in cases that were injected durinor the first three days. Of 4120 such cases the mortality was 7.3 per cent., and, excluding cases moribund at the time of the injection or dying within twenty-four hours, it was 4.8 per cent. 9. The mortality in 1448 cases injected on or after the fourth day was 27 per cent. 10. The most convincing argument, and, to the minds of the com- mittee, an absolutely unanswerable one, in favor of serum-therapy is found in the results obtained in the 1256 laryngeal cases (membranous croup). In one-half of these, in a large proportion of which the symp- toms were severe, recovery took place without operation. Among the 533 in Avhich intubation was performed the mortality was 25.9 per cent., or less than half as great as has ever been reported by any other form of treatment. 11. The proportion of cases of broncho-pneumonia (5.9 per cent.) is very small, and in striking contrast to results published from hospital sources. 12. As at'ainst the two or three instances in which the serum is be- lieved to have acted unfavorably upon the heart might be cited a large number in which there was a distinct improvement in the heart's action after the serum was injected. 13. There is very little, if any, evidence to show that nephritis was caused in any case by the injection of serum. The number of cases of SEPTICEMIA. 195 genuine nephritis is remarkably small, the deaths from that source num- bering but 15. 14. The effect of the serum on the nervous system is less marked than upon any other part of the body ; paralytic sequelae being recorded in 9.7 per cent, of the cases, the reports going to show that the protection offered by the serum is not great unless injections are made early. SEPTICEMIA. Definition. — A disease due to an introduction into the system of the products of putrefaction (sapremia) or to a microbic invasion of the blood and tissues (true septicemia), with or without the presence of a local seat of infection. Pathology. — After death the body putrefies early. The macro- scopic changes in the viscera are sometimes few and often wanting. The muscles present a brownish color-tint. The pia mater is generally con- gested, and, together with the nerve-centers, may be the seat of ecchy- moses. The blood is dark (" tar-like ") ; its coagulability is diminished, and, microscopically, it shows an abundance of micrococci and bacilli. The spleen is somewhat softened and its lymphoid elements more dis- tinct, and almost invariably ecchymoses are found in the serous mem- branes, especially the pericardium and peritoneum. In protracted septicemia more marked alterations exist, and among them may be briefly enumerated the following : endocarditis (rarely ulcerative); gastro-intestinal catarrh (of the duodenum and rectum, in particular) with punctiform extravasations ; enlargement of the lym- phatics and spleen, with softening of the latter ; cloudy swelling of the liver (rarely the so-called emphysema of the organ due to putrefaction) ; edema and catarrhal inflammation of the uriniferous tubules ; conges- tion, sometimes associated with edema of the lungs ; and inflamma- tion of the pleura, pericardium, and peritoneum, with ecchymoses and trivial effusions. Microscopically, the internal organs show numerous small foci of in- flammation, some of which may be the seat of " coagulation-necrosis." Bacteria are found in abundance in various situations, such as the exu- dations, the capillaries of the inflammatory foci, and especially in the renal glomeruli. lEtiology. —Bacteriology. — Septicemia is due to micrococci which Koch has shoAvn to be considerably smaller than pus-cocci, though no one form of bacterium has been found constantly present to the exclu- sion of all others. Besser, as the result of careful experiments, con- cludes that septicemia is caused solely by streptococci, while Bosenbach and others have found both staphylococci and streptococci. Doubtless in many instances of human septicemia the clinical manifestations are due partly to bacterial poisoning and partly to septic intoxication with the poisons (ptomains) developed by the organisms, and the ptomains probably kill the patient before the bacteria can propagate themselves throughout the system. Laboratory experiments teach us that in the 196 INFECTIOUS DISEASES. lower animals septicemia can be produced both by chemical poisons and by bacterial infection, and these two types are observed in human beings. With reference to the bacterial form Warren ' states : " Whether this process is caused solely by the multiplication of bacteria, or is depend- ent in part upon the liberation of intensely powerful poisons, or is due to some ferment-like substance capable of reproducing itself like the poison of the serpent, as are diphtheria and tetanus, much more ex- tensive studies upon the human subject will be necessary to enable us to say."' Modes of Infection and Introduction of the Poison into the System. — (1) Wounds, either surgical or the result of injury, with which we have nothincr further to do in this Avork. Since the davs of rigid anti- septic precautions this mode of entrance is, comparatively speaking, uncommon. (2) Through the uterus, following labor, miscarriage, or abortion. Generally in these cases there are accompanying local changes, but in a few the poison appears to pass the unguarded portals of the organ, while the latter exhibits nothing abnormal. (3) The cases in which the poison gains entrance into the body without obvious wounds or raw surfaces are relatively more common. When the skin is quite natural, septic infection or intoxication can- not occur, but the slightest abrasion or cut, bed-sore, etc. may serve as a gate of admission. These slight lesions "may be almost com- pletely healed by the time the severe symptoms of the disease are developed' (Strlimpell). (4) Mucous membranes often admit the virus, being less protective in nature than the skin. The numerous bacteria — benign and pathogenic — that are constantly present in the intestinal canal may also find in local lesions (as in typhoid fever, dysentery, etc.), or catarrhal inflam- mation even, points of lodgement and cause a systemic infection. To this category belongs that form of septic infection which follows gonor- rhea. The so-called cases of "spontaneous septicemia" are also usu- ally occasioned by absorption from the mucous surfaces. Rheumatic or septic manifestations often follow attacks of tonsillitis., and it is probable that the tonsils are more frequently points of en- trance for the organism than has hitherto been supposed (Wade. Ban- natyne). (5) " Sepsis Intestinalis." — This special form of poisoning is caused by canned meats, ice cream, sausages, and cheese. Vaughan. to whom we are indebted for the first description of "sepsis intestinalis." found in cheese a ptomain which he named tyr atoxic on., and which he regarded as the active agent in this group of poisoning cases. The symptoms are due, according to his statement, to poisoning by chemical substances, being instances of sapremia ; but it may yet be found that the intes- tinal micro-organisms play a more or less prominent part in the process. (6) Ogston^ recognizes as one of the mildest forms of sapremia the sickness and nausea produced by a bad smell, which, he claims, is but a ptomain of putridity that may, under certain contingencies, produce serious symptoms. On the other hand, persons who are habitually ex- ^ Surgical Pathology and Therapeutics, p. 340. - Warren, loc. cit., p. 342. SEPTICEMIA. ] 97 posed to bad odors (workers in sewers, in the dissecting-room, etc.) may acquire a considerable degree of immunity against poisoning of this sort. The fever in these cases corresponds in severity to the dose of the poison. (7) Septicemia may be associated with or folloAv osteomyelitis. Clinical History. — (1) Symptoms of Sapremia. — The "^fact that this form may occur without bacterial infection, either local or general, must be emphasized, but more frequently there will be either local infection or putrefactive changes, with the production of a grave general condition due to the absorption of the poisonous chemical products. In certain other acute infectious diseases (diphtheria, tetanus, typhoid fever, ery- sipelas, etc.) the general sj^mptoms are similarly engendered. Perhaps the most typical examples of sapremia seen by the physician are those due to tyrotoxicon and to the unaccustomed inhalation of foul odors. At the beginning a chill may occur, but this is more generally wanting. In '■'■sepsis intestinalis " marked local symptoms may initiate the attack, as nausea, vomiting, colicky pains, diarrhea, etc., and in all forms there is fever, the temperature often rising rapidly to 101° or 103° F. (38.3°- 39.4° C.) and sometimes higher. Prostration and anemia, particularly the latter, may be prominent symptoms. Microscopic examination of the blood generally shows leukocytosis, and always a marked reduction in the number of red corpuscles. Sapremia following childbirth is a most typical sub-variety, and, apart from the special history, the symptoms are much the same as those above detailed. It is the form most amenable to treatment, the removal of the cause being followed by a rapid disappearance of all alarming symptoms. (2) Symptoms of True Septicemia. — There is an incubation-period which is of variable duration, though usually averaging several days. The onset is more gradual than in the previous variety, and is rarely marked by a chill. Accession of fever following surgical procedures, with head- ache, anorexia, prostration, sometimes vomiting and diarrhea, and espe- cially dulness occasionally amounting to mild stupor, announce the affection : these symptoms should also excite suspicion in the absence of obvious causal factors. They become intensified, and now the attack may closely simulate certain other infectious diseases (typhoid fever, acute miliary tuberculosis, ulcerative endocarditis, etc.), the clinical picture as outlined presenting nothing characteristic. There are, how- ever, more or less distinctive features, which will be considered seriatim. (a) The Fever. — This is usually of the continued type, and tends to increase in degree, fatal cases often terminating in hyperpyrexia. At the beginning the temperature may rise quite rapidly, and in some cases it may even be subnormal. Deep morning remissions may be observed. (5) Tlie Circulatory System. — The pulse is frequent, and near the end becomes very weak. In subacute cases characteristic lesions (endocar- ditis in particular) may develop, but are difficult of recognition, since they do not, as a rule, give rise to audible murmurs or other .physical signs. In other instances soft murmurs may be heard, but it is indeed hard to discriminate these from functional sounds. Moderate leukocy- tosis is sometimes observed, and the presence of micrococci in the blood during life has been demonstrated. 198 INFECTIOUS DISEASES. {c) Gastro-intestinal System. — The spleen may become perceptibly enlarged, and gastro-enteritis is usually present, either in an acute form Avith vomiting and fre([uent serous discharges or more often merely with a diarrhea of moderate intensity (septic diarrhea). (t?) Cutaneous Symptoms. — Punctiform hemorrhages into the skin are of prime importance in the diagnosis. Occasionally more extensive ecchymoses appear, scarlatinal eruptions also showing themselves, but these are less characteristic. Among rare appearances herpes, roseola, edematous inflammations, and faint jaundice (affecting the skin and conjunctivae) may be observed. The icterus is probably due to disinte- gration of the red blood-corpuscles in the liver. (c) Renal Symptoms. — The lesions constitute the so-called ''septic nephritis," the urine often containing a fair amount of albumin, epi- thelium, tube-casts, and reil and white corpuscles. Diagnosis. — {a) Sapremia can be distinguished by the history, the immediate appearance of the symptoms, their character, and by the prompt effect of the removal of the exciting cause. The diagnosis often requires a most careful search for the known etiologic factors, though even without the latter we can sometimes arrive at a correct conclusion by a careful process of exclusion. {h) True Septicemia. — Here the existence of an incubation period, the contiued fever, mental apathy, faint jaundice, splenic enlargement, and the characteristics of septic nephritis, all combine to form a well- defined group of symptoms. A careful blood-examination should be made for micrococci, etc., and cultures should be undertaken in spon- taneous septicemia and associated forms {e. g. septico-pyemia). The surgeon should look to the condition of the wound if one is present. Course and Progtiosis. — The course may be brief, virulent at- tacks sometimes terminating fatally within forty-eight hours, this being especially true of sapremia Avhen the dose of the poison is large. The gravity of the case in the latter form is in direct proportion to the amount of virus that enters the system, the outlook being good when the cause is removable. On the other hand, in true septicemia this avails nothing, the progression tending steadily to the end. The mildest types may, in rare instances, reach a favorable end, but the effects are not dependent upon the dose, and the minutest quantity may lead to specific results in their fullest intensity. It must not be for- gotten that septicemia may pursue a chronic course in which the symp- toms are milder, though the termination is very generally unfavorable, as in the acute variety. Treatment. — Of first importance is the removal of the cause when- ever practicable, this part of the treatment often falling within the domain of surgery. The physician must support the patient's strength by a suitable dietary and by the judicious use of cardiac stimulants ; the former should consist mainly of liquids (milk, egg-w^hite, meat-juice, etc.), and the latter of alcoholics, together with strychnin and am- monia. Of medicines, internal antiseptics (mercuric chlorid. creasote, etc.) richly deserve a trial, though striking results have not been obtained from their employment. The fever calls for antipyretics, such as quinin, phenacetin, acetanilid, together with hydrotherapy. Cardiac depressants, as acetanilid and phenacetin, should not be resorted tOj PYEMIA. 199 however, when great cardiac asthenia exists. To meet the renal condi- tion the free use of water, together with the least irritating of the diu- retics, is to be advised and encouraged. The other internal organs should also receive careful attention. PYEMIA. Definition. — A disease of the blood invariably associated with sup- puration, and due to an absorption of pyogenic organisms. Pathology. — The cadaver does not undergo putrefaction as early as in septicemia. Briefly considered, the pathologic lesions that fall within the physician's province arrange themselves under the following heads : (1) Thrombosis and Embolism. — At first the veins leading to and from the seat of the local changes from which pyemia arises contain thrombi which may soften into a puriform material. Thrombi are also found frequently in the lungs, a circulating embolus first finding lodgement in the pulmonary artery and its branches ; they may be present in the liver, kidneys, spleen, cortical substance of the brain, and in other localities. (2) Abscesses. — These so-called metastatic abscesses are set up by septic emboli or result from the thrombi (chiefly pulmonary and portal), and are found in the various internal organs, mainly, perhaps, in the lungs, liver, spleen, and kidneys. They are not large, but may coalesce and form cavities of the size of an apple. The kidneys are the chief organs of elimination in this disease, and hence it happens that numer- ous clumps of micrococci, producing miliary abscesses, are frequently seen in the regions of the Malpighian bodies. Infarction may be ob- served also. There are many other, though rarer, seats of abscesses, as the muscles, submucous and subcutaneous tissues, bones, the parotid gland, brain (cortical portion), ovaries, and testicles. (3) Lesions of the Skin and of Mucous and Serous Membranes. — At the post-mortem examination hemorrhagic extravasations and pustules are often visible in the skin. The mucous membrane of the alimentary tract is rarely affected, differing in this point from septicemia, though occasionally ulcers may be noted, and most commonly in the stomach near the pyloric orifice (in puerperal cases) and in the large bowel. Prob- ably they are always secondary to the submucous miliary abscesses. The serous membranes (pleura, pericardium, meninges of the brain, synovial membranes) may be the seat of purulent inflammation and of hemor- rhagic extravasations. (4) Cardiac Lesions. — Ulcerative endocarditis forms the chief morbid lesion. It begins in the form of small nodular vegetations upon the valves (most frequently the mitral), which disintegrate and leave ulcers behind (vide Ulcerative Endocarditis). ]^tiolog"y. — Bacteriology. — Experimental investigations have shown conclusively that the organisms usually responsible for this condition are the staphylococcus and the streptococcus. Whether the former or the latter be the agent of infection in the given case depends chiefly 200 INFECTIOUS DISEASES. upon the condition of the tissues at the starting-point, especially with reference to the character of the local defensive processes ; also, though to a lesser extent, the degree of virulence of the micrococci. Other important pyogenic micro-organisms are the gonococcus, pneu- mococcus, bacillus pyocyaneus, bacterium coli communis, bacillus tetra- genus, and many of the specific micro-organisms. Paths of Infection of the Body. — {a) Almost always the entrance is by the blood-vesseh, the special varieties of micrococci that cause pyemia, reaching the veins and producing thrombo-phlebitis. Less frequently they reach the arteries and produce thrombo-arteritis. From the former con- dition emboli may be disseminated throughout the system, while from the latter the emboli are arrested in the neighboring capillaries to which the tributaries of the vessel lead. Micrococci independently of emboli may be found wandering in the blood-stream. [b) Another path of entrance is the lymphatic system, but here the cocci meet with greater forces opposing their attempts to spread than in the blood-vessels, and hence it is a much rarer mode of propaga- tion. [c) In spontaneous pyemia^ in which there is no wound to act as a point of departure, we must presuppose the existence of either a trivial lesion, as in " spontaneous septicemia," or an area of lessened resistance. The latter may be produced by inflammation, by a contusion, and in other ways, and all that seems necessary is a lowering of the tone of the general system (Warren). I am certain that ulcerative endocarditis is not frequently the starting-point, but is usually secondary to foci of inflammation elsewhere, as claimed by Osier. The appendix is often the primary or original focus in this category of cases, micrococci local- izing themselves here in consequence of a preceding disturbance of the circulation or catarrhal inflammation. I recollect one case in which no original abscess was found at the post-mortem. Predisposing Causes. — [a) Epidemic Injiuence. — It has been proved by abundant experience that certain seasons are characterized by epi- demic outbreaks of the disease. {h) Cases have sometimes been noticeably more frequent in the early months of the year (February and March) than in other seasons. {c) Age and Sex. — Males are more fre((uently affected than females, and most cases occur about the middle period of life or at the time of greatest danger from traumatism. Clinical History. — Incubation. — The disease sets in from a week to ten days after the reception of the wound or even earlier, and always develops secondarily to suppuration somewhere in the body. A most conspicuous symptom, and usually the first, is the chill : it may, however, be preceded for a variable time by fever of a continued or intermittent type. The fever of pyemia is of the suppurative type. Profound prostration develops early ; the skin presents an icteroid appearance ; and gastro-intestinal symptoms may appear, but are not prominent. The signs of abscess of the lung, liver, and other organs may develop in some cases, while in others the whole clinical picture is colored by the ill-defined characters of ulcerative endocarditis. (a) The Chill. — This may be mild, though oftener it is quite severe. It is repeated at somewhat irregular intervals, and rarely it may recur PYEMIA. 201 several times on the same day. Chills are most apt to occur during the daytime. (b) The Fever. — A rapid rise of temperature accompanies the chill. The fever-curve is of the irregularly intermittent or profoundly remit- tent type, with intervening periods, showing slight or marked variations, and as decided deviations may occur within a short space of time, a two-hour record should be kept. The temperature rarely falls to the normal level ; it may do so, however, and remain there for one or two days. To explain the peculiarities of the curve in this disease we need only recall the great variety of pathologic processes before noted. With the sharp fall of temperature sweating occurs, and leaves the patient more or less exhausted, though only temporarily so as a rule. (c) Respiratory System. — Symptoms referable to the organs of respi- ration appear early. The pulmonary abscesses are usually latent, but may give rise to dyspnea, cough, and occasionally a purulent expectora- tion. Pain is present if they are superficially located, and under such circumstances the physical signs of cavity or of pleural effusion may be noted. The signs of pneumonia at one or both bases may also develop, the expectoration now becoming rusty. (d) Splenic and Hepatic Symptoms. — The foci of suppuration in the liver are difficult of recognition unless they become large as the result of coalescence and are superficially located (see article Hepatic Abscess). Splenic infarction may also be safely diagnosed if there are pain and great tenderness (due to localized peritonitis) in the left hypochondrium, with progressive enlargenjent of the organ. In one case I detected distinctly crepitant sounds over the site of the spleen during life. (e) Cardio-vascular Symptoms. — The pulse at first is accelerated, but moderately full and regular; later it becomes exceedingly rapid and feeble. Frequently cases in which ulcerative endocarditis develops are apparently of spontaneous origin. (For a discussion of this grave con- dition the reader is referred to the description of endocarditis in the sec- tion on Diseases of the Heart.) Among the blood-appearances during life are leukocytosis and a rather marked reduction in the red corpus- cles, with moderate poikilocytosis. The blood-plaques are increased. (/) Cutaneous Symptoms. — The most prominent is a mild yet decided grade of jaundice, that is hepatogenous (?) in nature. Sweating has already been alluded to as a symptom, both during and after the febrile parox- ysms. The skin finally shrinks from emaciation. Skin-eruptions are common, particularly erythema, purpura, and pustules, and the general surface is often decidedly ht/per esthetic. {c)) Genito-urinary Symptoms. — The urine is concentrated and urates are copiously deposited. There is albuminuria, which may be due to the pathologic changes or may be ascribable to the fever. The micro- scope discloses the presence of tube-casts, micrococci, pus- and (more rarely) blood-corpuscles. Albumose has been found in the urine. (Ji) Nervous Symptoms. — The mind generally remains unclouded until an advanced stage is reached ; then delirium sets in, and is followed by a terminal coma. Metastatic purulent meningitis, with its usual symptoms (hemiplegia, strabismus, ptosis, deafness, etc.), may appear at any period of the disease. (i) Symptoms may be presented by the joints and bones. Metastatic 202 INFECTIOUS DISEASES. arthritis, usually suppurative, is a not unusual concomitant, and in some cases it is combine -< o > i C a -, t" o o w s ? ;=^ o o c o r^ ZL ^ ^J^ c c c c 1 — — C c ° ^ > 99 NORMAL 98 97 ■t of a o o o O — M o o o o ^ tn Oi O O 3 -J CD -0 3 > 2 r> 1 J ; ! i 1 — ^ 1 MM i kl i j 1 i ' X (D ■ i k _|_ 1 3 O ^_!^>< ■ ^ j i : =< "1 1 Y ■ __^— • — " <■' 1 1 ' 3 § T 1 1 K 1 i '• X ^ ^"^"^ .T~^ — ^- ^' 1 i . 3 ^ 1 "TF^ Ni^^ 1 ■c k:--^^- M> ; C" < ^^ =' X ;; +=K^ -^ n c it _ 1 =. ^ M> S -^^ ^fi'-' 1 =» X < C > I 3 g^ 1 , • ! ! - o V — ' ' i~^-^?S i ^ - c \ ■ , : j 1 L .^ ! 1 1 =• x < o - 1 ^ ^^ "1 f-rr 1 1 3 K 1 « l-^:~~ ! -jj. " i 1"" -X <£:^ i :; 1? ::::::::: ■~^-i-lJ_!_ MM \ 1 ■ rrts: »• T ^ X < 1 i ] 1 [ ^.TT --^ \ r"" — ^ Tj 3 M lu 1 \ L.^ ! i ^ O 1 l^ \ \ ""^Irhpf i - \\J^ T\ \ 1 i>^ 1 ! * ' ^ 1 M ! 1 1 <-'! 1 1 1 1 1 j L.+7 1 1 1 ! ? 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Involvement of the chief vessels that nourish the walls of the ventricles and the ependyma, and stretch from the vermis cerebelli forward over the quadrigemina, explains the con- stant presence of a turbid fluid in the ventricles, with softening of Iheir Avails. As the result of undue intraventricular pressure the cerebral convolutions become more or less flattened, with eff'acement of the sulci. The cortex, to a variable depth, is generally the seat of red softening, and more rarely of white softening alone. The tuberculous infiltration involves the cranial nerves. Histology. — The tubercles grow in the perivascular sheaths, which are often distended with lymphoid and epithelioid cells, and there is observed not infre(}uently a thrombosis of the arteries and of the venules of the pia, obliterating their lumen. The pia mater is gradu- ally thickened through cellular infiltration, and in a small proportion of the cases the spinal meninges are similarly involved, chiefly in the cer- vical portion of the cord. Symptoms. — There is a prodromal period which lasts one or more weeks, during which the patient (usually a child) is pale, peevish, has headache and photophobia, and grinds its teeth during sleep ; the tongue is coated, appetite impaired, and there may be occasional vomiting, either propulsive or regurgitative. Constipation is present and may be marked. Among rare premonitory symptoms are slight hyperesthesia of the abdomen and a diminished urinary secretion. A tendency to emaciation is quite constant. These prodromal symptoms present varia- tions as to their number and combinations in different cases. In few instances only is the onset acute. The symptoms usually indicate basic meningitis, and at first there is associated considerable mental excite- ment ; later there are pressure-symptoms (caused by the exudate), with total loss of the mental faculties. (1) Stage of Cerebral Excitement. — The invasion is generally gradual, or even quite insidious, its most characteristic phenomena being severe vomiting., marked headache, and chills follotced bg fever. Certain other symptoms now arrest the attention, such as extreme irritability, scream- ing, and great obstinacy, and occasionally drowsiness appears early. "When the onset is sudden the disease may be disclosed by convulsions, paral- ysis, wild delirium, or coma. The established disease exhibits certain distinctive features. The pain is often most excruciating, causing the child to utter short penetrating screams (hydrocephalic cry), and in rare instances the sharp cries may be continuous and lead to physical exhaus- tion. The headache is increased by light, noise, or movement. Vertigo is common ; the pupils are contracted at this period ; the face pales and then flushes ; the pupils alternately dilate and expand ; and the expres- sion is sometimes sad, though more often stupid. Generally hyperes- thesia or dysesthesia may appear, and there may be a slight mind-wan- dering at night, though active delirium is rare. Tdches cerehrales may be obtained, but are not characteristic. The patient is intolerant of every form of disturbance. All the symptoms of the prodromal stage are now aggravated ; slight muscular twitchings and sleep-starts occur ; the vomiting is apparently causeless, and may be frequently repeated ; and constipation persists. Fever is present, but is of slow development, and rarely rises higher ACUTE TUBERCULOSIS. 281 than 102° or 103° F. (39.4° C.) in the evening. The skin is dry and harsh, as a rule. The pulse is slow or moderately accelerated, but soon quickens to 120 or even 130, and later it may be irregular. At times the pupils are unequally contracted, and ptosis may also be looked upon as an early sign. (2) Second or Transitional Stage. — The symptoms of cerebral irrita- tion now abate, the patient becoming more quiet, while mental dulness often supervenes. The vomiting and headache subside gradually, and the child cries out only occasionally. The abdomen is now distinctly scaphoid and the head occasionally retracted. Constipation is obstinate. The evidences of localized organic foci, such as slight twitchings of the muscles of the face, followed by strabismus, ptosis, or paralyses of the face or limbs, may appear. Generalized convulsions may occur, and muscular tremors and athetoid movements may appear. Both pupils (or one only) may be dilated as intracranial pressure develops ; patchy flushing of the face is common. The respiration is now irregular and sighing. (3) The Stage of Paralysis. — On account of the exudation the mental faculties are abolished, so that the patient is comatose, though convul- sions or localized spasms of the muscles in different parts of the body (neck, back, limbs, etc.) may be observed. Optic neuritis develops, while the paralysis of the ocular muscles above noted deepens. The pupils are dilated, the eyes are partly closed, and the eyeballs at inter- vals slowly and alternately move in a lateral direction. Hemiplegia sometimes develops, and more rarely monoplegia, affecting the face or one of the extremities. There may be paralysis of the third nerve, with involvement of the face, hypoglossal nerve, and limbs on the opposite side (a combination of symptoms first observed by Weber), consequent upon a lesion localized in the internal inferior portion of the crus. Monoplegia of the right side of the face has been observed in a few instances, associated with aphasia. Exceptionally aphasia and brachial monoplegia have been combined. The temperature in the early part of this stage usually rises to 103° F. (39.4° C.) or higher, but later it may drop to a subnormal level, and in rare instances as low as 94° F. (34.4° C). Immediately preceding the fatal termination the temperature may rise to 106° or 107° F. (41.6° C), the pulse becoming frequent, small, and irregular. Anesthesia comes on with general muscular relaxation. Occasionally a typhoid state (great prostration, dry tongue, diarrhea, etc.) may develop, and Cheyne-Stokes respiration is almost invariably present, preceding the fatal event. Leukocytosis has been observed. OpJithalmoscopic Examination. — The ophthalmoscopic appearances are — hyperemia of the disk, later the changes belonging to neuritis (swelling and striation) appear, and choroidal tubercles may be detected. Diagnosis. — This is based : (1) On the reaction to tuberculin ; (2) Examination of eyes, which present the characteristic appearance of the choroid coat (Jacobi). Post-basic meningitis gives the same symptoms, and lumbar puncture is the only means of diagnosis. In tubercular meningitis the diplococcus is found. Clinical Types. — {a) Mild Type. — The marked or alarming symp- toms (tetanic rigidity of the muscles, convulsions, and paralysis) develop at a late period. In this class should be placed those cases in which the 282 INFECTIOUS DISEASES. meningitis is but feebly indicated — e. //. when it is but a small factor in the condition of acute general tuberculosis. {h) Malignant or Rapid Form. — This type is comparatively rare, oc- curring most frequently in adult life, while the lesions have their seat almost exclusively upon the convexity. The onset is marked by the most frightful tetanic convulsions, which precipitate a fatal termination in a couple of days. () A slowly-developed interstitial pneumonia which aims at arresting the progress of the affection. It develops in close proximity to caseous masses and around cavities. The new connective tissue thus formed in obedience to the well-known pathologic law tends to contract secondarily, and thus vomicae are often partly, though sel- dom entirely, obliterated. The shrinking of the connective tissue may also result in compression, and finally in the destruction of pulmonary tissue, just as in a tuberculous inflammation. The process in this in- stance, however, is on the whole conservative and calculated to repair tuberculous lesions. Disseminated Tuberculosis. — Miliary Tubercles. — This form has for its chief characteristic miliary tubercles, Avhich are scattered not only about the tuberculous area, but also throughout the rest of the lung, and usually in the loAver lobe. Most of the tubercles undergo fibroid or fibro-caseous change. These minute, hard gray or grayish-yellow nodules vary in size from a mustard-seed to that of a pea, and lung- tissue that is more or less studded with chronic miliary tubercles is apt to look pale, while the surrounding air-cells are emphysematous. The condition may lead to pneumonia, and the whole aspect then becomes altered. Here, as before described, fusion of miliary tubercles results in larger masses which become caseous, and hence the method of cavity- formation is identical with that observed in tuberculous broncho-pneu- monia. In the disseminated form tubercles may also be found in many other organs than those indicated (pleura, trachea, larynx, bronchial and other lymphatic glands, peritoneum, spleen, kidneys, liver, brain, mu- cosa, testes, etc.). Lesions of the Pleura. — This membrane is hyperemic and coated with fibrinous exudation coextensively Avith the affection of the parts in chronic ulcerative phthisis. The pleural membranes are only more or less thickened by organized adhesions, but in the latter and also in the pleura tubercles or cheesy masses may be found. Simple and other forms of pleurisy are also met Avith — sero-fibrinous, purulent, and hem- orrhagic. Lesions of the Bronchial Glands. — At first these are enlarged and CHRONIC TUBERCULOSIS. 289 edematous, containing tubercles, and later they present foci which often undergo purulent disintegration and sometimes calcification. Other lymphatic glands than these may be affected (mesenteric, etc.). Lesions of the Larynx. — The larynx is frequently the seat of tuber- culous infiltration and ulceration, particularly in certain parts, such as the vocal cords, posterior wall, ary-epiglottidean folds, etc. Lesions of the Heart. — Tuberculous endocarditis is present in about 5 per cent, of the cases, and congenital stenosis of the pulmonary ori- fice is noted in not a few instances (Chevers). The right heart is often hypertrophied or dilated. Other organs may present lesions in chronic phthisis, and these will be spoken of in connection w^ith the clinical history. Tuberculosis of the intestinal canal is a common though late lesion. Amyloid degeneration of certain organs is a not unusual secondary event, especially of the kidneys, liver, spleen, and intestinal mucosa, and in like manner enlargement of the liver due to fatty infiltration is noted not infrequently. Clinical History. — The modes of invasion are quite diverse, but with few exceptions the onset is either (1) gradual or (2) abrupt, and, as a rule, the health has been previously undermined for a longer or shorter period. (1) G-radual Onset. — (ri) Most frequently the disease originates in a manner similar to the origin of ordinary bronchitis, and often, com- bined with the symptoms of broncho-catarrh, are those of pleurisy. Tuberculous bronchial affections often follow certain acute infectious diseases — influenza, typhoid, measles, Avhooping-cough, etc. — and in this form are rarely curable. The physical signs may be negative for some time, and then appear at the apex of the lung. Over a small area there may now be slightly impaired resonance on percussion, with harsh broncho-vesicular breath-sounds and with or Avithout subcrepitant ra,les. The expansion, as noted on inspection and palpation, over the affected spots is more or less defective, Avhile the vocal resonance and fremitus are either increased or unaltered ; and the fact that the lesions are more commonly detectable in the suprascapular fossa than anteriorly must be remembered. At this period obvious constitutional disturbances are present (debility, emaciation, fever, etc.). (6) Onset ivith Pleurisy. — This may be sudden, as in an acute pleu- risy with effusion, but often the latter condition develops insidiously. Of 90 cases of pleurisy with effusion, one-third terminated in chronic phthisis (Bowditch). It may begin as a dry pleurisy at the apex, either anteriorly or posteriorly, or the evidence of pleurisy may be associated with the more common or bronchitic onset. (c) With Gfastro-intestinal Symj)toms. — There is impaired digestion, and soon the patient becomes anemic, loses flesh, and is debilitated. Later, the first indications of pulmonary tuberculosis develop in the lungs. (d) With indefinite peritoneal symptoms, lasting for months or even years. (e) With Laryngeal Symptoms. — This is a rare form. It begins with hoarseness, more or less aphonia, and considerable cough ; there is also a slight muco-purulent expectoration. Laryngoscopic examinations may 19 290 INFECTIOUS DISEASES. detect tuberculosis of the organ, and tubercle bacilli may be found in the sputum befoi'e involvement of the lungs is discoverable. (2) Cases with Abrupt Onset. — {a) The most important group under this category is heralded by the symptoms and signs of acute lyneumonia, more commonly of the lobular variety. As compared with ordinary pneumonias, these present some peculiar features : the fever is irregular and the expectoration is more abundant, is blood-stained, and contains bacilli. The signs are usually located in the apical region. Resolution may occur, but recovery is not complete, and the condition is likely to pass into chronic phthisis. ih) Onset with Fever. — Chills and fever are apt to arise in all instances in the advanced stage of pulmonary tuberculosis, and these symptoms may also initiate the attack. There is no mistake in diagnosis more commonly made in malarial regions than to ascribe such cases to pal- udism. (e) With Hemoptyds. — This symptom may be the first to invite at- tention to lung-trouble. In the majority of cases the amount of blood lost is considerable, and, less frequently, repeated slight hemorrhages occur. Pulmonary symptoms may be absent, sometimes temporarily, and in rare instances, perhaps, permanently ; but in a great proportion of cases the clinical picture of incipient pulmonary tuberculosis is re- vealed pursuing its accustomed course immediately after the occurrence of the hemorrhage. The physical signs may be latent for a time, and, whilst they are usually found to be at the apex, they may assume the guise of a pleurisy in the scapular or infrascapular region. A slight tuberculous lesion is most probably present in these cases before the occurrence of the hemorrhage. The symptoms are (1) local and (2) general. (1) Local. — ((/) Pain. — This is absent in many cases of chronic phthisis and in others it may be moderately severe. It is seated usually at the base, laterally or anteriorly, and not rarely there is pain of a lancinating character in the interscapular region in the early stages of the affection This symptom is of diagnostic Avorth only after other forms of pain (rheumatic, neuralgic, etc.) have been excluded. The most common cause of pain is pleuritis, with or without pleuritic adhe- sions; it is increased on deep breathing and coughing. Intercostal neuralgia and pleurodynic stitches may also develop in the course of this disease. {h) The Cough. — This may be looked upon as an essential feature, though in a few instances it may be slight or even wanting throughout. Its severity bears no constant relation to the extent of the pulmonary lesions, but rather to the degree of sensitiveness of the patient. It is dry and hacking at the beginning, and, if the larynx be involved, the cough is marked and takes on a hoarse quality. It is most pronounced at certain periods of the day — viz. on lying down at night and on awaking from sleep. Paroxysms may also occur after meals, and these occasionally induce vomiting. The cough is at times distressing and debilitating in its effects. ((?) Expectoration. — At the beginning the sputum is scanty and mu- coid, rarely hemorrhagic, or it may be merely streaked with blood ; later it may become muco-purulent, and the appearance of small gray CHRONIC TUBERCULOSIS. 291 or grayish-y ello w flocculi first suggests the nature of the affection. With the onset of the stage of cavity-formation the sputum becomes more abun- dant and more distinctly purulent, and, after the formation of cavities of any size, airless, opaque, and nummular (coin-shaped) masses are expec- torated. The latter are greenish-gray or greenish-yellow in color, and sink rapidly when discharged into water. They are often mingled with more or less bronchial secretion, and are not entirely characteristic of tuberculous cavities, being sometimes observed in pure bronchitis. They may even be absent, and the expectoration be merely purulent. The open- ing of a fresh cavity may be followed by very free expectoration. The sputum is sometimes fetid, and exceptionally it is horribly offensive, vary- ing greatly in amount in different cases and at different stages of the dis- ease. In certain cases it is absent throughout the greater portion of their course, and is especially apt to be slight in children and old people. In such instances it may be impossible to collect sufficient sputum to ex- amine for bacilli. Microscopic examination discovers alveolar epithelium (particularly in the earlier stages), pus-cells, blood, fat-globules, elastic fibers, and tubercle bacilli, the detection of the latter being the most important factor in the diagnosis. It may be safely stated that the finding of bacilli in the sputum is prima facie evidence of chronic phthisis ; on the other hand, however, their absence in the early stage does not exclude the disease. It is often needful to make repeated and delicate examina- tions of the sputa. It is also of the utmost importance to select for ex- amination the small grayish masses that are usually to be found, since they early contain the bacilli. In tuberculosis in the aged tubercle bacilli are not always detectable in the sputum. "A small amount of the purulent portion of the sputum is spread in a thin and uniform layer on a perfectly clear cover-glass by means of forceps, needles, or the Ohse, which must previously be held a moment in the flame of a Bunsen burner or a spirit lamp, or by pressing a small amount of sputum between tAvo cover-glasses, then sliding them apart. It is then dried in the air, or more quickly by holding the cover-glass with forceps some distance above the flame of a burner or lamp. Finally, it is to be passed three or four times through the flame, and so 'fixed ' " (Musser). The preparation may be stained with carbol fuchsin (basic fuchsin 1, alcohol 10, 5 per cent, solution of carbolic acid 90), either by dropping a few drops of the stain on the smeared side of the cover-glass and holding it above the flame until it steams, or by floating its face down- ward upon a watch-crystal containing the solution. It must then be decolorized either with a 30 per cent, solution of nitric acid, allowing it to remain until the red color has entirely disappeared (about fifteen seconds), and then washing and counter-staining with methylene-blue, or with Gabbett's solution (methylene-blue 2 gm., sulphuric acid 25 c.cm., water 75 c.cm.), in which it must remain until the red color has been replaced by a faint blue (thirty seconds or more). Instead of car- bol-fuchsin, anilin gentian violet may be employed (add a saturated alcoholic solution of gentian violet to a filtered saturated solution of anilin until a metallic luster appears on the surface). The specimen may lie either several hours in a cold solution or a few minutes in one 292 ISFECTIOUS DISEASES. that is steamino;. Decolorize with the nitric-acid solution and counter- stain with rubin or Bismarck brown. It is often much simpler to smear the sputum directly upon the slide, and then examine, when stained, without the intervention of a cover-glass. A much larger amount of sputum can thus be prepared at a single operation. In the microscopic examination use a jl^'i'^ch (2.11 mm.) oil-immersion lens and Abbe condenser, or. at the least, \- or |-inch (0.36 cm. or 0.31 cm.) objective. If carbol-fuchsin has been used in staining for the ba- cilli, and methylene-blue as a contrast, the former will be found as red rods in a blue field (background), while if gentian violet has been used, the tubercle bacilli appear as dark blue rods, with all other bodies brown, if Bismarck brown is used for the contrast stain. There may be visible in the field a few bacilli only, particularly during the early part of the case. In the stag* of cavity their number is usually in- creased, and sometimes they are quite numerous. Dorset ^ describes a rapid method of great practical value for staining the organism in tissues, and for the purpose of differentiating between the tubercle bacilli and the smegma-bacillus (the latter not taking the stain), as follows : Cover- glass preparations are made and fixed in the ordinary way, and then immersed in a cold, saturated 80 per cent, alcoholic solution of sudan III for five minutes. Any excess of stain is then removed by washing in several changes of 70 per cent, alcohol for five minutes. The bacilli are thus stained a bright red and the beaded appearance is quite distinct. The demonstration of elastic fibers is also an important aid to diag- nosis. Fenwick's method is the following : Boil the sputum with an Fig. 26.— Elastic fibers (after StrumpeU). equal quantity of a solution of caustic soda (gr. xv-3J — 0.972-32.0) ; pour the product into a conical glass and fill Avith cold water. The sedi- ment is subsequently examined with care for elastic fibers. The form and appearance of the elastic threads differ according to their special source. If they come from the alveoli, there is an inter- lacing of the fibers which may preserve the globular contour of the air- cells. If they come from the blood-vessels, they are single and elon- gated, or two or three of the fibers may be arranged side by side. Elas- tic tissue derived from the bronchi has a similar appearance. The presence of elastic fibers furnishes incontestable proof that destruction of lung-tissue has taken place. To show that this loss of structure, hoAvever, is due to tuberculosis, we must exclude abscess (an ' New York Medical Journal, Feb. 4, 1899. CHRONIC TUBERCULOSIS. 293 exceptional event) and gangrene of the lungs — diseases in which it also occurs. {d) Hemoptysis. — This symptom of phthisis will be spoken of under Diseases of the Lungs, but its importance as a diagnostic feature of this disease makes special reference to it here absolutely necessary. It is present in the majority of cases. Gabrilowisch ^ found that of 380 patients 213, or 56 per cent., had hemoptysis. The sputum may be merely blood-stained, or the hemorrhage may be excessive and prove rapily fatal, though hemoptysis is rarely the direct cause of death in tuberculosis. Slight hemorrhages are usually produced by mere hyper- emia, and are most apt to occur during the early stages ; while severe bleedings are produced by the erosion of a blood-vessel or rupture of a small aneurysm, and are most prone to occur during the stage of cavity. In certain cases hemoptysis is frequent. A third or capillary form of hemorrhage may occur in phthisis with cavity-formation, and in this variety, which is of a rather frequent occurrence, the purulent sputum is uniformly stained v.dth blood. It may also be nummular, but presents a reddish-brown or chocolate color. The exciting cause is seldom obvious, though in not a few instances ag- gravation of the cough, and in others great mental excitement, w^ould appear to excite bleedings. Slight hemorrhages often, and severe or^es rarely, afford more or less relief to the pulmonary condition. On the other hand, severe bleedings usually exert an unfavorable influence, being followed by debility and anemia. Moreover, in numerous cases hemoptysis is followed by a more rapid extension of the local lesions, with corresponding aggravation of the local and general manifestations. The fact remains, however, that the effect of severe hemoptysis upon the progress of chronic phthisis is by no means always untoward. In a case of my own there occurred periodically copious spontaneous bleed- ings (in spring and fall) for three years, which were as regularly fol- lowed by marked improvement for a period of three or four months. The physical signs of phthisis then developed. In a large number of cases of pulmonary tuberculosis the transition from warm to cold or cold to warm seasons corresponds with increased cough, hence with in- creased pressure in the pulmonary circulation ; and so bleeding is also favored, particularly in those having a hemorrhagic tendency. {e) Dyspnea is present, but is not a marked feature, as a rule, despite advanced pulmonary lesions. Perhaps the chief reasons for a lessened demand for oxygen on the part of the system are — first, the slow and gradual manner in which the lesions develop ; and second, the pro- nounced bodily wasting. The respirations, however, are moderately increased in rate, averaging from 20 to 30 per minute, and this compen- sates admirably for the diminished breathing-space. The dyspnea may be greatly intensified, however, as the result of intermittent 'pneumonia, pleurisy, active exertion, or great mental excitement, and toward the close of fatal cases the most intense dyspnea may be manifested. Physical Signs in the Stage of Consolidation. — Inspection gives most important results. The paralytic or phthisical thorax is generally pre- sented to view. It is flat, particularly the upper half; the intercostal spaces are wide ; the ribs slope at a sharp angle from the sternum, mak- ^ Berliner klinische Wochenschrift, Jan. 2, 1899. 294 INFECTIOUS DISEASES. ing the epigastric angle acute and producing elongation of the chest. The same sharp inclination downward from the vertebral column is observed laterally and posteriorly. The angle of Louis is prominent, and the depressions (supra- and infraclavicular, intercostal, etc.) are deepened, the costal cartilages being often prominent and the sternum, particularly in the lower part, sometimes much depressed or even con- cave (funnel-breast). The scapuL-e stand out prominently and may be distinctly winged. A second type of paralytic thorax is narrow and long. Pulmonary tuberculosis may, however, arise in chests of appa- rently normal build. With the development of phthisis at the apex the depressions of the side aifected are relatively deeper, Avhile the clavicle often stands out more prominently. The paralytic thorax is often a resultant of developed phthisis, and occurs in subjects in whom the chest was normal, preceding the invasion of the disease. Finally, both nar- rowing and flattening of the upper parts of the chest may result from great emaciation. Defective expansion is observed early, and usually at the apex of the side first affected ; subsecjuently this may be more general, and finally bilateral. To note the motions of respiration with precision the exam- iner should occupy a position exactly in front of the median line of the patient's body. The difference in the movement of the two sides often becomes more apparent on deep respiration than on quiet breathing, and while at rest the respirations are almost normal, but exertion decidedly increases their frequency. Palpation. — Testing the expansion by palpation gives better relative results than does inspection. To determine the comparative movements of the apices the extended hands should be so placed (by allowing them to diverge below) that the tips of the fingers touch the lower border of the clavicle, and then the patient should be asked to breathe deeply, though slowly. The expansion in the supraclavicular spaces is tested by standing behind the patient and using the tips of the fingers, or by allowing the two first fingers of each hand to pass parallel with the clavicles. In this way " lagging " over the apex will be the first symp- tom recognized, and may for some time be the only one. Tactile fremitus is early increased wdth oncoming consolidation, due to the growth of the tubercles, though it is normally more marked at the right than at the left apex. If there be great thickening of the pleura, however, it is more or less diminished, and if there be pleural effusion, it is usually absent. Mensuration. — The difference between the measurement of the chest in inspiration and expiration in any person of average health should be not less than three inches, and a difference below two and a half inches points strongly to tuberculosis. Percussion. — Resonance is deadened more and more as consoli- dation progresses. If the consolidated areas are minute, however, the percussion-note may be unchanged, and as the air-cells surrounding the latter are often emphysematous and relaxed, the note may be somewhat tympanitic. In many cases the tympanitic sound and deadness are intermingled, giving rise to the so-called tympanitic deadened sound. Slight dulness is, as a rule, noted first below the clavicle, though in not a few cases it is first detected upon and above the clavicle. The corre- CHRONIC TUBERCULOSIS. 295 spending regions of the two sides must be compared during a held inspi- ration, and also during a held expiration. The degree of dulness can sometimes be better estimated by comparing the apical note with that obtained loAver down on the same side, allowing for the normal topo- graphic differences of intensity. The latter method is especially applicable to cases in which both apices are involved. Impaired reso- nance may be detected early in the supraspinous fossa, and less frequently in the interscapular space if the subject be not too stout, though slight dulness in the absence of other signs has little diagnostic value. As the lung-tissue becomes airless throughout an area of considerable size it is markedly deadened, until dulness is heard ; finally, with extensive consolidation the note may be wooden and the feeling of resistance be much increased. Auscultation. — The vesicular breathing may be sharpened, owing to narrowing of the smaller bronchi, but more often perhaps it is dimin- ished by the swelling and secretion. The corresponding regions on the two sides must be compared — first during quiet, and then deep breath- ing, and it should be remembered that prolonged expiration is an early and important diagnostic mark, at first being somewhat sharpened, and later distinctly bronchial. Tuberculous bronchitis may cause interrupted or jerking inspiration at the apex. If heard elsewhere, little value is to be given it. With lobular consolidation at different points in the region affected, the conditions favor the transmission of the bronchial sounds, but these are toned down by the remaining intact air-cells ; hence there is "transition " or broncho-vesicular breathing. With com- plete consolidation pure bronchial breathing is audible, and with the latter two forms of breathing crepitant or subcrepitant rales are heard. Sometimes the first rales have a low Avhistling sound, which accompany the long expiration ; with liquefaction they become more moist, are louder (sometimes ringing), and often bubbling, and may be heard on inspiration and expiration. If scanty, they may be audible on inspira- tion only, though they are increased by coughing. If the moist crepi- tant and subcrepitant rales, often due to concurrent bronchitis, be very numerous, the breath-sounds Avill be obscured, but after free expectora- tion as the result of coughing the exact quality of the breath-sound is appreciable. Pleuritic friction-sounds may be heard, due to accompanying pleuri- tis sicca, and these may be audible before the bronchial r^les reveal the disease. Friction-sounds and rales often occur together. Pleuro-peri- cardial friction is present when the "lappet " of lung over the heart is affected, while clicking rales, occasioned by the heart's systole, are audible when the same area is pneumonic. The vocal resonance in- creases with the progress of the consolidation, and when the latter is complete hronchopliony (rarely pectoriloquy) is present. In the sub- clavian arteries a systolic murmur is not uncommonly heard, the latter being supposed to be due to pressure exerted by the thickened pleura upon these vessels. 296 INFECTIOUS DISEASES. Fig. 27.— 1. Small cavity near periphery, with thick relaxed walls, containing secretion and communicating with a bronchus (vide subjoined table). 2. Large parietal cavity, with thin, tense, smooth walls, comjnunicatmg with a bronchus (vide table). Physical Signs. (a) Percussion-deadness on a strong blow, mere impairment of resonance on a light blow : Wintrich's inter- rupted change of sound, detectable when patient is upright, but not when recumbent, {b) On auscultation low-pitched cavern- ous (hollow) breathing; gurgling (ringing) rales. (c) Pectoriloquy indistinct, owing to small size of cavity and the con- tained fluid. Physical Signs. {a) Amphoric percussion-resonance, cracked-pot sound, and Wintrich's chancre- of sound. (6) On auscultation, high-pitched am- phoric (musical) respiration and metallic rales. (c-) Amphoric (musical) voice and am- phoric whisper. Physical Signs of Cavity. — Inspection shows a more marked retraction and a more decided lack of local motion than during the previous stage. The degree of shrinking is proportional with the extent of fibrous-tissue formation. Palpation corroborates inspection as to lack of motion, and gives increased tactile fremitus if the cavity connects with an open bronchus and if it contains but little secretion. Excessive secretion interferes with conduction of sound. JPercussion. — Resonance is generally more or less impaired in con- sequence of the consolidation of the surrounding lung-tissue. The note may be somewhat tympanitic, but varies with the position of the cavities, the amount of fluid secretion contained by them, the condition of their walls, and the vibratory capacity both of the latter and of the individual thorax. Cavities of the size of a walnut situated in the apices usually give a distinctly tympanitic note, while cavities of the same dimensions, or even larger, in the lower portion of the lung do not. The metallic tone is especially noticeable over large cavities with smooth walls. The tympanitic sound may be deadened by closure of the connecting bronchus and by temporary filling of the cavities with secretion, and, again, if they are surrounded by thickened lung-tissue or by a large thickened pleura, there may be impaired resonance or absolute dulness even. Certain special conditions change the tympan- CHRONIC TUBERCULOSIS. 297 itic sound over a cavity. Thus the note will be louder and exalted in pitch when the mouth is opened wide, and lowered Avhen the mouth is closed (Wintrich's sign), there being dulness when the mouth is closed and tympanitic resonance when the mouth is open. If the cavity com- municates freely with the bronchus, it may be necessary to change the position of the patient, and a tympanitic note may change. in pitch with change in posture (Grerhardt's change of sound). If the patient changes from the dorsal to the upright position, resonance may give way to more or less flatness, since the fluid contents of the cavity are thus brought into contact with the chest-wall ; this, although an almost certain sign of a cavity when present, is exceedingly rare. The so-called cracked- pot sound is often elicited over large parietal cavities with thin walls, and may be quite intense ; but, since it also occurs in many other patho- logic conditions, its diagnostic significance in this disease is subordi- nate. There may even be normal resonance if the cavity is covered by a layer of unaffected air-cells of considerable thickness. Auscultation over small vomicse with lax walls reveals cavernous (low-pitched) breathing, while over large cavities Avith tense walls (if parietal and communicating with a tracheo-bronchial column of air) it gives amphoric (higher-pitched) respiration. Moist rales (bubbling and gurgling, according to the consistency of the secretion) may be pres- ent, and these correspond in the main to the amphoric breathing, hence being heard most frequently over large, smooth-walled and periph- erally-located cavities. The gurgling and slushing sounds caused by the air bubbling through the secretion in a cavity are always intensified by coughing. The sounds of falling drops (metallic tinkling) may be heard over large vomicse with tense, smooth walls containing thin secretion. JPec- toriloquy and amphoric whispers are the vocal sounds heard over huge cavities, and to the latter should be given the greatest diagnostic sig- nificance. General Symptoms. — («) Fever. — Whilst the disease is progressing fever is a constant, significant, and, it may be, the earliest, symptom. If a two-hourly record be kept for a few days, from time to time an accurate conception of the course and type of the fever can be formed. In the first and middle stages the highest temperature occurs about 4 or 5 p. m., the lowest about 4 or 5 a. m. The fever may be continuous, remittent, or intermittent, and in a general Avay these types, in the order named, cor- respond to the stages of tuberculization, softening, and cavity-formation. Modified types, due to the fact that the lesions often and simultaneously represent different stages, are also observed. Apyrexial periods are met with in the early as well as the late stages of chronic phthisis, and indi- cate cessation of the processes of tuberculization and caseation. A continued fever is most apt to be met with during the initial period of phthisis, the evening temperature sometimes registering but a degree higher than the morning. A similar curve may be presented at any later time if acute pneumonia supervene, though it is to be recollected that the remissions in such cases are usually greater than in primary lobar pneu- monia. A remittent fever is more common than the preceding type. It may be present from the start, but is oftener seen in the middle, and less fre- 298 INFECTIOUS DISEASES. quently in the advanced, stages of phthisis. This form of fever points to softening (see Fig. 28). 104 103 102' 101 100° 99 98° r 1 1 A A A / \ /\ /\ / I /\ /\ / \ / \ / \ / I A / \ / \ / \ A /\ /\ / ' / ' / A /\ /\ / ' / \ / /\ / \ / ^ / I / \ / / / \ , 1 / \ / \ / \ / \ , 1 \ / \ - \ , \ \ , \ / \ / / \ / \ 1 \ \ / \ / \ \ / \ \ \ \ / \/ \ \ / \ / V \l V \ / \/ \ I / \ \/ Y Y \ / \ \/ \ / \ V y \ \ \ 1 1 1 1 Fig. 28.— Temperature-chart of a case of phthisis. Quiescent cavity in right apex, and com- mencing excavation in left apex. Robert G , aged 21 years ; dyer. An intermittent fever is also frequent, and is characteristic of cavity formation, suppuration being invariably associated with the latter process. p ?- - o 104 - ) Tuberculous Pleuritis. — This subject will be referred to in the section on Diseases of the Pleura. Its import, however, is such that brief special consideration is demanded, and from a clinical view-point the cases may be grouped under two heads — namely, acute and chronic tuberculous pleurisy. The acute form often has a sudden onset, the initial symptoms being a rigor or repeated fits of chilliness, a stitch-like pain in the side affected, shalloAv, catching breathing, a cough, and fever. The ushering-in symp- toms sometimes suggest lobar pneumonia, and a fatal termination is not uncommon, though apparent recovery or a transition into chronic tuber- culous pleuritis also occurs. Chronic tubercular 2^l) moderate and regular physical exercise aids metabolism, and is thus directly useful ; massage may be substituted for active exercise when the latter is prohibited on account of weakness ; (c) the diabetic requires a temperate and equable climate; (f?) a daily tepid bath if the patient be feeble, and a cold bath if he be strong, are to be commended ; (g) flannels should be worn next to the skin all the year round; (/) the living and sleeping apartments must be thoroughly ventilated ; (^) the teeth must receive careful attention in order to prevent caries. 3. The medicinal measures deserve only third place in the treatment of diabetes, and of these opium is still the chief. It is not necessary to employ it in all cases, but it may be tried if the dietetic and hygienic treatment before recommended cannot be carried forward or fails to effect a cure. Opium seems not only to exert an influence over the polyuria and the excretion of sugar, but it almost invariably lessens the intense thirst and conduces to refreshing sleep. The drug is Avell tol- erated by diabetics. The commencing dose may be gr. j (0.0648) three times daily, and later increased to gr. v (0.324) or even to gr. x (0.648) three times daily. If morphin be employed, we may begin with gr. ^ (0.0162) and increase the dose to gr. j (0.0648) or more three times daily. Pavy Avarmly advocates the use of codein (gr. |^-iij — 0.0324- 0.1944, three times a day). My own best results have been obtained from the use of the latter remedy in the form of the sulphate, in ascend- ing doses, commencing Avith gr. ^ (0.0162) three times a day, and aug- menting the dose by gr. ^ (0.0162) every second day until gr. ij — 0.129 (rarely more) are taken thrice daily. Codein possesses the advantage of being less constipating and less likely to disturb the digestive func- tion than either opium or morphin. In patients of a full habit the alka- line waters exercise a valuable influence ; Bethesda, Carlsbad, and Vichy of France have long had a reputation. For the foreign water our native alkaline waters may be substituted, especially the Saratoga-A^ichy. While these are valuable adjuncts, they are, however, without the cura- tive and specific effect that is claimed for them by certain authorities. Among other therapeutic agents that have been employed are the following: the solution of the bromid of arsenic, TTliij-v (0.199-0.333) three times a day, after meals — in some cases a useful adjuvant to the treatment above outlined; potassium bromid, gr. xx (1.296), three times a day, approximating in efficacy the latter remedy : guaiacol. ITlv-x (0.333-0.666), three times a day in a tablespoonful of milk or cod-liver oil, has given excellent results (Clemens) ; antipyrin (gr. x — 0.648, three times a day) ; sodium salicylate, gr. xv (0.972), three times daily, lessens the formation of sugar : and strychnin, gr. -^ (0.0021). three times daily, is an almost invariably useful remedy. Of the numerous rem- edies in whose favor convincing evidence is wanting, but which are employed by different clinicians, the following may merely be enume- DIABETES INSIPIDUS. 385 rated : Fowler's solution, potassium iodid, iodoform, lactic acid, glycerin, nitroglycerin, creasote, quinin, jambul, lithium, and methylen-blue. The treatment of di&hetes hj fresh jjanci'eas or by dry or glycerin extracts has been generally unsuccessful. Fitz, however, mentions a case in which remarkable improvement followed the exhibition of raw calf-pancreas. These preparations have been employed to supply the ferment (internal secretion) essential to the assimilation of sugar. R. Lupine has obtained from the fresh pancreas, from saliva, and from the diastase of malt a glycolitic ferment by a method which, he tells us, still requires to be perfected. This agent he has used in 4 cases of diabetes with a fair degree of success. Williams tried grafting sheep's pancreas in diabetics in two cases, but the results Avere unsatisfactory. Gilbert and Carnot found that extract of liver, administered by rectal injection, caused a marked decrease in the excretion of sugar. Thyroid extract, in small doses, was followed by immediate improve- ment in two of my cases ; it is especially indicated in alimentary gly- cosuria. 4. Symptomatic Treatment. — Most symptoms demanding therapeutic interference the competent physician is prepared to meet by following general rules. The management of diabetic coma, however, Avill be briefly discussed. Believing it to be due to an acid-intoxication, Klem- perer gave large amounts of alkalies in 9 cases by intravenous injection, without preventing a fatal issue. To counteract the acids of the organ- ism, sodium bicarbonate (drams 5, daily) is advisable (Robin). The normal saline infusion, used by hypodermoclysis, has given fa- vorable results in some cases. Klemperer urges the use of fatty substances in large quantities as •the best means of restricting nitrogenous destruction, and thus prevent- ing the condition to which diabetics so frequently succumb. When a disgust develops for fats a substitution-method of treatment consists in administering alcohol (siss — 48.0 — per day). Like carbohydrates, alco- hol in small quantity checks waste and may lead to an accumulation of flesh (Hirschfolcl). Strychnin, digitalis, or ether may be tried hypo- dermically during the attack. Prolonged tepid baths with occasional douching have seemed to produce beneficial results in some cases, and are worthy of a trial in all. Elimination from the bowels is to be in- creased, and oxygen should be inhaled. DIABETES INSIPIDUS. Definition. — A chronic nervous affection, characterized by con- stant thirst and an excessive flow of urine, which, however, is free from sugar and albumin and is of low specific gravity. PathiOlogy. — No definite or characteristic lesions have been noted, though some degree of enlargement of the kidneys, together with saccu- lation, due to pressure backward upon the renal structure by the enor- mous quantities of urine in the bladder and ureters, has been observed. The ureters and pelves of the kidneys may be dilated, and the bladder, 25 386 CONSTITUTIONAL DISEASES. owing to constant over-distention, may be hypertropbied. Tbe nervous lesions are diversified, but are not peculiar to simple polyuria. Most important, perbaps, are tbe tuberculous and otber tumors about tbe fioor of tbe fourtb ventricle. Ktiology. — [a) Diabetes insipidus is often induced by nervous injiu- ences — sbock, frigbt, etc. — and may also be of traumatic origin. In tbe majority of tbe latter cases it follows injuries to tbe bead, but also, more rarely, it may be traced back to injuries of otber parts of tbe body. Tuberculous and otber lesions in tbe vicinity of tbe tloor of tbe fourtb ventricle may produce polyuria. It bas also been caused by paralysis of the sixth nerve, with or without meningitis. (6) It may occur during convalescence from acute infectious diseases. I have seen 2 instances after influenza in young subjects, (c) Intemperance, especially the con- sumption of inordinate quantities of malt li(}Uors, proves a cause. In several of my own cases the amount of urine passed was out of all pro- portion to the quantity of fluid ingested. One of these patients con- sumed three pints of beer daily, while the urine excreted amounted to eight quarts, (d) Ilerediti/. — Weil found in four generations of a certain family consisting of 91 members, that 23 exhibited continuous polyuria — all, however, remaining in good health, [e) Age. — The disease is rela- tively more frequent in childhood and early adolescence than is diabetes mellitus. Of 70 cases collected, 22 were under ten years of age, and 13 between ten and twenty (Roberts). Diabetes insipidus may be congeni- tal. (/) Tbe great proportion of cases occur in males as compared with females. Nature of the Affection. — The specific cause of the disease, if it have one, is as yet undiscovered. We are totally ignorant of its true nature, though the facts discovered by Bernard, that either a puncture at a cer- tain spot in tbe floor of the fourtb ventricle or section of the vagus causes polyuria, go to show that it is of nervous origin. It is true that the disease may come on in persons apparently in robust health without discernible causative agencies. In many instances, such as organic affections of the brain or abdominal tumors, the condition is purely symptomatic, and these are probably not to be classed as cases of gen- uine diabetes insipidus, which is a vaso-motor neurosis, usually of cen- tral, though sometimes of reflex, origin. Clinical Symptoms. — The onset is gradual, as a rule, but when it follows a fright or traumatism it may develop quickly. There are two main symptoms — the passage of an enormous quantity of limpid urine, and tbe constant thirst. The daily amount of urine varies from 20 to 60 pints (10-30 liters) ; it is transparent, and the specific gravity is low (1001 to 1005). While the percentage of solids is lessened, the total is usually about normal, and may even be increased. Albumin and suirar are rare, but in a few cases inosite has been detected. Tbe act of micturition is of very fre(iuent occurrence, and the quantity of urine passed at each sitting surprisingly large. The persistent thirst necessi- tates frequent drinking, but the voracious appetite seen in diabetes mel- litus does not mark this disease, in Avbich the appetite is only slightly increased. As a result of tbe polyuria tbe skin and mucous membranes are abnormally dry, as in genuine diabetes. But, unlike the latter affection, a fair degree of bodily nutrition is maintained as a rule. ARTHRITIS DEFORMANS. 387 « The saliva and other digestive secretions are scanty, and this, together with the good appetite, is a fact which explains the disturbances of digestion sometimes met with. The tolerance of the system to alcohol is often phenomenal. Associated nervous phenomena are frequently observed, such as neurasthenic symptoms, insomnia, and chorea. Prognosis. — The majority of instances proceed to recovery sooner or later, while others pursue an almost endless course — forty or even fifty years in duration — and the patient meanwhile retains his general good health. There is a small group of grave cases that are due to organic diseases either of the brain or abdominal organs. Death may also be occasioned by some intercurrent complicating condition. Diagnosis. — The clinical recognition of diabetes insipidus rests upon — (a) the enormous amount of urine passed ; (F) its low specific gravity ; and (c) the absence of sugar and albumin. Differential Diagnosis. — Among aifections that must be diff"erentiated are diabetes mellitus, which has a single point of resemblance — namely, • the polyuria ; hysterical polyuria., which is transient and accompanied by other hysterical manifestations ; and chronic interstitial nephritis, which generally distinguishes itself by the presence of albumin and hyaline casts in the urine, arterio- sclerosis, and cardiac hypertrophy. Treatment. — The amount of drinking-water is to be moderated in a gradual, cautious manner. To insist upon a sudden great reduction is productive of harmful effects, but the patient should be warned not to exceed his actual necessities. I also find that methodic physical exercise acts very beneficially. Of medicines, nervines, especially valerian and its preparations, are useful in the idiopathic variety of the complaint, and may be given in the form of the ammoniated elixir (oj-ij — 4.0-8.0) three or four times daily. The valerianate of zinc, quinin, and iron may be variously combined, according to the indications presented by special cases. Ergot and gallic acid have long enjoyed a high reputation in this disease. The commencing doses should be moderate, and then be increased until full physiological doses are employed, this method often bringing about ad- mirable results. Antipyrin, acetanilid, the bromids, and arsenic have been extensively employed and lauded by diff"erent writers in the treat- ment of this affection. My own best results have been attained by the use of ergot. Next to this agent the bromids and acetanilid, given alternately at intervals of a couple of weeks, have been found to be most useful. If a primary disease exists, it must be met on intelligent general therapeutic principles. ARTHRITIS DEFORMANS. (Rhetimatoid Arthritis; Rheumatic Gout.) Definition. — A chronic disease, characterized by progressive changes in the arthritic structures (cartilages, synovial membranes, etc.) and by osseous periarticular formations, producing great deformity. The affec- tion may rarely be acute in its course. 388 CONSTITUTIONAL DISEASES. Pathology. — It is here that the identity of the disease is distin- guishable. Among early gross changes there may be an effusion into the affected joints, but this disappears later. The cartilages are ab- sorbed, the process beginning centrally, ^vhere there are both the maxi- mum amount of friction between the opposed cartilaginous surfaces and the minimum blood-supply. Disappearance of the cartilages is natur- ally followed by contact of the ends of the bones, the latter becoming polished and resembling ivory as the result (eburnated). The friction between the bony extremities may lead to absorption of the latter. At the periphery, where pressure is slight or even absent, the carti- lages become greatly thickened in consequence of persistent irritation, and later become ossified, forming osteophytes which overlie the articular surfaces. These may lock the joints. Bony nodules may also be formed from the periosteum of the bony shafts. Almost simultaneously the synovial membranes become inflamed, a proliferation of their cells taking place, and this exudate may undergo organization and rarely ossification. Later the capsule and the Ujia- ments are thickened, causing a restriction of movement of' the affected joints and producing pseudo-ankylosis. Less frequently they soften and weaken to such an extent that often partial, and sometimes com- plete, dislocation of the joints ensues ; but displacement of the ends of the bones, amounting even to complete luxation, may also be due to absorption. This is often observed in the head of the femur, producing the so-called morbus coxce senilis. Muscular wasting occurs and may be profound. Neuritis has been noted. The histo-pathologic changes consist in cell-proliferation, with fibril- lation and softening of the matrix of the cartilages, followed by absorp- tion due to pressure. At the margin, however, proliferation of the cells leads to massive nodulation. Ktiology. — The nature of the diseas.e is still dubious, though the old view, that it is closely connected with rheumatism on the one hand or gout on the other, should be abandoned. J. K. Mitchell long since maintained that rheumatoid arthritis is of nervous origin, being espe- cially dependent upon affections of the spinal cord, and without stopping to adduce all of the facts that tend to support this theory, the following deserve mention : (1) Diseases of the cord (locomotor ataxia, etc.) are known to cause arthritic conditions ; (2) The character of certain causal factors, such as nervous shocks, griefs, etc. ; (3) The symmetry of the joint-deformities ; (4) The time of occurrence ; and (5) Noticeable trophic disturbances that are frequently associated. Falli ^ autopsied 4 cases, 2 of which were typical, and in the latter lesions were found in the anterior horns of the spinal cord, atrophic in the first case, but degenerative as well as atrophic in the second. According to Falli, not all cases of arthritis deformans are to be interpreted as instances of nervous disease. Another theory of the disease is the microbic, which has received some measure of support. Bacteriology. — Dor claims to have succeeded in finding a definite organism. He also claims to have reproduced the disease by injecting cultures directly into the blood of rabbits, and considers the germ an "attenuated culture " of the staphylococcus pyogenes aureus, v. Dun- 1 II Polidinirn, Dec, 1894. Fig. 31k -Hand of M. R., aged fifty years, showing characteristic deformity, including outward deflection of fingers, in advanced arthritis deformans. ARTHRITIS DEFORMANS. 389 gern and Schneider isolated after death from the mucus of the gall- bladder, and also from the exudate in the joints, small diplococci that did not resemble the organisms previously described by Blaxall and Schliller. Injections of the cultures into the knee-joint of rabbits resulted in the production of lesions similar to those observed in the patient. Predisposing Causes. — (a) Nervous shocks, mental worry, and deep grief, [b) Females are more frequently victims than are males, the pro- portion, according to the statistics of Garrod, being about one to five in favor of the former sex. To account in part for its greater frequency in Avomen is the fact that sterility and certain ovarian and uterine com- plaints seem to exert a strong etiologic influence, (c) Age exerts a de- cided influence. It is most frequently contracted in the third decade of life, though it has been noted as late as the end of the fifth. It occurs also in children, though rarely. Out of 307 cases treated in the Devon- shire Hospital during 1892, only 2 per cent, manifested the disease be- fore the age of ten. [d) Heredity has been traced in some instances, and in many o, family tendency to joint-afi'ectien. (e) Though it occurs in all classes of society, the poor or those exposed especially to debili- tating influences are more liable than the rich. (/) Ewart^ recognizes some mixed conditions in which rheumatoid arthritis may supervene on the gouty diathesis. (1) Symptoms of the Chronic Form. — At first one joint, usually of the hand, is slowly involved ; soon the corresponding joint on the opposite side is attacked. These may recover apparently, but are soon reinvaded and grow progressively worse. The aff"ected joints slowly en- large, and are moderately painful, particularly on movement. Pain, however, may either be slight or even absent, or severe (rarely agoniz- ing) in character. There is neither redness nor tenderness, as a rule, but on palpation an effusion, variable in extent, is generally detectable. The course during the early stage is often marked by periods of im- provement, alternating with exacerbations in the local symptoms, and especially in the swelling and pain. While, as intimated, one or two joints only are affected at the start, gradually those of the feet, arms, legs, and trunk are invaded symmetrically, until, in the worst cases, every joint is deformed. The most characteristic symptom is the deformity, which manifests itself earliest in the hands. The fingers are generally pointed toward the ulna, rarely toward the radius, and the presence of the osteophytes and the immensely thickened capsular ligaments, together with the re- tracted muscles, all tend to alter entirely the shape of the joints. The fingers, for example, are fiexed and extended upon the hand, and some- times overlie one another. With the progress of the deformity a partial, and less often a complete, luxation of the joints occurs (see Fig. 31). The joints may become finally either quite fixed, owing to the presence of the periarticular osteophytes, or a limited degree of movement may remain. Palpation and auscultation of the involved joints reveal crepitation during movement. Strangely enough, the thumb remains intact, com- pensating for the loss of the functional movement of the fingers to a remarkable extent. In addition, the hand is sometimes less affected ^ International Medical Magazine, April, 1899. 390 CONSTITUTIONAL DISEASES. tban the rest of the joints — a fact -which enables the patient to perform a great variety of even delicate movements. The adjacent muscles be- come Avasted and are the seat of contractures, causing flexion of the limbs, especially of the thigh upon the abdomen and the leg upon the thigh. Other trophic changes, such as paresthesia and pigmentation or glossy areas of the skin, may be observed. In 3 of my cases onychia was present. In extreme instances the decubitus is lateral and the patient utterly helpless. The course of the disease throughout the more advanced stages is exceedingly variable. Its advance may be arrested and the general health remain unimpaired, and this may take place after implication of but a few joints, so that the entire affection may be confined to a com- paratively small part of the body, either in the upper or lower extrem- ities. In progressive cases more or lessgastro-intestinal disorder arises ; the symptoms of indigestion appear, the appetite is impaired, and anemia develops. The patient's sufferings make him irritable. Hypo- chondriasis may be a concomitant. In established cases the pulse is per- sistently rapid and the skin inclined to free perspiration. Clinical Varieties. — (1) Of the chronic form there are certain sub varieties. The disease may be limited to a single joint {monartic- ular), this form most commonly affecting the hip-joint, when it is known as morbus cozce senilis. It is seen generally in old men. and often fol- lows an injury. Its features — pathologic and clinical — including the muscular wasting, are the same in kind as those of the polyarticular variety. Monarticular arthritis deformans may also be confined to the shoulder-joint or the knee, and, as in the preceding form, men who have passed the middle period of life are mainly affected. A special variety, which is generally not monarticular, involves only the vertebme {spondylitis deformans). This may be combined with morbus eoxce senilis, or the condition may be confined to the cervical spine, as in a recent case of my own, thus preventing flexion of the head. A fair degree of rotation usually remains, but it sometimes hap- pens that the entire spinal column is involved and held in a perfectly rigid position. Still another form in which the distal joints of the fingers become knobbed {Heberden's nodes) demands separate description. Heberden's nodosities occur chiefly in women between the thirtieth and fortieth years, though I have seen one case which began after the fiftieth year. According to Heberden, who first described them, the nodes have no intimate association with gout, and this view coincides with my obser- vations. At first the affected joints become swollen, tender, slightly red, and painful, and then seemingly undergo great improvement. The con- dition however, is progressive, advancement occurring in the form of fresh exacerbations, which are often traceable to errors in diet, and are separated by periods of remission. The morbid process is the same as in rheumatoid arthritis, and the destructive changes in the joints pro- ceed until distinct hard nodules are formed. These are usually most marked at the sides of the extensor surf\ices of the second phalanges. The disease does not spread to any of the larger joints, and, although incurable, it is free from danger to life. (2) The Acute Form. — This is comparatively rare, and occurs com- ARTHRITIS DEFORMANS. 391 monly between the ages of twenty and thirty. It occurs in children, and is more common in women than in men. Among its common ante- cedents in women are pregnancy, delivery, excessive lactation, and the menopause. 3Iultiple arthritis, affecting both the large and small joints, sets in acutely, and there are pain and either a slight redness or a con- siderable swelling, due chiefly to an eifusion Avhich is intra- rather than periarticular. There are only a slight tendency to migration from joint to joint, and a slight febrile disturbance. Still described a form of chronic joint-disease in children which he thinks presents differences sufficiently marked to suggest a distinct clinical and pathologic entity, and differing from the rheumatoid arth- ritis of adults. It is defined as a progressive enlargement of the joints associated with general enlargement of the glands and enlargement of the spleen. He has studied 22 cases, 19 of Avhich came under his per- sonal observation. It occurs before the second dentition. Stiffness, general thickening of the tissues around the joints without redness or tenderness, except in very acute cases, with limitation of movement and more or less rigid flexion of the joints, characterize the arthritic dis- turbance. The most distinct feature of the disease is the enlargement of the lymphatic glands, those in relation to the involved joint being primarily affected. The glandular swelling is general and constant. Enlargement of the spleen is also a striking feature. Cardiac compli- cations are absent. The course of the disease is slow. Differential Diagnosis. — The diagnosis between the chronic form of the disease and chronic rlieumatism is not ahvays an easy one. In the latter, however, a few of the larger joints only are involved, while there is an absence of the peculiar deformity and marked fixity of the articulations. On the other hand, cardiac complications are absent in chronic rheumatoid arthritis, and the course is progressive. A mon- articular arthritis which differs in its morbid process from rheumatoid arthritis sometimes affects the shoulder-joint. It is not uncommon, and is " characterized by pain, thickening of the capsule and of the liga- ments, wasting of the shoulder-girdle muscles, and sometimes by neuritis " (Osier). I have met with 5 instances of this sort, in all of which pain w^as intense and the course subacute. All ended in recovery. The acute form is frequently confounded with acute articular rheu- matism, from which it is to be discriminated by the special etiologic factors, the less severe pain, the less marked redness, the slight tendency to migration from joint to joint, the slighter febrile disturbance, and by the practical freedom from cardiac complications. G-out will be distin- guished in the description of that disease. Prognosis. — Though incurable, rheumatoid arthritis is not imme- diately dangerous to life, and in a certain proportion of the cases im- provement, and in a smaller proportion arrested progress of the disease, may be expected. Treatment. — This especially involves measures that are directed to- ward the improvement of bodily nutrition — a generous dietary, systematic \Yarm bathing, and an abundance of fresh air, with properly-regulated phvsical exercise. Tonics may be necessary to invig-orate the economy, and iron to overcome the anemia. The prolonged use of cod-liver oil in conjunction with other remedies has given me excellent results. Of 392 CONSTITUTIONAL DISEASES. special agents, the most satisfactory in their effects if administered early are iodin and arsenic. An eligible form of the latter is arsenious acid, given in granules (gr. ^ — 0.0018, after food) ; the former may be ad- ministered in the form of a saturated solution of sodium iodid, of which ten to fifteen drops may be given in milk one hour after food. The patient may be sent to a warm climate in winter and to a cooler one, preferably a mountain-resort, in summer. These patients also do well at certain mineral springs, such as the sulphur springs of Virginia, the hot springs of Arkansas or Toplitz, at Baden in Switzerland, and the warm sodium chlorid baths in Wiesbaden. Hot mineral spas should only be resorted to in the early period of the affection. Striimpell has seen excellent results follow the employment of hot sand-baths, which can be used at home. Stewart advocates the Tallerman method of treatment — i. e. of superheated dry air. Short employs the apparatus ordinarily used in hospitals for the administration of hot-air baths, with a view to producing diaphoresis. Fibrous anchylosis may be treated surgically. Eliminative Treatment. — Guaiacol carbonate may be given in doses of from 5 to 15 grains (0.3-1.0 gm.) daily and rapidly increased. This acts by combining with the bacterial toxins, to be eliminated as guaiacol sulphate (Bannatyne). The local means are of the highest value. If the joints be inflamed, cold compresses, covered with oiled silk, to which some narcotic agent may be added, will afford relief. This should be followed by thorough and systematic massage, which is our best measure for the reduction of the swelling (by promoting absorption of the inflammatory exudate) and for lessening joint-rigidity. It also restores the atrophied muscles and assists the general health. Swedish movements are useful in maintain- inor mobilitv and often in restoring that which has been lost. GOUT. [Podagra.) Definition. — A form of perverted nutrition due to an auto-infection, accompanied by the formation of a variable (usually increased) amount of uric acid, and characterized clinically by attacks of acute arthritis, with or without uratic deposits in and around the joints. Nature of the Affection. — The numerous theories that prevail at pres- ent in regard to the disease are irreconcilable, but it seems certain that there is {a) an excessive absorption of nutritive substances, both solid and li([uid : (h) a disordered metabolism growing out of the effects of imperfect physical development, combined with too little physical exer- tion ; (c) a defective elimination of waste-products, although in some cases a normal elimination of waste-products exists. There are a number of uric-acid theories., some of which may be briefly mentioned : 1. Garrod contends that an acute attack of gout is invariably produced by an excess of uric acid in the blood, due to increased formation and greatly decreased elimination : also, that inflammation is GOUT. 393 caused by the deposition in the joints of sodium urate. 2. Haig holds that there is a diminished alkalinity of the blood, and that the latter can- not therefore hold the uric acid in solution, so that it is deposited in the form of urates. 3. Ebstein thinks it probable that there exist an ex- cessive production and accumulation in the blood of uric acid. The sur- charo;ed blood excites local inflammation, followed bv necrosis, and uric acid deposits. 4. Sir William Roberts believes that acute attacks of gout are dependent upon the precipitation of the crystalline biurate of sodium ; that the urate is transformed into the less soluble biurate in the blood. 5. V. Noorden concludes that the essential process is a tissue-necrosis attributable to the presence of a hypothetic ferment, and that the uric acid, which is without etiologic eiFect, is deposited at the necrotic focus. 6. Klemperer ^ has shown as the result of observations made in cases of gout, that as long as the function of the kidneys is not materially inter- fered with the presence of considerable amounts of uric acid in the blood must be attributed to increased formation. But the presence of an equivalent of uric acid in the blood in certain aifections other than gout [e. g. leukemia) shows that this factor is not the sole cause of gout. 7. Morhorst, in dealing with the pathogenesis of gout, states that in any alkaline liquid th-e basic substances combine with uric acid, if this be present, to form a urate. These uratic precipitations are met in non- vascular tissues only, the alkalinity of which is less than that of the blood, and that they are the essential cause of the symptoms. 8. Kolisch main- tains that the more serious features in gout only exist in the presence of impairment of the renal function. When the kidneys are healthy the alloxuric bodies are, in great part, excreted as uric acid; but when they are diseased the xanthin bases are increased at the expense of the uric acid. Chittenden and others, however, hold that the xanthin bases are practically free from toxic effects. 9. Luff thinks that uric acid is formed in the kidneys from a combination of urea and glycocin, an increased amount of the latter substance being formed in the liver. The recent view that failure of the renal function precedes the de- velopment of gouty manifestations, although not established, and the older view, that an increased proportion of uric acid is found in the blood in gouty subjects, seem to be the most Avidely accepted. Patliology. — The post-mortem history of gout is concerned princi- pally with the arthritic changes, including the deposits of the urate of sodium in the cartilao-es, the ligaments, and the synovial membranes. These are fluid in their earliest state and contain numerous small crys- talline masses ; they soon inspissate and later become hard and dry (tophi). The latter excite secondary inflammatory changes that may lead to fibrous overgroAvths, distortion, and fixation of the joints. Gouty tophi may be absorbed or they may finally be discharged through the skin in consequence of an ulcerative process. The chalky concretions have been found also in the cartilages of the ears, less frequently of the nose, eyelids, and larynx. They have also been described in the peri- osteum and along the tendons of the palms of the hands, where they produce a characteristic form of contraction of one or more fingers (Du- puytren's contraction). Charcot has found them in the penis. If death occur in the acute attack, hyperemia and swelling of the capsule, liga- ^ Deutsche m'^dicinische Wochenschrift, 189-5, Xo. 40, p. 653. 394 COySTITUTIOXAL DISEASES. ments, and syuovial membrane are found, together with an inflammatory exudation into the joint. The kidneys are usually involved, the changes being similar in char- acter to those observed in the joints, and innumerable areas of necrosis, followed by uratic deposits, are seen throughout the organs, though chiefly in the papillie. Osier says that '• the presence of these uratic concretions at the apices of the pyramids is not a positive indication of gout." X. S. Davis, Jr., points out that the kidneys are afi'ected in spots, with intermissions in the degenerative changes, which are microscopical in size, until finally large areas are involved. Granular contracted kid- ney (chronic interstitial nephritis), with or without arteriosclerosis, is sometimes caused by the gouty condition {vide Interstitial Nephritis). The Iteart and blood-vessels always present changes. Gout induces arterio-sclerosis, and the latter in turn causes cardiac hypertrophy, particularly of the left ventricle. In chronic cases fatty degeneration of the heart-muscle sometimes occurs, and chronic valvulitis, with de- posits of urate of sodium in the valves, has been noted. Chronic bronchi- tis, asthma, and emphysema are among the more common changes connected with the I'espiratory tract, acute conditions being rare. Ktiology. — The following are the principal contributing causes : (a) Heredity. — Garrod's dictum, '" that more than one-half of all gouty subjects can distinctly trace their ailment to an hereditary taint," is doubtless correct, heredity from the grandparents, which is not of in- frequent occurrence, being included in this estimate. If the better class of society alone be considered, the percentage will probably be still larger. It must not be forgotten, however, that patients out of pride represent other articular afl'ections as gout. (Jj) Age. — Primary attacks are most frequent in middle life. They are rare before puberty, though exceptionally seen even in suckling infants: but after the age of puberty they become more frequent. After the fiftieth year they de- crease rapidly in frequency, and are very rare in quite advanced life. The cases that develop quite early in life often show a striking heredi- tary taint. ('-) Sex. — The arthritic form is less fref|uent in women than in men, while the former are disposed to the irregular type of chronic gout quite as strongly as the latter, {d) Diet. — Over-indulgence in the pleasures of the table, together with defective physical exercise, consti- tutes a potent factor, and this even in persons who are endoAved with exceptional powers of digestion. ('') AIcohoL and particularly the fer- mented liquors, are among the chief favoring influences. The fact ex- plains the relatively greater frequency of gout in certain countries (e. g. England and Germany), in which the heavier beers and ales are freely used, than in America, where lighter fermented drinks are more popular. The cases, however, are on the increase in this country. (/") Social State. — Most cases occur among the upper class of society, but there is also a well-defined form of " pour-man's gout " due to an excessive use of malt beverages, (g) Lead. — Workers in lead furnish numerous typical ex- amples of gout. Garrod found that in 30 per cent, of the hospital cases the patients had been painters or workers in lead. He also showed that the administration of lead salts to gouty persons almost invariably determined a gouty paroxysm. AVhether lead produces gout by arrest- ing the excretory processes, especially from the bowel and kidney, and GOUT. 395 by thus inducing a fibroid change in the kidney and liver, as is held by Oliver of New Castle, is not definitely settled. Poore points out that gout produced by lead or chronic kidney trouble is constantly associated with anemia and emaciation, and forms a distinct clinical entity. (Ji) Cornillon and others detail cases in which injuries were folloAved by the first appearance of the disease. Clinical History. — 1. Acute Gout. — The earliest manifestations of the disease are apt to take the form of a more or less typical attack of acute arthritic gout. The latter is usually preceded by certain prodromal symptoms, which vary in different cases, but are almost constantly simi- lar for the paroxysms of individual cases. The patient may complain either of slight muscular cramps and articular pains, or of dyspeptic dis- order, or of an asthmatic seizure ; or he may exhibit mental disturbance — irritability of disposition, broken, restless sleep, and depression of spirits. In a small percentage of instances, just prior to the attack the patient feels better than ordinarily. It has been observed that imme- diately before and also during the early part of a paroxysm the daily amount of uric and phosphoric acids found in the urine is diminished ; but Klemperer has shown that no relation exists between the amount of uric acid present in the urine and the character of the disease. The attack generally develops in the very early morning hours. The patient awakens suflFering from pains in the metatarso-phalangeal joint of the great toe, that soon become excruciating, while the joint feels as if it were tightly compressed in a vise. The local signs of inflamma- tion — heat, redness, swelling, and excessive sensitiveness — quickly super- vene. The skin pits on pressure and becomes shiny. The body-tem- perature rises to 102° or 103° F. (39.4° C), and the patient manifests intense irritability. At the end of an hour or two the sufferings abate, the fever often declines, with free perspiration, and the patient may be able to pursue his avocation. During the next day some degree of enlargement and inflammatory edema remains, and on the following night the symptoms are usually repeated in all their violence. The condition usually pro- gresses in this manner from four to seven or eight days, though after a few days the intensity of the paroxysms is apt to lessen. After the attack the swelling subsides and there is a slight desquamation of the skin, which resumes its normal color, and the general health is often unusually good. These so-called fits of gout usually recur from time to time, the duration of the intervals depending largely upon the patient's habits or routine of life. On the whole, the first interval is apt to be the longest, while later the intermissions may not exceed two or three months. With subsequent attacks the affection is apt to spread to other articulations. There is no tendency to suppuration. 2. Retrocedent Gout. — This term implies the sudden transmission of the arthritic process to some internal organ. During a paroxysm the joint-inflammation may quickly disappear Avith an equally sudden de- velopment of intense pain in the region of the stomach, vomiting, diar- rhea, faintness, and a rapid, feeble pulse. Suppressive gout may attack the heart and produce precordial pain, dyspnea, cardiac palpitation, and much anxiety of mind. It may also excite pericarditis with a fatal result. Transmission to the head, with the development of intense 396 CONSTITUTIONAL DISEASES. cerebral symptoms (maniacal excitement, coma, and apoplexy), also occurs. Nervous phenomena, however, are more commonly due to uremic poison. 3. Symptoms of Chronic Gout. — Chronic gout follows the acute variety. The transition is o-radual, the intervals between attacks shorter, Avhile the attacks themselves grow milder and longer. At last the local in- flammation does not appear. The condition extends to other joints: first, to the corresponding joint on the opposite side, then to the other toes and the ankles. Later, the fingers and wrists may be invaded, but almost never the largest joints (hip, shoulder). With the progress of the affection the chalk deposits slowly and gradually increase until the characteristic deformity is produced. The skin covering the tophi may ulcerate, exposing the chalk-stones, an unmistakable picture. When the fingers are affected we note a deflection at the second or third joint, con- stituting a peculiar habitus. Among important associated conditions are chronic gastric catarrh, arterio-sclerosis, cardiac hypertrophy with considerable functional dis- turbance of the heart, and "contracted kidney," forming a much com- plicated yet easily recognized clinical picture. If in cases of this sort the urine of a gouty person is carefully examined, and is found to con- tain a small percentage of albumin and tube-casts, the whole train of events becomes easy of interpretation. The cases may be divided into two classes : (a) those in which the complexien is florid and the general health vigorous ; {b) those with pale, sallow facies, emaciation, and en- feeblement. These groups are chiefly dependent upon the differences in the etiologic factors. Gouty subjects often manifest unusual mental vigor. The course of chronic gout is liable to be interrupted by acute exacer- bations with fever, during which dangerous complications may arise — e. g. uremia, pericarditis, pleurisy, pneumonia. 4. Irregular Gout. — Says Sir Dyce Duckworth: "Gout manifesting itself anywhere but in a joint is to be considered irregular or incom- plete." Such cases are confined chiefly to persons of gouty heritage, though I feel confident that the diathesis may be also acquired. But though the etiologic factors that produce lithemia also in time produce gout, these two conditions should be discriminated ; for, while in both we usually note an excess of uric acid in the blood, in lithemia there are no tophi present, and hence no necrotic foci in the joints or else- where. Irregular gout, then, rarely occurs in persons who have had previous typical attacks, but should any of the conditions described below as being dependent upon the gouty diathesis be associated, or should they alternate, with acute gout, they may be properly ascribed to the latter. On the other hand, when these conditions occur in persons who are free from hereditary taint, and who are not addicted to the intemperate use of alcoholic beverages, or excessive indulgence in the pleasures of the table, and are not possessed of luxury- and rest- loving temperament, the diagnosis of irregular gout is to be made with extreme caution. It is perfectly justifiable to apply a therapeutic test when other means of diagnosis fail. The features of irregular gout are exceedingly diversified ; the follow- ing are the more important : (a) Joint- and Muscle-pains. — The muscular pains may be anywhere. GOUT. 397 and "flying" in nature, but the muscles of the back of the neck, the lumbar region, the abductors of the thigh, and the gastrocnemii are especially liable (Tyson). These pains are most severe in the early morning hours and subside as the day grows. Articular pains attended with some degree of swelling and deformity of the joints (the latter, how- ever, not due to uratic deposits) may be of gouty origin ; and, according to Paget and Garrod, Heberden's nodosities (previously described under Rheumatoid Arthritis) may present vesicular eminences due to gout. [h) Gfastro-intestinal Disturbances. — The symptoms referable to the intestines are identical with those presented by lithemia. In one of my cases intestinal colic followed by diarrhea put in an appearance at long intervals. Tonsillitis, pharyngitis, pericarditis, and even parotitis, may also be manifestations. (c) Cardio-vascular Symptoms. — Just as in pure lithemia, so in atypi- cal gout, the increased amount of uric acid usually present in the blood, by increasing the blood-tension, excites arterio-sclerosis and chronic in- terstitial nephritis — affections which are fully described in appropriate sections of this work. {d) Nervous Manifestations. — The different varieties of headache, including migraine, are common. Sciatica and other forms of neuralgia, tingling, itching, burning sensations, and even pain in the palms of the hands and soles of the feet, are of frequent occurrence. Hot and itch- ing eyeballs are, according to Hutchinson, among frequent manifesta- tions ; apoplexy may arise, secondary to atheroma induced by gout ; and rarely meningitis (basilar) is among the gouty morbid states. The latter also include certain psychopathia — insomnia, irritability of temper, and melancholia. The possibility of gouty neuritis is to be remembered. (g) Urinary Symptoms. — The urine is highly colored, of high specific gravity, often scanty, and the standing specimen deposits lithic acid. This is not peculiar to gout, how^ever. In many cases uric acid is in excess only at intervals, giving rise to so-called uric-acid showers, while at other times it is diminished in quantity. The results of the investi- gations by Klemperer are to be recollected here {vide ante). Gouty persons are liable to gravel : I agree Avith Tyson, however, in thinking that the tAvo conditions more frequently alternate than coexist. Inter- mittent glycosuria is also common in gouty subjects, and may lead to true diabetes mellitus ; this glycosuria may alternate with uric-acid showers. Oxaluria has been noted. Grandmaison believes the associa- tion of albuminuria with gout to be a frequent one, and that the early albuminuria is often intermittent. Among grsiye secondary affections chronic interstitial nephritis, ivith its characteristic features (slight albu- minuria and later casts), very commonly develops, sooner or later, and cystitis (with gouty hemorrhage into the bladder), urethritis, prostatitis, and orchitis, all may be dependent upon gout. (/) Pulmonary Disturbances. — Chronic bronchitis, to which asthma and emphysema are frequently secondary, is often the asthma of podagra. (g) Outaneous Uruptions. — Eczema is frequently associated with the gouty diathesis, and I have often observed eczematous eruptions in gouty subjects alternating with the symptoms of bronchitis or gastric catarrh. (A) Ocular Disorders. — The chief eye-symptoms are conjunctivitis and keratitis (with tophi in the cornea and eyelids), iritis, hemorrhagic 398 CONSTITUTIONAL DISEASES. retinitis, and glaucoma. Gouty involvement of the ear (external canal and the auricle particularly) occurs oftenest late in life, though hereditary gout may rarely cause ear symptoms shortly after birth. Differential Diagnosis. — The distinction between typical acute gout and acute articular rheumatism is a simple matter. But when, as is rarely the case, the former manifests itself as a polyarthritis, the dis- crimination is sometimes difficult. W. H. Thompson has pointed out that in gouty polyarthritis, when the knees, elbows, and phalangeal tinger-joints are affected, the points of greatest tenderness on transverse pressure are over the condyles. On the other hand, in acute rheuma- tism the cutaneous tenderness is greater, while the points of maximum tenderness correspond with the tendons anterior and posterior to the joints. Moreover, gout distinguishes itself by its previous history (heredity, alco- holism, gluttony), by the tophi, which may be first detected in the ears or conjunctivEe, by the development of contracted kidneys, and the less marked fever. After repeated attacks deformities of the joints ensue. In a doubtful case the blood-serum may respond to the uric-acid test, as follows: Add 5-6 minims (0.399) of acetic acid to 2 drams (8.0) of blood-serum in a watch- glass ; then place a linen thread in the solution and after twelve to twenty- four hours this will be incrusted with crystals of uric acid. The result is not, however, obtained exclusively from the blood of gouty subjects. Chronic rheumatism is distinguished from gout by the fact that the latter disease involves chiefly the small, and chronic rheumatism chiefly the large, joints. Moreover, chronic interstitial nephritis and arterio- sclerosis, with their varied and often serious consequences, are fre- quently attendant upon gout, but not upon chronic rheumatism. To diff'erentiate chronic gout and rheumatoid arthritis is sometimes a hard problem, but the following table will indicate the main points of difi'erence : Gout. Arthritis Deformans. Frequently hereditary. Not so. Causes are chiefly dietetic. Causes chiefly nervous. Affects males and the better classes most Affects females and lower classes most frequently. frequently. Begins in the big toe and extends to Begins in the fingers, Avhieh point to the other toes. ulnar side. Attacks are periodic. More steadily progressive. Deformity due to tophaceous deposits. Deformity due to exostosis and anky- losis, and more marked. Uric acid usually in excess. Not so. Complications (nephritis, arterio-sclero- Very rare. sis). Treatment. — (1) Prophylaxis. — In order to prevent the develop- ment of gout, especially in persons who have inherited or acquired a strong predisposition to the disease, temperate and even rigid habits of life should be adopted. Alcohol, particularly the heavier wines (Madeira, port, sherry, champagne, etc.) and heavier malt liquors, must be eschewed, and the patient must eat sparingly of concentrated meat (particularly red meat). A residence in the country with active out-of-door exercise is of paramount importance, but straining eff"orts, both mental and phys- ical, are to be avoided. The climate should be temperate and mode- rately dry. The sleeping apartments should be capacious, Avell venti- GOUT. 399 lated, and free from draught, and the action of the skin is to be favored by cleanliness, and if the patient be strong by a cold bath in the morn- ing with friction. For the robust, Turkish baths at intervals of two or three weeks constitute an excellent measure. In the class of patients that are pale and debilitated warm baths on retiring are preferable, and the chilling of the skin-surface is to be carefully guarded against. The patient should wear flannels next to the skin in all seasons. (2) Active Treatment. — (a) Dietetic. — " There is no diet for gout, but there is a diet for the patient " (H. C. Wood). The amount of food must be lessened as a rule, and taken at regular intervals. On the other hand, spare gouty subjects are met with, and in such I have found a rather generous diet, including fat-producing foods, of great service. Broadly speaking, the dietary should be constituted as follows : succulent vege- tables (cabbage, salads, string-beans) ; fruits (except bananas, tomatoes, and strawberries) ; farinacea, as rice, hominy and the like (oatmeal to be avoided); meats should be restricted; beef and mutton may be allowed in corpulent subjects, but are otherAvise to be interdicted, particularly in well-marked cases of gout ; oysters and fish (except those that contain too much protein, salmon, smoked herring, canned sardines, mackerel, halibut, salt codfish, flounder), and fowl, particularly the white meat of chicken, are permissible ; fats in the form of good butter may be taken freely — from 2 J to Zh ounces (70.0-100.0) per diem, according to Ebstein ; milk is entirely unobjectionable, and should be used in large quantities. If Avhole milk does not agree, it may be mixed with an equal part of Yichy. According to Kolisch, eggs are not objectionable, as the neucleins contained do not form alloxins. Stale breads may be used. I have observed that occasionally patients do best on albuminoids, while, on. the other hand, with about equal frequency they improve on a vege- table diet ; but I am convinced that a mixed diet, such as has just been indicated, is best adapted to the vast majority of the cases. Among articles to be avoided are pastry, tea and coffee, hot bread and cakes, sweet puddings, cheese, dried meats, and all highly seasoned dishes. Beverages. — Alcohol is ordinarily to be interdicted. Rarely it becomes necessary to administer it, particularly in cases of suppressed gout, and when needed Avhiskey or gin (diluted) is to be preferred. Most wines, and especially champagne, Tokay, Port, and malted liquors are particu- larly injurious in their effects. llineral tvaters, particularly the alkaline, are highly advantageous, and sometimes are even curative. Their value, like that of the warm baths and systematic exercise, is dependent upon their power to increase renal elimination. Whether they promote solubility of the uric acid in the blood is questionable ; moreover, according to the observations of Klemperer, this is not a rational indication. The carbonate and citrate of lithium are efficient diuretics, but have no other claim to virtue in this disease. Among natural waters of special value abroad are Yichy, Carlsbad, Homburg, Ems, Kissingen, Aix, Buxton, and Bath, and in this country Saratoga and Bedford. These waters are to be taken in large quantities and when the stomach is empty. It is highly probable that the environment, rigid system of hygiene, including exercise and an appropriately modified dietary, play the principal role in producing the favorable results obtained at these noted springs. 400 CONSTITUTIONAL DISEASES. (b) Medicinal Treatment. — During an acute attack the pain, if ex- cruciating, is to be relieved by a hypodermic injection of morphin, which is to be followed by a purgative dose of some mercurial. Colchicum is the specific remedy, and must be administered, in the form either of the wine or the tincture, in doses of Ttlxx-xxx (1.333-1.999) every four hours. It alleviates the inflammation and promptly relieves the pain, but its effects during the attack should be carefully noted. After the paroxysm it should be continued, though in small doses, combined with the citrate or bicarbonate of potassium or lithium. The limb should be raised and the affected joint or joints wrapped in flannel or cotton-AVOol. Warm alkaline solutions or hot fomentations often afford relief in the worst cases, and anodynes may be tried locally. The diet should con- sist chiefly of milk, animal broths, and egg-white during the attack, while after the latter rice, eggs, fish, and other light forms of meat may be added, the more liberal dietary previously indicated being slowly resumed. In the intervals between the acute attacks the prophylactic and dietetic measures previously mentioned are to be resorted to with a view to preventing recurrences of the disease, and in addition the alkaline diuretics and saline laxatives, together with warm bathing, will be found of the utmost value. In chronic and irregular forms of gout medicines are of subsidiary importance, and are in no wise comparable in their beneficial effects tO' the previous recommendations. Two agents deserve prominent mention, however. They are piperazin and the extract of thymus gland. The ingestion of the latter, as obtained from the calf, is followed by an in- creased excretion of uric acid. Piperazin has been warmly advocated in all forms of gout for its supposed effect as a solvent of uric acid, and clinicians are almost unanimous in reporting its favorable results. Its beneficial effects are probably due to its diuretic action. The dose is gr. v-x (0.324-0.648) thrice daily, freely diluted with water. Some authors highly recommend the salicylates for acute attacks of gout, both primary and intercurrent, in the course of the chronic form. In my own experience they have been less effective in this disease than colchi- cum, though ammonium salicylate or salicin may be tried if there be present marked gastric disturbance, since they are better borne under these circumstances than colchicum. Luff has demonstrated by experimentation the negative value of the alkalies and salicylates in the treatment of gout. If nephritis or a failure of compensation be present, even the former remedies should be administered with extreme caution. For chronic gout potassium iodid has been much used, though with slight advantage to the patient, I think. The bitter tonics, combined with a vegetable salt of iron, should be resorted to in the anemic, debili- tated class of gouty patients, and a change of climate often serves to improve bodily vigor in the same category of cases. LITHEMIA. Definition. — A condition due to a disturbed cellular metabolism. It is characterized chemically by an excess of uric acid in the blood, and L IT H EMI A. 401 clinically by various digestive, cir'culatory, genito- urinary, and nervous phenomena. My purpose in describing lithemia is that the common error may be avoided of attributing its symptoms to other causes. Pathogenesis and etiology. — Lithemia is comparatively a latent condition. There is an excess of uric acid, which may be for a time eliminated through the natural channels (kidneys, lungs, skin, etc.) with- out the occurrence of symptoms. On the other hand, when, as the result of too little exercise, impaired elimination, high living, the use of sweet wines, combined with the neurotic temperament, uric acid is allowed to collect in different parts of the organism, marked disturbances — nervous, gastro-hepatic, etc. — follow. We are not here concerned with the artic- ular type. C. G. Stockton holds that lithemia is a gastro-intestinal auto- intoxication. Among agencies that predispose to the onset of lithemia are alcoholism, heredity, climate (temperate or cold climates favor diminished actions of the skin), and the male sex. Symptoms. — The nervous, circulatory, respiratory, integumentary, and genito-urinary symptoms are practically the same as those described under Irregular Gout ; but I would here emphasize the broad clinical fact that the urethral and genital mucous membranes often become inflamed on slight provocation, producing urethritis, cystitis, orchitis, epididymitis, vaginitis, endometritis. These conditions resist treatment. Gastro-intestinal Symptoms. — The appetite is variable, sometimes voracious, and at other times it is impaired or perverted. The tongue is coated, and a metallic taste is often complained of, while various forms of indigestion attend. There may be a delay in the conversion of the albuminoids, causing pi/rosis, gastric oppressio7i, fulness, and sometimes nausea and vomiting soon after food. These symptoms, together with marked flatulence, are manifested at a later period after meals if there be failure in the digestion of the carbohydrates. The bowels work irregularly, and there may be diarrhea attended by colicky pain, Avith frothy and ill-smelling discharges. Hemorrhoids are usual, and melena may occur independently of the hemorrhoids. The liver is somewhat enlarged and often tender. A few prominent cardio-vascular symptoms should be mentioned, such as palpitation, particularly after eating. More rarely it occurs while the patient is at rest or even lying abed. Increased arterial tension develops early, but may not be constant, and is due probably to the action of the uric acid in the blood upon the vaso-motor nerves, exciting universal contraction of the arteries. This condition may be present for a long time before actual arterio-sclerosis is in evidence. The latter complaint invariably follows, however, and sooner or later the well-known group — chronic gout, arterio-sclerosis, and granular kidney — will be presented. Treatment. — (1) Prophylaxis. — The patient should be taught the lesson of thorough mastication, and robust, plethoric persons should ex- ercise with method in the open air, with a view to consuming the fats in the body. For this purpose cycling, horseback-riding, rowing, and walk- ing are all excellent. Nervous persons, however, demand rest (Gray). The constant use of lithia-Avater, more particularly in the spring of the year, is warmly advocated by Wilcox. (2) Diet. — As in gout, so in the preliminary stages of lithemia, no sin- gle dietary suits all'cases, though I agree with those who contend that a. 26 402 CONSTITUTIONAL DISEASES. diet consisting chiefly of albuminoids is proper in most cases. The lighter forms of albuminous articles of diet are to be preferred, and, if well borne, fruits and green vegetables may be added ; but fried meats of all sorts and made-over ciishes are to be eschewed. Assuming that certain cases are dependent upon an auto-intoxication from the gastro- intestinal tract, the object should be to limit fermentation by the use of a nitrogenous diet ; and I have found large amounts of water very bene- ficial in such instances. There are cases in which the gastric digestion is feeble, and in such the carbohydrates are better borne than the albu- minoids. Cream and good butter are the only forms of fat to be allowed. Alcohol should be interdicted. (3) Medicinal Treatment. — If the patient be robust, it is well to begin with a saline laxative, such as Carlsbad Sprlidel salt (3J-ij — 4.0-8.0). moderately diluted and taken before breakfast. If necessary, the hepatic function may be stimulated still further by a mild mercurial or by podo- phyllin. On the other hand, the neurasthenic, delicate sufferer must use a milder form of laxative, such as Rochelle salt in the same dose, or sodium phosphate in the morning, or a rhubarb pill at night. This class of lithemics also requires nerve-sedatives (sodium bromid, etc), and diuretics to aid in the excretion of uric acid. If it be true, as some claim, that the sodium phosphate is for the greater part excreted by the urine, and that it holds in solution more uric acid than any other salt, it is one of the foremost remedies in the treatment of the affection. Per- sonally, I have found it to be a most useful agent. To reduce acidemia and to stimulate gently hepatic activity the salts of lithium, highly di- luted, may also be tried. To aid in the digestion of the albuminoids hydrochloric acid may be needful, and if the appetite be impaired it may be combined with a simple bitter or with nux vomica (tTlx-xv — 0.666- 0.999) thrice daily. RACHITIS. (Bickets.) Definition. — A constitutional disease of childhood, exhibiting gross nutritive changes, chiefly in the bones and cartilages, causing deformities. Pathology. — A mere summary of the anatomic characters can be given here. There is a derangement of the nutritive processes which retards and otherwise modifies the growth of the bony skeleton, particu- larly of the skull, the ends of the ribs and of the long bones. The latter soften or remain unduly flexible as the result either of the absorp- tion of ossified structures or of the greatly diminished deposition of lirne- salts. Longitudinal section of the long bones shows the seat of the chief changes to be at the junction of the epiphysis with the shaft. In health we note at this point two thin layers, an outer (next to the epiphyseal cartilage) proliferative zone, and an inner layer (of ossification). In rachitis both zones, though more particularly the proliferative, are greatly thickened, much softened, and their margins irregularly notched. The periosteum is thickened and easily separable from the shaft. A microscopic examination shows an increased rate of proliferation of the cartilage-cells with a scanty, fibroid matrix, while the ossific layer presents disseminated and imperfectly calcified areas. Similarly, the BACHITTS. 403 deep (osteoblastic) layer of the periosteum is thickened, and remains spongoid. It is highly probable that absorption of true bone-tissue rarely occurs, and that the most characteristic pathogenic change is a lack of development of the normal structures. The morbid changes probably arise, as Kassowitz contends, from the presence of hyperemia of the cartilage, marrow, and periosteum — a process that interferes with the deposition of lime salts. The cranial bones present areas of the so-called craniotabes, and yield to the pressing finger in consequence of delayed ossification. This may lead to a disappearance of the cranium in certain areas, causing depressions, while flattened protuberances may develop over the arterio-lateral regions. When cases terminate in recovery the bones become hard and ossify, although the deformities persist. The chemist has shown us that rachitic bones may contain less than half the normal percentage of lime-salts. The liver and spleen are moderately enlarged, and rarely the mesenteric glands are increased in size. l^tiology. — (1) Rachitis may occur in the 7iew-horn. Schwartz states that among 500 new-born children in Vienna, 75.8 per cent, show dis- tinct signs of rachitis. Doubtless this estimate is too high, and entirely at variance with the experience of clinicians in general ; but I believe that congenital rickets is by no means a rare condition. Many of the cases are still-born, and those that outlive childhood become peculiarly dwarfed (^micromania). (2) Heredity/. — The instances in which rachitis de- velops at an early period of life, due to ante-partum causes, are not rare, but it must not be forgotten that it is extremely hard to estimate the influence of heredity where both parent and child are exposed to similar unfavor- able hygienic and dietetic conditions. Ill-health, malnutrition, close con- finement, lactation, and syphilis may all act as predisposing factors dur- ing pregnancy. Setting aside syphilis, and perhaps phthisis, the state of the health of the father has little if any effect in the causation of rachitis in his off"spring. (3) G-eograpliical Distribution. — The disease is more common by far in large cities than in rural districts, and in European countries — Russia, Germany, Great Britain, and Italy more especially — the disease prevails more extensively than in America. (4) Race. — The colored race furnishes a preponderance of rachitic subjects. The reason for this may be a racial need of warmth that is not supplied by the tem- perature of more northerly latitudes, their native habitat being in a more southerly climate. The Italian race also suffers inordinately. (5) Sta- tion. — It is especially -among the ranks of the poor children, whose en- vironment is highly unfavorable, in large cities that rachitis is seen. Joukownski, from personal observations in over 3000 poor children in St. Petersburg examined for rachitis, found that from the Avorkino-- classes come the greatest number of cases. Like scurvy, rickets may be found in the families of the wealthy under perfect hygienic conditions (Osier). The quarters of the cities in which the poorer classes live are densely crowded, the dwellings are insufficiently ventilated, and there is a great lack of sunlight. (6) Diet. — The disease is dependent largely upon improper or insuflficient food, and among hand-fed children the dis- ease is much more common than among those at the breast. It also occurs in breast-fed infants Avhen the mother's milk is poor in quality as the result of previous ill-health or too long-continued lactation. The 404 CONSTITUTIONAL DISEASES. view -was at one time widely belt! that rickets Avas produced by a fari- naceous diet, and that the active agent was lactic acid, produced by the fermentative processes set up by the starch. Even granting, however, that the lactic acid forms a soluble salt by union Avith the lime of the bone, thus removing it from the system, this does not explain the pro- ductive lesions described under Pathology. According to another view, rachitis is apt to develop Avhen the system is deprived of an adequate amount of proteids and fats, and for this belief there is considerable ex- perimental proof. Certain forms of diet predispose to rickets, princi- pally for the reason that they do not supply certain necessary articles in adequate proportion. (7) Age. — Of 903 cases, more than 75 per cent, occurred before the end of the second year ; but of these only 99 com- menced during the first half year (Bruennische, Von Rittershain, Ritsche). It may occur as late as the tenth year. (8) Sex is Avithout effect. (9) Sypfiilis. — Divers views are entertained regarding the role played by syphilis as a cause of this disease. Doubtless the tAvo affec- tions are sometimes associated, and it cannot be denied that syphilis brinws about a marked impairment of nutrition both in the mother and the child, so that the disease may engender a predisposition to rickets. Bacteriology. — Mircoli contends that it is produced by the action of ordinary pyogenic organisms upon the osseous and nervous systems. He adduces clinical and pathological evidence in support of this position. Symptoms. — The onset is slow^ and the symptoms of gastro-intes- tinal catarrh, Avith their usual effect upon the general nutrition, may pre- cede or accompany the true rachitis symptoms. At the beginning the infant is restless, 'irritable, and sleeps poorly, and slight fever is present in some cases. About the head and neck the child perspires freely, espe- cially when asleep, Avetting his pilloAv Avhile the rest of the bed is dry. It is also annoyed by the bed-clothes, Avhich it continually throAvs off, lying exposed even in a cool temperature. Among the earlier symptoms is a tenderness both over the bony surfaces and the soft parts, so that the patient wishes to keep still and dreads to be handled. The child is languid and disinclined to move his limbs or to walk or play, even if he have done so previously. The symptoms are progressive in their development, rachitis being ordinarily a chronic disease, so that after many months more pronounced features, including various bone-deformities, appear. OAving to the im- pairment of nutrition of the muscles the use of the limbs may become impossible, and these cases have been spoken of by Avriters as *• rachitic paralysis ;" this, hoAvever, is a misnomer. Cases have been reported by Berg and others that resembled spastic paralysis, pseudo-hypertrophic paralysis. Urinary phenomena are neither constant nor characteristic. Secondary anemia of mild grade supervenes, and there may be a leuko- cytosis. The first rachitic osteal changes are presented by the cranial bones, the ribs, the radius, and the ulna. The cranium appears enlarged, though this enlargement is more apparent than real, being due to the diminished size of the facial bones. The sutures remain open, the fontanels are large, and their closure is delayed, sometimes until the fifth or even the eighth year. Craniotabes is most frequently seen in infants under one year of age. This soft, thin condition of the bones is due to pressure RA CHITIS. 405 both from within and without ; it occurs on the surfaces on which the head of the child rests while lying. To detect the presence of cranio- tabes light pressure with the fingers is to be made in a direction away from the sutures. It is to be recollected that craniotabes is often a syphilitic manifestation. Per contra, increased hardness of certain bones may be observed (cranio-sclerosis). A rachitic head generally ap- proaches a square in outline, or it may present marked angularities, with an increase in the antero-posterior diameter and a flattened top. Hyperostosis may cause prominence of the parietal and frontal emi- nences, giving the forehead a square, broad outline. A short, round head (brachycephaly) may rarely be met (Bonnifay). The veins of the scalp are enlarged, and the hairy growth is usually scanty, being often re- moved from the back of the head by rubbing. Drs. Whitney and Fisher first called attention to the fact that the ear placed over the anterior fontanel often detects a systolic murmur, A considerable patency of the anterior fontanel both in health and disease allows of detection of this murmur, however, and hence its diagnostic value is slight. A prom- inent feature of the disease is delayed teething, the teeth that appear being deficient in enamel, ill-shapen, and prone to early decay. The ribs become aifected very early. Anteriorly, where they join the costal cartilages, swellings occur, causing the "rachitic rosary." This is composed of nodules corresponding Avith the costo-chondral articulationSr and these can generally be seen and always felt under the skin. They rarely outlast the fourth or fifth year. The ribs present two short curves — one at the junction of the dorsal and lateral parts of the thorax, and the other in front, where they turn sharply inward toward the sternum. This deformity is the result of the atmospheric pressure upon the softened bones, a shallow groove usually being produced in the line of the costo- chondral articulations or obliquely from the second or third rib downward and outward. These changes lessen the transverse diameter of the thorax in front and interfere with the lung-expansion in the antero-lateral por- tions of the chest. They also produce bulging of the sternum, resulting in the so-called pigeon or chicken breast. On both sides, from a point corresponding to the anterior end of the eighth or ninth rib, there passes outward toward the axilla a furrow (Harrison's groove) which is caused by an eversion of the low^er part of the thorax, and is heightened by atmo- spheric pressure, particularly during inspiration. This thoracic deformity is not peculiar to rickets, but is met with in all cases in which there is moderate obstruction to the ingress of air into the lungs. Among the first indications of rickets is an enlargement of the lower end (junction of the shaft and epiphysis) of the radius. The radius and ulna are sometimes twisted and deflected outward, ownng to the fact that some of the body-weight is supported by the hands when sitting or crawd- ing. The clavicle may be thickened and curved near either end, and occasionally the scapulae may be enlarged, but deformities of the upper ex- tremities are rare as compared with those of the lower. Occasionally the vertebrae and intervening cartilages soften, with a resulting spinal curva- ture, and in such instances there is usually an antero-posterior curvature with which lateral deflexion may be associated. Pelvic deformities are not uncommon, and are of no little importance in female children as bearing upon the questions of marriage and subse- 406 CONSTITUTIONAL DISEASES. quent labor. The femora may be curved, often forward and more rarely out- ward ; swelling of the lower end of the tibia is, however, the first change to be observed in the lower extremities. In some well-advanced cases the heads of the bones forming the knee-joints are also enlarged, and outward curvature of the femora and tibia is common, especially under the Age of one year (see Fig. 32). After the child begins to walk a forward bowing of these bones, due to the weight of the body and to muscular action, occurs. Knock-knee is sometimes observed. Those who have suffered from rickets in infancy usually fall short of the average stature on reaching adolescence, giving rise to disproportion between head and height — a most characteristic sign of rachitis. These skeletal changes sustain a causal relation to many, and some serious, aifections, chiefly nervous. Thus, craniotabes is supposed to in- duce laryngismus stridulus, though this condition may also arise in the rachitic Avithout cranial softening. In like manner, rickets predisposes to tetany, which affects most commonly the upper extremities. Convul- sions are also prone to occur in this disease. The reflex nervous excita- bility is unquestionably exaggerated in rickets, and another exciting cause for the eclampsia so often met with is the associated gastro-intes- tinal catarrh. The abdomen becomes greatly enlarged, chiefly by flatu- lence, though to a less extent also by the swelling of the liver and spleen. Chest-complications are common. Most of them are due pri- marily to a mechanical interference with the cardio-pulmonary circula- tion, and with the respiration. Among these are atelectasis, bronchial catarrh, broncho-pneumonia, and emphysema. Green-stick fracture of the bones often occurs in the rachitic subject. Prognosis. — The evolution of rickets is a long process, accompanied by a slowly progressive impairment of the general nutrition ; and hence most patients become weak, anemic, and emaciated. The so-called " fat rickets," however, is not rare. Innately, the disease tends to spontaneous cure, which is attained from the end of the second to the fifth year ; but its course may be abridged to a few months by appropriate treatment. When death occurs it is usually occasioned by one or other of the com- plications before mentioned, and especially by laryngismus stridulus or pneumonia. Treatment. — Prophylaxis. — The institution of preventive measures is a matter of first importance, and by simple means directed to the ante- partum causal factors in the mother rickets may in a large proportion of the cases be prevented. Prophylaxis also embraces appropriate feeding and other agencies that tend to maintain the normal nutrition of infants. Hygienic Management. — As faulty diet is in a great measure responsi- ble for rachitis, proper feeding is an important factor, and if the child cannot be satisfactorily nursed by its mother and if it is under the age of six months, a wet-nurse should be procured. Should this not be prac- ticable, it must be hand-fed, and the best artificial food is cow's milk, if properly prepared. In cities it is to be sterilized, and then diluted to suit the age, and I have found that barley-water, when made in the man- ner recommended by J. Lewis Smith, may be added to milk, replacing the water most advantageouvsly. A heaping teaspoonful of barley-flour is poured into 25 teaspoonsful (siij — 96.0) of water, and when the mixture is lukewarm 10 or 15 drops of diastase (Forbes) ai'c added to it, the gruel Fig. 32.— Outward curvature of tibia and fibula (Willard). SCORBUTUS. 407 in a few minutes becoming much thinner from the digestion of the starch. The physician must regulate with much precision the frequency of the feeding, and the amount of food taken according to the age of the child. The stools are also to be inspected. If they are green or if curds appear, either digestion is imperfect or the child is being over-fed. Older children may be given the lighter meats, green vegetables, and fruits, but these must be carefully selected. Other hygienic details are of little less importance than a proper diet. The decubitus of the child must be changed frequently, so as to prevent bony deformities ; moreover, the rickety child should not be allowed to walk, and to prevent his doing so splints extending beyond the feet have been recommended. A tepid bath, warm clothing, and a prolonged daily stay in the open air are measures that should not be neglected. Of medicines^ those that rank highest are phosphorus, the hypophos- phites, iron, and cod-liver oil. The officinal oleum phosphoratum (gr. y^-jj- — 0.0021) is used by Jacobi. Phosphorus is highly spoken of by many writers. It may be given either pure(gr. yto^'^t^t — 0-0003 to 0.0006) or preferably in the form of an emulsion with sweet oil or cod-liver oil : "E^. Phosphori, gr. ^ (0.00648); Oleioliva;, §ij(64.0); M. et ft. emulsio. Sig. 3J three times a day, after meals, for a child under the age of one year. Kissel states there is no evidence in favor of the use of phosphorus in rickets. Baginsky, Leray, Weiss, and others have found from its extensive employment that it is of doubtful value in the majority of cases. Kassowitz, Swetchen, and others, however, observed cases with cure, hence the remedy deserves a trial. When it is desired to administer cod-liver oil and it is not tolerated by the stomach, it may be rubbed gently into the skin of the thighs and trunk. Arsenic in small doses has proved to be a capital remedy in selected cases ; and iron, particularly in combination with arsenic, is in- dicated if anemia be pronounced. The numerous complications to which rachitic subjects are liable pre- sent special indications which are to be met by the same measures as when they arise under other circumstances. The condition of the diges- tive organs must be kept constantly in mind ; and no remedy, however promising, that is designed to assist the general condition should be con- tinued if it tends to aggravate the digestive disturbance. The treat- ment of the rachitic deformities belongs to the domain of the orthopedic surgeon. SCORBUTUS. {Scurvy.) Definition. — A constitutional disease, caused by a lack of fresh vegetables in the diet, and characterized by anemia, excessive weakness, spongy gums, a tendency to muco-cutaneous hemorrhages, and a brawny 408 CONSTITUTIONAL DISEASES. induration affecting chiefly the muscles of the calves and the flexor muscles of the thighs. Pathology. — We know nothing concerning the pathogenesis of scurvy. Evidences of profound anemia are found upon microscopic ex- amination of the blood, which is thin and dark, but there is no leukocy- tosis. The skin may show spots of subcutaneous hemorrhage (ecchy- moses), but the most characteristic hemorrhage is that under the periosteum of the femora. Bleedings into the articulations and muscles may also at times be noted, and occasionally the serous membranes are the seat of hemorrhao;es, as well as the internal organs. Submucous hemorrhages are extremely common. The intestinal mucosa may also present ulcers. The gums are swollen, spongy, dark in color, and sometimes ulcer- ated, and the teeth may be loose or missing. The epiphyses, par- ticularly of the lower end of the femora, may be congested, and rarely they are detached. The spleen is soft and swollen. The heart, liver, and kidneys sometimes show fatty and usually parenchymatous degeneration. Ktiology. — In former times scurvy was very prevalent among sailors at sea and soldiers in the field, and epidemics were com- mon. Doubtless, however, it has declined in importance as a disease incident both to sea-life and to armies ; but, as pointed out by Wise, it would seem that changing physiological and economical conditions may cause it to be dreaded on the land as it has hitherto been on the sea. Osier states that the disease is not infrequent among Hun- garians, Bohemians, and Italian miners in Pennsylvania. It is rarely epidemic at the present day. F. A. McGrew records an epidemic (with a total of 42 cases) in Chicago, in 1894. Undemic appearances of scurvy are still common, particularly in portions of Russia (Hoff- man) and elsewhere also, sweeping through prisons, barracks, alms- houses, and other institutions of like kind. While the majority of cases met with are sporadic, the above facts point to the infectious character of scurvy. Bacteriology. — Testi and Beri have isolated a micro-organism which has been cultivated and inoculated into guinea-pigs and rabbits, pro- ducing in the latter pathologic lesions and symptoms simulating closely those of scurvy. The microbe is perfectly round and is a diplococcus. These experiments require confirmation. Predisposing Causes. — The chief factor is the long-continued use of a dietary deficient in fresh vegetables. Precisely what there is in the lat- ter, the absence of which in the system produces scurvy, is not known to a certainty, but it is probable that it consists of the organic (potas- sium) salts present in the fresh vegetables, which elements are requisite to normal histogenesis. Albertoni has recently shown that in scurvy of a protracted course free hydrochloric acid is absent from the gastric juice, and that the total acidity is much reduced, but this is neither so in every case nor at all stages of the disease. He found no deficiency of chlorids in the body. Peptonization is feeble. Debilitating influences, as unhygienic surroundings, excessive mus- cular exercise, humidity, and cold, often play no mean role in causing scurvy. Mental anxiety and depression seem to have etiologic signif- icance. The old are very susceptible, and all ages are liable to the dis- SCORBUTUS. 409 ease. Sex has no special influence upon scorbutus. Starvation does not predispose to the disease. Sytnptoms. — Scurvy has a sloiv onset. The earliest symptoms are crenerallv a swellincf around the eves, over which the skin has the color of a bruise, and a pale face, which looks bloated and wears an apathetic expression. There is noticeable almost from the start a gradually in- creasing debility, emaciation, an inability to perform mental or physical labor,' and despondency. The patient experiences arthritic and muscular rheumatoid pains and dyspnea on slight exertion. With rare exceptions the gums swell, sometimes enormously, and be- come spongy, bleeding' most readily. They may become ulcerated, and may be, though rarely, fungoid in appearance. The teeth often become loose, and in rare cases drop out. The hreatJi emits an offensive odor. that is sometimes due to necrosis of the jaw. The tongue swells, though it is usually clean and often pale. In the mouth may be observed sub- mucous hemorrhages in many cases. There is loss of appetite, but the digestion is usually good ; there may, however, be constipation or diar- rhea, more frequently the former. Scorbutic dysentery has been de- scribed by certain writers. The skin is dry and of a muddy color, blended occasionally with a greenish or greenish-yellow tinge. At the end of a week or ten days jyetecMce and eccJiymoses appear upon the legs, arrano[incr themselves about the hair-follicles. These mav also come out later on the trunk and upper extremities. Submucous hemorrhages may give rise to circumscribed swellings, and subperiosteal hemorrhages may occur and engender node-like protuberances. There may be frequently noticed a peculiar brawny induration, due to extensive hemorrhagic infil- tration of the muscles and subcutaneous tissues, most marked in the hams and calves. The condition is not without considerable pain, particularly if the parts be touched, and in severe cases buUee and vibices may be seen, as in a recent case of my own. Hemorrhages from the mucous channels of the body occur, and epistaxis is frequent. In bad cases hematuria, also melena and rarely hematemesis, may be observed. Blood may be efiused into the serous membranes, accompanied sometimes by inflamma- tory changes in the latter ; also into the lungs, which are rarely the seat of secondary pneumonia. Pulmonary infarction occurs, but is a rare event. Hemoptysis may be a symptom of the lung-complications or may occur as an independent phenomenon. The heart may present symptoms, such as palpitations, feeble impulse, arrhythmia, and sometimes a basic blood-murmur, but these are without diagnostic importance. The pulse is soft, small, and on exertion much accelerated. The temperature is sometimes subnormal, and the presence of fever is a certain indication of the existence of some complication. The nervous symptoms^ aside from the profound mental depression, are not prominent. Insomnia may be a distressing symptom. Delirium (late) is sometimes witnessed. Meningeal hemorrhage may supervene. Both night-blindness and day-blindness are among the rarer and extraordinary ocular features. The urinary symptoms vary in different cases. Albuminuria is, how- ever, common. The specific gravity of the urine is increased, the color high, and the solid constituents diminished, except the phosphates, which are abundant. Albertoni found the proportion of chlorids less than the 410 CONSTITUTIONAL DISEASES. normal, while other investigators claim that the percentage is high. Nephritis may occur as a complication. The bones in long-standing cases may be congested and sometimes necrotic, and the epiphyses may separate from the shafts. In one of my cases an old cicatrix reopened. Diagnosis. — This rests upon the following points : the history, the peculiar facies, the spongy and swollen gums, the gingival and deep- seated cutaneous hemorrhages, the progressive loss of strength and energy, great mental depression, and the speedy recovery after an appro- priate regimen. Scurvy will be distinguished from purpura under the description of the latter disease. Prognosis. — Unless far advanced, the prognosis generally becomes good upon the institution of correct dietetic principles. If the disease have made extensive inroads, the danger to life is considerable. The gravity of the internal symptoms (particularly pulmonary) is far greater than of the external, and, indeed, the presence of the latter is a favor- able omen. Certain complications augur a serious termination, such as pneumonia, hemorrhagic infarctions of the lung, pleurisy with bloody effusion, dysentery, acute nephritis, etc. Treatment. — Prophylaxis. — By carrying out the known means of prevention the disease has been diminished more than 90 per cent, among mariners and soldiers. This change has been brought about by the enforcement of governmental regulations which demand that an ade- quate supply of antiscorbutic articles of food must be provided for military campaigns and for long sea-voyages. Fresh fruits and vegetables can be readily transported in hermetically sealed jars or cans. Treatment of the Attack. — The chief indication is to be met by the use of fruits and fresh vegetables. Of the former, two or three lemons daily or oranges and other fruits suffice to work a surprising de- gree of improvement in a short space of time. Antiscorbutic vegetables (potatoes, water-cresses, raw' cabbage, lettuce, saur-kraut) in liberal quan- tity should also be given. Meats, eggs, milk, and farinaceous dishes are not to be prohibited, since the patients require all forms of food to invig- orate the system and to render normal the constitution of the blood ; but if the digestive power be feeble, it is advisable to begin with the juice of oranges or lemons, conjoined with meat-juice, egg-white, milk, and light farinaceous articles, adding the stronger forms of animal food and fresh vegetables when improvement is noted. We may assist the digestive function in bad cases by the use of simple bitters, strychnin, and hydro- chloric acid (after meals) ; hematinics are sometimes indicated. Special si/mptoms may call for appropriate measures. Constipation requires simply an enema. On the other hand, diarrhea presents an in- dication for intestinal antiseptic and astringent remedies. The oral con- dition varies, hence the measures to relieve it vary also ; but if ulcers be present, the solution of potassium chlorate is best. For swelling of the gums the application by means of a cotton swab of tannic acid (2 per cent.) or a solution of silver niti-ate (2-5 per cent.) is serviceable. A combination of boric and carbolic acids in a solution of suitable strength may be used as a mouth-wash. If copious hemorrhages occur, hemostatics are eminently useful. The various complications must be met by the usual measures, accordincj to their nature. SCORBUTUS. 411 Infantile Scorbutus. Definition. — A constitutional disease, characterized by the same symptoms as scurvy in adults, except that in many instances undoubted evidences of rachitis are associated. Pathology. — The bones are thickened and excessively sensitive, owing to a marked subperiosteal hemorrhage, with more or less macera- tion, and want of firmness between the epiphysis and shaft. The muscles may also be the seat of effusion. The characteristic lesions of rickets are often associated. The nature of the affection is unsettled. Originally looked upon by most observers as acute rickets, it was subsequently described by Cheadle (from the clinical sidej and Barlow (from the anatomo-pathologic side) as infantile scurvy. On the other hand, Ashby of Manchester, Fiirst and other German writers, are inclined to the view that the affection should be considered a hemorrhagic form of rachitis. The belief that rickets predisposes to scurvy, but that the two diseases have not the same patho- genesis, is probably the correct one. Ktiology. — Scurvy is almost solely confined to hand-fed infants, especially those reared upon the numerous infant-foods Avhich have been foisted upon the market, including condensed milk, etc. Louis Starr, Jacobi, and others have shown that it sometimes follows the prolonged use of sterilized milk, either exclusively or in combination with artificially prepared foods. An investigation by a committee of the American Pedi- atric Society ^ showed that of 379 cases the majority occurred between the ages of 7 and 14 months, inclusive, and that the disease has a greater tendency to occur among the rich or well-to-do. This committe's report also embraces the following among other justifiable conclusions : " The farther a food is removed in character from the natural food of a child the more likely its use is to be followed by the development of scurvy." Symptoms. — The skin presents the muddy color peculiar to the dis- ease in adults. The patient may be well nursed, but more often there is a tendency to wasting, and other symptoms of impaired nutrition appear, particularly irritability and disinclination to exertion. The more cha- racteristic features appear after one or tw^o months, and the child cries when handled, especially on touching the lower limbs. About the same time there is an irreo;ularly cvlindrical swelling of one of the thighs, due to subperiosteal effusion. Soon the other limb is similarly involved, though not always to a like degree. At first the legs are flexed, but later they become straightened and slightly everted on account of the progres- sive hemorrhage or separation of the epiphyses. The bones in other por- tions of the body may be involved secondarily in more or less rapid suc- cession, but the swellings are less marked than in the lower limbs. Later, if teeth be present, the gums may swell and become spongy. Ecchymoses in the form of petechise appear upon the skin-surface, and particularly about the eyes. Barlow describes a remarkable ocular phenomenon : " There develops a rather sudden swelling of one eyebrow, with jjufliness and very slight staining of the upper lid. Within a day or two the other lid presents similar appearances, though they may be of less severity. The ocular conjunctiva; may show a little ecchymosis or may be (|uite free." 1 Medical Record, July 2, 1898. 412 CONSTITUTIONAL DISEASES. Hemorrhages from the mucous surfaces may finally put in an appearance. To complete the statement of characteristic features, it should be men- tioneil that rapid improvement invariably follows an antiscorbutic regimen. Diagnosis. — To distinguish rickets from infantile scurvy Barlow's brief though clear aggregation of the characteristics of the latter disease may be quoted: "(1) Predominance of lower-limb affection, in which there is immobility going on to pseudo-paralysis ; excessive tenderness ; general swelling of the lower limbs ; skin shiny and tense, but seldom pitting, and not characterized by undue local heat ; on subsidence reveal- ing a deep thickening of the shafts, also liability to fracture near the epiphysis. (2) Swelling of the gums about erupted teeth only, varying from definite sponginess to a minute, transient ecchymosis."" Prognosis. — Favorable, even in well-established instances, if brought under the proper regimen. Treatment.— An antiscorbutic dietary — mother's milk or fresh cows' milk, meat-juice, and orange- or lemon-juice — meets the main indication. If there be systemic exhaustion — a condition that is not infrequent — gentle stimulation with brandy (highly diluted) and an abundance of fresh air are pre-eminent among the measures to be employed. Iron, arsenic, and cod-liver oil may be needful to complete the cure, but usually the simple means already mentioned will prove effective. The limbs, espe- cially the lower, may claim attention. Local treatment, however, is rarely necessary, except there be separation of the epiphyses, when suitable splints are to be applied. PURPURA. Tavo main groups are to be distinguished : (1) Secondary purpura, which occurs from a great variety of causes and in numerous aft'ections, in which its clinical significance has been pointed out in appropriate sec- tions of this work. It seems pertinent, however, to enumerate the chief among the diseases and conditions under which it may arise, as follows : (a) scurvy ; (b) acute, infectious diseases (cerebro-spinal meningitis, vari- ola, measles, septicemia, ulcerative endocarditis); {e) hemophilia; {d) numerous chronic affections, as nephritis, leukemia, pernicious anemia, jaundice, Hodgkin's disease, and tuberculosis; {e) malignant sarcomata; (/) nervous afi"ections, as locomotor ataxia, acute and transverse myelitis, and hysteria ; {g) mechanical causes, straining efforts, intense paroxysms of whooping-cough, and violent convulsions ; (h) certain drugs may pro- duce a petechial eruption — quinin, copaiba, belladonna, ergot, mercury, and the iodids ; (/) snake-poisons produce rapid and extensive hemorrhagic extravasations, as shown by the careful studies of S. Weir Mitchell. (2) Primary or idiopathic purpura forms the second group. It is di- visible into {a) simple purpura [purpura simplex) ; (6) arthritic purpura, of which two varieties may be recognized : (1) peliosis rheumatica, and (2) Henoch's purpura; (e) hemorrhagic purpura (purpura hcemor- rhagica). (a) Simple Purpura. — The cause is unknown. Among predisposing PURPURA. 413 influences, however, is age, the condition being most common in children about the time of puberty. It may be a sequel of the acute, infectious diseases, and in not a few cases develops in seemingly healthy subjects. Symptoms. — This is the mildest variety of primary purpura. The hemorrhages into the skin take the form of petechise, vibices, or ecchy- moses. The first are extravasations of blood in the form of minute points, that appear, as a rule, in the hair-follicles, and, unlike the ery- themas, do not disappear upon pressure. The vibices receive their name from the fact that the hemorrhages occur as streaks, while the ecchymoses are larger, but similar in nature and behavior to the petechias. They may exceed in size that of a split pea, and their hue ranges from a deep red to a livid bluish tint. As they fade away they assume at first a yel- lowish-brown, then a yellow color, and finally disappear. The eruption appears in a series of crops, and its seat of election, often favored by the erect posture, is the legs. Bloody serum may be eifused into bullae or large blebs. Shepherd and others have reported cases in which the purpuric eruption ended in gangrene, though in Shepherd's case the gan- grene was believed to be due to the use of sodium salicylate. {h) Arthritic Purpura. — (1) Peliosis Rheuviatica {jSchonlein s Disease). — The cause of this remarkable disease is unknown. Formerly many writers inclined to the view that it is of rheumatic origin, and since en- docarditis and pericarditis are occasionally observed in association with peliosis rheumatica, considerable coloring is given to this belief. On the other hand, the fact that the cardiac complications are rare in arthritic purpura shows that not all cases of the latter disease are genuinely rheu- matic. It occurs chiefly in males from the twentieth to the thirtieth year of age. Among the prodromata are angina, slight articular pains, headache, loss of appetite, and fever ranging from 100° to 102° F. (37.7°-38.8° C). The affection is especially characterized, however, by polyarthritis, the joints being swollen, painful, and very tender ; also by purpura, associated or not with urticarial wheals or erythema exudativum ; and by subcutaneous edema. The purpuric eruption is the only symp- tom that has pathognomonic significance, and in this aff"ection it shows a strong preference, as regards distribution, for the affected joints and the legs. The eruption, as already intimated, does not display constant cha- racteristics. It may not differ from that of simple purpura, and the rash consists of petechias, ecchymoses, streaks, and rarely of bullae (pejnphi- goid purpura) ; or it may be made up of wheals of urticaria, attended with intense itching ; and, finally, it may be identical with erythema nodosum. These forms of eruptions may be variously combined. Hemorrhages from the mucous surfaces rarely occur, though epistaxis is the most common. The extent of the edema varies greatly, in rare cases being quite extensive and overshadowing all other symptoms (febrile pur- puric edema). Albuminuria may be noted, and accompanying the pur- puric eruption there will be a mild febrile movement. Convalescence is usually protracted (even into years), and is often interrupted by recur- rence of the characteristic features. The diagnosis is made from the presence of three characteristic symp- toms — polyarthritis, a purpuric rash, and edema. The combination of purpura and urticaria is one of the chief distinguishing features. It is not always possible to eliminate rheumatism, but the non-rheumatic cha- 414 CONSTITUTIONAL DISEASES. racter of some of the cases may be clearly shown by the therapeutic test, as happened in one of my own patients. Prognosis. — This type of the disease is generally benign, death being very rare. Complications, however, may prove serious, especially the cardiac. The throat-condition may outlast the attack, and terminate in gangrene of the uvula or tonsils. (2) Henoch's Purpura — Henoch and Couty have described a form of rheumatic purpura occurring chiefly in children, and characterized by painful and sometimes swollen joints ; by a purpuric eruption, plus ery- thema multiforme ; by vomiting, diarrhea, and intestinal pain ; by local- ized edema of the skin ; and by hemorrhages from the mucous membranes and sometimes into the kidneys. The diagnosis is difficult in proportion to the scanty development of the purpuric symptoms, some of which are often wanting. The prognosis is favorable, though complications of more or less seri- ous import may arise. One of Osier's cases proved fatal with the symp- toms of acute hemorrhagic Bright's disease. (3) Factitious Purpura. — Bruce and Galloway ^ report a case in which any irritation of the skin, such as might be caused by drawing the blunt end of a pencil over it, produced a white line, which presently l)ecame pink and then intensely purpuric. In this way letters, figures, and the like could be shown as hemorrhagic outlines. (c) Purpura Haemorrhagica {Morbus Werlhofii). — This is the severest form of purpura, and its apparent etiologic connection with certain infec- tious diseases, particularly rheumatism, malaria, etc., is interesting, but not well understood. The disease is perhaps most common in young females, particularly if they have fallen into general ill-health ; but all persons are liable, and post-mortem anatomo-pathologic pictures of the disease leave little room for doubt that it is an infectious complaint. Synqytoms. — Prodromal symptoms, (malaise, headache, depression, anorexia) may appear, and last one or two days. The invasion is moder- ately abrupt, with fever, and soon cutaneous ecchymoses appear upon the skin, quickly increasing in size and numbers. Slight hemorrltages from the mucous membranes into the internal organs occur. Epistaxis generally comes first ; it tends to persist and to recur, and the same pecu- liarities pertain to bleedings from other points. Prostration now becomes rather marked, the patient complaining of pains in the limbs, loins, abdo- men, and chest, and the latter often presage a fresh hemorrhage. There is moderate /ever, as a rule, the temperature during the height of the attack ranging from 101° to 103° F. (38.3°-39.4° C), or it mav reach 104° to 105° F. (40.5° C), though rarely. Th^jmlse is accelerated (120 to 130 per minute), but full and regular, though in the worst cases it becomes small and very rapid. The mind is usually clear. Hematuria followed by nephritis may occur. There is anemia var^'ing in intensity with the extent of the hemor- rhage and the severity of the type, and showing the characteristics of symptomatic anemia. The face may be exceedingly pale and anxious. The course is run in from seven to ten days in mild cases, while the severer attacks pursue a longer course. It is to be recollected, however, that the malignant form {^purpura fulminans) has a speedily fatal termination. ' British Jour, of Dermatology, Jan., 1898. HEMOPHILIA . 415 The diagnosis of purpura hggmorrhagica rarely presents any difficulty. Scurvy may simulate it in some particulars, but is distinguished by its chief etiologic factor — a diet deficient in fresh vegetables and fruits — by the spongy, swollen condition of the gums, the loosened teeth, and brawny induration of the limbs. Moreover, in purpura hsemorrhagica the hair- follicles do not occupy the centers of the ecchymotic spots, and the hemor- rhages from the mucous membranes are more copious than in scurvy. Malignant types of the eruptive fevers distinguish themselves by the his- tory of the prevailing epidemic, by the characteristic prodromes and in- vasion, and by the high temperature. It must be remembered, however, that variola purpui'a often pursues an afebrile course. Prognosis. — Grave, except in mild cases. In the malignant type death may come before hemorrhages from the mucosa appear. Certain com- plications may prove fatal — cerebral hemorrhage, inundation of the lungs with blood, Bright's disease, and shock from rapid, profuse bleedings. Death may also be the result of exhaustion due to protracted bleedings. Treatment. — («) The management of secondary j^'Utyura is em- braced, in other portions of this volume, in connection with the treatment of the diseases and conditions which it accompanies. ih) Simple jjurpura demands arsenic, first in moderate doses, and then increased until slight toxic effects are noticeable. Legroux speaks in warm terms of the iron compounds, and especially of ii'on perchlorid in doses of 3SS-J (2.0-4.0) daily, and if the child is somewhat anemic, the inhalation of oxygen will promote hematosis. The disease also requires fresh air in abundance and a generous diet. (c) In peliosis rhewnatica, in addition to the measures recommended in purpura simplex, the salicylates should be tried. (d) Purpura Hcemorrhagica. — In all kinds of purpura the patient should be confined to bed. An abundance of nourishment, by support- ing the patient's power, is of the greatest service. Internally, ergot, turpentine, tincture of the chlorid of iron, acetate of lead, and dilute sulphuric acid enjoy the widest reputation. Calcium chlorid, suggested by Wright, should be tried when other remedies fail. The following combination, recommended by Hardaway, I have found useful : ^. Ext. ergotse fl., Tr. ferri chlorid., aa f.5ij (64.0).— M. Sig. Three to ten drops in ^vater, t. i. d. HEMOPHILIA. [Bleeder^ s Disease.) Definition. — An hereditary affection, transmitted by females who are themselves not affected (Nasse's law). It is characterized by fre- quent uncontrollable hemorrhages that are either spontaneous or due to slight traumatism. Pathology. — The constitutional changes or peculiarities on which the disease depends are to be found in the blood-vessels rather than in the blood itself (Henry) ; microscopic changes have been found in the 41 <) CONSTITUTIONAL DISEASES. arterioles, the middle muscular tunic being either absent or much atro- phied. Vaso-motor influences also play an important part in causing an attack, as is shown by the frequent flushings of the face preceding an attack, and also by the fact that bleeding may follow emotional excite- ment (Henry). Synovitis Avith hemorrhages into the joints may some- times be observed. The blood presents slight change. Btiology. — Hemophilia is more distinctly hereditary than any other known disease, but Nasse's law is not of such universal application as is generally supposed. R. Kolster found that of 50 hemophilic families, 18 cases followed this law, 16 others with some exceptions to its pi-ovis- ions, and 12 without any regard to it. The law embraces the following points : The daughter (not herself affected) of a bleeder transmits the tendency to her sons, who become bleeders ; her daughters do not suffer, but in tui'n transmit the disease to their sons. Females, however, may be bleeders, and, according to Virchow, one woman is aff"ected to every seven men. The disease has been traced for centuries in a few families. The disposition may be acquired, but of the conditions that may lead to its development we are entirely ignorant. It is observed in all classes of society, and is most frequent in families whose members are large, vigorous, and have delicate complexions, the complaint usually manifest- ing itself before the end of the second year of life, though exceptionally as late as puberty. Symptoms. — The occurrence of profuse and persistent bleedings that are either spontaneous or the result of slight injury characterizes hemophilia. The character of the injuries that lead to dangerous bleed- ings is often exceedingly trivial ; thus a slight scratch, cut, blow, the ex- traction of a tooth, and other minor surgical operations (e. (/. circumcis- ion) may be followed by severe hemorrhage. If we include spontaneous hemorrhages, bleedings take place most frequently from the nose. Legg has made three clinical groups, based on the intensity of the symptoms, as follows : (1) Seen most frequently in men, and characterized by external and internal bleedings of all kinds and by joint-aff"ections ; (2) most frequent in women, and distinguished by spontaneous hemorrhages from mucous membranes only ; and (3) cha- racterized simply by ecchymoses. The capillaries ooze blood — a process that may vary in duration from a few hours to as many weeks. A fatal result may thus occur in a few hours, while, on the other hand, recovery may follow a slow ooz- ing of blood that has continued for many days. In the latter instances profound anemia follows, the blood, however, being rapidly replaced. Extensive blood-extravasations (hematomata) usually follow contusions. Petechias, when they occur, are apt to be spontaneous. The blood coagulates, except in long-standing hemorrhages, when it becomes thin and watery (late). Fussell made blood examinations in two cases, and found the leukocytes slightly increased (14,000 and lo,000 per c.mm.), while the red cells were moderately diminished. Arthritic s/pnptoms are common, the larger joints, and especially the knees, being most frequently aff'ected and showing swelling that is due chiefly to hemorrhages into the joints. In other instances febrile syno- vitis may be present, resembling rheumatism. The joint-svmptoms may either announce an approaching hemorrhage or pain alone mav be ex- HEMOPHILIA. 417 periencecl. The attacks are liable to recur, especially in cold, damp ■weather, and may result in stiffened, deformed joints (Musser). Diagnosis. — When persistent capillary oozing occurs in a person with a clear, hereditary disposition the diagnosis is clear. Without an inherited tendency we cannot be certain of the diagnosis unless pro- tracted hemorrhages from insufficient causes are repeatedly manifested. The presence of joint-involvement is very helpful. Differential Diagnosis. — Peliosis rlieumatica is an affection which, as Osier remarks, touches hemophilia very closely, particularly in the re- lation of the joint-swelling. It is true that the former may also show itself in several members of a family, but the presence in this affection of more or less edema, and often of wheals of urticaria, accompanied by intense itching, aids greatly in its elimination. Prognosis. — In undeveloped forms the outlook is not particularly grave, since in these the tendency may either lessen or become alto- gether arrested after childhood. In the majority of well-marked cases the children do not survive this period. On the other hand, those who live to become full-grown show a diminished, and in a small class of cases an absolute, disappearance of the tendency. The first hemor- rhage rarely proves fatal. Boys suffer from a more serious form than girls. Moreover, menstruation, though sometimes very copious, does not to any great extent endanger the life of a hemophilic woman. Of 130 cases of pregnancy and labor, the death of the mother occurred in only 3, and abortion in 16 cases (Kolster). Treatment. — The physician can do most in the direction of pro- phylaxis. All surgical operations that are not absolutely necessary must be avoided ; neither should the teeth be erupted nor the operation of. circumcision be permitted. Leeches are not permissible. Females who belong to bleeder families, as Avell as males who have had hemo- philia, should not marry. During the attack absolute rest — mental and bodily — must be en- joined, and light compression, and if this fail strong pressure or styp- tics, should be tried. It is, however, a great question how far agents that destroy the already weakened tissue are useful. In epistaxis ice, tannin, and turpentine should be tried before using nasal plugs ; and if the latter prove indispensable, the lightest only should be employed. J. Greig Smith regards lint saturated with spirit of turpentine as the best local application in epistaxis. The application of normal human blood to the bleeding surface is warmly recommended. Internal medicines are of secondary importance, though they may be tried, and opium is un- questionably of signal value, since it tends to quiet the patient, thus favoring repose. The remedies that have been given are various. Dela- field, Flirth, and others have used successfully the fluid extract of hy- drastis canadensis, the dose being from 20 to 40 drops daily ; amono- other hemostatics, gallic acid, turpentine, and iron perchlorid produce the best results. The dose of the latter should be .5ss (2.0) every two hours, with a purge of sulphate of soda (Legg). The use of calcium salts has produced good results in some cases and merits a trial. Thyroid ex- tract and inhalations of oxygen have also been advocated. Durino- con- valescence arsenic, iron, and the bitter tonics, together with a liberal dietary, will aid recovery. 27 418 COySTITUTIOyAL DISEASES. HEMORRHAGIC DISEASES OF THE NEW-BORN. (a) Epidemic Hemoglobinuria ( WtDckers Disease). — This affection, Avhich is septic in nature, is occasionally met with in lying-in hospitals, and occurs in children from one to ten days after birth. The infants re- fuse the breast and show hematogenous (?) icterus; gastro-enteric catarrh is an attendant of the disease. The stools are meconic ; the urine is scanty, dark-colored (from the presence of methemoglobin). often albu- minous, and may contain casts. Hemorrhages occur into organs other than the kidney and into the mucous membranes, there also being mild fever, rapid emaciation, and often mild convulsions. It is a very fatal disease. Bacteriologic experiments have shown that the disease may be produced bv the growth of the colon bacillus in the buccal epithelium of infants. Kilham and Mercelis * report an epidemic of 10 cases oc- curring in the New York Infirmary ; complete bacteriologic studies were made in all, and the organism discovered suggested the diplo- coccus of pneumonia or the pneumococcus group. There is, however, great confusion in regard to the possible specific micro-organism of this disease. (b) Acute Fatty Degeneration of the New-bom (Buhrs Disease). — This disease may be similar to Winckel's in nature. It was first de- scribed by Hecker and Buhl as an infectious disease of the new-born, characterized by C3'anosis, jaundice, and copious visceral hemorrhages. The chief pathologic change is an acute fatty degeneration of the inter- nal organs. (c) Syphilis Hsemorrhagica Neonatorum. — Either at birth or soon thereafter bleedings take place into the skin (ecchymoses) and from the mucous surfaces and the navel. Jaundice may be associated. The viscera are found upon post-mortem examination to be the seat of syphi- litic lesions. (d) Morbus Maculosus Neonatorum. — Hemorrhage from the gastro- intestinal mucosa of the new-born (meltTena neonatorum) occurs, and may be due to intracranial lesions during birth ; it may also take place independently of the latter. Preuschen has collected the reports of 37 cases, in 5 of which the brain was examined, and all of these showed cerebral hemorrhages. The latter may occur in spontaneous births and give rise to melsena neonatorum. Gartner believes the dis- ease to be an infectious one, and claims that in 2 cases he was able to identify a bacillus for which the navel is believed to be the entrance- point. The blood may also come from the mouth, nose, navel, etc. Townsend found morbus maculosus neonatorum in 45 cases in 6700 deliveries, and in most of these instances the bleeding was general. The hemorrhage usually sets in during the first week, rarely later, and the du- ration of the disease is between one and seven days, the mortality being a little over 50 per cent. Vomiting of the blood which the child has drawn from the breast must not be confounded with true melena. The treatment is by gallic acid and ergotin, the latter hypodermicallv : stim- ulants may also be required, and warmth to the extremities if the per- ipheral circulation be feeble. ' Archives of Pediatrics, March, 1899. PART III. DISEASES OF THE BLOOD AND THE DUCTLESS GLANDS. ANEMIA. Definition. — A pathologic condition, characterized either by a diminution in the quantity of blood or by a deficiency in one or more of its constituents. Anemias may be subdivided into — I. Primary or Essential (simple, chlorotic, and pernicious) ; II. Secondary (symptom- atic) ; III. Leukocytosis ; IV. Leukocythemia (splenic, myelogenic, and lymphatic). Pathology. — Anemia, in its different forms, is characteristic of dis- eases of the blood or of the blood-making organs. It may be manifest, on examination, as a diminution of the total quantity or body of the blood {oligemia) ; of the number of red corpuscles {oligocythemia) ; of the hemoglobin {oligocliromemia) ; and of other constituents, as albumin {anhydremia). The diminution of hemoglobin gives rise to the most obvious sign of anemia or impoverished blood — namely, the pallor of the cutaneous surface — but it is important to point out here that the quan- tity of hemoglobin in the blood is not necessarily proportionate to the number of red corpuscles. Thus the percentage of hemoglobin con- tained by the red corpuscles may vary in disease, so that a reduction in its amount does not necessarily involve a corresponding decrease in the number of red corpuscles. Conversely, a diminution in the number of the latter may not be accompanied by a proportionate diminution in the amount of hemoglobin, the corpuscular richness in coloring-matter being quite normal. As a matter of fact it frequently happens that oligo- chromemia is associated with a certain degree of oligocythemia, and vice versd, though where they coexist the degrees of reduction may neither be relatively nor proportionately equal. Anemia can be positively ascertained only by an adequate examina- tion of the blood. It may be inferred from the presence of pallor, languor, dyspnea, palpitation, etc. ; but it should be borne in mind that not every pale person has anemia, since pallor of the face may be hered- itary, and, at the same time, perfectly consistent with good health, a normal number of corpuscles, and a normal percentage of hemoglobin. Conversely, a person with marked vascularity of the face, and a rosy complexion even, may have anemia. The anemias embrace those conditions, also, in which there are 'changes in the shape of the red corpuscles {poikilocytosis), and in their size {niioro-, macro-, or megalocytosis). 419 420 DISEASES OF THE BLOOD AXD THE DUCTLESS GLANDS. I. THE PRIMARY OR ESSENTIAL ANEMIAS. Primary anemias constitute those forms in Avhich, so far as our pres- ent knowledge of their etiology and pathology goes, no other tissues or organs than the blood and the blood-making organs are either at fault or are directly aifected. Future investigations of the life-history of the blood may reveal the exact causation of what are now^ regarded as pri- mary or essential anemias, and thus permit of a clearer discrimination and a more accurate classification. SIMPLE OR BENIGN ANEMIA. This form is not infrequently met with as a congenital, constitutional affection, Avithout any assignable cause, and is entirely free from per- nicious manifestations or tendencies. There is no discoverable element of relationship between simple benign anemia and chlorosis, nor is the former symptomatic of any disease in Avhich anemia is common, such as tuberculosis, carcinoma, and nephritis. Ktiology. — Simple constitutional anemia is often met with among the poorer classes, and from this fact it is probable that living or work- ing in a vitiated atmosphere, as well as deficient sunlight and nutriment, is primarily active in reducing the general health. In this way is often caused a lifelong pallor, due to an interference with the normal process of blood-making {Jiemogenesis). There are also certain individuals in whom slight pallor and systemic feebleness have existed from infjincy (thus probably congenital), and whose modes of life and environment have been more or less uniformly hygienic and provident. In such cases we may assume that there is some innate imperfection — anatomic or physiologic, or both — in the blood-forming organs. Finally, in the later manifestations of slight general anemia a devel- opmental strain or abnormality may start a disorder of hematopoiesis in organs congenitally insufficient for new and greater demands for blood made by the system. Symptoms. — There is some pallor, often with languor, slight pal- pitation, and dyspnea, occasional headache, and a tendency to fatigue. The general health is not otherwise disturbed, and an active life may be enjoyed for many years. Examination of the blood shows a slight re- duction in the number of the red cells and of the hemoglobin (rela- tive). This degree of anemia persists without aggravation or amelio- ration. It may be found to affect males and females, and is observed principally in adult life. The diagnosis of simple, benign, or constitutional anemia should be made with considerable caution and reserve, and it should be arrived at only after the closest scrutiny of all the symptoms and signs, the most careful study and judicious balancino- of the data entering into the previous history of the patient. If there be a latent or incipient tuberculosis, carcinoma, or nephritis, a previous attack of some infec- tious fever, rheumatism, etc., this fact clearly bears upon the case, and the diagnosis of simple anemia is precluded. The progfnosis is usually favorable. On account of the possible existence of one of the above-mentioned diseases, or from the fact that CHLOROSIS. 421 a grave variety of anemia may be superadded, however, it should be guarded in the mind of the physician, at least. The treatment of simple, benign anemia is an expectant one in most instances. Hematinics (iron, arsenic, etc.) are seldom required, as they have little if any influence upon the blood or upon the pallor or other symptoms. A rigid system of hygiene, together with attention to proper food and drink and to the manner of eating and drinking, will probably ensure to the patient all the benefit that may be obtained. Cardiac tonics (digitalis, strophanthus) may be useful in controlling the palpitation. It is worse than futile to attempt to eradicate any con- genital defect of the blood-vessel system or hematopoietic organs. CHLOROSIS. [Green Sickness.) Definition. — A blood-disease, occurring chiefly in adolescent fe- males, and characterized principally by a deficiency of hemoglobin in the red corpuscles. It runs a mild course, though with a tendency to relapse. Pathology. — It is so seldom that death occurs in cases of chlorosis that autopsies of this disease have not been frequent enough to determine definitely the nature of the findings. There is no loss of fat in the body, but signs of physical degeneration and disorders of development are quite common, hypoplasia of the vascular system and of the genital organs seeming to be the most prominent. Incurable cases of chlorosis are nearly always characterized by anomalies of the blood-vessels and genitalia (Rokitansky). Virchow has also shown that congenital arrest of development of the aorta and larger arteries, as indicated by their small size, their soft and elastic walls, is quite constant in chlorotics. The uterus (especially) and adnexa manifest the hypoplasia, and yellow- ish spots and streaks of fatty degeneration are sometimes seen in the intima of the arteries. The cardiac muscle is softened, the whole heart is dilated, and the left ventricle is usually somewhat hypertrophied. !^tiology. — Chlorosis occurs most frequently in girls at or near puberty, and also may appear between that period and twenty or twenty-five years of age. It usually happens that the condition dates from a scanty menstruation, beginning late in the "teens," but it should be recollected that amenorrhea is not, as formerly supposed, a cause, being rather an efi'ect of the underlying blood-disorder. Blondes are oftener afi'ected than brunettes. In males the disease is rare, though cases may develop at puberty or during adolescence. The influence of heredity in the causation of chlorosis is undoubted in those cases described by Virchow, in which congenital hypoplasia of the blood-vessels and genitalia is found to exist. Other cases, moreover, in which such anatomic evidence is wanting, also bear the stamp of hered- ity, in that their mothers have been, and their sisters are, chlorotic. A family tuberculous taint may predispose to chlorosis (Jolly). Such un- hygienic conditions as bad air, dimly-lighted rooms, a lack of nutritious food and out-door exercise, a sedentary occupation, hasty and irregular eating, excessive tea- and cofi"ee-drinking, irregular and insufiicient hours of rest and sleep ; bodily fatigue, as from stair-climbing and standing in 422 DISEASES OF THE BLOOD AND THE DUCTLESS GLANDS constrained positions without intervals of rest, — all these predispose to the disease. And yet girls living amid the most luxurious and favor- able surroundings have had chlorosis. It is not at all improbable that, as the late Sir Andrew Clarke believed, eopremia — the absorption of the toxic ptomains and leucomains from the colon in constipation — is often the cause of chlorotic symptoms and signs, though physiological chemists fail to find in the urine the evidences of intestinal putrefaction {i. e. an increase of the aromatic sulphates). Sometimes a previously existing simple constitutional anemia appears to be an underlying cause for an exacerbation of genuine chlorosis. In such instances, however, I be- lieve additional exciting causes to be operative. Sudden emotional excitement and prolonged mental over-exertion operate as causative agencies. Shock from bad news, such as loss of relatives, crosses of various kinds, home-sickness, disappointment in love, rankling grievances, and perhaps uugratified sexual desires or masturbation, may contribute to the "neuropathic" origin of chlorosis. A change of climate seems to operate as a cause, and is manifested especially in the case of girls emigrating from Ireland to enter domestic service here ( Townsend). Symptoms. — A brief outline of the more frequent and prominent general manifestations of chlorosis — or "green sickness " — may be nar- rated at the outset. The gradual onset is usually marked by languor, indisposition to either physical or mental exertion, motor weakness, irritability or inertia of mind, depression of enex'gy, and a more or less constant fatigue. Palpitation of the heart and ch/spnea on slight exer- tion are much complained of in most cases ; headache is also an early symptom, and may be accompanied by vertigo in some cases; and dys- pepsia and constipation occur in 65 per cent, of cases (Townsend). Probably in one-half of all cases cessation of, or scanty and irregular, menses may form the burden of complaint. Gastro-intestinal Symptoms. — The appetite is either poor or perverted, and a capricious desire for such innutritions substances as chalk, slate- pencils, and even bits of earth (pica), or for sour, highly spiced, and unwholesome articles of food (malacia), is not uncommon. Morning vomiting or regurgitation of food and eructations occur, in some cases, pain after eating may be noticed, and dilatation of the stomach and high position of the diaphragm are found in many instances. The tongue is pale, flabby, often dry, and the edges show indentations. Constipation is usually present, though sometimes diarrhea, lasting for a day or two, may alternate, as after the ingestion of some unwhole- some article that has been eaten to satisfy the perverted appetite. General Appearance. — The subcutaneous fat is not only well re- tained, but in many cases is even increased, and the rotundity of the body and members preserved. The peculiar greenish-yelknv tint of the complexion is, however, the most striking manifestation to the eye. It differs thus from the muddy pallor of cancerous anemia, from the lemon-yellow tint of pernicious anemia, from the saiFron hue of jaundice, and from the blanched pallor after severe hemorrhages. The scler?e are often pearly- or bluish-white ("cerulean hue"), and, though this is considered by many the earliest positive indication of anemia, when the skin-tint is not characteristic, yet, according to Townsend's analysis of 87 CHLOROSIS. 423 cases of chlorosis, it is not the most constant. The nails showed pallor in 95 per cent, of the cases ; the cheeks, tongue, and lips were paled in 89, 84, and 76 per cent, respectively, while the sclerse were pale in but 64 per cent. On exertion the cheeks and lips may become quite ruddy in cases of moderate anemia {chlorosis rubra). Circulatory symptoms arebreathlessness, palpitation, and the tendency to vertigo and syncope complained of in the majority of cases ; other circulatory disturbances may occur. The skin and the extremities are frequently cold, owing to sluggish heart-action. The pulse is usually full and easily compressible, and, owing to its excitability, it may be accelerated for the time being by various external influences (see Fig. 33). Visible undulating pulsations of the carotid vessels are frequent, 140 136 132 128 124 120 116 112 108 104 100 96 92 88 84 80 76 72 A. M. P. M. ~ ■^ ~ — T ~ ■^ ■" ~ ~ ■SI ~ T "ffl ~ 1 1 T "to o. » ~1 ^' ~ ^ ■.Is ■ ■" t ^ 1 V 1 ; r i.K 1 • i ' \ A \ • ♦,000,000 j 1 y.f, , > 4,000,000 1 1 1 < ■■ \ \ \ 1 '\ ' i ' ' ! i / Mm: =H \ ■ 1 1 ■ 1 1 : ,^ -V V ' ■ ' ! ,^f*^ , :■ i \' 1 , ''^*-,»^l 1 1 V ' ' \ ; 1 1 > ^ ■/■ k. ' 1 1 : 1 - \ . : i : 1 ^ -^ ^ \ ' 1 ^ ^ 1 ■ 1 ■ 1 \ ' ' ' 1 ! 3,000,000 ' 1 1 M ' 1 ■■ 1 ■ \ 3,000,000 • / ( 1 1 V a 1 1 i A y \ ■ ^ 1 1 i 1 f 1 ! \ _M ! 1 1 \m , / ! 1 i 1 M \: M 1 ] / 1 1 1 -^ ~!_ / i i ■ \ ■ i ■^ 1 2,000,000 : 1 ^ 1 1 s ' 1 ' ' i '■ 1 M ■ ' M ' ! ! ; ! 1 1 ' ' ■ 1 ■ ! 1 / MM 1 ; ■ ■ V 1 i M i : ■ ■ ' ! \ ■■ ' A ' ! i M ! 1 ' ! ; ' ' i 1 1 1 I ' ■ M ' ' ■ M ■ ■ 1 A --' ; 1 M ' 1 MM 1,000,000 ^ ■ 1/ 1 ' ' 1 1 1,000,000 .1 / \ / ' 1 ' ' ■ i . ■ 1 1 i 1 i , 1 1 : 1 : ' V ' ■ '1 1 1 , . ■ 1 i j < ! 1 I'll: i 1 1 MM 1 1 1 1 i 1 ■ 1 I ; ■ 1 J : ; 1 1 14,000 ' 1 ' 1 1 1 i 1 1 \ 1 ! 1 ' ; 1 14,000 1 1 1 1 I 12,000 1 1 12,000 ' i 13.000 1 .->'*r^ 1 ! : 1 10,000 ^ . ! 1 ) 3,000 > v\ ; 1 3 . 000 Vi 1 1 n* ^. 1 ll ' 1 ^^.-^ 6.000 '1 i 1 1 1 , -^— »^ 1 1 -^ >+- e.ooo 1 1 1 1 ■ • i*" 4.000 ' ! i 1 . 1 ~T^ -- 4,000 • i 1 J ] ! _^ ; , ■ ; .2^000, , 1 1 1 1 ! 1 ! 1 1 1 ; 1 ' i : ' 1 1 . 2,000 1 ! 1 1 : _ _L 1 _ _^ L. L LL. _ _ ! i 1 1 MM 1 i ! 1 i 1 Fig. 34.— Chart of a case of chlorosis, showing the improvement following the administration of iron. Convalescence almost complete ; relapse. Black, red corpuscles ; red, hemoglobin ; blue, white corpuscles. green vegetables, stewed fruit, apples, etc.). Fats and carbohydrates should generally be avoided. Ferruginous mineral waters may be freely drunk, but coffee, tea, and alcoholics do more harm than good. Medicinal. — The one remedy, jiar excellence., on both rational and empirical grounds, is a good preparation of iron. This should be given methodically and persistently, until the percentage of hemo- 426 DISEASES OF THE BLOOD AXD THE DUCTLESS GLANDS. globin is 90, and then maintained there by continuing the adminis- tration of the iron for several weeks to prevent a recurrence (Fig. 34). Exactly how the iron acts in curing chlorosis has not been definitely proved, but its almost specific action is indubitable. Not all prepara- tions of iron are equally well borne by the stomach, however, and sev- eral changes may be necessary during the course of a given case. Prob- ably the best form for general use is the dried sulphate, usually given together with potassium carbonate in the well-known Blauds pills — 2 grains (0.129) of each to the pill. Starting with one pill thrice daily for a week or ten days, the daily dosage is increased until nine pills daily are administered in the third week, and continued for several weeks or as long as the case m^ay require. It is very important, meanwhile, that the bowels should be kept soluble by the use of cascara sagrada. salines, and the like. A preliminary course of intestinal antiseptics for a week or so is strongly advised by some authorities, and is Avorthy of recom- mendation. Beta-naphtol, thymol, guaiacoi, and salol are used for this purpose. The hematinic effect of the iron seems to be produced earlier and better when this plan is followed ; and this fact seems to give cor- roborative evidence to Bunge's theory of the absorption of the iron in chlorosis — in a certain class of cases at least. Other iron preparations of value in this disease are the citrate, protoxalate, lactate, carbonate, the succinate, and the reduced iron. The albuminates of iron, so much vaunted for a time, are practically worthless. In severe cases Quincke uses at first a 5 per cent, solution of the ferric citrate, hypodermically (nivijss-5ijss — 0.5-10.0, daily). The preparation known as ferratin is also highly recommended by some, and the therapeutic efficacy of gly- cerin extract of bone-marrow in chlorosis is as yet doubtful. Bitter tonics and dilute hydrochloric acid are indicated in a certain number of cases in which indigestion is troublesome. The acid tincture of iron chlorid is sometimes used in such cases. Mild cases often yield to the simple use of remedies for the cure of gastro-intestinal derangement. Adjuvants in the treatment of chlorosis that may be of use are arsenic, manganese, mercuric chlorid, and arsenite of copper in minute doses. PROGRESSIVE PERNICIOUS ANEMIA. [Idiopathic Anemia.) Definition. — A grave blood-disease characterized by a great de- struction of red corpuscles, and a persistent tendency from a bad to a worse condition. It usually ends in death, and seldom exhibits causal lesions other than those of the blood or blood-making organs. The term "idiopathic anemia" applied to this disease by Addison, whose first clear description of its clinical history has become classical, is applicable to a proportionately smaller number of cases to-day than during his time. This is owing to the later discovery (post-mortem) of adequate causes for the pernicious anemia that during life could not be found. Thus, while still a primary essential anemia in most cases, and whilst future investigations may show the true Addisonian type of pernicious anemia to be a severe secondary anemia, for descriptive pur- poses it will nevertheless be convenient to classify both groups under the title of prognssive pernicious anemia in order to describe the PROGRESSIVE PERNICIOUS ANEMIA. 427 invariable tendency of both. Under Diagnosis {vide infra), however, will be found some differential clinical features. Pathology. — As in chlorosis, the subcutaneous fat is rarely dimin- ished, so that emaciation is exceptional. The skin is pale and of a lemon-yellow tint, and most of the tissues and organs are anemic, ex- cept the muscles, which are often decidedly red in color. The fat is usually pale and yellowish, and fatty degeneration is one of the most striking changes in this affection. The heart is usually large and flabby, and on section of the ventricular walls there is a marked pallor, as well as a friability, and a fatty change shown by the yellow tint. Micro- scopically, the fibers or columns of heart-muscle are seen to be distinctly fatty. The heart-cavities contain very little light-colored blood. Other organs showing the fatty degeneration (of the epithelium) are the liver, kidneys, gastric and intestinal walls, and the intima of many of the smaller blood-vessels (in patches). This general fatty change is prob- ably directly due to the deficient oxygenation of the tissues and to the anemic blood-supply. Owing to the above degenerative change, and consequent weakening in the vessel-walls, small extravasations of blood are found in dif- ferent parts. Most frequently these punctiform hemorrhages are seen in the retina and on serous membranes, as on the inner surface of the dura mater, the pericardium, and the pleura. Ecchymoses are also ob- served occasionally on the mucous membranes and on the skin. More or less general edema and dropsical accumulations in the serous cavities are not uncommon. The spleen and liver are seldom and only very slightly enlarged. The lymph-glands are often somewhat swollen and intensely red in color, owing to the unusual number of red corpuscles, some of which are nucleated. A marked and important pathologic feature of pernicious anemia is the presence of abundant deposits of iron-pigment, especially in the liver, but also in the spleen, kidneys, pancreas, and other organs. The fact that the abnormal quantity of iron in the liver is peculiarly distrib- uted about the periphery and middle zone of the lobules is particularly noteworthy, and quite characteristic of pernicious anemia. The origin of this iron is doubtless the enormous destruction of red corpuscles, and that the pigment in the hepatic lobules is ferruginous may be determined by a micro-chemic test with ammonium sulphid, granules of black sul- phid of iron being formed. Of special interest are the lesions found in the bone-marrow on account of its hematopoietic function. This is virtually hypertrophied, and is in many cases deep-red instead of yellow, and more like the hemoblastic marrow of childhood (H. C. Wood). Indeed, the fat-mar- row of the long bones is often entirely replaced by the red marrow, which makes evident the contrast between it and the icteric pallor of the fatty tissues elsewhere in the body. Cellular hyperplasia may be seen microscopically in the great number of large and small granular medul- lary cells, and also in the nucleated red cells. An atrophied and polypoid condition of the gastric mucosa, more or less extensively involving the gastric tubules, is noticed in some cases. The sympathetic ganglion cells may also show changes. More constant, hoAvever, is the sclerosis of the posterior columns and, to some extent, 428 DISEASES OF THE BLOOD AND THE DUCTLESS GLANDS of the lateral columns of the spinal cord : this is especially marked, according to Burr, in the cervical swelling. Patveu examined 9 cases ; in 4 he found hyaline degeneration of the vessels of the white substance, and in 5 small hemorrhages. Ktiology. — There are three etiologic categories into which cases of pernicious anemia may be grouped : (1) those cases in which no discov- erable cause for the hemolysis (blood-destruction) is ascertained, either during life or after death — i. e. the idiopathic variety of Addison ; (2) those in which an adequate cause is found post-Diortem only ; (3) those that are plainly traceable, ante-mortem, to some sufficient primary causal condition acting directly or indirectly. (1) As regards the obscure cases of idiopathic anemia — or cachexia — the essential cause of the symptomatic condition is evidently an actively increased hemolysis. The blood-destruction is so great that blood-gen- eration (hemogenesis) is overbalanced. The latter may be normal in power or there may be a congenital or acquired underlying deficiency in hemogenetic power ; but in either event the hemolysis far exceeds the hemogenesis in pernicious anemia, the liver being the principal seat of the hemolytic changes — in the final stages, at least. Stengel believes that the hemolysis originates in the gastro-intestinal capillaries, and depends upon poisons generated or absorbed from that tract — an auto-intoxication. (2) Apparently causeless cases of progressive pernicious anemia may be found post-mortem to have been caused by (a) obscure malignant dis- ease ; {b) parasites, especially the Anchylostoma duodenalis, and rarely by the Bothriocephalus. Not infrequently, by a careful study of the anamnesis of a patient, aided by modern methods of examination, the cause of pernicious anemia may be detected during life. Atrophy of the stomach and chronic gastritis, with polypoid growths of the mucosa, may be included in this category. The Bothriocephalus latus may be discovered during life, though more frequently only after death. (3) Certain exhausting causes, operating directly or indirectly, may precede this affection, as severe or prolonged hemorrhages, or diarrhea, fevers, mental shock, profound chlorosis, pregnancy, and parturition. Unfavorable hygienic surroundings and insufficient nourishment, habitually kept up, may also favor the development of the disease ; but, as in chlorosis, the most favorable environment is not by any means preventive of its development. Males are more frequently affected than females, and especially does it occur during middle life. Griffith has collected several cases occurring under twelve years of age. The disease is widely distributed, and, whilst it has been observed to behave almost endemically at times, as in Switzerland and Leipsic, no infectious origin has been shown to exist. Heredity is rarely noticed. Symptoms. — Idiopathic pernicious anemia develops so slowly and insidiously that it is hardly ever possible to fix upon any precise date as the commencement of the disease. The transition from health to pro- gressive pernicious anemia, particularly in persons previously feeble and pale, is usually too gradual to be demonstrable ; though a rapid and acute onset is rare, it may occur in pregnant or puerperal women. Pallor is soon noticed and gradually increases, or when there has been a previous pallor, this becomes more marked. Shortness of breath and palpitation of the heart, especially on exertion, are complained of; PROGRESSIVE PERSICIOVS ASEMIA. 429 the patient is also easily fatigued, and becomes quite languid. Occa- sional nausea mav come on early in those cases in -which a previous gastro-intestinal disturbance has been noted, and headache, vertigo, tin- nitus aurium, and anorexia ensue and grow progressively worse. Gen- eral weakness increases, and occasional attacks of faintness and vomit- ing supervene. Meanwhile, the skin takes on a bloodless, waxy appear- ance, and soon the characteristic lemon-yelloiv tint appears. The mucous membranes (lips, gums) are likeAvise pale and colorless. Prostration in bed graduallv becomes almost absolute as the feebleness and flabbiness of the tissue increase. Jlalleolar edema is sometimes noticeable, and ecchymoses — mucous and cutaneous — are seen in profound cases of anemia. Although the intellect is not impaired, except that mental ex- ertion becomes irksome, the tone and manner of speech are feeble. As the debility becomes severe the mind wanders, and, to use Addison's words, the patient '• falls into a prostrate and half-torpid state, and at length expires." Emaciation is rare, the fat being preserved and sometimes increased in quantity. Pulsation in the large arteries is abnormally visible, and a diffuse, exaggerated cardiac impulse is felt. The pulse early in the case may be strong, and generally it is rapid (100-120), soft, and com- pressible, and as full and quick, often, as the water-hammer pulse of aortic regurgitation. Auscultation reveals the constant and character- istic hemic murmurs^ best heard at the base of the heart, and the bruit de diable in the veins of the neck. There may also be visible pulsations in the latter. G-astro-intestinal symptoms may be the most prominent signs in cases where gastritis polyposa and gastritis atrophica are causal. Diarrhea, dvspepsia, nausea, and vomiting are then present throughout the long course ; otherwise, constipation, eructations, and simple anorexia are most common. An ophthalmoscopic examination shows the cause of the anemic amaurosis, in the profound cases of anemia, to be one or more retinal hemorrhages. The whites of the eyes become pearly, the conjunctivae pale. The liver and spleen are rarely palpable. The bones, and especi- allv the sternum, are sometimes sensitive to pressure. Respiratory Symptoms. — The breathing is accelerated, and the anemic dyspnea may become very pronounced and stertorous, accompanied by a sense of oppression in the chest and a "hunger for air." Xear the end pleural and pericardial serous effusions and pulmonary edema tend to appear. The urine is of low specific gravity, and. on account of its pigmenta- tion with pathologic urobilin, dark in color. The urobilin is detected both by chemic and spectroscopic examination. In the former the addi- tion of a few drops of an alcoholic solution of zinc chlorid to the urine D-ives a green fluorescence. Peptonuria is of doubtful significance. Albumin and glucose are absent, but uric acid and urea are both in- creased in amount, the former occasionally and the latter usually. Fever of a moderate degree is commonly, though not invariably, present, the evening temperature sometimes reaching 102° F. (38.8° C). Previous to death the temperature may be subnormal. Nervous Symptoms. — Paresthesia, spastic paralysis of the limbs, and 430 DISEASES OF THE BLOOD AND THE DUCTLESS GLANDS a loss of control of the sphincters indicate the paralytic tendency of those cases in which sclerosis of the cord occurs. Tabetic symptoms are sometimes marked. Blood-examination. — The blood is usually pale, though sometimes dark and ^vatery, and the oligocythemia is distinctive of pernicious anemia. The number of red corpuscles may be reduced to less than 200,000 per c.mm., and is seldom more than 1,000,000. There is ordinarily no increase in the number of leukocytes ; on the contrary, they may be somewhat diminished. This diminution usually affects the polynuclear cells most. The percentage of hemoglobin may be approximately pro- portionate to the number of red corpuscles, but more often it is relatively increased, so that the individual corpuscles are rich in hemoglobin. In other words, although there is a reduction in the total amount of hemo- globin, it is usually not so great as the reduction in the number of ery- throcytes ; therefore, the percentage of hemoglobin is nearly always relatively higher than that of the red globules (see Fig. 35), a condition 100- 90;; 30;. 70r; 60;; 50;; 305 20;; 10;; MONTH JUNE JULY AUGUST SEPT. MONTH 100; 90;S 80,'? 10% 60^ 501 *'^^ 30; 20; 10;* DAY i'E S S ?, r-i--'- i z "i ^z i. i. •^ - e :• £ : s S|S s - ~ .^ o = DAY 5,000,000 1 5,000.000 1 1 1 1 i 1 4,000.000 4,000,000 f 3,000,000 1 2,000,000 2,000.000 s ^ ■i ~ ^ , s r - - ~ ,. 1,000,000 1,000,000 ' --■ '~. 1 .~ , 500,000 — 1 500,000 1 -- .... ^ — ^1 - 1 1 . 1 1 1:^1 Fig. 35.— Blood-chart of a case of progressive pernicious anemia. hemoglobin. Black, red corpuscles ; red, in marked contrast with chlorosis. Macrocytes, microcytes, and poi- kilocytes are abundant, and the macrocytes are supposed to give rise to the relatively larger percentage of hemoglobin. The presence of nu- cleated red corpuscles is also a striking characteristic of pernicious anemia. AVhen normal in size they are known as normoblasts ; when very large, as gigantohlasts. In the former, according to Ehrlich, the eccentrically-placed nuclei .stain deeply ; in the latter the large nuclei stain faintly. The former are typical of those nucleated red globules found in the hematopoietic organ of adults ; the latter, of those found in the blood-development of embryonic life. The gigantohlasts are numerous in this disease. There are other and various forms of degen- eration of the red cells, but these are of minor import. There may be an increase in the small lymphocytes at the expense of the polynuclear cells; and, according to Cabot, the presence of large numbers of poly- chromophilic red cells has been noted in a series of 50 cases. The blood-plates are generally fcAver than normal. The relative proportion of the proteids in the blood-plasma is altered (Adami). Diagnosis.— It is important to determine, if possible, whether the PROGRESSIVE PERNICIOUS ANEMIA. 431 anemia is truly primary (or idiopathic) or secondary. Moreover, the possibility of hidden carcinoma, gastric atrophy, the anchylostoma or other parasite, and incipient tuberculosis should be borne in mind. Intestinal parasites may be inferred from the microscopical examination of the feces after a brisk purge if the eggs of the parasites or the para- sites themselves be found. Atrophic gastritis may be discriminated by examining the viscus and gastric juice by modern methods. The fol- lowing table will permit the elimination of obscure gastric carcinoma : Progressive Pernicious Anemia. Obscure Gastric Carcinoma. The blood shows characteristic changes, Blood shows characteristics of secondary and the red corpuscle count falls to or anemia, and the count does not fall to below 1,000,000 per c.mm. 1,000,000, as a rule. Found earlier in life. Occurs after middle life. Gastric symptoms not so prominent. Gastric symptoms more suggestive. Lemon-tinted skin common. Skin of a pale, muddy-color, or only slightly jaundiced (saffron-yellow). Adipose tissue fairly Aveil preserved. Progressive emaciation. No glandular enlargements palpable. Supraclavicular or inguinal glands may be palpable. No physical signs over stomach. There may be an area of increased re- sistance over the stomach. Examination of gastric contents after Examination of gastric contents shows test-meal usually negative. deficiency or absence of free hydro- chloric acid and presence of lactic acid. Some improvement may be brought about Condition becomes steadily worse until — even cure, though very rarely. death ends the case. From chlorosis the affection may be differentiated easily by the blood- examination. The relative increase in hemoglobin, the presence of gi- gantoblasts and many macrocytes, and the severe oligocythemia are pathognomonic of pernicious anemia, and are in marked contrast to the oligochromemia, and slight, if any, reduction in the number of red globules of chlorosis. Again, the progressive pernicious character of the former and the tendency to hemorrhage should be remembered, as well as the contrasting factors of age and sex in the two affections. Prognosis. — The disease, as a rule, terminates fatally, though not so frequently now as at one time, for obvious reasons. The course of pernicious anemia is usually slow and gradual, and may be interrupted by improvement or apparent recovery. Recurrences, however, are prone to occur, even after intervals of several years, " attacks of anemia " alternating with periods of improvement, accompanied by enlargement of the spleen. Idiopathic anemia is therefore almost hope- less, although a few apparently substantial recoveries have been reported. The duration of the disease is seldom more than a year, and may not be more than two or three months. Death may be caused either by syncope, cerebral hemorrhage (most commonly), or by slow asthenia. Treatment. — Hygienic measures must be regarded as of signal im- portance, and rest in bed, together with light nutritious food given at short regular intervals, is indicated first of all. Salt-water baths and gentle and systemic massage when the patient is at absolute rest and is not too weak, are useful adjuvants. The value of arsenic in this disease is, I think, analogous to that of iron in chlorosis. The best action of the drug will be ob- 432 DISEASES OF THE BLOOD AND THE DUCTLESS GLANDS. tained by the administration of gradually ascending doses of Fowler's solution or of arsenous acid. Beginning with four or five drops of the former, three times daily during the first week, and thereafter adding one drop to the dose every day or two up to the point of tolerance, as much as twenty or thirty drops, well diluted, may be taken (see Fig. 36). Evidences of gastro-intestinal irritation should be Avatched for, 100; 80,t 70>5 60,c 5C;- 40;. 3C-- 20'" MONTH SEPT. OCTOBER NOVEMBER DECEMBER JANY. MONTH ■00% 30,-^ 80;; t'0% DAV " sisisij „ .-- -'^1:2 sis ; ^- s .. o . z : 2 t S s 5 - - - £ Z t : s £ S - ' - ^ ; DAY 6,000,000 5,000,000 1 ♦,000,000 4,000,000 ,>^ ,, . ' «.< .H 3,000,000 y ^ ^ ■— 3,000,000 r V ,y / V / / 2,000,000 ■r ^ V 2,000,000 •^ / ^ y V, f y .> ' 1,000,000 y ^ -> 1,000,000 ^ v 600,000 ^ /• 600,000 y ^ . _ Fig. 36.— Chart of a case of progressive pernicious anemia, showing the improvement following the administration of arsenic. Black, red corpuscles ; red, hemoglobin. and the arsenic either discontinued or the daily dose reduced should they appear. Sometimes it is advisable to use the remedy hypodermic- ally. Arsenous acid is given in pill form, commencing with -Xr or -Xr gr. (0.0021-0.0032). The introduction by Fraser of Edinburgh of bone-marrow in the treatment of pernicious anemia has been followed by various results : some cases have been reported in Great Britain and in the United States in which it has seemed to do good, while in others it was found to be useless. While the glycerin extract is the preparation generally used, it is not so reliable as the raw red bone-marrow, or that freshly prepared each day by mixing with it an equal quantity of glycerin ; an ounce or two may be administered daily. The remedy is worthy of trial, and if found to be non-efficacious in the given case, arsenic may either be com- bined with it or used alone. Near the end of the disease the danger often greatly increases, owing to the marked reduction in the quantity of the blood {oligemia). This may be combated by the injection of Avarm Avater or a Aveak saline solu- tion into the colon (enteroclysis) and also into the subcutaneous tissue (hypodermoclysis). Both the former procedure and gastric lavage are of value in preventing and ameliorating the gastro-intestinal disturbance from fermentation and putrefaction. Intestinal antiseptics (thymol, guai- acol carbonate, salol, beta-naphtol, and hydro-naphtol) should be given by the mouth in conjunction Avith the injections, and lavage of the tract should be employed for the same purpose. Anthelmintics must be used in those cases of pernicious anemia in which intestinal parasites are associated. Dilute hydrochloric acid, nux vomica, and bitter tonics are serviceable in cases in Avhich gastric diges- tion is impaired. THE SECONDARY ANEMIAS. 433 During the convalescence in favorable cases iron seems to be pecu- liarly valuable, sometimes alone and frequently in conjunction vi'iih arsenic. Thus, arsenious acid and either the carbonate of iron or re- duced iron may be combined in pill form, or Fowler's solution and the tincture of the chlorid of iron, or Blaud's pill, may be used with satis- factory results. Recurrences will yield to the same treatment, if they yield at all, except that the doses may have to be increased according to the tolerance of the individual case. II. THE SECONDARY ANEMIAS. The secondary anemias are symptomatic of abnormal processes or of existing disease, whether acute or chronic, and their causes are numer- ous and various. I have already stated that secondary anemia may occur when the true primary form cannot readily be determined and when the course of the anemia is progressive and pernicious. Further- more, several possible causes may exist in a given case of symptomatic anemia, and it may be quite difficult to discover which of these is the active factor in the condition. In certain secondary anemias, also, the associated impairment of the blood-making organs is so evident that the anemia may assume almost a primary importance. This was exemplified in Strlimpell's case of carcinoma and anemia, with secondary implication of the bone-marrow. The variety and uncertainty of the causes of secondary anemias thus prevent a satisfactory classification. The Blood. — In most cases this distinctly differs in character from the blood of the primary or essential anemias. There is oligocythemia, usually of a moderate degree, about 3,000,000 red corpuscles per cubic millimeter being noted, though in cases of severe hemorrhage the reduc- tion may be as great for a time as in pernicious anemia. There is also a relative decrease in the amount of hemoglobin, and sometimes the per- centage may be relatively lower even than is compatible with the de- crease in the number of the red corpuscles. There is a relative, and often an absolute, increase in the number of leukocytes {vide Fig. 37). Either a few or many poikilocytes, a few macrocytes, microcytes, and nucleated red cells, some showing fragmented nuclei, are found. Free nuclei may occur. Gigantoblasts are not seen, and the relative increase in the percentage of hemoglobin is also absent. The most important etiologic groups of secondary anemias are as follows : (1) Hemorrhage. — Hemorrhages occur under a great variety of circumstances, and if copious result in an acute secondary anemia. Thus there may be the rupture of an aneurysm, menorrhagia, post- partum hemorrhage, hemoptysis, gastrorrhagia, enterorrhagia, etc., all of which produce the same general effect upon the system. Repeated small hemorrhages may finally produce the same result as a single large one, and spontaneous hemorrhages or epistaxes, such as occur in persons of a hemorrhagic diathesis (hemophilia) or in purpura and scurvy, may cause profound secondary anemia. Females are most tolerant of losses of blood, but infants of both sexes bear depletion very badly. The total mass of blood may be much diminished (oligemia), and the sudden loss of a great volume of blood may prove fatal in a few moments ; but 28 434 DISEASES OF THE BLOOD AND THE DUCTLESS GLANDS. it is often surprising how recovery can take place, and often does, after the rapid loss of several pounds of blood — e. g. in hemoptysis, hematem- esis, or menorrhagia. Sometimes the source of bleeding is obscure, as in cases of intestinal parasites, hepatic cirrhosis, or duodenal ulcer ; or it may be intentionally kept suh rosa by females having uterine dis- order or bleeding hemorrhoids. The quick blanching of the counte- nance, the weakness, the coldness of the skin, fointness, dimness of vision, tinnitus aurium, sighing respiration, and feeble, ra})id pulse are charac- teristic symptoms of acute anemia. Unconsciousness and epileptiform 100^ 70,"? 60;J 50,- 40,-i cc,.s:... ^ FEBRUARY 1 MARCH | APRIL | MAY c;Pr-bS.;..>s 5,000,000 100:? SC:^ 701 5C;: 40;f 30,t 20,: :: : 2 5 g J s ?, s:^ -^ -- = £ 2 ; ; 5 s .; 5: s s s ■" -- -• 2 f ; ; 2'g s ; s s Si" 'i" = £ S'iiS t s 1 1 r 1 1 .1 1 1 1 1 ' uLu ^ 1 ; ' i 1 ' h ' ' i ' ' 1 T i 1 ! hi . ■ ' ' ! 1 , ^ 1 i / ' ' 1 1 ' ' V' '' ' ■ ! y , , 1 '■ i ■ ■ ' ! , -- ,,->■ . , 1 , 4-. 000, 000 1 \Z' . _. . : 1 , ■ 1 1 1 ; 1 y , ' 1 i X '^ t -^ : ^ ^ 1 } - -* ' / / 1^ / 3,000,000 ^ _^'^ \i ' ■ y / ■ 1 t 1 ^ ■ : 1/ / 1 ■ 1 1 1 j 1 t yV ■ . 1 1 \ / X / - I i 1 1 M / \/ ^ I >'^'---^y - '■ \'' \' ^ till . ^ 2,000,000 2,000,000 - -vV ^' _i 1 I 1 / N /" i^_ (^ / en * \ \, / / ^ 1,000,000 - 1,000,000 12.000 - 12,000 • 1 \ ' 1 ' I 1 lO.fiOO - r ' 1 1 10,000 j^ ' ! ■' ,. 'X 1 '' v 3.000 - /] ' \ 8,000 /' ■ ' \ f \ "* 1 ^ 6 , 000 - , 6,000 ' •n s . ' [ ^ J _ J _ J _ J - _ i_ _ ■ >' ; ; 1 1- 4.000 4,000 - - - -J - - - - - - r r - - - - ; i:!: ' j-L _ ^ L LL L Fig. 37.— Blood-chart of a case of symptomatic anemia. Black, red corpuscles; red, hemoglobin; blue, white corpuscles. convulsions precede death in cases in which the total volume of blood lost is sufficiently large. When recovery takes place the blood-regen- eration goes on rapidly, so that within from one to three weeks restitu- tion is complete. The normal volume is soon restored — first by the absorption of water, hydremia existing for several days before the saline and albuminous elements are renewed. The white corpuscles are earlier restored than the red, so that there is a temporary relative leukocytosis. The hemoglobin is restored still more slowly than the red corpuscles. (2) Inanition. — Anemia from inanition may be caused by a food- supply that is insufficient either in quantity or quality, or both; or, even with abundant food of sufficient nutritive qualities the digestive power may be so impaired as to cause defective assimilation. Esophageal THE SECONDARY ANEMIAS. 435 carcinoma and chronic gastritis, especially of the atrophic variety, may thus cause anemia from inanition. The reduction of the blood-plasma forms a feature, while the corpuscles may be affected but slightly. (3) Excessive albuminous discharges, as in chronic Bright's disease, prolonged suppuration, long-continued lactation, chronic dysentery, etc., drain the system so that marked anemia may be produced. (4) Toxic Agents. — The poisons may either be organic or inorganic, though toxic anemias are most common from the absorption of lead, arsenic, mercury, and phosphorus. The poisoning is usually chronic, and affects principally the corpuscles. Anemia due to the poisons of acute or chronic infectious diseases is also frequently met Avith, and may thus be observed after typhoid fever, diphtheria, yellow fever, and in- flammatory (articular) rheumatism among the acute diseases, and during chronic malaria, tuberculosis, and syphilis ("syphilitic chlorosis"). There is considerable destruction of the red corpuscles in some of these diseases, either directly or indirectly, and the greater the pyrexia the greater the action upon the blood or blood-making organs. Symptoms. — The common indications of secondary anemia are the pallor of the face and mucosae, muscular and mental weakness, loss of nerve-function, neuralgias, coolness of the skin, dyspnea on exertion, cardiac palpitation, impaired appetite and digestion, and a weak pulse. The physical signs are those of the primary or essential anemias. Diagnosis. — Here may be advantageously contrasted the distin- guishing features naturally grouping themselves under symptomatic and essential anemias, respectively : Symptomatic or Secondary Anemia. Idiopathic or Essential Anemia. A symptomatic blood-condition secondary A primary disease of the blood and to disease elsewhere. blood-making organs. _ Occurs at any age. Occurs principally during adolescence and early middle life. Previous or associated history of trau- Previous history negative in its bearings matic or spontaneous hemorrhage, upon the disease. chronic suppuration, prolonged lacta- tion, chronic Bright's disease, carci- noma, chronic lead-poisoning, chronic malaria, etc. Blood-changes not so marked and more Distinctive blood-characteristics, and variable. often profound changes, both as to blood-cells and hemoglobin. Moderate reduction in both, merely the Marked reduction in either the hemo- relative proportion being maintained. globin percentage or in the number of red corpuscles. General symptoms and signs usually sub- General symptoms and signs also more ordinate in manifestation to those of characteristic of the respective form the primary disease or lesion. of anemia in the case. Gravity of anemia depends on that of the Gravity depends on type of blood- primary disease. changes and progressiveness of dis- ease. Often responds to treatment, depending One variety (chlorotic) quite curable, the on the cause ; in a few instances, as other (progressive pernicious) com- in hemorrhage, it is short in duration. monly fatal. The prognosis depends upon the cause of the anemia. Treatment. — Symptomatic anemia is amenable to treatment accord- 436 DISEASES OF THE BLOOD AND THE DUCTLESS GLANDS. ing to the cause. The traumatic acute variety does well under simple hygienic measures after the urgent indications have been met. Plenty of pure air, wholesome food, and graduated rest and exercise may suf- fice, and drugs not be needed. Cases in which it is difficult or welhiigh impossible to remove the cause of the anemia of course do not improve under any treatment other than that which may favorably influence the primary affection. Xutritious aliment, iron in some form, a judicious hygienic regimen calculated to increase the assimilation, and stomachic and general tonics are required in the majority of cases. Toxic sub- stances must be eliminated, their re-introduction into the body prevented, and the repair of the blood and tissue actively promoted. LEUKOCYTOSIS. Definition. — A temporary increase in the number of leukocytes in the blood, especially of those of the polynuclear variety. These in normal blood constitute about three-fourths of all the leukocytes. The number of white corpuscles in a moderate leukocytosis would be about 10.000 per cubic millimeter; in marked leukocytosis there might be as many as from 20.000 to 40,000; a count of over 50.000 leukocytes to the c.mm. may, however, usually be considered to indicate leukemia. Von Limbeck, notwithstanding, reported a case of leukocytosis accom- panying carcinoma of the kidney with metastasis, in which there were 80,000 white corpuscles per cubic millimeter. Physiologic leukocytosis occurs in infants during the first few days after birth, in pregnancy, during digestion, and after exercise. Accord- ing to Carter, the " digestion leukocytosis is present after a meal of proteids or hydrocarbons, but not after a meal of carbohydrates." ^ Massage and cold baths also produce leukocytosis, probably by stimula- ting the circulation, and not by increasing the actual number of leuko- cytes, some of which have simply become stagnated. Pathologic leukocytosis is secondary to various affections. It may be temporary, as in the curable primary diseases, or permanent, as in those that do not permit of recovery. It is also found to be well marked in acute inflammations and in infectious febrile diseases accom- panied with exudation, such as pneumonia and diphtheria. In pleuritis, peritonitis, pericarditis, erysipelas, and in all suppurative processes there is an excess in the number of polynuclear neutrophiles. Inflam- mations of the serous membranes, when not tuberculous, cause leukocy- tosis, so that a purulent meningitis may be differentiated from tubercu- lous meningitis by the pronounced leukocytosis in the former and its absence in the latter. As a rule, the greater the local reaction and the stronger the resistance to severe infections the greater the leukocytosis. As is well known, the pus-cells of an abscess consist almost wholly of dead white corpuscles — phagocytes — that have been overcome or ex- hausted, directly or indirectly, in the struggle against the toxin of the infection. Cachectic states, as in cases of malignant tumors, are often attended with an increase in the number of colorless corpuscles in the blood, especially in the region of the tumor and where the lymph- glands are involved. Leukocytosis may be very marked in carcinoma, ' Univ. Med. Magazine, vols, vii and viii, p. 181, Dec., 1894. LEUKOCYTHEMIA. 437 the ratio of reds to whites being, in some cases, 25 to 1. Chemical irritants, such as turpentine, may also produce leukocytosis, and whatever the substance causing the condition it is spoken of as positively chemo- tactic — attractive to the white blood-corpuscles — in contradistinction to negatively chemotactic substances, which repel the white corpuscles. In non-leukocytotic infectious diseases, such as typhoid fever, the diagnosis of a complicating pleuritis, for example, may be confirmed, even at its onset, by the detection of the leukocytosis. Leukocytosis under such circumstances has prognostic importance. Diminishing leu- kocytosis during the height of a grave disease may be significant of less- ening powers of resistance, though this is not an invariable rule, since just before the crisis of a pneumonia or when there is marked emacia- tion, as in typhoid fever, a diminution of the leukocytes is apt to occur. The object of the leukocytosis is naturally protective, beneficent, and reparative. It is accomplished either by direct antagonism or by the formation of substances that enter the fluids and tissues of the body, and counteract the influence of the toxic substances causing the disease. The existence of leukocytosis can best be determined by the examination of stained specimens of the blood. Physiologic digestion leukocytosis is to be discriminated from the pathologic variety by making the ex- amination several hours after the last meal has been taken. LEUKOCYTHEMIA. {True Leukemia.) Definition. — A blood-disease, usually chronic, characterized by a peculiarly marked and persistent increase in the number of leukocytes, associated with lesions occurring either respectively or unitedly in the spleen, bone-marrow, and lymphatic glands. Pathology. — Bodily emaciation and pallor are pronounced, and edema, with dropsical efi"usions in the serous cavities, is by no means uncommon. The cardiac chambers and principal veins are distended with large blood-clots of a greenish-yellow or, in extreme cases, yellow- ish-white, purulent appearance. Subserous ecchymoses of the pericar- dium and endocardium are frequent, and the myocardium is often found to have undergone a moderate degree of fatty degeneration. Various abnormal substances have been found in leukemic blood, and among; them the following may be mentioned : hypoxanthin, leucin, tyrosin, acetic, formic, and lactic acids, and certain albuminous substances (deutero- albumose and nucleo-albumin) resulting probably from the destruction of blood-corpuscles. The alkalinity and specific gravity of the blood are both diminished. The minute, colorless, octahedral, so-called Charcot's, crystals are found most abundantly in settled leukemic blood, and have also been detected in the spleen, bone-marrow, and liver, as well as in other afi"ections. Their composition is not clearly known. Although the spleen, bone-marrow, or the lymph-glands may alone show the pronounced pathologic changes of leukemia, it is usual to find all more or less afiected. Purely splenic or myelogenic leukemia, and the latter especially, are rarer than the lymphatic type, so that it is customary to speak of two principal groups : (1) sj^lenic -myelogenous (or spleno-medullary) leukemia, the most frequent variety ; and (2) lym- phatic leukemia. 438 DISEASES OF THE BLOOD AND THE DUCTLESS GLANDS There is nearly always some splenic enlargement, and in many cases the enlargement is considerable, as in spleno-meduUary leukemia. Leukemic spleens sometimes weigh as much as from two to eighteen pounds, and their lengths may vary from six to twelve inches. The enlargement is generally uniform, and the notches upon the anterior border may be much exaggerated. White patches of perisplenitis and a thickened capsule adhering to the surrounding organs and the abdom- inal wall may also be noticed. The consistence of the spleen is firm and resistant to the knife, though in the earlier stages it may be quite soft and pulpy. The cut surface is either of a uniformly brown color or mottled by the presence of grayish- or yellowish-white circumscribed lymphoid tumors, or by deep-red or brownish-yellow hemorrhagic in- farcts. The Malpighian bodies may or may not be visible. The blood- vessels at the hilum are enlarged. Microscopic examination shows the change to consist in a true hyperplasia of the organ, there being an in- crease in all the normal histological elements. The cells of the pulp sometimes show granular and fattv desreneration. and in advanced cases the trabeculcTB may be thickened by a considerable amount of firm con- nective tissue. In the majority of cases the bone-marrow is affected as well as the spleen, and a purely myelogenous leukemia is extremely rare. Indeed, the few reported cases of the latter may be doubted. The medullary substance, instead of being fatty, is rich in lymphoid and blood-cells in various stages of development, and is either reddish-brown or greenish- yellow in color. Neuman regarded the marrow-change as a constant and essential lesion of leukemia, and called the former transformation "lymph-adenoid," and the latter "pyoid." The pus-like marrow and the dark-red may exist side by side, although the former is more common. A fine reticulum may be seen between the cells, especially in the dark-red variety, and small hemorrhagic infarcts may also be noted occasionally. Microscopically, the medulla contains an abundance of lymphoid cells and nucleated red corpuscles. Eosinophilic, mononuclear, and polynuclear leukocytes are also present, the first-named being quite numerous, as are also certain myelo-plaques and cells showing karyo- kinetic figures. The It/mphatie glands are more or less enlarged in the splenic and medullary forms of leukemia. In the lymphatic variety, especially when acute, an early and mai'ked hyperplasia of all the glands takes place. The cervical, axillary, in- guinal, and mesenteric glands ai-e usually involved, and may form dis- tinct, soft, and movable tumors, their color being a reddish-gray, and section often showing hemorrhagic points. The histological examination shows an increase in the cellular ele- ments. A similar hyperplasia occurs in those glandular tissues that are allied to the lymphatic glands, such as the tonsils, lymph-follicles, the tongue, mouth and pharynx, thymus gland, and the solitary and Peyer's agminated intestinal glands. The liver may be greatly enlarged ; indeed, some of the instances of greatest enlargement of this organ have been those due to leukemia, the Aveight being as much as fourteen pounds. The enlargement is uniform and due to a diffuse leukemic infiltration. The capillaries and inter- lobular tissue are distended with leukocvtes, and disseminated whitish LEUKOCYTHEMIA. 439 or grayish nodules, usually quite small, consisting of lymphoid cells undergoing indirect division of their nuclei, are frequently found. Sometimes these leukemic nodules appear as definite growths, with an adenoid reticulum between the cells, on account of which they have been called lymphomata or lymph-adenomata. Similar changes are observed in the kidneys, enlargement, paleness, and diffuse and circumscribed leukemic infiltration of the capillaries and intertubular tissue all being noted. Leukemic nodules may also be found in other parts of the body, such as the retina, brain, serous mem- branes, lungs, testicles, and skin. Karyokinetic figures are numerous in the cells accompanying these leukemic growths. Ktiology. — The primary cause of leukemia is unknown ; that it directly affects the blood-forming organs, however, is most probable, though with differences of selection and co-ordination and with different degrees of intensity. The combination of lesions in the spleen, lymph- glands, and bone-marrow, along with the histologic similarity of the leukemic growths to the infectious granulomata, and the clinical history of cases of acute leukemia, Avould seem to point strongly to the microhic origin of the disease. Moreover, various cocci and bacilli have been found, but not one of them has been definitely proved to be the specific cause of the disease. Auto-intoxication by toxic albuminoids from the digestive tract is believed by Vehsemeyer,^ who analyzed 600 cases, to be the important point of departure of the disease. It is likely that the direct cause of the leukocythemia is a simple increase of the cytogenic function of one or more of the hematopoietic organs. Kottnitz held leukocythemia to be a reactive condition following auto-intoxication with peptones, and consequently a leukolysis, the over-action of the hematopoietic organs leading to hypertrophy. Whether the reduction of the erythrocytes is due to diminished production or to increased destruction is not positively known, although the former factor is more probably operative. The disease has often been preceded by an injury or a blow in the splenic region, but its direct traumatic origin is hypothetic only. In- testinal ulceration has been a frequent feature prior to leukemia, and undoubtedly affords a source of possible infection from the tract. Stomatitis also may furnish a means of entrance for the infectious agent. The causal relation of pseudo-letikemia and ti'ue leukemia is uncertain, although a few cases of the one have been observed to pass into the other. In a considerable proportion of cases leukemic patients have had malaria of some form. Syphilis may be associated with the disease, but it is not probable that it acts in a causative manner. Hereditary influences undoubtedly play a part; a "lymphogenous diathesis " may thus be transmitted, and several generations may be affected by the disease. Adverse hygienic and social conditions may also predispose to leukemia. It may also develop after pregnancy, or more commonly at the climacteric. Anxiety, worry, and mental depression have been mentioned as predisposing causes, with doubtful justification. Leukemia occurs most frequently in males during the middle period of life, and is apt to attack young persons. It has occurred during in- fancy, and as late also as the seventieth year, but the average age ranges ^ International klin. Mundsch., Vienna, Nov. 25, 1894. 440 DISEASES OF THE BLOOD AXD THE DUCTLESS GLANDS. from twenty-five to forty-five years. Sometimes the previous condition was one of apparently perfect health. Symptoms. — Acute leukemia, although comparatively rare, ma}^ be described briefly first. It usually occurs in an adolescent who may have enjoyed previous good health. Fussel and Taylor collected 56 cases from the literature. Its onset is sudden, and usually begins with pros- tration, hemorrhage of the mucous membranes, and high fever. Acute splenic tumor rapidly develops ; the lymphatic glands niay enlarge ; and palpitation, dyspnea, and gastro-intestinal symptoms of a severe type appear. The skin becomes anemic, and edema of the feet is common. The blood shows a marked increase in the number of leukocytes, the ratio to the red corpuscles being 1 to 30 or 1 to 50, instead of the nor- mal 1 to 350 or 1 to 600. In acute lymphatic leukemia the lympho- cytes are very numerous. Large mononuclear leukocytes and myelo- cytes are also numerous, while the eosinophilic cells are few in number compared with those found in the blood of chronic leukemia. The case grows progressively worse ; hematemesis, cerebral or retinal hemor- rhages, and petechije supervene perhaps, and the clinical features may then resemble an infectious disease with hemorrhagic and purpuric manifestations. Death occurs in from two to three months. In chronic leukemia the onset is generally slow and insidious and its development imperceptible, and for many months the earlier symptoms may not differ from those of simple anemia. Languor, a deranged appetite, dizziness, noises in the ears, faintness, breathlessness on exer- tion, and palpitation may all appear. Sometimes, however, not even these symptoms are present, common as they are to most anemic cases, and the patient may first consult the physician, because of a swelling or distress in the left side of the abdomen — the enlarged spleen. Early manifestations may be hemorrhagic in some cases (epistaxis, hematem- esis, enterorrhagia), with nausea, vomiting, and diarrhea ; or increas- ing pallor of the countenance, yet at times a patient may appear to be plethoric ; or troublesome priapism may be the first indication. As the disease progresses the anemia becomes more marked, edema of the de- pendent portions of the body may appear, and fever, though slight at first (99.5° F.— 37.5° C), may gradually rise to 102° or 103° F (39.4° C), either remaining constant or alternating with periods of apyrexia. The pulse-rate is increased ; in quality it is soft and compressible, though sometimes full in volume. The dyspnea may be aggravated by the hydrothorax of a general di'opsy in advanced cases, or by the up- ward displacement of the diaphragm owing to the increasing splenic and hepatic enlargement. Epistaxis may become obstinate. Retinal hemor- rhage is common, and there may be aggregations of leukocytes (leukemic growths). Hemorrhages from mucous membranes are common, and localized gangrene may occur, in which case the symptoms of infection appear. Hemic murmurs are quite constant. Ulcerative processes in the bowels may give rise to severe dysenteric diarrhea. Ascites is usually present in advanced cases on account of the splenic tumor, or owing to pressure upon the portal vein hj enlarged glands. Jaundice is an occasional event. Leukemic peritonitis may occur from the presence of lymphomatous growths in the membrane. Nervous symptoms, such as headache, vertigo, and syncopal attacks, LEUKOGYTHEMIA. 441 are liable to recur as the anemia and prostration increase and the lia- bility to hemorrhage becomes more frequent. Sudden coma and hemi- plegia following upon the rupture of a cerebral vessel (apoplexy) may be the immediate cause of death. Minute brain-hemorrhages, which may occur at any period of the disease, probably account for deafness. Priapism may be very troublesome. Peripheral paralysis of several cra- nial nerves, due to hemorrhages into their sheaths, has been reported. Cutaneous eceJiymoses are sometimes observed, and sometimes there is a troublesome pruritus. The urine contains an excess of uric acid, but albuminuria does not occur, except as a complication. Along with the anemia and debility are the signs of splenic and lymphatic involvement, and rarely of the bone-marrow. The liver may also become enlarged. Leading Symptoms in Detail. — The Spleen. — This organ is generally enlarged in all forms of leukemia, but especially in the spleno-medullary, the most frequent form. It is a prominent feature, both on account of its being the first subject of complaint, and because of the huge size it frequently attains. The enlargement is gradual, and there may be neither pain nor tenderness over it. The tumor may cause a visible projection below the ribs, and in marked cases great abdominal disten- tion may be produced, pushing up the diaphragm and thoracic organs, and extending to the navel in tne median line and to the pelvis below, in which case the cardiac pulsation is seen at the second or third inter- space. The edge and notch or notches may be felt easily in such in- stances, while the surface is smooth and the consistence firm. A friction- fremitus is felt sometimes during respiratory movement. The tumor may vary in size, and after severe hemorrhage or diarrhea it may become swollen. Gastric distress after eating and obstructive constipation are usually complained of in cases of great splenic enlargement. Jaundice may also be present. Pulsation has been noted and a systolic murmur — " splenic souffle " — has been heard at times over the tumor. The percus- sion-note is dull over the tumor, and areas of movable dulness, due to fluid occupying the peritoneal cavity, are not infrequent. A wave of fluctu- ation may be detected over the abdomen. The liver is often enlarged. Lymphatie Glands. — In the splenic-lymphatic variety, which is less common than the splenic-myelogenous, and in the still rarer purelv lymphatic leukemia, the superficial lymph-glands may be both visibly and palpably enlarged, though not in bunches as in Hodgkin's disease. They are soft, resilient, and movable. The JBoties. — Purely myelogenous leukemia is very rare, and local hone-symptoms are scarcely ever manifested. There may be some ten- derness on immediate percussion over the sternum or some of the long bones, and slight swelling, irregularity, or deformity of the ribs, the sternum, or other bones may result from leukemic hj'perplasia. The Blood. — It is by the blood-examination alone that the pathog- nomonic features of leukemia are determined. The blood is paler than normal, and sometimes has a brownish-red or chocolate color. Upon a microscopic examination of the blood in the spleno-medullary form of the affection the striking increase in the number of leukocytes is ob- served at once. The count shows usually from 85,000 to 500,000 white corpuscles per cubic millimeter, and the ratio of the white to the red 442 DISEASES OF THE BLOOD AND THE DUCTLESS GLANDS. cells may thus vary from 1 to 150 doAvn to 1 to 1 or 1 to 5 in the aver- age case, instead of the normal, 1 to 500 (see Fig. 38). In extreme cases the number of leukocytes may be equal to, or even slightly greater than, that of the erythrocytes, and such an instance has been recorded by Sorensen, in Avhich the'proportion of Avhites to reds was 3 to 2. Stained specimens of the blood enable us to recognize the variety of leukemia (see Fig. 39). Thus, in the ordinary spleyiic-myelogenous form the characteristic change is the presence of the abnormal myelocytes — large, mononuclear leukocytes with the protoplasm filled with fine neu- trophilic or occasionally eosinophilic granules. These may make up 25 per cent, of the white cells, whereas they do not occur in normal blood, and very rarely, and only in small numbers, in leukocytosis. They probably correspond to the cells found in the bone-marrow, the large, 100% 90% 80% 70% 60% 607„ 4C% iO% 20% MONTH SEPTEMBER OCTOBER NOVEMBER MONTH 1'jo'X, so';r, 70% 60% 50% 40% 30% 2) to hasten the expulsion of the sputum after it has been loosened. The first leading indication is to be met by the use of diaphoretics, diuretics, and relaxants. The subjoined formula combines these classes of agents, and will be found to be highly serviceable : 3v (20.0); gr. iv- -vj (0.259-0 .388); 5SS (16.0) ; Siiss (80.0) ; ad 5iv (120.0).- -M. 484 DISEASES OF THE RESPIRATORY SYSTEM. I^. Potassii citrat., 3vj (23.3) ; Liq. ammonii acetat., Iv (148.0) ; Spt. reth. nit., 5J (30.0); Vini ipecac, oij (2.0) ; Syr. pruni virg., q. s. ad 5viij (236.0). — M. Sic §ss (2.0) in water every tAvo hours until the secretions are loosened. If the temperature in any given case be maintained at a consid- erable elevation, such as 102°-103° F. (38.8°-39.4° C.) or over, tinc- ture of aconite (iTlxvj — 1.065) may be added to the above mixture; and if there be present much tickling with distressing cough, due to irrita- bility of the affected mucosa, codein (^r. ij-iij— 0.129-0.194) may be added to the same. For the incessant irritative cough which is present in severe forms of catarrh opium alone is really effective. "When the above prescription is not productive of free secretion and troublesome cough continues, I employ the following : I^. Ammon. muriat., Codeinae, Spt. junip. CO., Mist, glycyrrh. comp., Syr. pruni virg., q. s. Sig. 3j (4.0) every two hours. Apomorphin is also excellent as a soothing relaxant in doses of gr. To ^^ To (0-003 to 0.006) every two hours. Mild counter-irritation by means of mustard-paste, followed by the application of iodin once daily, is also helpful. The patient should keep to his room, in which the at- mosphere should be kept moist and of even temperature. The expul- sion of the sputum may demand stimulating expectorants, though rarely. It is to be recollected that when the tracheal secretion becomes copious the period of convalescence is usually reached, and stimulating expec- torants are then entirely unnecessary. When, on the other hand, the cough is no longer dry, and on auscultation the rales are found to be moist, and Avhilst, at the same time, the expectoration is expelled with difficulty, or if the bronchitis tends to become chronic, then such stim- ulating expectorants as senega, squills, and ammonium muriate are to be employed. In cases in which expectoration continues to be too abundant terebene, tar syrup, and oil of sandal are to be resorted to, the choice of the special remedy being governed by the requirements of the individual instance. Debility and secondary anemia must be speedily overcome by exhib- iting quinin, bitter tonics, iron, and arsenic, and a suitable change of air often yields prompt and excellent results in protracted cases. The treatment of the various forms of secondary bronchitis will be consid- ered in their appropriate connections in this work. Apart from the method above given, of attempting to abort the attack in children, acute bronchitis is in the main to be treated in the same manner as when it occurs in the adult. Opium, however, is to be used very sparingly, and generally in the form of paregoric. If the secretion is abundant and imperfectly raised, it is well to administer an CHRONIC BRONCHITIS. 485 emetic, such as the wine of ipecac (3ss-j — 2.0-4.0), and repeat in ten minutes if necessary. If dyspnea be urgent and cyanosis be marked in the lips and finger-tips, a prompt emetic is then imperative in order to save life. A child suffering from acute bronchitis should be kept in bed until the fever subsides. The diet during the dry stage should consist of liquid forms of nour- ishment, vrhich should, for the greater part, be taken hot. After the " cold " has been loosened solid food should be resumed. CHRONIC BRONCHITIS. Pathologfy. — The lesions of chronic bronchitis manifest considerable variety both as regards their nature and extent. The epithelial layer is, in great part, missing, and sometimes the mucous membrane is quite thin. In consequence the longitudinal elastic fibers appear unduly prominent. The mucous glands and the muscular coat undergo atro- phy in long-standing cases, and the bronchial tubes are dilated (bron- chiectasis). In another large group of cases the mucosa is irregularly thickened or infiltrated and granular. Small ulcers corresponding to the mucous follicles are common, and almost constantly emphysema develops in consequence of secondary changes in the vesicular structure. Ktiologfy. — Chronic bronchitis may either he lorimary or secondary. The affection is. however, almost ahvays a secondary one, and, though sometimes the result of repeated attacks of acute bronchitis, it is oftener caused by certain chronic complaints and certain diatheses, as chronic alcoholism, rheumatism, gout, syphilis, pulmonary tuberculosis, and pulmonary emphysema. Organic valvular affections of the heart and chronic Bright's disease cause hypostatic bronchitis. The primary form, which is rare, is the result of exposure to wet or cold or to the daily in- halation of some irritant that produces and maintains a low grade of catarrhal inflammation (dust, vapors). When chronic bronchitis follows the acute form we are often able to detect the operation of some favor- ing cause, as age, climate, or season. It is most common in the aged, though younger persons occasionally suffer, and it occurs by preference durino- the cold season, often recurring regularly in the cold and varia- ble weather of autumn, winter, and spiring, and disappearing in summer. Symptotns. — The symptoms are similar to those of acute bron- chitis, though rather less severe. Pain is rarely present, the patient complaining merely of a feeling of substernal constriction. There may be soreness at the base of the chest if the cough be frequent and severe, and occasionally in the epigastrium as a result of traction of the dia- phragm on the ribs. Cough is not a constant accompaniment, however, but is paroxysmal and varies in severity and frequency. The degree of the violence of the paroxysm depends upon two factors — the charac- ter of the bronchial secretion and the seat of the catarrhal inflammation. Thus when the expectoration is tenacious and small in quantity, and when the small-sized tubes are affected, cough is most violent. It also varies both with the weather and the season, as is evident from the fact that there is often an absence of cough in summer, while it returns un- failingly with each winter. 486 DISEASES OF THE RESPIRATORY SYSTEM. The expectoration differs widely in different cases. It is sometimes abundant and sero-mucous in character. On the other hand, there are cases of dry cough in -which there is little or no expectoration. As a rule, however, it is rather copious, and either muco-purulent or dis- tinctly purulent in character. Fever is usually absent, though there may rarely occur a slight exacerbation at night. The appetite remains good as a rule; the bodily weight is also well maintained, and the nutrition may manifest little or no impairment. Physical Signs. — On inspection we usually note undue enlargement of the thorax, with a decrease in expansile movements that is due to the associated emphysema. The dyspnea so commonly observed is due either to the same cause or to associated asthma. Percussion yields a clear or hyperresonant note. Dulness or im- paired resonance is sometimes met with, however, during acute exacer- bations, and especially over the bases, and is due to congestion and edema (Fox). On auscultation rhonchi of various forms and moist rales are heard, their number and size being in proportion to the extent of the swelling of the mucous membrane and the amount and fluidity of the secretory products. The respiratory murmur is somewhat enfeebled, though roughened, and the expiratory sound is prolonged and wheezy. Clinical Varieties. — Special forms, depending largely upon spe- cific causal factors, remain to be described : 1. The commonest variety of chronic bronchitis has been called the "winter cough of the aged," and, as before intimated, is usually accom- panied by emphysema and cardiac disease. For this form the gouty diathesis is often responsible. The cough occurs in paroxysms that are most severe at night, and during the early morning hours it is attended with free expectoration of the secretion that has accumulated during the night. 2. Bronchorrliea. — In this form there may be an abundant bronchial secretion, composed largely of serum {bronchorrhoea serosa), but more frequently perhaps the expectoration is purulent and thin, containing greenish or greenish-yellow masses. It may at times be thick and puru- lent. Dilatation of the tubes and resulting fetid bronchitis may be de- veloped as secondary conditions. 3. Fetid Bronchitis. — In this variety the expectoration emits the characteristic odor of decomposing animal substances. The fetor may indicate gangrene of the lungs, abscesses, bronchiectasis, decomposition of matter within phthisical cavities, or empyema with perforation of the lung. It may, however, occur independently of the above-mentioned conditions, and hence these must be carefully excluded before the diag- nosis of true fetid bronchitis is made. In the latter disease the expec- toration is usually copious, and on standing separates into three layers, of which the uppermost is composed of frothy mucus, the intermediate of a serous liquid, and the lowest of a thick sediment, that presents a granular appearance and is made up chiefly of small yellow masses — the so-called Dittrich's plugs. These plugs are characteristic of fetid bron- chitis, and are the cause of the fetor. On microscopic examination the Dittrich's plugs are seen to be composed of micro-organisms, chief among which is the Leptothrix pidmonalis ; they may also contain pus- corpuscles, fat-granules, and crystals of margarin. CHRONIC BRONCHITIS. 487 The condition may be a grave one, and associated with it may be observed ulceration of the bronchial tubes, vrith dilatation, pneumonia, abscess, gangrene, and rarely metastatic cerebral abscesses. When putrefactive changes take place in the bronchial secretion in the course of chronic bronchitis a new group of symptoms, as a rule, immediately appears. This comprises rigors that occur at irregular intervals and are associated with high fever and increased prostration. Cough and pain in the chest also become aggravated, but these acute symptoms may shortly subside and the usual course of chronic bronchitis be resumed. Even under the latter conditions fetor of the breath and sputum may persist. 4. Dry Catarrh. — The cough is both severe and paroxysmal, and there is little or no expectoration. When expectoration is present the sputum is very tenacious and is expelled with great difficulty. An asthmatic disposition is sometimes noticeable in this variety, and emphys- ema is commonly associated." The dry condition of the bronchial mu- cosa is evidenced by sibilant and sonorous rales. This form occurs in old persons, as a rule. 5. Osier has described a form of chronic bronchitis that occurs most frequently in women, and dates its onset from a comparatively early period of life. It does not undermine the general health. The cough is most pronounced in the morning, and is accompanied by a rela- tively small amount of muco-purulent expectoration (§iv— vj- — 120.0— 178.0 daily). An examination of the chest yields negative results. The etiology is as yet uncertain, although the condition seems to proceed from a gouty or tuberculous diathesis in some instances. I have had under observation for several years a young woman, now aged twenty- eight, who has from time to time during the last five years suffered from eczema of the face, and in the intervals, when not afflicted with this dis- ease, has manifested the symptoms of the form of chronic bronchitis under discussion. She comes of arthritic stock. Diagfnosis. — The diagnosis of chronic bronchitis is rarely difficult. Since it is usually a secondary condition, it is of the utmost importance to determine the nature of the primary affection. An examination of the heart and of the urine should not be overlooked. Pulmonary tuberculosis is to be discriminated from chronic bronchi- tis, and the distinctive points are — (1) A clear tuberculous history. In phthisis there are fever and loss of flesh and strength, Avhile in chronic bronchitis fever is absent and the general health is not impaired. (2) In pulmonary tuberculosis the signs of localized consolidation (usually at one or other apex) appear early, while in chronic bronchitis the vesic- ular structure is not involved. (3) In phthisis the sputum, when examined microscopically, shows the presence of the tubercle bacillus. In acute jjulmotiary tuberculosis the fever, dyspnea, cyanosis, and in- creased prostration constitute a group of features that should serve to avert the danger of its being confounded with chronic bronchitis. Co- existing pulmonary emphysema is to be recognized by the characteristic symptoms and signs of this complaint. Primary fetid bronchitis must be differentiated from the various other conditions previously mentioned, in Avhich the breath as well as the sputum may emit the characteristic fetor. In abscess of the lung the sputum contains shreds of lung- tissue, including elastic fibers, crystals of hematoidin, cholesterin, and 488 DISEASES OF THE RESPIRATORY^ SYSTEM amorphous blood-pigment ; usually localized dulness and broncho-car- ernous breathing coexist. In gangrene there are contained in the spu- tum shreds of lung-tissue, but separate elastic fibers are often absent, on account of the presence of a ferment that causes a solution of the elastic tissue (v. Jaksch). Bronchiectasis is usually unilateral, and gives rise to areas of dulness and other physical signs that are confined to limited areas, while in chronic bronchitis the signs are general. Prognosis. — Recovery is the exception, though improvement may frequently be observed. The course of chronic bronchitis is exceedingly protracted, and the danger from the late development of certain compli- cations and sequels, such as emphysema or right-sided cardiac disease, must be constantly borne in mind. Since the disease is generally a secondary aifection, the prognosis in most instances depends upon the outlook in the primary disease. Treatment. — The treatment falls naturally under two main heads — (1) Hygienic, and (2) Medicinal. 1. Hjigicnic. — This has reference, frequently, to the removal of various noxious influences. When the patient cannot make a suitable change of air during the cold season, he must keep his room during in- clement weather; he should, however, be allowed to spend as much time as possible in the open air during clear and pleasant weather. The vitiated atmosphere of saloons or public halls is to be avoided. The patient should be carefully clad ; he should wear flannels next the skin during all seasons of the year, but his outer clothing need not be unu- sually cumbersome. If the case be of an aggravated type and the cir- cumstances of the patient permit, he should be sent to a warm latitude in the autumn, in order thus to escape the efiects of a severe northern winter. It is an excellent rule to send patients in whom the bronchial secretions are abundant to a dry, warm climate or to a region whose atmosphere is impregnated with the balsamic vapors of the pine. Un the other hand, patients with dry bronchial catarrh are most relieved by an equable, moist, warm climate. Among suitable resorts, those that should be mentioned are the Riviera, Cannes, San Remo, Sicily, and Algiers abroad, and Florida, Southern Georgia, and Southern California at home. Change of air becomes not only a means of relief, but also an eff'ective means of prevention if resorted to at the proper time. Prophylaxis also includes the removal of any diseased conditions that are causally related. The coexistence of cardiac disease, the gouty diathesis, and particularly any renal disturbance, call for the primary treatment of these conditions. The diet should be ojenerous, but not stimulatinor, and articles easy of digestion should be selected. Wines and liquors are to be avoided unless special indications for their use exist. Special conditions, how- ever {e. g. albuminuria), may render necessary a special dietary. 2. Medieinal. — In this disease medicines are palliative in their effects rather than curative. Relaxing expectorants are to be avoided, owing to their depressing action, and the stimulating expectorants are, in a majority of cases, not only valueless, but hurtful, since they are liable to lessen the appetite and disorder the digestion. When, however, the sputum is muco-purulent in character and is dislodged with difficulty, expectorants of this class (squills, senega, ammonium muriate) may be BRONCHIECTASIS. 489 tried. I have obtained good results from the use of the following in cases attended Avith severe paroxysms of cough : ^. 01. eucalypti, 3Jss-3iij (6.0-12.0) ; CodeinfB, gr. vj (0.388). M. et ft. capsulse No. xviij. Sig. One every four hours, as required. Occasionally potassium iodid exerts a curative influence, but its use may be limited to cases that are due to the syphilitic, rheumatic, and gouty diatheses. Five or ten grains of the iodid four times daily may be exhibited, and should there be present a syphilitic taint the remedy should be pushed to the limit of tolerance. The balsam of copaiba is sometimes efficacious, several instances in my own experience having yielded to the following combination : ^. Balsami copaibse, 3j -3 ij (4.0-8.0) ; Ammon. muriat., 3ij (8.0); Extr. glycyrrh. pulv., 3j (4.0). Mist, ammoniaci, q. s. ad fsiij (96.0). — M. Sig. 3ij (8.0) every four hours. Other remedies that possess great value in certain cases are creasote (in ascending doses), turpentine, terebene, tar, the balsams of tolu and Peru, and sandal-wood. H. C. Wood praises sulphuretted hydrogen in cases in which there is profuse expectoration : " From two to four ounces of the saturated watery solution may be administered by the mouth four or five times a day or until the breath has a perceptible odor." If the vital powers are poor, bitter tonics, as iron, quinin, and strychnin, and other measures calculated to invigorate the system, are indicated. When the sputum is excessive in amount, astringents (zinc sulphate and oxid) are sometimes useful. Astringents may also be used with advantage in the form of a spray when the expectoration is too free. On the other hand, sprays from properly selected solutions {e. g. am- monium muriate, gr. v-x ad sj — 0.324—0.648 ad 32.0) are valuable in assisting expectoration. In fetid bronchitis sprays of antiseptic solu- tions are to be used, and the following will be found serviceable : ^. Acidi carbolici, gr. ij-iv (0.129-0.259); Olei eucalypti, lUij-iv (0.133-0.266); Aquge, 5j (32.0). Sig. To be inhaled from a steam- or hand-atomizer. Pneumato-therapy has given brilliant results in certain instances, and G. Carriere obtained good results in streptococcic chronic bronchitis from the use of antistreptococcic serum. BRONCHIECTASIS. Definition. — The universal or circumscribed dilatation of the bron- chial tubes. Pathology. — Two main forms are recognized — the cylindrical or simple, and the saccular, and both of these maybe met with in the same 490 DISEASES OF THE RESPIRATORY SYSTEM. lung. Rarely the condition is congenital. It may be general or par- tial, the former variety being ahvays unilateral, the latter sometimes bilateral. In universal bronchiectasis the bronchial tubes, throughout their extent, are the seat of numerous sacculi communicating with one another. These present smooth, shining Avails, except in the most de- pendent parts, where ulcers are sometimes seen. Extreme conditions of dilatation may take the form of huge cysts, Avhich may extend to the periphery of the lung ; the lung-tissue lying between the sacculi then becomes cirrhotic as a rule. In partial dilatation the bronchial mucous membrane is implicated, with an occasional narrowing of the lumen. Most commonly these narrowings are cylindrical, though they may be saccular, and rarely fusiform. The partial is much more common than the general variety. Histology. — Wiien the walls of the larger dilatations are examined microscopically, the cylindrical epithelium is seen to be replaced by a pavement epithelium. The elastic and muscular layers are thin, and the fibers are usually separated. Contained in these dilatations are frequently found secretions that may be fetid. Ktiology. — In the majority of instances the condition doubtless arises from an involvement of the bronchial mucosa that extends to the submucous tissue and leads to muscular, fibrous, and cartilaginous atrophy. These changes render the wall of the tube unable to resist the pressure of the air in violent paroxysms of cough, and, once the process of dila- tation is commenced, the accumulated secretions tend by their weight to distend further the already weakened walls. Thus the elasticity of the latter is impaired, and finally destroyed. The etiological factors show the affection to be secondary as a rule, and are — (1) Chronic bronchitis and emphysema, chronic phthisis (usually when the seat of the dilatation is at the apex), broncho-pneumonia (in children), and compression of a bronchus. Heubner believes that bronchiectasis in adults may be sometimes traced to whooping-cough and measles in young children. (2) Great thickening of the pleura, especially when associated with bronchitis or interstitial pneumonia, with contraction of the lung. (3) Rarely it is a congenital lesion. Among predisposing conditions are — (a) Age, bronchiectasis being most common in adult or middle life ; and (6) Sex, it being more com- mon in males than females. Symptoms. — There is always cough, and this usually occurs in prolonged and severe paroxysms. The attacks take place most gener- ally after the dilated tubes fill in the morning, and a change of posture may excite them. Accompanying the cough there is profuse expectora- tion, which may amount to a pint or more in twenty-four hours. The sputum is grayish-brown in color and muco-purulent, emitting a sour or, more frequently, a horribly fetid odor. On standing, the expectoration separates into three strata — the uppermost, of brownish froth ; the mid- dle, of a thin, sero-mucous fluid ; and a thick sediment, of cells and granular debris. Examined microscopically, the sputum is seen to be composed chiefly of pus-corpuscles, Avith Avhich are intermingled Char- cot-Leyden and fatty-acid crystals, the latter being arranged in the form of bundles ; also leptothrices, vibrios, and bacteria are found. Elastic fibers may be observed if ulcers be present. BRONCHIECTASIS. 491 Dyspnea is noted, but is not a prominent symptom, unless some other chronic aiFections of the chest already coexist or some compli- cation arises. Hemoptysis occcurs rarely, and may be due to the bron- chiectatic lesion. Physical Signs. — These differ in character according to the size, situ- ation, and nature of the dilatation, and also according to the condition of the surrounding lung-tissue. On inspection retraction of the chest-wall may be noted when chronic pleurisy and interstitial pneumonia are associated. The tactile fremitus is usually increased, but may rarely be diminished. The fercusmon resonance is impaired or even flat, and on auscultation bronchial breath- ing is heard, with occasional rales that have a metallic quality. A sac- cular dilatation immediately beneath the pleura may give a tympanitic note, and may also give typical cavernous or amphoric respiration. A tympanitic resonance over a circumscribed area which prior to cough and expectoration presented dulness, is a significant sign (Babcock), These signs are generally discoverable at the base of one or other lung. Diagfnosis. — Simple dilatation of slight degree may exist without appreciable signs, and in other instances the breathing is broncho-vesic- ular over localized areas, with rales displaying increased metallic quality. Saccular Bronchiectasis. Pulmonary Tuberculosis. History of chronic bronchitis, chronic History of cough, hemoptysis, with pro- pleurisy, and interstitial pneumonia, or gressive loss of flesh and strength, of foreign body. Family history. Cough is paroxysmal, and sputum cha- Cough less paroxysmal. Sputum num- racteristic and copious. mular in the stage of cavity. Tubercle bacillus absent. Tubercle bacillus present. Course longer, with little impairment of Course relatively shorter, powers of the the general health. system progressively undermined. Physical Signs. The condition is persistent, but non-pro- Generally progressive, more frequently at gressive. Usually located near base one or other apex, posteriorly. Circumscrihed empyema with a fistulous connection with the lung may simulate bronchiectasis. There is often in such cases a clear his- tory of an acute illness with a sudden onset, the symptoms pointing to pleural inflammation. The patient suddenly expectorates, at irregular intervals, large quantities of purulent matter. Actinomycosis may also cause conditions that simulate bronchiectasis. The diagnosis may be made by finding granular particles containing the actinomyces in the sputum. Prognosis. — Apart from certain remote dangers {e. g. abscess, gan- grene), these cases pursue a favorable but exceedingly protracted course. Treatment. — The lesion being a permanent one, there is no known remedy that will either abridge or influence the course of the affection. Again, since the cough is protracted and attended with profuse expec- toration, sedatives and ordinary expectorants are contraindicated. For the fetor, antiseptics are to be employed both topically and internally, and a solution of carbolic acid (1-3 per cent.) or thymol (1 : 1000) is to be used by inhalation. Internally, terebene (TTLv-x — 0.333-0.666) in capsules every four hours is valuable ; also creasote in increasing 492 DISEASES OF THE RESPIRATORY SYSTEM. doses (mj — 0.066. increasing by IfTlj each day. till ITLvj — 0.399 — are taken three times daily) is to be persistently employed. Should the above methods prove unavailing, intrathoracic injections of disinfectants are often resorted to with gratifying results. _ In instances in which the dilatation is situated superficially and is not amenable to therapeutic measures, it may be freely opened and thorouahlv drained. BRONCHIAL STENOSIS. Definition. — Narrowing of the bronchus, due either to constriction or to compression. Pathology and l^tiology. — (a) Stenosis due to Constriction. — This form is most frequently occasioned by the presence of foreign bodies ; by new groAvths (polypoid) within the bronchi, or by growths without, extending from the lung to the bronchi, and in the case of the smaller bronchi by swelling of the mucosa. The bronchial walls also sometimes become" thickened by inflammatory exudates in certain acute and chronic affections, such as syphilis, tuberculosis, and glanders. (h) Stenosis due to Compression. — Compression of one or more bron- chi may be met with in a variety of enlargements involving the organs within the thorax, among which are aneurysm, echinococcus cyst, solid tumors, enlarged glands, mediastinal and pulmonary abscesses, and ex- tensive pleural effusion. Symptoms. — The symptoms do not depend upon the cause of the obstruction, but their extent and character are in proportion to the size of the bronchus affected and the degree of stenosis. i)ys- pnea is the most conspicuous symptom, and when this is marked the accessory muscles of respiration are brought into active play, and still the proper filling of the lungs with air is not accomplished. Under these circumstances the air in the lungs becomes rarefied, and instead of normal expansion everywhere the lower part of the sternum and the lower ribs are retracted on inspiration, and expiration is accomplished only with difficulty. Obstruction of the primary bronchus on either side of the chest would naturally be followed by inspiratory retraction of the inferior part of the chest-wall and intercostal spaces upon the affected side. It is to be recollected that the movements of the larynx are slight in bronchial stenosis, while they are marked in laryngeal ob- struction. Cough and expectoration are sometimes present, and febrile development of moderate severity is often noted. Physical Signs. — Inspection shows defective respiratory movement upon the side involved. The local tactile fremitus is diminished or absent upon the affected side, owing to the obstruction to the passage of the vibrations of the voice to the pulmonary periphery. The per- cussion-note remains unaltered, though less influenced by forced respira- tion, and particularly expiration, than in health. Pulmonary atelectasis may occur as a secondary event, and is shoAvn by dulncss on percussion. The nuseidtatorif signs consist of a greatly diminished vesicular murmur on inspiration, due to the diminished amount of air entering the air- ASTHMA. 493 cells during inspiration, and the presence of rales, sibilant and sonor- ous in character, at the seat of obstruction. Obstruction of a small bronchus may, however, be present without appreciable physical signs, owing to the fact that the surrounding lung-tissue may take on com- pensatory emphysema. Diagnosis. — The nature and site of the aifection may be determined by auscultation, and sibilant and sonorous rales will be conspicuous at the point of constriction. A clear history, together with a careful in- vestigation of antecedent aifections of the thoracic organs leading up to the stenosis, are factors that must furnish the etiological data in indi- vidual cases after the exclusion of foreign bodies as the possible cause. Tracheal or laryngeal stenosis may be eliminated by careful laryngo- scopic examination. Progfnosis. — The duration is indefinite, though usually protracted, and most cases yield an unfavorable prognosis. In those instances, however, in which the narrowing is due to foreign bodies the latter may rarely be dislodged and fortunately ejected, thus averting danger to life. Treatment. — The treatment must be addressed to the cause in in- dividual cases. Obviously, the question of the removal of foreign bodies from the bronchi falls within the domain of surgery, though the administration of an emetic has been followed by complete success in certain instances. Obstruction due to stenosis of a main bronchus may be treated by dilatation with bougies, the treatment of course being carried out by a specialist. ASTHMA. {Bronchial Asthma.) Definition. — A chronic affection, characterized mainly by paroxys- mal dyspnea, due to contraction of the muscles of the smaller bronchi. The paroxysmal dyspnea produced by arterial contraction is also termed asthma by many writers. Pathology. — In many cases there is hyperemia of the bronchial mucosa, due to pneumogastric or vasomotor functional disturbances, and also a characteristic exudate of mucin. In others there may be no lesions whatsoever, and the condition is a pure neurosis, often of reflex origin. Von Leyden considers asthma to be a reflex neurosis, the primum movens of which may be situated almost anywhere in the body. The morbid changes peculiar to chronic bronchitis, pulmonary emphysema, and right- ventricular hypertrophy with dilatation are found at autopsy. Ktiology. — There is present either a constitutional peculiarity or a singular susceptibility of the local muscular fibers to spasmodic con- traction, both of which are of unknoAvn nature. The exciting factors are very various, but may be grouped under four heads : (1) Acute Bronchitis. — It must not be forgotten, however, that a bronchitis may be set up by the paroxysms. Curschmann has observed also a local croupous inflammation of the smaller bronchioles in some 494 DISEASES OF THE RESPIRATORY SYSTEM. of his cases, "which he describes as hronchiolitis exfoliativa^ and which seems to have given rise to the seizures in grave cases. (2) The inhalation of numerous and widely various irritants, as chemical vapors, smoke, fog, dust, and emanations from jalants or cer- tain animals. (3) Meflex Causes. — The causal connection between obstructive affec- tions of the nose and asthma is a subject that is appreciated by the specialist. Gastric disturbances and, as I have observed, intestinal irri- tation are productive of this complaint. In dyspeptic asthma Boas found the diaphragm elevated above its normal position. (4) Asthma may be secondary to, and most probably excited by, cardiac disease, emphysema, gout, rheumatism, syphilis, Bright's dis- ease, emotional excitement, and irritating lesions in the region of the medulla. Possibly, some of the latter affections merely constitute pre- disposing factors. In this connection it is to be pointed out that indi- vidual liability to the disease depends upon the special etiologic factor. Predisposing Causes. — Heredity takes first place, and is, when discov- erable, well marked ; it is noted in about 50 per cent, of all cases. The complaint is about twice as frequent in males as in females, and, if we except hay asthma, it is more prevalent in winter and early spring than during the Avarm season. Clinical History. — Hyde Salter's collective statistics show that prodromal symptoms appeared in about one-half the instances (in 111 out of 226 cases). They differ widely, but are chiefly nervous in a great proportion of cases, and appear as irritability of temper, either depression or unusual buoyancy of spirits, headache, neuralgia, drowsi- ness, and vertioro. Abundant diuresis and digestive disturbances tend to appear. The attack usually comes on in the night during sleep, and at a definite time. It may develop, however, while awake or, again, though rarely, during the day. The onset may be sudden, but perhaps more frequently the patient first experiences a moderate grade of dyspnea and thoracic constriction. This augments with unwonted rapidity, and often attains to an inordinate degree, until the patient feels smothered, sits up, grasps his knees with his hands, or places the palms upon the bed so as to raise the shoulders and thus reinforce the accessory mus- cles of respiration. If the attack be severe, he rushes to an open win- dow when able to leave his bed, or sits on a chair and places his arms on the back of another chair, so as to fix the shoulders and thus give purchase to the auxiliary muscles of respiration while frantically en- deavoring to maintain the act of breathing. The face is pale, anxious, and soon is bedewed with cold perspiration, while the lips, eyelids, and finger-tips are livid, owing to defective oxygenation of the blood. The temperature becomes subnormal and the pulse feeble and rapid. The clinical picture wears an alarming aspect, but in uncomplicated cases death never supervenes. Physical Signs. — Inspection shows enlargement of the chest, which in the advanced stage becomes barrel-shaped. The reason for this is the presence of an increased amount of air in the thorax with a total inabil- ity to expel it. The respirations are diminished in fre<|uencv to 12 or 10 per minute. The natural rhA-thm is also greatly disturbed, and in- ASTHMA. 495 spiration is seen to be short and gasping, and followed immediately by expiration, which is greatly prolonged. The expansile movement of the chest is very limited, and in inverse ratio to the patient's efforts at breathing. There is lowering of the diaphragm. Palpation is negative in its practical results. Percussion yields a hyper-resonance ; in ad- vanced cases with associated emphysema semi-tympanitic resonance is common. On auscultation the inspiration is ib imd to be short and feeble, and the expiration much prolonged and accompanied by a Ioav- toned wheezing sound that may also be audible to onlookers. A great variety of dry rales are heard, chiefly high-pitched, sibilant, and sonor- ous, that are more marked on expiration than inspiration. They also change their character and situation frequently. At the close of the attack moist rales may be heard, and occasionally, Avhen bronchitis complicates asthma, the moist rales may be combined throughout the paroxysms. The duration of the attack is various, ranging from a few minutes to several hours, though rarely it may endure a week or two, with spontaneous remissions during the day (e. g. when chronic bronchitis coexists). Usually it subsides abruptly, with the expectoration of rounded gelatinous masses and, later still, of muco-purulent material. The former, Avhen floated in water, are found to be composed of the so- called Curschmann's spirals (mucous moulds of the smaller tubes), and the spiral character of these small, ball-like pellets may even be detect- able with the naked eye. When examined microscopically their spiral structure is evident. Two forms are recognized : (1) Composed of mucin, arranged spirally; in its meshes may be observed alveolar cells, many of which have undergone fatty degeneration. (2) A perfectly clear and translucent filament that is most probably composed of trans- formed mucin and occupies the center of the coiled spiral of mucin. In the early stage of the attack Curschmann's spirals (Fig. 44) are invariably Fig. 41.— Curschmann's spirals. present in the expectoration, and in many instances Leyden's octahedral crystals are also visible. For a time the latter were supposed, though erro- neously, to excite the paroxysms by means of their irritating character. Similar crystals are found in the semen, as well as in the blood in cer- tain conditions {e. g. leukemia). Mliller, Fink, Leyden, and others have demonstrated extremely large numbers of eosinophile leukocytes in the 496 DISEASES OF THE RESPIRATORY SYSTEM. sputum. Fink and GabritclieAvski likewise have found a large excess, up to 15 per cent., of eosinophile leukocytes in the blood. Y. Xoorden and SwercheAvski found the same increase, but only at the times of the attacks. Diagnosis. — A clear history, together with the physical signs and a microscopic examination of the sputum, should lead to correct results. The history alone is inadequate to put the physician upon the right track. Laryngeal affections, which give rise to spasm of the glottis and dyspnea, are to be eliminated by the alteration of the voice and the aphonia which are usually present, while the characteristic physical signs of asthma are absent. Again, the dyspnea is inspiratory, not expiratory as in asthma. Emphysema may be confounded with asthma. The presence of recog- nized causes, of typical physical signs, and the paroxysmal dyspnea in asthma are the chief points of distinction from emphysema. The spu- tum should be examined microscopically if doubt remain. Course and Prognosis. — In mild cases of asthma there may be but one or two nocturnal paroxysms, Avith entire freedom from cough and dys- pnea during the following day. On the other hand, in severe cases there is a repetition of the pai'oxysms from three to five or six nights. Under these circumstances in the intervals (usually corresponding to the period of day) there are slight wheezing and some cough. In long-standing cases asthma leads constantly to the development of chronic bronchitis and emphysema, and in such these affections are invariably combined. The paroxysmal character of the affection is often partly or wholly lost, the patient rarely being entirely free from asthmatic dyspnea, combined with cough and muco-purulent expectoration. The periodicity of the attacks varies greatly ; in some it recurs monthly or at even shorter intervals, and in others only annually. There is rarely any danger to life, except when the secondary affection is emphysema and its remote consequence is dilatation of the right ven- tricle ; but the percentage of cases in which recovery actually takes place is comparatively small, since the affection may reappear long after the paroxysms have ceased to recur in the usual manner. Treatment. — The indications for treatment are — (1) to cut short the paroxysms, and (2) to prevent a recurrence of subsequent attacks. (1) To bring relief during the paroxysms we should ascertain the ex- citing cause, and remove it promptly if possible to do so. In one of my own cases a prolonged paroxysm Avas cut short by a calomel purge fol- lowed by an enema. An overloaded stomach calls for an emetic, and other causal factors are sometimes removable {e. g. congestion of the nasal mucosa, dust, animal and vegetable emanations). If the cause is irremovable, the patient should be kept in a large and freely ventilated apartment, and everything that tends to impede respiration must be re- moved. The choice of posture as affording the greatest relief may usually be left to the patient. To cut short the paroxysms : The particular mode of treatment that will afford most speedy relief differs Avidely in different cases, and not infrequently the patient, as the result of experience, is aware of the rem- edies that are most efficacious for good. As a rule, however, sedative antispasmodics, relaxants, and stimulants are the classes of medicinal ASTHMA. 497 agents from which a careful selection is to be made ; and whilst a great variety of these have been employed, I shall content myself by adducing here only the most valuable and their mode of administration. In the hands of some observers a few whiffs of chloroform have proved highly efficacious, but in my own they have produced only momentary good effects ; ether is the safer remedy and may be tried in like manner. In a certain proportion of the cases from four to six drops of amyl nitrite thrown upon cotton-wool or a handkerchief, and inhaled, bring speedy and permanent relief. Of stimulants, coffee is the best : immediately upon the appearance of the paroxysm about one pint of strong coffee is to be taken hot (without cream or sugar), and in this way the seizure inay sometimes be arrested. Alcohol when given hot and in sufficiently large doses to induce mild intoxication may be found very useful ; and by adding to "hot toddy" a dose of spirits of chloroform an efficient combination is the result. The inhalation of the fumes of niter-paper ^ often gives quick, tempo- rary, and, less frequently, permanent relief. When employed, the atmo- sphere of the room occupied by the patient must be well filled with the fumes. Among depressant antispasmodics are belladonna, hyoscyamus, stra- monium, and lobelia, and these seem to be of most value Avhen used in the form of cigarets. The leaves of the plant employed are first steeped in a concentrated solution of potassium nitrate or chlorate, and a trial should be made of different sorts of cigarets or pastilles (which are simi- larly prepared), since all cases are not benefited by the same brand. The inhalation of tobacco-smoke is equally beneficial in a limited number of instances. A large number of cases, despite the use of the measures above indi- cated, exhibit an obstinate tendency, and for their treatment no remedy bears favorable comparison with morphin, administered hypodermically, for potency and permanency of its beneficial effects. It is best given in full doses (gr. -I— i — 0.0216-0.0324), and may be combined with atropin or cocain. Strychnin also has its advocates (Mays). The use of opium, oft repeated, has occasionally led to the establishment of the morphin- habit ; hence it must not be used indiscriminately. I have for a number of years been in the habit of supplementing the action of the first dose of morphin with the following formula : ^. Tr. lobelige, 3J (4.0); Tr. nitro-glycerini (1 per cent.), tilxvj (1.06); Sodii bromid., 3v (20.0); Vini ipecac, 3v (20.0); Ext. hyoscyami, gr. viij (0.518) ; Elix. simplicis, q. s. ad siv (128.0). — M. Sig. 3j (4.0) every one or t\YO hours in water. S. Solis-Cohen lauds hyoscin hydrobromate (gr. ^-ro) administered hypodermically. In the protracted cases of old asthmatics, associated with chronic bronchitis and emphysema, the above mixture may be also employed, though sodium iodid (gr. v — 0.324) should be substituted for the bromid, and the same dose given at intervals of three or four hours. 1 Niter-paper is prepared by dipping bibulous paper (filter- or blotting-paper) in a solution of saltpeter. 32 498 DISEASES OF THE RESPIRATORY SYSTEM. (2) In order to prevent subsequent attacks : The history of each ease should be carefully inquired into during the intervals, with a view to as- certaining whether any of the numerous causes (bronchitis, gastric disor- ders, dust, emanations from plants) are discoverable; and if so, eiforts to re- move them should be instituted. iV methodical interrogation of the vari- ous organs of the body and their functions must be carried out, and the therapeutic or hygienic indications presented by them, if any, must be met judiciously. The nasal passages should be examined by a specialist, and any causal conditions found therein are to be promptly removed. If the affection be a pure neurosis or due to bronchitis, a suitable climate may often be found in which the patient will enjoy complete immunity from asthma. The choice of the locality cannot, however, be determined by any known rules. The patient must travel from place to place until he finds the climate that possesses preventive properties in his particular case. To those who cannot adopt this plan potassium iodid offers the best hope of relief, though its use must be long continued (gr. x-xx — 0.648-1.296, three times daily). The systematic use of compressed air in the pneumatic cabinet, and also the inhalation of oxygen, are worthy of trial. The presence of any conditions of ill-health calls for treatment directed to their removal. There are also certain means of prophylaxis for impending attacks. Thus, if there be premonitory symptoms, the use of such measures as strong coifee or the " hot toddy " above mentioned, Hoffman's anodyne, stramonium or belladonna cigarets, the inhalation of the fumes of niter- paper or of a few drops of amyl nitrite, or the removal of the sources of irritation, may suffice to ward off the attack. FIBRINOUS BRONCHITIS. {riastic Bronchitis : Croupous Bronchitis : Mucous Bronchitis.) Definition. — A rare acute or chronic catarrhal affection of the bronchial mucosa, attended with the production of fibrinous casts (?) that are expectorated in severe paroxysms of cough and dyspnea. These casts, when unfolded, are found to be solid moulds of the bronchial tubes from which they come, being shaped like the branches of a tree, and thus proving that a bronchial tube and its subdivisions had been blocked. When the moulds are large or medium-sized they are hollow, and when from the smaller bronchi they are solid. Pathology. — The pathology is but little understood, but in one of my own cases I found the composition of these casts to be identical with that of croupous exudates met with elsewhere, though more dense, per- haps, than the latter. Croupous bronchitis is attended with loss of epi- thelium in the implicated bronchi, as is the case in croupous inflamma- tion wherever it occurs ; but the answers to the questions, '' Why should the affection be limited to a definite portion of the bronchial tree ? " and " Why does it recur from time to time ? " are obscure indeed. In fatal cases the lesions of associated or antecedent complaints, such as chronic pleurisy, pneumonia, and pulmonary tuberculosis, have been found. FIBRINOUS BRONCHITIS. 499 Ktiology. — What the irritant is that causes the condition is un- known, though streptococci have been found in the moulds and in the mucosa. Some of the predisposing causes, however, have been recog- nized, and are — (1) Sex : it being about twice as frequent in males as in females. (2) Age : though met with at all periods of life, it is relatively more frequent from the twentieth to the fortieth year. (3) Season : the seizures are most common in the spring months. (4) Epidemic influ- ences : Pichini has described a group of instances that occurred in indi- viduals in the same locality. (5) Hereditary influence has been trace- able in a few cases. (6) Other affections, as tuberculosis (quite fre- quently), chronic pleurisy, and certain skin-affections, as herpes, im- petigo, and pemphigus, form antecedent and coexistent conditions. Symptoms. — (a) The acute form is rare. It begins with rigors and fever that are soon followed by urgent dyspnea and severe paroxysms of cough, which are usually attended, soon or late, by the expulsion of bronchial casts, and sometimes rather profuse hemorrhage. Abundant expectoration usually causes amelioration of the severer symptoms. On the other hand, urgent dyspnea, oppressiveness, and severe cough, with little expectoration, are grave symptoms, often leading to fatal asphyxia. {h) The Qhronic Form. — The paroxysms recur at irregular intervals and are less severe than in the acute form, the interim varying from one week to a year or more. In a case observed by myself the patient has experienced a recurrence once annually (on or about May Istj, commen- cing three years ago. The paroxysms may occur at regular though much briefer intervals. The cases usually manifest ordinary bronchitic symp- toms, with or without fever at the onset. The cough soon becomes troublesome and is paroxysmal in character. There is expectoration in the form of rounded masses, Avhich, when unravelled, are found to be true moulds of the affected tubes that exhibit a laminated structure. The larger casts (which are of the size of a goose-quill or even larger) may be hollow. They are of whitish or grayish-white color. When ex- amined microscopically they are seen to consist of a fibrillated base, a few scattered leukocytes and mucous corpuscles, and, rarely, gland- and blood- cells. Occasionally Leyden's crystals and Curschmann's spirals have been found. First, Beschorner and later Grandy have shown the casts to be composed of mucin. In other cases, however, similar studies show fibrin. Hemorrhage, trivial or copious, may occur. Physical Signs. — Owing to the obstruction offered by the casts, there is a diminished amount of air entering the corresponding part of the luno-. As a necessary result the tactile fremitus, local expansion, and respira- tory murmur are diminished over the affected area. The note on percus- sion over the uninvolved portions of the lung is clear or hyper-resonant, though if the portions of the lung supplied by the affected tubes collapse, there is dulness on percussion. Dislodgement of the casts is followed by a return of the normal respiratory murmur. Diagnosis. — From ordinary bronchitis it is to be distinguished by the presence of casts of mucin or fibrin, which alone are sufficient for a posi- tive diagnosis. The fibrinous moulds met with in diphtheria and pseudo- membranous croup, Avith extension into the bronchi, must also be elimi- nated. The history and course of the latter will, as a rule, suffice to make a positive discrimination; but if doubt remain, a bacteriological examina- 500 DISEASES OF THE RESPIRATORY SYSTEM. tion of the membranous casts should be made. If the Klebs-Lbffler ba- cilli are then found, all doubts as to its diphtheritic nature are set at rest. Prognosis. — The prognosis in the acute form is quite grave ; the chronic variety, though pursuing an exceedingly long course that ranges from five to fifteen years, rarely terminates fatally. Treatment. — This is to be conducted on the same principles as those in simple acute bronchitis. In the acute form an attempt should be made to soften and separate the casts by the topical application of steam, by inhalation, and alkaline sprays (e. g. lime-water). Pilocarpin Avas em- ployed in one instance under my own observation with apparent good results ; it tends to excite free bronchial secretion. Emetics should be resorted to without delay when the signs of cyanosis show themselves. In the chronic form nothing can be accomplished by treatment, dur- ino- the intervals between the acute exacerbations, that will tend to obviate a recurrence of the attacks or to mitigate their severity. IV. DISEASES OF THE LUNGS. CIRCULATORY DISTURBANCES IN THE LUNGS. CONGESTION OP THE LUNGS. [Hyperemia of the Lungs.) Definition. — The surcharge of the pulmonary vessels with blood. Two forms are recognized : (1) Active hyperemia, and (2) Passive hy- peremia. ACTIVE HYPEREMIA. Pathology. — The blood-vessels in the bronchial mucosa often appear intensely injected, and the capillaries in the alveolar walls are prominent, while on section a scarlet-colored, frothy liquid flows. The alveolar epi- thelium may become swollen and granular. Htiology. — Active hyperemia is usually a symptomatic condition, though rarely it may arise as a distinct primary affection. Active con- gestion of the lungs exists as an associated condition in many pulmonary affections, as pneumonia, pleurisy, bronchitis, and tuberculosis. On the other hand, active congestion of the lungs may be engendered as an independent affection by the inhalation of hot air, highly irritative sub- stances, as well as by violent physical exercise, the ingestion of large amounts of alcohol, and strong mental emotion. Active hyperemia has, however, little clinical significance. Symptoms. — The capacity of the air-cells is diminished ; hence the oxygenation of the blood is markedly interfered with. This embarrass- ment of the function of respiration is compensated for in part by accel- erated breathing, there being a degree of dyspnea proportionate to the extent and intensity of the congestion. There is some cougli, accompanied by frothy, bloody expectoration. The physical signs are bilateral, as a rule, and are generally confined CONGESTION OF THE LUNGS. 501 to the bases. Palpation shows increased tactile fremitus. The percussion- note is impaired or, rarely, dull, and it is generally exceedingly difficult to determine the pitch of the note, owing to the fact that both sides are usually involved. On the other hand, when the condition is unilateral and not associated with diseases of the opposite side, the impairment is readily appreciated. The vesicular element of the respiratory sounds is diminished, and the bronchial element relatively increased {hroncho-vesic- ular hreathing). Less frequently there is bronchial breathing. Diagnosis. — In the presence of the etiologic factors the sudden development of dyspnea^ cough., and a frothy, hloocly expectoration, and the physical signs before enumerated, in the absence of fever, the diag- nosis is easy. Prognosis. — Active hyperemia is frequently folloAved by collateral edema. Its course is brief, and terminates either fatally in a few hours, in perfect recovery in a few days, or in pneumonia. The condition is therefore ominous. Treatment. — Prompt measures must be instituted in order to arrest the active fluxion. The special causative factors must be actively treated, so as to diminish the quantity of blood in the pulmonary vessels ; dry and wet cups over the entire seat of congestion must be tried : and in the worst cases venesection is demanded. Following the application of the cups, turpentine stupes, sinapisms, and linseed poultices may be em- ployed. I have observed excellent results from the use of veratrum viride combined with saline purgatives. Other cardiac sedatives may also be employed, including nitroglycerin in full doses. PASSIVE HTPEEEMIA, Passive, unlike active, hyperemia is always a secondary condition, and is quite common. Two forms are distinguishable : (a) Mechanical, and (h) Hypostatic. (a) Mechanical Hyperemia [Brotcn Induration). — Pathology. — The pulmonaiy vessels are distended, the lungs as a whole enlarged, and the air-cells crepitate but little, owing in great part to the encroachment upon the air-spaces by the dark venous blood. The lungs are of a reddish-brown color and afford increased resistance to efforts at cutting or tearing. On section the reddish-brown tint rapidly changes to a vivid red, from oxi- dation of the hemoglobin when exposed to the atmosphere. The process commences at the extreme base, extends upward, and may finally become general. The interstitial connective tissue is increased, and is often edem- atous. Avhile the epithelial cells of the alveoli show altered blood-pigment, usually in the form of hemosiderin and responding to the usual tests for iron. Etiology. — Mechanical hyperemia results from the obstruction of the return of blood to the left heart, and among special causative conditions are mitral constriction, mitral regurgitation, dilatation of the right ven- tricle, and certain cerebral injuries and diseases. It may also be a symp- tom of asphyxia, and rarely it arises from pressure of tumors. Symptoms. — The most marked feature is dyspnea, particularly when secondary to organic cardiac diseases with failure of the right ventricle. Cough is common, and an expectoration of frothy serum or blood (hemop- 502 DISEASES OF THE RESPIRATORY SYSTEM. tysis) containing pigmented alveolar epithelial cells, is the most cha- racteristic clinical feature. Diagnosis. — With a clear history, in addition to the dyspnea, cough, and the characteristic expectoration, the recognition of passive hyper- emia of the lungs is a simple matter. The prognosis and treatment will be considered in connection with the causative affections. {h) Hypostatic Hyperemia. — Pathology. — The parts of the lung that are affected are dark in color and the vesicles distended Avith a transudate of blood and serum. In this way the air-cells may become emptied of air {spJenization, hypostatic piieumonia), and the resulting condition is in most instances to be regarded as a mild grade of lobular pneumonia. This view is confirmed by "the fact that the same etiologic conditions that favor the development of hypostatic congestion also favor to an equal extent the development of hypostatic pneumonia. Etiology. — Feeble cardiac action, as in long-continued fevers, debili- tating chronic affections, and in old persons, combines with a prolonged dorsal position of the body (gravitation thus favoring its development) in producing the condition. * This explains why the condition is found usu- ally at the bases of the lungs, and is most marked posteriorly. It is common for the same reason in carcinoma, tuberculosis, paralysis, chronic rheumatism, typhoid fever, etc. Symptoms. — The symptoms are wholly indefinite ; indeed, none may be present. Priory has pointed out that old persons in the incipiency of the disease begin to sleep with the mouth open, so as to effect the entrance of more air. Commencing cyanosis may indicate the development of hy- postasis, and a careful physical examination of the lower lobes of the lungs will show increased fremitus, slight dulness, diminished vesicular murmur, and, in the higher grades, bronchial breathing, with liquid bub- bling rales. The prognosis is based upon the character of the underlying affection. Treatment. — This is an affection in which the treatment of causes alone will suffice, save in instances that are secondary to organic heart- affections, in which prompt bleedings are to be advocated. From a pint to a quart of blood should be taken, and I have seen happy results from the employment of this measure in extreme cases. Tapping the right auricle when the blood refuses to flow from an arm vein has also been successfully accomplished by competent surgeons. The patient's posture must be changed from the dorsal to the lateral, and even ventral, and as soon as possible he should be gotten out of bed. PULMONARY EDEMA. {Edema of the Luugs.) Definition. — An effusion of serous fluid into the air- vesicles and in- terstitial lung-tissue. Pulmonary edema is scarcely to be regarded as an independent affection, but as a secondary condition, being in most in- stances associated with pulmonary congestion. Pathology. — It consists of a transudation of serum into the alveolar walls, interstitial connective tissue, and air-cells, and rarely the process is limited to the interstitial tissue. Two forms may. for the sake of con- venience, be recognized : PULMONARY EDEMA. 503 (a) Collateral Edema [Inflammatory Edema). — This is usually local in character, cii'cumscribing an area of the lung that is affected by pneu- monia, abscess, or pulmonary infarction, and is the result of a mild in- flammatory process affecting the vessel-walls. When the condition follows hypostatic congestion the terms "hypostatic edema" and " splenization " have been applied. {h) General Pulmonary Edema. — If congestion be not associated, the portions of the lungs involved by this type look pale ; when pulmonary congestion or pigmentation of the tissue is present, the lung ajopears darker than the normal and the serum is blood-tinged. The weight of the lung-tissue, owing to the more or less airless Condition of the alveoli, is increased, and yet, though heavier than the normal lung, the affected tissue does not sink in water. To the feel it is boggy, and pits on pres- sure, while on section a serous or sero-sanguinolent (if congestion be pres- ent) fluid of low specific gravity, and poorer in albumin than plasma, flows from the cut surface. Edema is most frequently observed at the bases of the lungs, though it may become general, and as a rule the surface of the pleura is moist ; hydrothorax may be present. The mode of production of pulmonary edema is not definitely known. Increased fluidity of the blood on the one hand, and increased tension in the pulmonary vessels on the other, seem to be influential factors in many cases. The heightened blood-pressure may be in great part due to a fail- ure of cardiac power, and particularly to failure of the left ventricle (Welch). When weakness of the left is out of proportion to the weak- ness (paralysis) of the right ventricle, Ave are apt to have the tension in the pulmonary capillaries greatly increased, at least until transudation of serum is induced. Edema also occurs as a result of weakness of the right ventricle alone. Obstruction to the outflow, such as occurs in weakening of the left ventricle, or even obstruction in the aorta, leads to heightened tension and, secondarily, to paralysis of the right ven- tricle. The third factor entering into the production of pulmonary edema is the increased permeability of the vascular walls, due to im- pairment of their nutrition and "disturbance of the cardiopulmonic innervation " (Huchard). This usually arises in connection Avith toxic and infectious diseases, when the blood also exhibits more or less change, as in cachectic states, uremia, general septicemia, or some of the infec- tious diseases. Local edema also occurs in the neighborhood of inflam- matory foci, as in pneumonia. Etiology. — Pulmonary edema is secondary to pneumonia and acute and chronic affections, but not with any degree of constancy ; nor is it especially liable to be associated with congestion or with low" grades of inflammation of the lungs. Among the diseases of which it forms a ter- minal condition are — valvular affections of the heart, fatal forms of anemia, acute and chronic Bright's disease, cerebral lesions (hemorrhage, trauma- tism), and acute infectious fevers with failure of cardiac power. Symptoms. — In edema of the lungs the air-space is lessened in di- rect proportion to the amount of serum occupying the alveoli ; hence dyspnea is always present and is often a conspicuous symptom. There are cough and bronchorrhea. The sputum is usually abundant and frothy, and is expectorated Avith difliculty. At times, and especially in the acute forms, it is tenacious and may give rise to alarming laryngeal obstruction. 504 DISEASES OF THE RESPIRATORY SYSTEM It is blood-stained if congestion be combined. Tbe condition does not give rise to elevation of temperature, , except in the inflammatory type, in which fever is constantly present. The pulse is accelerated and feeble, and cyanosis, particularly in cases of collateral edema, usually appears. The extremities are cool and often livid. Physical Signs. — The reasons adduced to explain the dyspnea likewise render intelligible the physical signs encountered. There is dulness, though rarely complete, over the areas involved ; the vesicular murmur is feeble or absent, or there may be broncho-vesicular breathing. Since the bron- chioles contain serum, small rales, having a liquid character, are audible with inspiration and at 'the beginning of the expiration over the seat of the edema. The diagnosis, with a clear history, is based upon the incomplete dulness that is usually bilateral and most marked at the bases, upon the bubbling rales heard over the corresponding area, and upon the absence of any febrile movement, except the latter be due to some underlying affection. Rydrothorax bears some points of resemblance to edema of the lungs, but in this condition the upper level of dulness is movable in con- sequence of change of position of the patient, as is not the case in edema of the lungs. On the other hand, in the latter affection moist rales are present, while they are absent in hydrothorax. Broncho-j^neumonia may be mistaken for pulmonary edema, though it has a different mode of onset. It is also accompanied by fever, glairy, tenacious expectoi'ation, and more sharply-localized areas of dulness then appear in edema. The prognosis is governq,d by the pre-existing condition to which the edema is due. Thus, if secondary to a general dropsy due to renal or cardiac disease, it often destroys life with great rapidity. Inflammatory edema, following lobar pneumonia, is also grave in the exti-eme. Treatment. — The treatment is that of the associated or causative affections. These must be sedulously treated, and the limitation of the transudation and the direct removal of the serous effusion from the lungs is of great importance. We should not fail frequently to change tlie position of the patient's body, so as to prevent the gravitation of blood to the dependent portions of the lungs. I have witnessed excel- lent results from the use of dry cups placed over the thorax, particularly over its posterior and lateral aspects, and renewed at intervals of six to eight hours. The number applied should range from one and a half dozen to three dozen. In aggravated forms that develop quickly prompt venesection is imperatively demanded. This is a measure which, if resorted to at the proper moment, will often rescue the patient from imminent danger. The condition of the heart and kidneys must receive attention. Tincture of strophanthus (iTliij every three hours) is eft'ec- tive in pulmonary edema in children. HEMOPTYSIS. {Broncho-pulmonary Hemorrhage.) Definition. — An expectoration of blood. Its source may be the bronchial mucous membrane (usually the small bronchi), and less fre- quently it comes from eroded vessels in lung-cavities or their walls ; rarelv from the larynx, trachea, and larger bronchi. When from the bronchial tubes the term bronchorrluujia should be applied. The source HEMOPTYSIS. 505 of the hemorrhage, however, is not always easily demonstrable, even when it has resulted fatally and the lungs are minutely examined. Pathology. — The lesions are often microscopic, and consist for the most part of ruptured capillary blood-vessels, though larger vessels mav also become the seat of erosion or rupture. After death the bronchial mucosa is sometimes found to be swollen, bleeds easily, and is of a dark-red color — soon becoming decidedly pale. The lung-tissue projDer may look paler than in the sound lung. When hemoptysis occurs in advanced pulmo- nary tuberculosis the lung-cavity may contain a ruptured aneurysm, or mere ulceration of an exposed vessel may be observed. I have witnessed small, dark-red, dense masses in the air-sacs scattered throughout the luno- whence came the hemorrhage. Doubtless these are blood-coagula, which result from the clotting of the blood after the latter has been carried into the alveoli. Various associated lesions may be observed. Ktiology. — (1) Pulmonary Affections. — (a) Pulmonary congestion from whatever source may result in hemoptysis, although the amount of blood lost under these circumstances is usually small. There are many causes that excite congestion of the lungs, some of which reside in ad- jacent organs, it being common in organic disease of the heart, and par- ticularly in disease of the mitral segments. That form of pulmonary congestion which is associated with other affections of the lungs, as well as primary active congestion due to inhalation of hot air, irritating substances, and violent physical exercise, may also result in hemor- rhage. {V) Hemorrhagic infarction may lead to slight hemorrhage {vide Pulmonary Euibolism). (c) Croupous Pneumonia. — In this disease hemorrhage is caused by the rupture of the capillaries, and the blood, when expectorated, has undergone a change, has become rusty-colored. {d^ Pulmonary Tubercidosis. — This is pre-eminently the most common cause. Hemorrhage may take place early when it originates from a sharply-limited and minute tubei'culous focus, and it may also be attrib- utable to congestion. Undoubtedly its exact source is the mucosa of the small bronchi ; later it is the direct consequence of the ulceration of an artery or of the rupture of an aneurysmal sac that has its seat in a branch of the pulmonary artery. After the tuberculous cavities have healed or while quiescent, calcareous masses are, from time, to time, expec- torated, together with more or less blood, (e) Ulcers of the Larynx, Trachea, or Bronchi. — Rarely ulcers in adjacent structures erode the larger branches of the pulmonary artery and cause copious and speedily fatal hemorrhages. Osier observed a fatal hemorrhage in a case of chronic bronchitis with emphysema. (/) Fibrinous hroncMtis induces hemop- tysis by rupturing the capillaries in the bronchial mucosa at the time of separation of the bronchial casts, [g) Carcinoma of the lung produces frequent expectoration of blood, (li) G-angrene of the lung. (2) Diseases of Other Organs than the Lung. — [a) Affections of the heart act as a cause, and especially advanced mitral disease, when it is due to pulmonary congestion. It not infrequently develops during the stage of adequate compensation. In a preponderating pi'oportion of the latter instances the hemorrhage is slight, but it may be profuse and recur at intervals for many years, (h) Aneurysm of the branches of the pulmo- nary artery and of the arch of the aorta (usually with rupture of its coats) is a rare cause of hemoptysis. 606 DISEASES OF THE RESPIRATORY SYSTEM. (3) Certain diseases, such as purpura licemorrhagica, scurvy^ anemia^ hemophilia, and malignant forms of certain acute infectious diseases {e. g. yellow fever), cause hemoptysis. In this class of cases the hemor- rhages are due either to a diseased condition of the A^essel-walls or to blood-changes. (4) Vicarious hemoptysis is not uncommon during menstruation or when amenorrhea is present. Unless occurring at the time of the regular menses it is not to be regarded lightly, and is of the same significance as when taking place in the male. I cannot agree Avith those authors who contend that hemorrhao-e from the lungs in women is without the same dire significance as in the opposite sex. {vide infra). (5) Arthritic (Gouty) Endarteritis. — According to Sir Andrew Clarke and others, this is a common cause of recurring hemorrhages in aged per- sons (over fifty years). Sytnptoms. — Hemoptysis is so commonly a symptom of that most frequent and dread disease, phthisis, as to raise suspicions of the latter in the minds of the patient and physician as soon as it occurs. It is ap- propriate, therefore, to note, first, the features of hemoptysis when depend- ent upon pulmonary tuberculosis, and then to point out its clinical peculiarities when due to other conditions. In incipient pulmonary tuberculosis hemoptj^sis develops suddenly as a rule, a 7varm, saline taste, lasting but a few moments, generally pre- ceding the expectoration of blood. The blood is coughed up, and the bleeding may last onW a few minutes or may continue for days, the sputum being apt to remain blood-stained for a longer interval. The immediate effect of the hemorrhage, however slight, is to alarm the patient, inducing, besides mental agitation, cardiac palpitation and other nervous concomitants. A small hemorrhage is not attended with any other results, but large ones give rise to the symptoms of shock, com- bined with those of symptomatic anemia. When the hemorrhage is large, blood to the amount of a mouthful may be ejected with each cough, and in these instances the effect of the profuse bleeding is evidenced by such symptoms as vertigo, syncope, cold extremities, excessive pallor, perspi- ration, and a rapid, small, feeble pulse. This is followed, if the attack does not prove speedily fiital, by considerable restlessness, and later not infrequently by mild delirium and more or less fever. In comparatively rare instances the same patient has a single hemor- rhage ; more frequently he has several at shorter or longer intervals. Large or small bleedings may precede by weeks, months, or even years any rational symptoms or physical signs of pulmonary tuberculosis. In such instances latent foci of disease may be assumed to have pre-existed. In quantity the hemorrhage varies greatly : there may be less than one ounce ejected or it may amount to a pint or more before the bleeding ceases. In advanced cases in which cavities have formed large vessels may become eroded, followed by copious and dangerous hemorrhage- Fatal hemorrhage may take place into a cavity without the occurrence of hemoptysis, as in a case dissected by Osier at the Philadelphia Hospital. The distinctive characters of the blood discharged are mainly as follows: bright color, xerj frothy (being mixed with air), and not clotted. A rare exception to the rule may be noted in the case of hemorrhage proceeding from a large cavity, the blood pouring forth in a free, dark stream. HEMOPTYSIS. 507 Physical Signs. — These are, for the most part, negative. Quite com- monly moist bronchial r^les are audible on auscultation ; palpation and percussion should not be practised either during or immediately after the hemoptysis. Hemoptysis not Due to Pulmonary Tuberculosis. — (a) In affections of the mitral and aortic valves., especially in mitral stenosis, hemorrhage from the bronchi is not uncommon, and the way in Avhich these lesions lead to pulmonary congestion is explained in the discussion of Organic Affections of the Heart. During the progress of these cases, hemorrhages often occur at considerable intervals ; they may either be slight, lasting only a few minutes, or quite free, extending over periods of a few days or a Aveek. (6) As a rule, in the beginning small hemorrhages occur for several weeks from pressure of an aneurysmal dilatation upon the bronchial mu- cosa, or there may be weeping of blood through the exposed layers of fibrin composing the walls of the sac. The bleeding point can be dis- covered with the laryngscope, when an aneurysm of the innominate or of the aorta impinges upon the trachea. A large and often quickly fatal hemorrhage occurs from rupture into the respiratory tract. (c) '■'■ Arthritic hemoptysis'" is undoubtedly associated with gouty, degenerative changes in the terminal blood-vessels of the lung, though no coarse pulmonary lesions are induced by the recurring hemorrhages. Although the hemorrhages may occur at intervals for years, as a rule they finally become arrested, and only rarely lead to a fatal issue. I have never observed this form of hemoptysis occurring independently of chronic hronchitis. In emphysema and chronic bronchitis small hem- orrhages may occur, and occasionally coagula in the form of casts are formed in the bronchi and afterward ejected. It is probable that the source of the large bleedings that occur under these circumstances is an ulcer in the bronchial mucosa. (d) The hemoptysis that is connected with the menstrual function is of frequent occurrence. I saw recently a patient in whom free bleeding has occurred at intervals of four Aveeks for a couple of years, with an absence of the menses. In another instance, a patient of Dr. Byers, recurring hemorrhages of the lungs took place instead of the regular menstrual discharge for three successive months, and a comparatively rapid and fatal form of phthisis Avas developed. This case typifies a large class that is especially prone to develop pulmonary tuberculosis. (e) The preceding group is to be distinguished from those cases in AA'hich trivial bronchial hemorrhages sometimes occur, and in delicate, hysterical females. Although these bleedings are accompanied by cough, it is not uncommon to find, upon careful examination, that the blood comes from the upper air-passages. (/) Hemoptysis may result from severe injuries inflicted upon the thorax, and last for days together. {g) A person may have a single or many recurring attacks of hemop- tysis ivithout assignable cause, if Ave except severe muscular strain or in- tense mental excitement. Although pulmonary tuberculosis does not supervene in instances of this sort, yet not a feAv may be excited by a permanently limited tuberculous focus AA'hich may be indeterminable by the usual methods of examination. I have more than once seen a cure 508 DISEASES OF THE RESPIRATORY SYSTEM. result from an active course of treatment with creasote and appropriate hygienic measures. In Mell-marked instances of the kind a complete arrest of the trouble resulted from a change of climate. Differential Diagnosis. — A reliable diagnosis necessitates the cer- tain exclusion of hemorrhage from the higher air-passages, pharynx, esophagus, and stomach. In epistaxis the blood may directly enter the naso-pharynx, exciting cough and being discharged as in hemoptysis. An examination of the nasal chambers should be made when the symp- toms are suggestive of epistaxis. Bleeding may take place from the gums, from chinks in the pharynx, or from varicose veins. If the seat of the bleeding be the pharynx, the hemorrhage is not free, the blood being commingled Avith a preponderating proportion of mucus ; if from the gums, it may be more copious (as in ptyalism or scurvy), and the hemorrhage then simulates that of pulmonary hemoptysis. An inspec- tion of the mouth will disclose whether or not the gums are the source of the hemorrhage. Strlimpell distinguishes hysterical hemoptysis by the smaller amount of bleeding, the absence of pus-elements, and the large amount of squamous epithelium, leptothrix. and the food-remnants present. (For the distinctive points between hemoptysis and hematemesis, vide Hematemesis. Prognosis. — The gravest apprehensions are constantly entertained by sufferers from hemoptysis, but immediately fatal results are of rare occur- rence : and of this fact the patient should be repeatedly assured by the attending physician. In case, however, the existence of thoracic aneur- ysm is definitely known, the consequences of hemoptysis are certainly fatal. With reference to the effect of hemoptysis upon tuberculous pulmo- nary disease opinions differ widely ; I am of the belief, however, that prior to the existence of cavities it exerts a favorable rather than an unfavor- able influence upon the course of the disease. On the other hand, in cases in which cavities exist at the time of the occurrence of hemoptysis an opposite effect is observed. The fact that hemoptysis often precedes by prolonged intervals of time the development of pulmonary lesions is no argument in favor of Niemeyer's view, that phthisis is caused by hem- optysis. There can be no doubt, however, that some blood finds its way into the bronchi below the point of bleeding and into the air-cells, causing, at times, irritation and even lobular inflammation. In this way hemorrhages may aid in rendering the tissues more susceptible to tuberculous infection. In cases of profuse hemorrhage, due to aneur- ysm or to the erosion of large branches of the pulmonary artery in phthisical cavities, death may be suddenly induced, and is caused largely by inundation of the lung and the consequent impossibility of respiration. Treatment. — Since the hemorrhage is ascribable to (1) congestion of the bronchial mucosa. (2) erosion of the vascular walls, and (3) blood- changes, obviously the treatment of individual cases must be modified according to the character of the causative condition. In many instances of Itemoptysis due to congestion of the bronchial mucosa the hemon-hages are, comparatively speaking, slight ; hence, apart from keeping the patient at absolute rest, little treatment is re- quired. If not excessive, they are often salutary in their effect. If free, the physician's aim should be to decrease the power of the heart's HEMOPTYSIS. 509 contraction, and to accomplish this end the patient should be placed in bed, and not allowed to change his position nor to speak above a whisper. The diet should be light, nutritious, and non-stimulating, all hot drinks and alcoholics being prohibited. Among cardiac sedatives to be em- ployed with a view to reducing the rapidity of the heart's action and low- ering the blood-pressure, if the patient be neither feeble nor anemic, the ice-bag to the precordia is most valuable ; if the pulse be full and strong, we may use aconite and other arterial sedatives. Arthur Foxwell ^ recom- mends venesection in cases in which venous congestion is present, and also lays stress upon measures that confine the blood to the systemic circula- tion — i. e. nutritious food, large doses of the nitrites, hot foot-baths, leeches to the anus, and ligatures applied to the thighs and arms. The pulmonary capillaries may also be effectually depleted by the use of salines, which should be given in full doses. In my own experience dry cupping over the chest has been of the greatest service in cases dependent upon pulmonary congestion. Eating ice and partaking freely of iced drinks are also useful measures. If the attack tends to become prolonged and exhausting, we may increase the coagulability of the blood by the use of such remedies as gallic acid, acetate of lead, or calcium chlorid. Hemoptysis is usually accompanied by cough, that constantly disturbs the vascular serenity and excites fresh bleeding ; it demands opium or morphin (hypodermically). In blood-spitting due to the gouty diathe- sis Mays recommends the salicylate of sodium. When hemoptysis is associated with organic disease of the heart, the main indication is to strengthen that organ by bodily rest and quiet and by the use of cardiac tonics, especially digitalis. I have had under ob- servation and treatment for several years a young physician Avho has been suffering from frequent, marked hemoptysis, due to mitral regurgitation, and in whose case the bleedings are readily controlled by the free use of digitalis. When in thoracic aneurysm or advanced "pidmonary tuberculosis the blood is ejected in mouthfuls, we may safely infer that erosion of a ves- sel or rupture of the aneurysm has taken place. Here the object is to bring about the formation of a thrombus that will arrest the hemorrhage. Perfect quiet in the horizontal position tends to allay the vascular excite- ment, and the induction of fainting by venesection is a measure worthy of a trial. Opium is contra-indicated in the latter class of cases, since if cough be checked inundation of the bronchial system Avith the blood (the chief danger) will be favored. R. H. Babcock gives an immediate injection of atropin sulphate (gr. gV^A") ^^^"^ hemorrhage occurs from a cavity. In all instances of hemoptysis treatment should not cease wuth cessa- tion of the hemorrhage. A tendency to recurrence is manifested in many cases, and hence measures calculated to avoid this event must be brought into play. The patient should not be allowed to indulge in a stimulating diet ; he should eschew tobacco and alcoholic stimulants, and avoid all physical and mental strain. Every source of bronchial irritation should be carefully avoided, and attacks of bronchitis, however mild, should re- ceive the most careful attention. Moderate exercise is serviceable, as well as a liberal amount of nutritious food. ^ British Medical Journal, 1894, p. 1 94. 510 DISEASES OF THE RESPIRATORY SYSTEM PNEUMORRHAGIA. {Pulmonary Apoplexy.) Definition. — An escape of blood into the air-cells and interstitial tissue, witli or without laceration of the pulmonary i.arenchjma. Pathology. — It may be, though rarely, {a) diifuse, when the lung- tissue is lacerated, as in cerebral apoplexy ; or it may be {h) circum- scribed, as when the blood is effused into the air-cells and the interstitial tissue. Avithout rupture of the parenchyma. The latter form will be considered in the discussion of Pulmonary Infarction. Htiology. — Bitf'iise pidmonary apoplexy is caused by the rupture of a thoracic aneurysm that has become adherent to the surface of the lung. Its most common cause is traumatism, especially penetrating wounds of the lung, but adult life and the male sex are to be regarded as predisposing factors. The lung-tissue is sometimes the seat of diffuse hemorrhagic infiltration in septico-pyemia and cerebral disease. Symptoms. — These are ill-defined. Profuse hemoptysis, urgent dyspnea, and cyanosis, followed by increasing evidences of collapse, together with a clear history, should raise suspicions of the existence of diffuse pneumorrhagia. The physical signs are indicative of extensive consolidation arising suddenly, and not of the nature of the lesion. The prognosis is practically hopeless, and abscess or gangrene may result if these cases recover from the immediate effects of the hemorrhage. Treatment. — Absolute rest of the body in the horizontal position is the one measure that offers a slight prospect of alleviation, for thus the formation of a clot, followed by arrest of the hemorrhage, is encouraged. It is unwise to use opium to allay the cough, since the action involved assists in ejecting the extravasated blood, which will, in consecj^uence of gravitation and the effect of respiration, submerge speedily so much of the lunu;-tissue as to hasten the fatal termination. Erfjot is not to be given hypoderraically, since it raises the blood-pressure in the lesser cir- culation, but the internal and external use of cold has been highly recom- mended. With the onset of collapse cardiac stimulants become absolutely necessary, though many cases are so rapidly progressive as to reach a moribund state before remedial agents can be applied by the physician. PULMONARY EMBOLISM. {Hemorrhagic Infarction ; Embolism of the Lungs.) Pathology. — Embolic infarctions are firm, airless, brown or black, wedge-sliaped masses, with their bases usually at the pleura, which soon becomes lustreless and covered with a delicate layer of fibrin. The in- farctions may be single or multiple, and sometimes occupy the greater portion of the lobe; in the majority of cases, however, their size equals that of a walnut. Their most frequent seat is at the back of the lower lobe. The microscope shows the presence of leukocytes and red blood-corpuscles in the air-cells and in the alveolar septa. Collateral congestion and edema are frequent concomitants, and, less frequently, pneumonic consolidation appears. PULMONARY EMBOLISM. 511 Ktiologfy. — The condition is produced by the blocking of the pulmo- nary arteries by an embolus or thrombus. When the circulation in the pulmonary capillaries is feeble, hemorrhagic infarction may be the result of stasis, and this is probably the most frequent form. It is met with in connection with diseases of the lungs, and also with mitral affections. The plug that occludes the blood-vessel may be composed of leukocytes, as in leukocythemia, and the chief sources of the emboli are the thrombi in the right heart, in consequence of dilatation, and in the systemic veins. Infectious emboli, resulting in abscess, will be considered in connection with Abscess of the Lungs. Occlusion of a branch of the pulmonary artery cuts off completely the circulation to the territory supplied by that branch, and hemorrhagic infarction occurs — venous extravasation, with expression of air. Symptoms. — Not all infarctions give rise to symptoms ; on the con- trary, occlusion of a main branch of the pulmonary artery usually ter- minates life speedily. The latter accident occurs not infrequently in connection Avith organic disease of the heart, and if death be not the immediate result or if a narrower branch be occluded, alarming symp- toms ensue, such as syncope, dysfnea, ■pain in the side, and convulsions with unconsciousness. The first and most distressing symptom is dysp- nea, Avhich is attended by frantic efforts at breathing and by great. mental anxiety. Occasionally hemoptysis is an early symptom, and of primary significance if it occur in a patient suffering from mitral disease. If, together with these symptoms, loss of consciousness with convulsions occurs, the diagnosis becomes wellnigh complete. Cough usually super- venes, accompanied by the expectoration of dark, gelatinous, mucoid masses. Large lymph-cells containing blood-corpuscles are found in the sputum, these giant-cells being most commonly seen in instances of organic cardiac affections. They are supposed to transform the blood- corpuscles into pigment-matter. The physical signs may either be negative — as, for example, Avhen the infarctions are small or deeply located — or they may give informa- tion as to the seat and extent of the affected part. When present they are the symptoms of sharply-localized consolidation (increased fremitus, percussion-dulness, moist rales, and bronchial breathing), and it is not improbable that in many cases the physical signs are due, in great part, to associated conditions, such as bronchitis, edema, or collateral consoli- dation. The appearance of the friction-sound in the course of suspected cases is a great aid in diagnosis. The heart's action becomes enfeebled, the pulse is small and frequent, and the surface of the body is cool and frequently bedewed with cold sweat. Fever may either be present at the onset or absent throughout. The signs of embolic abscesses in the lungs will be elsewhere detailed (vide Pulmonary Abscess). Diagnosis. — To establish the diagnosis of pulmonary embolism there must be a clear history of some etiologic condition, and the sudden appear- ance of such symptoms as dyspnea, cough, bloody expectoration (in par- ticular), chest-pain, loss of consciousness, and convulsions, corroborated by the physical signs of a sharply-defined spot or spots of consolidation. Prognosis. — The prognosis differs with the character of the primarv condition. On the whole, it is exceedingly grave, though the absorption of an embolism, followed by the disappearance of the urgent symptoms. 512 DISEASES OF THE RESPIRATORY SYSTE3L is not impossible. In case decath does not occur soon, infarcts may give rise to abscess or gangrene, the result either of the presence of bacteria in an original embolus or of their entrance through the air-passages. In other cases an infarct may undergo fibroid change and contraction, and may even calcify. Treatment. — Beyond procuring absolute rest of the body and a re- lief from the distressing symptoms, the treatment should be aimed at the affections on which this form of embolism depends. Dyspnea and pain may require the hypodermic use of atropin and morphin, preferably in combination. CHRONIC INTERSTITIAL PNEUMONIA. {Fihroid Induration ; Cirrhosis of the Luiiy.) Definition. — A chronic inflammation of the lungs, characterized by the formation of fibrous or connective tissue. It may occur as a primary or as a secondary affection. Pathology. — Two leading forms of cirrhosis of the lung may be recognized : {a) Local., and {b) Diffuse, though these do not demand sep- arate description. It is a unilateral affection, and the lung of the side involved is much shrunken, its dimensions in some cases being incred- ibly small. I have seen an instance in Avhich the organ measured four inches in its longest and less than three in its shortest diameter. It lies tightly against the spine, and has frequently been overlooked. The heart occupies the affected side, being drawn in that direction during the progress of the disease, and it is enlarged, principally owing to hyper- trophy of the I'ight ventricle, and the pulmonary artery is the seat of atheromatous change. The other lung is overdistended {compensatory emphysema), and may encroach upon the mediastinum. Intrapleural and pleuro-pericardial adhesions may be exceedingly firm and thick on the one hand, and only moderately so on the other, though rarely the pleurpe are intact. The cut surface of the affected lung is hard, dry, airless, shiny, and usually light-gray in color (rarely, reddish-yellow), and the lung- tissue cuts with great resistance. The mouths of the blood-vessels and bronchi, which are often greatly dilated (bronchiectatic), may be observed gaping in the cut section. Cavities may be wholly or in part due to the superaddition of a tuberculous process, though even when the affection is non-tuberculous they may be quite numerous. Phthisical cavities may often be discriminated by their usual situation at the extreme apex. The lung that is unaffected by the fibroid process is also quite often the seat of tuberculous change. Ktiologfy. — The disease is almost invariably secondary, and very generally accompanies prolonged inflammatory and chiefly local changes in the lungs. It may also follow acute inflammatory processes. Ex- amples of localized interstitial pneumonia are seen in connection with pul- monary tuberculosis, emphysema, syphilis, hydatids, and fibroid indura- tion secondary to thickening of the pleura. Diffuse interstitial pneumonia has a variety of causes : [a) It may fol- low acute lobar pneumonia in cases in which resolution is delayed, and CHROyiC INTERSTITIAL PXEU2I0XIA. 513 here the fibrinous exudate filling the air-cells becomes oi'ganized into connective tissue. Fibrous tissue is also substituted for the alveolar walls. The condition is exceedingly rare, and no instance of the sort has fallen under mv own observation, (b) Pneumonia, appearing as a complication in influenza, is very liable to produce chronic interstitial pneumonia. (c) The disease may also result from atelectasis due to compression, as by aneurysms or neoplasms. (d) It most frequently, however, follows hroneho-pneumonia in either its acute or subacute form (Charcot). The process starts in the bronchi and extends to the surrounding lung-tissue, till finally an entire lobe, or even an entire lung, may become involved. Tuberculous broncho-pneu- monia also leads to the production of new fibrous tissue, but here the pro- cess is a conservative one [vide Pulmonary Tuberculosis), and hence is not to be classed with chronic interstitial pneumonia. (e) The initial lesions may be located in the pleura, and the lung be- come involved as a sequel, and the principal lesions may be located in the adherent pleural membrane, with bands of connective tissue extend- ing into the lung. The bronchi are inflamed and sometimes dilated. Chronic interstitial pneumonia may, however, exist without implica- tion of the pleura, and in view of this fact the primacy of pleural thick- enings cannot be granted without reserve when they form a part of the lesions of fibroid induration. The various forms of the disease thus far described arise secondarily. It may also occasionally originate as a primary affection (1) from the inhalation of different forms of dust {vide Pneumonokoniosis). (2) Delafield describes ''a special form of lobar pneumonia." He contends that lobar pneumonia terminates only in resolution or in death, and that this special disease, with its production of newly -formed connective tissue, is from the first a special form of inflammation of the lung. This variety runs a subacute or even chronic course, and terminates by crisis. It is an exudative inflammation, with the formation of new tissue from the onset ; but the consolidated areas are not so large as in ordinary pneu- monia, and cut sections lack the granular character of the latter. Symptoms. — The patient suffers from cough, which increases in in- tensity with the progress of the aff"ection. There is a mucous, sero-mu- cous, or rarely bloody expectoration ; dyspnea occurs early, and fre- quently is present only on ascending heights ; and uneasiness, or even pain, over the side of the chest involved may be experienced. In cases in which the bronchi become dilated the characteristic symptoms of bron- chiectasis are superinduced. The general symptoms consist merely in a loss of flesh and of strength. Fever is altogether absent. Physical Signs. — Inspection. — The chest-wall of the aff"ected side is re- tracted, while the healthy lung is enlarged [compensatory emphysema). The spinal column is curved laterally. The aff"ected side is fixed during respiration, and the heart is displaced by traction tOAvard the affected side. If the left lung be involved, the apex-beat will be displaced to the left and slightly upward ; if the right, the apex-beat will be observed to the right of the sternum. The ribs approximate, thus obliterating the inter- spaces, and the shoulder droops over the shrunken chest-wall. Palpation. — The tactile fremitus is usually increased ; if the pleura be 33 514 DISEASES OF THE RESPIRATORY SYSTEM. much implicated or thickened, however, fremitus maybe decreased. Pal- pation discovers no expansile motion. Percussion. — The percussion-note varies. Dulness is common, owing to consolidation of the lung, but flatness is sometimes met Avith, and a tym- panitic or amphoric note is occasionally elicited over a dilated bronchus. AuseuUation. — The breathing is bronchial or more or less sonorous as a rule, and over bronchiectatic cavities it is cavernous or, rarely, amphoric. Near the base it is frequently feeble, distant, or even altogether sup- pressed. Subcrepitant, sonorous, sibilant, or gurgling rales may be audi- ble, and dry, creaking, or leathery friction-sounds may also be heard. Prognosis. — The course of the complaint is exceedingly chronic, and lasts over many years. Death may result from an intercurrent attack of acute pneumonia aifecting the other lung. The disease always shortens the duration of life, and it may be the direct cause of death. Rarely a fatal issue is due to dilatation of the right heart, followed by tricuspid regurgitation. Treatment. — The condition is incurable. The patient should, how- ever, be placed under the best sanitary conditions, and if practicable he should make a permanent change of climate. A suitable resort should be selected in accordance with the rules indicated in the treatment of Pulmonary Tuberculosis, and every effort should be put forth to improve the general nutrition of the patient. Due attention should be given to the associated bronchitis, as well as to any symptoms that may arise vduring acute exacerbations. BRONCHO-PNEUMONIA. {Capillarji Bioiichiti.s : Cafarr/iul I'lietdtionia.) Definition. — An inflammation of the minute bronchi and air-vesi- cles, due either to the extension of inflammation from the capillary bronchi to the air-vesicles or to an inflammatory process set up in ate- lectatic lobules. Pathology. — Macroscoi)ically, the lungs present decided variations in persons Avho have died of broncho-pneumonia. On the pleural sur- face may be noticed purplish or slaty patches, often sunken (atelectasis), intermingled with the more elevated patches of healthy lung and gray- ish consolidation, and smoother and more moist than croupous pneu- monia. Similar appearances are presented by the cut surface. On pressure fluid exudes — edematous from the healthier areas, and gray- ish and puriform from the consolidated areas. The mucosa of the large bronchi may look natural, though frequently it is congested, while the small bronchi usually contain more or less muco-purulent mate- rial. Their walls are greatly thickened, and on section the cut sur- face presents a nodular appearance. Dilatation of the smaller bronchi may be observed, and minute consolidated areas, varying in size from that of a pin's head to that of a pea, may be seen surrounding the thick- ened walls of the bronchi. When, as frequently happens, they become <;onfluent, large areas — an entire lobe and even an entire lung — of lung- BRONCHO-PNEUMONIA. 515 tissue may become consolidated. The solidified zones are firm to the touch, being destitute of air, and at first they contain blood ; hence their color is a dark -red, but later it presents a grayish hue. The condition is usually bilateral. As a rule, the bronchial glands are SAVollen and in- flamed. In the non-consolidated portions of the lung the air-cells are found to be considerably dilated. The pulmonary pleura is often coated with fibrin, but less regularly than in croupous pneumonia. The essential lesion is a productive inflammation of the bronchi and of the immediately surrounding air-spaces. The inflammation is from the first not exudative, but productive ; that is, with the formation of noAV tissue (Delafield). This form of inflammation naturally lasts for a longer time than would the exudative, and merges into a chronic pro- ductive inflammation of the lung, it may be Avith subsequent sclerosis or chronic thickening of the pleura. The exudate is always more marked toward the center of the process, while the air-cells toward the periphery show much less exudate. The latter consists of serum, some mucus, and many swollen cells from the alveoli (soon showing fatty degeneration), leukocytes, and also red blood-cells in small numbers. Fibrin is seen in small quantity if at all. In deglutition- and aspiration-pneumonia the leukocytes are present in much larger numbers, and the exudate tends to suppuration, while in the hemorrhagic forms the red blood-cells are relatively increased. Kikodse ^ found the blood in broncho-pneumonia to contain an in- creased number of white corpuscles, except in fatal or very severe cases. The cause of this increase appears to be the return into the cir- culation of the corpuscles that have passed into the alveolar spaces ; hence it ceases after the fever declines. Among the associated lesions that remain to be mentioned are — {a) Catarrhal inflammation of the mucous membrane of the bronchi ; and (h) Exudative inflammation of the air-cells, which become filled with epithelium, fibrin, and pus, with resulting consolidation of the lung. The epithelial cells lining the air-sacs, since they are more numerous in young children than in adults, form a larger part of the inflammatory exudate in the former than in the latter. !^tiolog"y. — (1) A marked predisposing influence is age, the disease being most prevalent amongst young children. In them it may appear in association with measles, Avhooping-cough, scarlet fever, and diphtheria, but not infrequently it is entirely independent of these diseases. Infants are especially susceptible to the affection, most instances of pneumonia at this period of life being of the lobular form. Other conditions that act as predisposing factors in children are improper exposure to cold, unsanitary surroundings (especially impure air), rickets, and chronic diarrhea. Broncho-pneumonia is also frequent in the aged, often being occasioned by certain debilitating causes and chronic diseases that are common to advancing years. (2) Season. — The aff"ection prevails especially in the winter and spring months ; particularly is this the case in those forms that are unassociated with the acute infectious group of diseases. (3) It also supervenes as a complication in such acute infectious dis- eases as influenza, typhoid fever, erysipelas, and small-pox, and is of ^ A'unual of the Universal Medical Sciences, 1892, vol. i. sec. A. 516 DISEASES OF THE RESPIRATORY SYSTEM. serious import. According to my own observations, it is more com- monly met with in the diseases above mentioned than is lobar pneumonia. (4) The inhalation of food-particles and other substances often serves to convey the agents of inflammation to the lobules of the lungs. Thus a long-continued recumbent posture disposes the patient to broncho- pneumonia, since it affords a ready entrance to inflammatory irritants. It is, however, in conditions in which the larynx and bronchi have totally or in part lost their sensitiveness — as in coma due to apoplexy, uremia, and allied cerebral states— that retention of bronchial secretions occurs, and that, owing to gravitation, these secretions reach the minute bronchi. Particles of food and drink are also inhaled. Inhalation pneumonia may follow operations upon the nose, mouth, larynx (trache- otomy particularly), and is often secondary to carcinoma of the larynx and esophagus. It is also the pneumonia of new-born children. (5) It must not be forgotten that quite commonly broncho-pneumonia is caused by the tubercle bacillus {vide Pulmonary Tuberculosis). A subacute type may also occur in the course of vesicular emphysema. Bacteriolog//. — Weichselbaum has shown the presence of strepto- cocci with the greatest frequency. The pneuraococcus has frequently been found, and in a goodly number of cases the staphylococcus aureus (Neumann, Birch- Hirschfeld), Avhile in influenza the specific organism may itself cause broncho-pneumonia (Pfeiffer and others). Numerous other organisms have been found, and it seems a well-established fact that various pathogenic bacteria may cause the disease. Symptoms. — Two clinical forms may be distinguished : (a) primary; and (b) secondary. (a) Primary broncho-pneumonia is met with generally in adults, and presents, in great part, the symptoms of an acute bronchitis of severe grade {cough, dyspnea, pain, fever). When occurring in weakly sub- jects the onset may be gradual. The cough is 'attended with expecto- ration (glairy and tenacious) that may be blood-tinged in the form of droplets or points. The fever is moderate, the temperature ranging from 101° to 104° F. (38.3°-40° C), and is of irregular type ; in severe cases, however, continued high temperature may occur. Physical ex- amination gives the same result as in the secondary form. The duration is from two to four weeks, the fever terminating by Igsis. West holds that primary broncho-pneumonia in children is of pneumococcus origin. (6) Secondary broncho-pneumonia is the variety usually met with. The symptoms are fre(iuently veiled by those of the primar}^ affection, and, indeed, a moderate grade of lobular pneumonia is frequently unsuspected during life when arising in the course of other grave diseases. It is usually preceded by bronchitis affecting the larger bronchi, and in this common event the first symptom that directs attention to the dis- ease is the sudden increase in the frequency of the respirations, which rise as high as 60 or even 80 per minute. An initial chill is rare. Fever develops suddenly, or, if previously present, increases rapidly. An early symptom is the cough, which is usually hard, harassing, frequently pain- ful, and accompanied by expectoratioyi. The pulse-rate is abnormally frequent, and in the later stages may be quite rapid, feeble, and irreg- ular. The type of the fever is similar to that of the primary form. Physical Signs. — At the beginning of the attack the only sign is the BR ONCHO-PNE UMONIA. 517 presence of subcrepitant and sibilant rales, pointing to a general capil- lary bronchitis. Shortly larger or smaller areas of consolidation become manifest. At first rapid breathing, and soon cyanosis, affecting -first the lips and conjunctivae, may be observed ; later, the face becomes dusky Fig. 45.— Illustrating broncho-pneumonia. The dark spots represent the consolidated areas ; the white dots indicate rales : A, coalescence of two areas of consolidation. and the finger-tips blue. Palpation shows defective expansion and in- creased tactile fremitus over the consolidated areas. The percussion-note is dull or, less frequently, hyperresonant if the area be small. Auscul- tation reveals numerous fine, subcrepitant rales, corresponding to the con- solidated portions. The respiratory murmur may be bronchial, though more often broncho-vesicular. The signs are usually noted in both lungs. Duration. — (1) In children this varies considerably in different ^cases. Rarely do fatal instances last more than two or three weeks, while they may be as brief as two or three days. On the other hand, cases in which recovery ensues frequently last from six to eight weeks, though in some instances from one to three weeks only. Two special forms demand brief description : (a) The cerebral, in which restlessness, convulsions, and delirium be- 518 DISEASES OF THE RESPIRATORY SYSTEM. come so marked as to overshadow entirely the puhiionary symptoms. Not infrequently the onset is characterized by convulsions, high fever, pros- tration, and alternating stupor and delirium. After such symptoms have continued for from two to five days, pulmonary symptoms appear, while the cerebral decline. {h) Other cases may manifest a subacute onset, in which there is ano- rexia and occasional vomiting, with the nervous symptoms before noted. (2) The protracted forms are those in which (a) the symptoms of acute broncho-pneumonia give place to those of a similar though chronic state. The general disturbances may not be marked in some in- stances, but usually there are cough, loss of appetite, or inability to gain in liesh and strength, and the signs of consolidation persist. (h) Those presenting fever of an irregular type, together with decided prostration, in addition to the symptoms of the preceding variety. In many cases belonging to this form the lesions are tuberculous. In adolescence the cerebral symptoms are not as Avell marked as in children. Two anomalous varieties are met with in practice that demand brief separate description : General Broncho-pneumonia. — The attack develops suddenly and is severe. There are chills, high fevei", marked prostration, headache, chest and loin pains, a rapid pulse (soon becoming feeble), rapid and labored respirations, cyanosis, restlessness, delirium, and cough that is at first dry, and followed by mucous, muco-purulent, blood-tinged sputum. The physical signs are defective expansion and an increased tactile fremitus. The percussion-note may be either normal, tympanitic, or dull ; the auscultatory signs are large moist, subcrepitant, crepitant, sib- ilant, and sonorous rales over both lungs, and a harsh or broncho- vesicular respiratory murmur. The affection is very grave. Resembling Tuberculous Broncho-pneumoma. — The symptoms appear slowly, and the case pursues a subacute or even chronic course. Cough, catarrhal expectoration, moderate fever (often of a hectic type), and night- sweats are noted. Physical examinatioii discloses generalized bronchitis, coupled with cir- cumscribed areas of consolidated lung-tissue. Resolution may take place at the end of eight or ten weeks, and complete recovery ensue ; when, how- ever, this favorable event does not occur, the case drags on for an indefinite period, and finally terminates fatally. There are no bacilli in the sputum. Diagnosis. — This can be arrived at by considering — (a) The nature of the antecedent affections and their etiologic circum- stances : (6) The distribution of the consolidated areas in both lungs ; ((•) The fact that the physical signs of consolidation are subsidiary to those of generalized bronchitis; (d) The intense dyspnea and cyanosis ; (e) The type of the fever, irregular as a rule, and its gradual decline ; (f) The frequent long duration. Differential Diagnosis. — Doubtless, lobar pneumonia is constantly mis- taken for broucho-pneumonia, and particularly when, in the latter disease, a large portion of one or both lungs becomes inflamed in consequence of the coalescence of small areas of consolidation. The points of distinc- tion may be tabulated as follows : BRONCHO-PNEUMONIA. 519 Broncho-pneumonia. Lobar Pneumonia. Etiology. Presence of pathogenic organisms^ (strep- Presence of the Diplococcus pneumoniae, tococci). Usually secondary to bronchitis and acute Usually a primary disease, infectious diseases (e. g. measles, whoop- ing-cough). Clinical History. Onset gradual. Onset abrupt ; previous health generally good. Fever is, in proportion to the extent of Fever is high, of continued type, and inflammation, of irregular type, and falls betvreen the fifth and ninth days declines by lysis after a variable dura- by crisis. tion. Sputum glairy, tenacious, and in adults Sputum characteristic (rusty or prune- may be blood-tinged. juice). Dyspnea and evidence of carbon-dioxid Respiration panting, but dyspnea and poisoning prominent. cyanosis relatively less marked. Physical signs of generalized bronchitis Signs of bronchitis generally absent, always marked, and usually preponder- those of lobar consolidation always ating over those of consolidation. preponderating. Consolidation commonly bilateral. Commonly unilatei-al. Duration indefinite, often extending over Duration definite as a rule, convalescence many weeks. following crisis. Consolidated areas liable to become the Far less likely to become the seat of tu- seat of tuberculous infection. berculous infection. It maybe difficult to distinguish tuberculous hroyiclio-pneumonia from the disease under consideration. Indeed, a non-tuberculous broncho-pneu- monia may be located at the apex of the lung and accurately simulate the symptoms and signs of the tuberculous form. The differentiation is to be based upon the presence or absence of the signs of softening, and upon a microscopic examination of the sputum (which in a child may be vomited). The softening in tuberculous pneumonia does not, however, begin very promptly ; but if elastic fibers and tubercle bacilli be found, the diagnosis is at once set at rest. Prognosis. — In broncho-pneumonia the severity and gravity of the symptoms and the extent of the involvement of lung-tissue are propor- tionate to one another ; hence it follows that the disease may either be devoid of serious import or it may be fraught with great danger to life. Its course is subject to decided fluctuations, the periods of exacerbation in the symptoms often marking the time of the development of the gravest features. Apart from the extent of the lung-tissue involved, hoAv- ever, we must consider especially the condition of the patient at the time of invasion. If the constitution have been previously undermined, as is frequently the case in children, broncho-pneumonia is very apt to be fatal. The disease is less dangerous w'hen it develops in the course of, or follows, measles than when secondary to whooping-cough, influenza, or diphtheria. Wiry, thin children seem to stand broncho-pneumonia better than fat, flabby ones (Osier). Deglutition and inspiration lobular pneu- monia, especially when occurring after operations upon the larynx or ^ The diagnostic value of the discovery of streptococci is not pronounced. Numer- ous other organisms have been found in broncho-pneumonia in their absence, and a sim- ilar organism {Streptococcus pneumonicE, Weichselbaum) has been found in a number of cases of croupous pneumonia. 520 DISEASES OF THE RESPIRATORY SYSTEM trachea, are frequently fatal. The mortality -rate in this disease varies from 25 to 50 per cent. Treatment. — Prophylaxis. — There are few diseases that can be so eflfectually prevented as can broncho-pneumonia. In the first place, proper attention to the mouth as well as to the position of the patient (which should be changed frequently) during attacks of acute infectious diseases will prevent its development in a great proportion of this large class of cases. Adequate protection against exposure to cold during con- valescence from measles, whooping-cough, etc. is also a potent factor in preventing the disease, as is the timely handling of catarrhal affections of the nose, pharynx, larynx, and larger bronchi. Treatment of the Attack. — Certain sanitarn arrangements are of the utmost practical importance. The sick-room should be well ventilated and its atmosphere kept at a uniform temperature — 68° to 70° F. (20°- 21.1° C). The air of the room should also be well laden Avith moisture, which may be generated from a croup-kettle or other suitable vessel. Local Measures. — In young children the chest should be enveloped in a jacket-poultice of linseed meal, which should be covered with a layer of oiled silk or waxed paper so as to prevent its growing cool. This should be renewed at intervals of about six hours. After the more active symptoms have subsided the linseed jacket-poultice may be re- placed by one of absorbent cotton, which should also be covered with oiled silk or wax paper. In older subjects the application of iced poultices to the chest exercises a most favorable influence, not only upon the local inflammation, but also upon the fever and the nervous symptoms. General Measures. — High fever calls for tub-baths, the temperature of the water at first being set at 95° F. (35° C), and then gradually cooled to 75° or 80° F. (26.6° C). The gradually cooled bath or the cold pack may be used two or three times daily. The effects are to reduce temperature, to promote refreshing sleep, and to improve the character of the respiration. This mode of treatment is especially effective in cases that begin abruptly. In such the tincture of aconite or veratrum viride may be employed temporarily. In cases presenting modei'ate pyrexia cold spongings, combined with the use of the ice-bag to the head, may sufiice. The following fever-mixture may be employed, though it is not to be regarded as a substitute for the cold-water method of treatment, but is merely supplemental to the latter : IJi. Potassii citrat., oijss(lO.O); Spts. ammon. aromat., f^ij (8.0); Spts. aether, nitrosi, f5ss (16.0); Liq. ammon. acetat., f^iij (96.0); Glycerini, q. s. ad f.5iv (128.0).— M. Sig. 5j (4.0) every two hours for a child of five years. In children a mild mercurial purge at the outset is advantageous, and subsequently by the use of salines or glycerin suppositories a daily evacuation of the bowels is to be secured. The Diet. — The bodily strength is to be maintained by careful, methodical feeding, milk, eggs, albumin, and broths being the best forms of food. The milk should be predigested if there be marked PULMONARY ATELECTASIS. 521 pyrexia, and egg-white may be given in cold water with a small amount of sugar or in the form of egg-lemonade. The cough is often wellnigh constant and very distressing. Fre- quently the use of remedies that promote secretion, combined with a small dose of opium, will, under these circumstances, aiFord relief. A useful formula is the following : I^. Vini antimonii, 3j (4.0); Spts. seth. nit., 3ijss (10.0); Tr. opii camph., 3ijss (10.0); Liq. ammon. acetat., q. s. ad 5ij (64.0). — M. Sig. 3j (4.0) every two hours, diluted, for a child of from three to five years. Dover's powder is also of value in relieving the cough. When the expulsion of the sputum is attended with great difficulty the preparations of ammonium often meet the indications. Of these the muriate is the most effective, but, unfortunately, this is often objected to, and we must then rely upon the carbonate or the aromatic spirits. The bronchi may contain an abundance of secretion that cannot be expelled, despite the use of the above measures. Under these circumstances an emetic may be given, composed of the wine of ipecac (sj — 4.0), combined with alum (gr. xx to xxx — 1.296-1.944), and administered to a child every ten or fifteen minutes until emesis occurs. Cardiac stimulants (alcohol and strychnin) are required if the pulse fails. The preparations of ammonium owe much of their reputation in this disease to their stimulating properties. These agents when boldly used may suffice to re-establish the cardio-pulmonary circulation ; but if they fail in this and cj^anosis supervenes, oxygen by inhalation should be used also. Sudden heart-exhaustion may occur, associated with mucous rales in the larger bronchi and rapidly increasing cyanosis. Alternating douching with hot and cold Avater and electricity should be given a trial. Injections of salt solution increase arterial tension and act as a "whip" to all emunctories ; they may also stimulate phagocy- tosis, and may be tried in serious cases. PULMONARY ATELECTASIS. ( Collapse of the Lungs ; Compression of the Lungs.) Definition. — Atelectasis of the lungs is a condition occasioned by the removal of the air from the air-cells — a state directly the opposite of emphysema. The air disappears largely in consequence of the process of absorption. Pathology. — The affected lung-spots sink in water, being non-crep- itant. They also present through the pleura a bluish-red tint, and on cross-section a brownish-red color. The surface of the affected areas is smooth and depressed beloAv the level of the adjacent lung-structure. The bronchi supplying the collapsed parts are frequently occluded by inflammatory products, but in all cases, as shown by Legendre and Bailly, the latter may be inflated by means of a blowpipe. 522 DISEASES OF THE RESPIRATORY SYSTEM. Apart from more or less distention of the pulmonary capillaries with blood, there are no histologic changes in the atelectatic areas, though they are of firm consistence (splenization, carnification). There can be no longer any doubt as to the entire propriety of the pathologic distinc- tion between lobular pneumonia and atelectasis. Ktiology. — The condition occurs most frequently in the new-born, and is then due to defective respiration. Thus in children dying soon after birth the lower lobes may be found to be atelectatic. When ac- quired, however, there are three modes of production : (1) The first step consists in a more or less complete plugging of the smaller bronchi with muco-pus and other products of bronchial inflammation. If complete, air can no longer enter on inspiration, and as the contained air gradu- ally becomes absorbed atelectasis is the natural result. This condition is very commonly associated with broncho-pneumonia, especially in chil- dren. (2) A fre((uent mode of origin is through compression of the lungs, resulting from positive intrathoracic pressure, after the normal contractility of the lung has been overcome. Instances of this may be produced by pleural effusion, hydrothorax, pneumothorax, pericardial effusion, great cardiac hypertrophy, a solid tumor, or an aneurysm of the arch. Not infre([uently abdominal tumors, excessive meteorism, and ascites make sufficient upward pressure against the diaphragm to cause compression of the lower lobes of the lungs. (3) Conditions that weaken and obstruct the inspiration may produce this disease, such as certain brain-affections, paralysis of the pneumogastric, and paralysis of the chest-walls. Thoracic deformities may produce pulmonary atelectasis, and in extreme grades of kyphoscoliosis the lung occupying the side cor- responding to the convexity of the spinal column is small. Whilst the lung-expansion and the growth of the organ are greatly interfered with, however, and particularly if the condition arises in youth, true atelec- tasis rarely occurs from this cause, owing to the natural retractility of the lung. Among conditions arising from deformities of the chest is the so-called aplasia of the lungs. Symptoms. — Atelectasis is a secondary condition, and its symp- toms are very generally veiled by those of the primary disease. It arises frequently in the course of broncho-pneumonia, but passes unno- ticed unless it becomes very extensive. Bei^piration is carried on by the upper and anterior portions of the lungs, is increased in frequency, and is laborious. The pulse is small, rapid, and feeble ; the skin- surface., especially that of the extremities, is cool. The form presenting the most typical symptoms is that occurring in the new-born. It is evidenced by sliallow, rapid bi-eatJiing, livid- ity, cold extremities, a faint whining cry, droiosiness, and sometimes by evidences of motor irritation, such as muscular twitching and con- vulsions. Congenital anomalies of the circulatory organs are asso- ciated. Physical Signs. — When it involves a goodly portion of the lower lobes posteriorly, as frequently happens, there is marked retraction during in- spiration over the lower portion of the thorax, due partly to external atmospheric pressure, and partly to the contractile efforts of the dia- phragm. Dulness on percussion is revealed, though only wh(5n the ate- lectasis is extensive, and the tactile fremitus, though very various, is PULMONARY ATELECTASIS. 523 generally decreased. Localized compensatory emphysema may present semi-tympanitic resonance over small areas of collapse. Auscultation shows a greatly diminished or absent vesicular murmur, and, if the area of collapse be large, bronchial breathing. Among asso- ciated sounds is the subcrepitant r^le, due to broncho-pneumonia, and, indeed, capillary bronchitis and atelectasis are often combined, there being, moreover, no reliable signs that will separate them clinically. The aplasia of the lung that is produced by spinal curvature {kyijlio- scoUosis) richly deserves brief separate description, owing to its clinical importance. In many instances the chest is more or less twisted on its own axis, shortened in the vertical diameter, and thoroughly fixed. Under these circumstances lung-expansion is impossible, and hence res- piration is purely diaphragmatic. In many other patients life may be prolonged for an indefinite period, nothing more being observed than slightly labored breathing. Such persons, however, upon great physi- cal exertion suffer from urgent dyspnea, and the development of an ordi- nary bronchitis may lead to similar results, and even to speedy death. The physical signs are those of localized emphysema, combined Avith those of more or less compression of the lungs. There is an extension of the cardiac dulness to the right, and other evidence of right ventricu- lar enlargement, to which may succeed dilatation with the usual clinical events produced by the latter condition. Death is not rarely due to this failure of compensation. Autopsies have shown the lungs to be small and more or less com- pressed, some portions being almost airless. Areas of emphysema of the lungs are often associated. The right ventricle may be found to be hypertrophied merely, or dilatation may also have taken place. Con- genital atelectasis, by keeping up high pulmonary pressure, may lead to a persistence of the ductus Botalli and of the foramen ovale. Diagnosis. — Atelectasis may be distinguished from loha^^ pneu- monia by the absence of an initial rigor, fever, crepitant rales, and the pain of the latter disease, and by the characteristic inspiratory retrac- tion of the lower portions of the chest and the smaller areas of dulness. Pleuritic effusion gives a flat percussion-note, the upper level of which varies with a change in the position of the patient — a sign that is wanting in atelectasis. Prognosis. — When the condition is limited to small areas it is rarely serious, but equally seldom does extensive atelectasis lead to recovery. The outlook depends to some extent upon the nature of the associated aflfectioDS ; thus, when it is secondary to whooping-cough and widespread broncho-pneumonia, it is very fatal. Other diseases that may complicate and increase the gravity of the atelectasis are pleurisy and pulmonary tuberculosis. On the other hand, compensating emphysema often coexists, and is to be regarded as salutary in its efi"ects. When due to compression by pyo-pneumothorax, tumors, and the like, the prognosis is especially gloomy. Treatment. — The treatment corresponds with that of the primary disease. Capillary bronchitis, which is so apt to be followed by collapse of the lobules, must receive active treatment, and prophylactic measures are of the utmost practical importance. The patient should be instructed to practise full inspiration at regular intervals ; he should not be allowed 524 DISEASES OF THE RESPIRATORY SYSTE3I to lie continuously in the dorsal decubitus, but should be told to change his position frequently. Another measure that may effectually pre- vent the development of atelectasis is the use of cold shower-baths (/. e. a stream of cold water poured over the region of the neck), and this can sometimes be depended upon as a curative agency when the condi- tion already exists. Tonics and the judicious use of stimulants, together with a nourishing diet, are invariably required. I have also seen good results follow the inhalation of compressed air. In kyphoscoliosis tepid baths are indicated. The heart-condition de- mands careful attention, and cardiac stimulants are to be resorted to at the first loss of compensation or when compensation fails to become established. EMPHYSEMA. Definition. — In general this term implies the presence of air in the interstitial alveolar tissue. As applied to the lungs, however, two forms are recognized : (1) Interlobular ; and (2) A'esicular, an abnormal dila- tation of the alveoli. INTERLOBULAR EMPHYSEMA. This is produced by the rupture of the air-cells, the air contained in the lung escaping into the interlobular connective tissue. Among its causes are — [a] Injuries of the lung (usually by a fractured rib) and perforating wounds of the chest ; (6) Violent paroxysms of coughing, as in whooping-cough ; and rarely defecation, parturition, and hysterical convulsions. When arising in this way its favorite situation is the an- terior margin of the upper lobe. Pathology. — In the interlobular septa immediately beneath the pleura air-bubbles are sometimes seen to be arranged in well-defined rows. The pulmonary pleura may become detached, and the air-tumors may then become as large as an English walnut or even of greater size. Unlike the condition in vesicular emphysema, these sacs are freely mov- able, and the air may find its way from the root of the lung into the mediastinal connective tissue, and thence into the subcutaneous tissue of the neck and the wall of the thorax. Rarely these air-sacs perforate the pleura, setting up pneumothorax, with or without pleuritis. Interlobular emphysema is sometimes associated with advanced vesic- ular emphysema. VESICULAR EMPHYSEMA. [Alveolar Ectasis.) Definition. — Dilatation or enlargement of the alveoli and infundib- ular passages. Varieties. — The cases are classified into — (1) Compensating, (2) Hypertrophic, and (3) Atrophic forms. HYPERTROPHIC EMPHYSEMA. 525 COMPENSATING EMPHYSEMA. This variety is limited to certain parts of the lung, and arises in consequence of pathologic changes in other parts of the same organ that prevent full expansion of the lung on inspiration. Hence a vica- rious increase in the volume of the air-cells is observed in circumscribed morbid processes such as occur in pulmonary tuberculosis, lobular pneu- monia, cirrhosis, and pleurisy with adhesions (particularly when the latter is situated at the inferior border of the lung). An entire lung, unaffected by the primary disease, may be the seat of compensating em- physema when the causal disease invades the whole or a greater portion of the other lung, as in cirrhosis, extensive pleurisy with effusion, lobar pneumonia, and pyo-pneumothorax. When, however, the latter condi- tions are confined to a portion of one lung, the remainder of the same organ becomes distended also. As a rule, this pulmonary change is physiologic and beneficial : only rarely secondary atrophy of the walls of the air-cells develops, Avhen the latter may coalesce. Symptoms are not presented by the lungs in consequence of the changes met wath in compensating emphysema. The condition is some- times recognizable by means of the usual physical signs, but even these are not always to be relied upon. Fortunately, its existence may be safely inferred when there is conclusive evidence of the presence of the local causative diseases (broncho-pneumonia, pulmonary tuberculosis, pleurisy, lobar pneumonia). HYPERTROPHIC EMPHYSEMA. Nature of Umph/sema. — The symptoms are dependent upon a loss of elasticity in the lungs, and, the latter condition being the result of overstretching, the contractile energy of the lungs is in great part destroyed ; hence they become permanently enlarged. Nor do the em- physematous lungs contract when the thorax is opened, as they do ordi- narily. We may in some cases account for the loss of elasticity in the lungs by the operation of causes that produce an abnormal degree of stretching, either temporarily or constantly ; but under these circum- stances emphysema would be developed despite the pre-existence of nor- mal contractility of the lung. In true emphysema, however, which de- velops at a comparatively early period in life, we may safely assume that the retractile energy is defective (probably a congenital condition), and hence in such cases the action of the usual causal factors will speedily engender over-distention, or emphysema may develop even in the ab- sence of causative influences. In these instances there is probably a quantitative as well as a qualitative defect in the elastic-tissue element of the lungs. Path.olog"y. — The thorax is enlarged (barrel-shaped), and upon re- moving the sternum the lungs are found completely to fill the mediasti- num, and do not retract as in health. They present a pale, anemic appearance, although pigmented patches and streaks may be noted, while to the feel they appear soft and feathery, though dry. They readily pit on pressure (a leading characteristic). 526 DISEASES OF THE RESPIRATORY SYSTEM Immediately beneath the pleura enlarged air-cells can be distinguished macroscopically, and air-sacs as large as a walnut or even larger may project above the lung-surface. Occasionally they may be so far de- tached as to be pedunculated. At the anterior borders a series of air- blebs, resembling a frog's lung, may be observed. Here, as well as near the root of the lung, distention is usually more marked than else- where, due to the direction taken by the distending force. The pleura is pale, and in patches the pigment may be absent ( Virchow's albinism). Upon microscopic examination it is observed that the dilatation starts in the infundibular and alveolar passages. The septa are partially obliterated, the alveolar walls thinned and, lastly, perforated, while in consequence of these changes the air-cells communicate with one another, and thus form larger or smaller air-sacs. The process is an atrophic one, in which the smaller elastic fibers at first disappear, while the larger be- come less prominent and often ruptured. After the latter changes have begun the capillaries likewise disappear, and the epithelium of the air- cells undergoes fatty degeneration, though in the larger bullae a pave- ment layer is retained. The smooth muscular element may also occa- sionally be seen to be hypertrophied (Rindfleisch). The clinical phe- nomena probably arise from the loss of the capillary blood-vessel sys- tem and collateral hyperemia of the larger bronchial vessels. The bronchial mucous membrane is usually the seat of chronic inflam- mation. It may be roughened and thickened, or the submucous elastic tissue may present prominent longitudinal lines, while the bronchial mucosa is covered with muco-pus. The smaller tubes may be dilated (bronchiectasis), and this condition may be associated with hyperjdasia of the peribronchial connective tissue. The diaphragm is lowered and the subjacent viscera correspondingly depressed. Physiologic Pathology. — The heart is pushed downward and somewhat backward, the rio-ht side showino; well-marked changes; the cavities are dilated and hypertrophied, due to obstruction in the pulmonary circulation ; and in long-standing cases hypertrophy of the left chambers may also de- velop. The pulmonary artery and its branches are enlarged and the seat of atheromatous degeneration. The liver, kidneys, and other viscera present the changes that belong to long-continued venous engorgement. Ktiology. — The affection is often secondary to, and develops in consequence of, other affections of the lung — notably, chronic bronchitis and ivhooping-couf/h. The dry form of chronic bronchitis, in particu- lar, is apt to generate pulmonary emphysema. Under these circum- stances the disease is directly attributable to the mechanical influences to which the alveolar walls are subjected during respiration. This ab- normal strain attends inspiration to some extent, but mainly expiration, owing to the obstruction to the egress of the air in the smaller bronchi, Avith increased intra-alveolar air-pressure. The increased tension in the air-cells may be accounted for, partly, by the severe and persistent cough, the air being forced during violent coughing into the upper part of the lungs, forcibly expanding them and causing emphysema. Bronchial asthma, on account of the obstruction of the exit of the air from the lungs, produces during the attacks an acute empbysema that may result finally in a condition of permanent over-distention. Certain occupations, such as blowing wind-instruments, or those that HYPERTROPHIC EMPHYSEMA. 527 entail severe muscular strain {e. g. blacksmithing), act as predisposing causes, and hence emphysema is of common occurrence among the working classes, and is more common in males than females. The dis- ease is often hereditary, there frequently being several suiferers in the same family. During advanced years the lung-elasticity often dimin- ishes, and as a consequence a disposition to emphysema is engendered. On the other hand, emphysema is not infrequently met with in children, and in such there may be a respite during early adult life, with a recur- rence at a later period. An emphysematous tendency also results from congestion of the lungs associated with mitral valvular disease. Clinical History. — In nearly all cases the disease develops insidi- ously, the symptoms being gradually added to those of the primary affec- tions (chronic bronchitis, asthma, etc.). When due to the occupation of the patient its development is also slow, and not infrequently its origin dates back to childhood or beyond the recollection of the patient. Rarely it may exhibit a more acute development, as, for example, after whoop- ing-cough. The first symptom is a variable degree of dyspnea, and to this may be added temporary cyanosis and cough. The severity of the dyspnea varies with the degree of distention of the air-cells, even though addi- tionally aggravated by the coexistence of the primary disease. In moderate emphysema the dyspnea is only apparent on going up stairs, running, walking rapidly, or after a hearty meal ; on the other hand, in advanced grades of the affection it is constant, and is intensified by. the slightest exertion, even to orthopnea. Speech is interfered Avith, the patient's utterances taking the form of fragmentary sen- tences or syllables. The labored breathing is shown particularly in expiration, and, as in asthma, in Avhich the alveolar spaces are acutely distended, so in emphysema the rhythm of the respiration is changed. The inspiration is shortened, and the expiration is greatly prolonged and accompanied by wheezing v»'hen chronic bronchitis coexists. In the later stages cyanosis becomes more marked, and is noticeable in proportion to the loss of compensation and interference with the car- dio-pulmonary circulation. It often attains to an extreme degree, and the patient's alarming appearance may be in striking contrast with his apparent degree of comfort. In mild forms the cyanotic tint is con- fined to the lips, lobes of the ears, and the extremities. Any increase in the degree of dyspnea after exertion results in an increased blueness of the surface. The cough is dependent upon the presence of chronic bronchitis, and the latter disease is frequently found in combination, particularly during the Avinter. There is also an expectoration that is identical with that of chronic bronchitis, and when this disease reaches an advanced stage the cough persists throughout the year {vide Chronic Bronchitis). In- tercurrent acute attacks of bronchitis are often followed by temporary attacks of asthma ; and since chronic bronchitis in its highest grades is met with at an advanced period of life, so, as would be expected, the cases of advanced emphysema are also met Avith at the same period. Osier has described a group of cases occurring in patients " from twenty- five to forty years of age who, winter after winter, have had attacks of intense cyanosis in consequence of an aggravated bronchial catarrh." 528 DISEASES OF THE RESPIRATORY SYSTEM. These patients are short-breathed from infancy, and their condition is attributed to a primary defect of structure in the lung-tissue. General Symptoms. — There is an absence of febrile movement ; the pulse is not increased in frequency, though sometimes feeble ; and the temperature of the body is generally subnormal. There is a very gradual loss of flesh and strength, and the patient is stoop-shouldered, present- ing a peculiar cachectic appearance — a condition that is in strong con- trast with the dusky appearance of the face, the swollen neck, and the enlarged chest. Finally, other symptoms may be mentioned that are for the most part secondary to hypertrophy, followed by dilatation, of the right ven- tricle. This hypertrophy is the result of pulmonary congestion and obliteration of the pulmonary capillaries induced by the emphysema. Under these circumstances severe attacks of cough occur, attended with extreme dyspnea and lividity, and later the conditions that usually suc- ceed a moderate grade of tricuspid insufficiency supervene, such as con- gestion of various viscera and edema of the feet. Anasarca is rare. Physical Signs. — The shape of the chest is characteristic : owing to the increased antero-posterior diameter, it becomes barrel-shaped (Fig. 46), and the sternum bulges, as do also the costal cartilages. The infraclavicular and mam- mary regions are also promi- nent, and give the thorax an abnormally rounded appearance. The episternal notch is deeper than the normal, the clavicles and muscles of the neck are unduly prominent, and the neck itself appears to be shortened, owing to the elevated position of the clavicles and the ster- num. There is an antero-pos- terior curvature of the' spine and a winged condition of' the scapulfe — changes to which the stooping posture is ascribable. Below, the thorax appears con- tracted. The intercostal spaces are widened and depressed, and a network of dilated venules fre- quently extends laterally above the inferior costal border, but is by no means characteristic of the affection. The movements of the chest are vertical rather than expansile, and the lungs are constantly in a state of extreme expansion ; in the lower thoracic and upper abdominal regions there may be observed retrac- tion rather than expansion during the act of inspiration. The respi- ratory acts, as a whole, are labored, and the diaphragm and abdomi- nal muscles are seen working with considerable violence. The heart's apex-beat is invisible, but marked epigastric pulsation is frequently Fig. 46. — Barrel-shaped chest in emphysema. HYPERTROPHIC EMPHYSEMA. 529 noticeable. A transverse linear depression across the abdomen, on a level with the lower ribs, may also be present during inspiration. Ven- ous pulsation may be seen in the neck after failure of the right ventricle has occurred. On paljjation the character and direction of the chest-movements may be accurately appreciated. The tactile fremitus is decreased, but not absent. In advanced cases the apex-beat cannot be felt, and even in the earlier stages it becomes more and more enfeebled. Owing to displacement of the heart and engorgement of the right ventricle there is a distinct systolic shock over the ensiform cartilage, and also a pul- sation in the epigastrium. Percussion yields a characteristic hyper-resonance. This may be distinctly " Skodaic " or semi-tympanitic, and in extreme dilatation of the air-cells the tone may be woodeny. The area of cardiac dulness, owing to the fact that the lungs overlap the heart, becomes lessened and finally obliterated ; while the upper limit of liver-dulness, both ante- riorly and posteriorly, is found to be one or two interspaces lower than normal, owing to the fact that the diaphragm is depressed. The upper level of splenic dulness is also lowered, and the area of percussion- hyper-resonance extends higher above the clavicle than naturally. On auscidtation the inspiration is short and feeble, while the expira- tion is greatly lengthened, the ratio of these sounds as to duration being reversed as compared with the normal. Their pitch is somewhat low- ered, particularly that of expiration ; and Avhen rales are present the respiratory murmur (particularly the inspiratory) may be scarcely audible. In well-marked instances of emphysema inspiration and expiration may rarely be of equal length. It is a fact worthy of emphasis that the parts of the lungs that are not so markedly emphy- sematous as others give a harsh, exaggerated vesicular murmur, OAving to the great eiForts of breathing. Rales of various sorts are frequently audible, due to bronchitis, which, it must be recollected, accompanies emphysema in a majority of instances ; less frequently the auscultatory signs of asthma, pleuritis, and phthisis are encountered. Rarely, rub- bing sounds, that have been attributed to the friction of enlarged air- cells against the pleura, are audible, and when the interlobular variety supervenes upon vesicular emphysema a crumpling sound is heard. The so-called ^'- Laennecs rale,'' which resembles somewhat the subcrepitant rale, is not infrequently present. The vocal resonance varies from an almost total absence to a greatly increased intensity. The tricuspid in- sufficiency that develops late in this aifection is betrayed by its charac- teristic murmur. Diagnosis. — A positive diagnosis may be arrived at from a consid- eration of the history, including such points as heredity, occupation, the long duration of the condition, together with the most characteristic symptoms (dyspnea, cyanosis, signs of chronic bronchitis), and from the physical signs. In a case of beginning emphysema, particularly among children, a certain diagnosis is not to be attempted. Diflferential Diagnosis. — Pneumothorax is the disease most apt to be confounded with emphysema. It develops suddenly, however, while emphysema is of slow development, and the rational symptoms of pneumothorax are more constant and urgently distressing than those of 34 530 DISEASES OF THE RESPIRATORY SYSTEM. emphysema. Pneumothorax is unilateral, and gives a purely tympanitic percussion-note, while hypertrophic emphysema is bilateral and its per- cussion-note is hyper-resonant. Auscultation in pneumothorax usually gives amphoric breathing, metallic tinkling, the characteristic succussion splash, and an absence of the vesicular murmur ; all of which ausculta- tory signs are very unlike those of emphysema. Another affection giving rise to dyspnea, cough, and cyanosis is pleurisi/ with effusion, but the slow course, the absence of fever, and the universal hyper-resonance that characterize emphysema do not be- long to pleurisy. The latter aifection is usually unilateral, and over its seat a flat percussion-note is obtained. Prognosis. — Hypertrophic emphysema of acute form [e. g. result- ing from whooping-cough) is often curable ; but the usual slowly- generated variety, so far as recovery is concerned, gives a totally un- favorable prognosis. In many cases, however, life is not materially shortened. Temporary improvement is possible when the lesion con- sists merely of a distention of the air-cells, and this is shown by a corresponding improvement in the physical signs. The effect of frequently recurring attacks of bronchitis is only to intensify the symptoms of a disease that is innately progressive. Intercurrent affections, however, such as pneumonia (lobar and lobular) and pulmo- nary tuberculosis, may prove fatal. Dropsy, following broken compen- sation, is often a late and dangerous complication ; other late accidents of the disease are hemoptysis and sudden dilatation of the right heart. Individual circumstances, such as the patient's social condition, the stage of the affection in which he comes under proper treatment, and the degree of care he is willing to exercise, greatly influence the out- come of the case. Treatment. — The treatment is to be directed toward the removal of the causes of emphysema, and chiefly of the chronic bronchitis. From personal observation I am firmly convinced of the fact that the progress of the disease can be arrested, and that the condition is some- times improved, by relieving the chronic bronchitis. The iodids (po- tassium, sodium, and ammonium) will sometimes produce effects that are truly remarkable, and the syrup of hydriodic acid may be employed when the iodids are not well borne by the stomach. If the occupation of the patient tends to aggravate the disease, it must be forsaken for one that is less harmful. Violent paroxysms of cough also contribute to the production of alveolar distention, and hence must be alleviated promptly. Intercurrent attacks of asthma have a similar effect, and must be relieved as speedily as possible by a resort to appropriate ther- apeutic measures. Attacks of acute bronchitis are to be prevented, if possible, by suitable clothing, by avoidance of exposure to inclement weather, dust, and the vitiated atmosphere of overcrowded halls, churches, and the like ; whenever practicable the result can be most successfully obtained by a residence in an equable climate. Since a severe bron- chitis is apt to increase the severity of the emphysematous symptoms, it must be relieved as speedily as possible. As soon as passive congestion, flatulence, and constipation, with other gastro-intestinal symptoms, appear, the diet will demand careful regulation, and especially a restriction in the use of carbohydrates. GANGRENE OF THE LUNGS. 531 The bowels must also be moved regularly with a view to obviating the flatulence and portal engorgement. The heart needs to be carefully watched, and as soon as signs of broken compensation appear digitalis and strychnin will be found highly useful. Diuretics and cathartics may also become necessary. The sudden development of urgent dyspnea (or orthopnea) and extreme lividity, especially if associated with weak cardiac action and a rapid, feeble, irregular pulse, calls for free bleedings, and more than once in the course of my hospital practice have I seen the lives of patients suffering from emphysema saved by timely venesection. Besides meeting the pathologic and symptomatic indications, we should aim to assist the patient in expiration, and Gerhardt has sug- gested systematic mechanical compression of the thorax during expira- tion as a useful measure. This external pressure must be made by an attendant, who places his hands flat on the lower lateral portions of the thorax, and the manipulation is to be continued for from ten to fif- teen minutes daily. The results obtained by certain German authors have been encouraging, but in my own hands the method has failed, except in two instances occurring in young adults with yielding chest- walls, in whom it Avas of the greatest service. The pneumatic treatment, comprising the inhalation of compressed air and the breathing into rarefied air, richly deserves further trial, ^ its use having been productive of permanent improvement in a number of cases, as shown by physical examination (including mensuration). SENILE EMPHYSEMA. This variety is in reality a senile atrophy of the lungs, and has been appropriately termed "small-lunged emphysema" by Sir Wm. Jenner. In consecjuence of the complete atrophy of the alveolar walls, coalition of the air-cells takes place, with the production of large air-sacs. The lungs contain less than the normal volume of air, instead of an abnormal quantity as in true hypertrophic emphysema, and as a result occupy less space in the chest-cavity than do healthy lungs. The pulmonary tissue elements are deeply pigmented. The condition does not produce right ventricular hypertrophy. The symptoms are negative, although subjects in Avhom senile em- physema develops may have previously had chronic bronchitis with more or less dyspnea. They quite frequently present a Avithered ap- pearance, and the chest on inspection is seen to be contracted, owing to the fact that the ribs approximate more closely and take a more oblique direction than in health. Treatment is unavailing. GANGRENE OF THE LUNGS. Pathology. — The affection presents itself in two forms — as a (a) diffuse, and a {b) circumscribed process. (a) The diffuse variety is rare. It may, however, be met with in ^ Waldenburg's portable apparatus is convenient for use. 532 DISEASES OF THE RESPIRATORY SYSTEM. lobar pneumonia, and very rarely in consequence of occlusion of the large branch of the pulmonary artery ; it may also be secondary to the circumscribed form. The greater part of the lobe, or even an entire lung, may be involved, the pulmonary parenchyma degenerating into a putrid, greenish-black, pulpy mass, Avith no obvious line of demarcation. (6) The circumscribed form may involve either one or both lungs, though the right is aifected somewhat oftener than the left. To this category belongs the so-called embolic gangrene, the nodules of which have their favorite seat in close proximity to the pulmonary pleura. All etiologic varieties of the circumscribed form more frequently implicate the lower than the upper lobe of the lung, occurring in sharply defined areas, which may either be single or multiple. The affected area first presents a greenish-brown appearance ; its central portion soon under- goes softening, and a cavity is thus formed whose walls are ragged and irregular and contain a foul-smelling, dark, greenish liquid. The sur- rounding lung is inflamed, and the air-sacs contain inflammatory prod- ucts (fibrin, epithelium, pus), while the highly-irritating and putrid material sets up an intense bronchitis. These gangrenous foci may in- crease in size by a peripheral extension, and thus the adjacent veins may become plugged with infectious thrombi or the vessels may become eroded. Emboli may then be detached from the infectious thrombi, and, entering the circulation, may set up foci of septic inflammation in re- mote organs. A truly remarkable connection exists between circum- scribed gangrene of the lung and cerebral abscess. "When the gangren- ous spot is situated near the pleura, simple or gangrenous pleurisy may arise as a complication, or the pulmonary pleura may be perforated and pyo-pneumothorax result. When recovery ensues the cavities formed as the result of the conversion of lung-tissue present a limiting wall of dense connective tissue. Such cavities may remain permanently or may slowly become contracted. Etiologfy. — Gangrene of the lungs is caused by the bacteria of putre- faction (probably the staphylococcus albus or aureus). The disease is rare, even though the opportunity for inhaling the bacteria that cause it is a constant one. It is only when the lung-tissue has become im- paired or peculiarly altered that the specific bacteria are capable of pro- ducing gangrene. It may occur in several ways : (1) Secondary to lobar pneumonia, hemorrhagic infarctions, cavities in the lungs, bronchiectasis, wounds of the lung, contusions of the thorax, carcinoma of the esophagus, or to compression or embolism of the pulmonary artery or of the bronchial vessels. (2) As an embolus, derived from a gangrenous area in some other organ of the body, it may lodge in the lung and set up putrefactive changes. (3) Pressure from a thoracic aneurysm may give rise to gangrene. (4) The most important causal factor, however, is the entrance of foreign bodies, especially bits of food, into the bronchi and lungs. AVhether or not the specific bacteria of putrefaction enter the lungs Avith the foreign bodies, the latter render the tissue-soil receptive to the former, and once the process has been initiated it is apt to. extend itself. There are several ways in which these foreign particles gain entrance into the bronchi and lungs : {a) By a faulty swallowing of the food ; [b] GANGRENE OF THE LUNGS. 533 By inhalation ; (c) By a carcinomatous perforation of the esophagus into the bronchus or into the lung. (5) In the course of debilitated states of the system, as during con- valescence from protracted fever (rarely), and in diabetes mellitus (frequently). Symptoms. — These are local and general, the former alone being diagnostic. Local Symptoms. — There is cough accompanied by an exceedingly fetid expectoration that is usually quite profuse. When abundant, and when expectorated into a conical glass and allowed to stand for a time, it separates into three layers : (a) the uppermost, being frothy, opaque, and of a grayish-yellow color ; {h) the middle, clear and watery ; and (c) the lowest, appearing as a greenish-brown sedi- mentary layer containing shreds of lung-tissue and sometimes blood. The microscope shows it to consist of numerous elastic fibers, bacteria, fat-crystals, muco-pus, granular matter, and leptothrices. Small quan- tities of blood in the sputum are very common. Kannenburg and Streng have also described ciliated monads as occurring in the sputum. The patient's breath is, as a rule, intensely fetid, even though there be no expectoration, but this fetor of breath may be absent, as in a case of my own (which came to autopsy), in which the localized gangrenous process had no fistulous connection with the bronchus. It is to be recollected that if any of the large branches of the pulmonary artery be eroded, free and even fatal hemoptysis will result. Physical Signs. — The physical signs are sometimes obscure, as when the areas involved are smaller and deeply situated, and in such instances signs of bronchitis only may be detectable. When large and favorably situated, however, the affected spots usually give signs of consolidation, rapidly followed by those of cavity. In addition bronchial rales — usually moist — and coarse cavernous rales are usually audible. It is obvious that when the pleura is implicated the signs of pleurisy are added, and if pneumothorax be present those belonging to the latter condition also. The chief general symptoms are irregular fever, emaciation, and profound prostration. A septic condition of the system is commonly developed, and the patient sinks from exhaustion. Rarely there may be an almost total absence of constitutional disturbances, and such instances terminate in recovery. Diagnosis. — The distinctive feature is the intense fetor both of the sputum and the breath. The physical signs may readily determine the existence of the pulmonary lesion, but it is difficult to eliminate abscess and fetid bronchitis associated with bronchiectasis. The results of a careful examination of the sputum, together with the less horribly fetid odor of the breath, in abscess will usually suflBce to eliminate the latter aflFection. In fetid bronchitis the fetor of the breath and sputum is also less marked than in gangrene, while its course is slower and more favor- able than that of the latter aifection. Progfnosis. — The prognosis is always grave, though rarely recovery in circumscribed gangrene of the lungs ensues. The chief dangers are exhaustion and hemorrhage. Improved methods of surgical treatment, however, have saved life in a few instances, and promise to reduce still further the mortality-rate of this serious aifection. 534 DISEASES OF THE RESPIRATORY SYSTEM. Treatment. — The leading indications are — (a) The disinfection of the gangrenous focus or foci in the lungs. This may be accomplished by the internal administration of creasote or carbolic acid or by the use of an antiseptic spray. In a recent case the employment of Robinson's inhaler, charged with equal parts of creasote, alcohol, and chloroform, gave encouraging results. (6) The patient's nutrition must be maintained, if possible, by a con- centrated liquid diet, administered in fixed quantities and at regular intervals ; also by the judicious cultivation of the digestive functions, together with the use of stimulants and tonics. For a description of the surgical treatment of gangrenous cavities of the lungs the reader is referred to special works on surgery. It is the physician's duty, how- ever, to determine whether or not the patient's general condition will admit of surgical interference, and also to localize as nearly as may be the affected zones for the surgeon's o-uidance. ABSCESS OF THE LUNGS. {Suppurative Pneumonitis.) Pathology. — This affection is characterized by the formation of pus and the degeneration of lung-tissue. It may be (a) a mere infiltra- tion of the bloo.d-vessels, bronchi, or interstitial tissue, but more fre- quently purulent inflammation of the lungs takes the form of {h) an ordinary abscess. In size the abscesses range from that of a walnut to an apple, and I have observed in one case inflammation of the whole of the middle lobe of the right lung. The abscess-walls are irregular and decidedly ragged ; and in the case of old lesions there is a dense fibrous wall ; the contents are purulent and rarely necrotic. If the contour of an abscess touches the pleura, empyema is the usual result, though sero- fibrinous pleurisy may rarely follow. Rupture of the abscess into the pleura may also occur. Ktiologfy. — Streptococci are found, though they are not the only direct causes of abscess of the lung. The diplococcus pneumoniae and Friedliinder's bacillus have been found, as well as certain other pyogenic organisms. Predisposition is noted in certain conditions, as (1) during or following the occurrence of inflammation, as in lobar and lobular pneumonia. Suppurative infiltration, howevei', more frequently arises under these circumstances than abscess, and in the rare instances in Avhich the latter occurs it is apt to be comparatively small and multiple. In all forms of inhalation and deglutition broncho-pneumonia, however, abscess of the lung is a frequent sequela. (2) Perforation of the lung from without or from adjacent organs, as in carcinoma of the esophagus, abscess of the liver, or suppurating hyda- tid cyst. (3) Infectious emboli, found in connection with septico-pyemia, fre- quently cause metastatic abscesses in the lungs. In a mechanical manner they may produce hemorrhagic infarctions, followed by suppuration, or the latter process may occur independently of the former. The abscesses PNEUMONOKONIOSIS. 535 are usually situated close to the pleura, and are frequently wedge-shaped ; they vary in number from one to several hundred, and in size from a pin's head to an orange. (4) Abscess of the lung may result from inward extension of a puru- lent pleurisy ; and, oppositely, purulent pleurisy may result from an extension of abscess of the lung. (5) As elsewhere stated (vide Pulmonary Tuberculosis), suppuration is quite generally associated with chronic pulmonary tuberculosis. Symptoms and Diagnosis. — The examination of the sputum is of the greatest value in the diagnosis of this disease, since, being puru- lent, it usually presents a yelloAv, or less frequently a greenish- or brownish-yellow, color. It emits a fetor that is less pronounced than that of either gangrene or putrid bronchitis. Particles of lung-tissue may be visible in the pus, and on microscopic examination of the latter, elastic fibers, the presence of which is of the utmost importance in the diagnosis, may be found in profusion. Next to the investigation of the sputum, the physical signs of cavity are of the greatest assistance in distinguishing abscess of the lung; these, however, are wanting unless the abscess is of a considerable size. By themselves, the signs of cavity do not suffice for the recognition of abscess, but when combined with the characteristic sputum leave no room for doubt. Chills and suppurative fever often attend. The history is of considerable importance, as con- firming the more characteristic features. Thus antecedent pneumonia or septico-pyemia would be strongly corroborative. Prognosis. — The prognosis is often hopeless, as, for example, when the disease is associated with pyemic processes in other parts of the body. On the other hand, those rare instances in which it is secondary to pneumonia give a comparatively favorable prognosis. Treatment. — The chief aim in the therapeusis should be to sup- port the system by the administration of tonics, stimulants, and anti- septics, as well as by methodic feeding with light and concentrated forms of nourishment. Inhalation of antiseptic sprays (creasote, thy- mol) should be tried. When the abscess is situated near the periphery of the lung, surgical interference is to be advised as soon as the first indications of increasing Aveakness appear. For the details of the ope- ration of pneumonotomy for pulmonary abscess the reader is referred to special works on surgery. The statistics of Eichhorst,^ showing its favorable results, may, however, be mentioned, as follows : in 13 opera- tions recovery or improvement Avas noted in 6, while fatal terminations occurred in 7. PNEUMONOKONIOSIS. {Anthracosis. Chalicosis, etc.) Definition. — A form of chronic interstitial pneumonia that arises from the inhalation of dust-like particles. Diiferent terms have been applied to the condition according to the nature of the dusts inhaled, the chief among these being — (1) xA.nthracosis (coal-miners' disease), ^ Specielle pathologie, Bd. 1, S. -519. 536 DISEASES OF THE RESPIRATORY SYSTEM due to the inhalation of coal-dust ; (2) Chalicosis (stone-cutters' phthi- sis), caused by the inhalation of mineral dusts; and (3) Siderosis, caused by inhaling metallic particles, particularly iron oxid. (1) Anthracosis. — Among dwellers in cities a moderate degree of pigmentation of the lung-tissue with coal-dust is the rule, while in those residing in rural districts the condition is decidedly less common. True anthracosis, however, has reference to such an accumulation of the car- bon particles as can be due only to the inhalation of a well-laden atmo- sphere, or under circumstances when the mucous membrane is unhealthy or without perfect ciliary action. Under such circumstances the normal scavengers of the respiratory organs — the mucous corpuscles lining the trachea, the bronchi, and the alveolar cells — fail to deal successfully with the numerous dust-particles that gain entrance along with the inspired air ; hence some of the latter pierce the mucosa and reach the lymph-spaces and lymph-vessels. On reaching the bronchial mu- cosa they become enclosed in leukocytes, mucous corpuscles, and alve- olar cells, and are conveyed by the latter to a more remote destination. Arnold shows that after the particles enter the lymph-system they are carried " (a) to the lymph-nodules surrounding the bronchi and blood- vessels ; (6) to the interlobular septa beneath the pleura, where they lodge in and between the tissue-element ; and (e) along the larger lymph- channels to the substernal, bronchial, and tracheal glands, in which the stroma-cells in the follicular cord dispose of them permanently and pre- vent them from entering the general circulation." Rarely the carbon particles may find their Avay into the general circulation ; this may occur, as shown by Weigert, when the pigmented bronchial glands be- come adherent to the pulmonary veins, thus giving opportunity for the escape of the carbon granules into the blood. Anthracosis leads, primarily, to chronic bronchitis, to be soon fol- lowed by emphysema ; but it must be recollected that extensive anthra- cosis may be present without any other changes in the lung than the presence of carbon particles stored in the protoplasmic cells. The lung- tissue presents great variations in its degree of susceptibility to these foreign particles. Sooner or later, there is usually produced, as the result of their irritant action,^ a proliferation of the connective-tissue elements — L e. a chronic interstitial inflammation. This fibroid change usually starts in the peribronchial lymph-structures, though the bronchial and tracheal glands are, as a rule, similarly involved at a comparatively early period. The affected lung-tissue is frequently coal-black, dense, and airless. The pneumonokoniotic areas vary greatly in size and numbers, and not infrequently they coalesce, in which case large portions of the lung-tissue may become the seat of fibroid change. The alveolar walls are observed to be much thickened in some instances, and firm pleuritic ad- hesions exist. Bronchiectatic cavities may be present, and later necrotic softening of the indurated areas occurs, leading to the formation of small cavities that contain a dark fluid. When the latter communicate with the bronchi their walls are prone to ulcerate. I have noticed that the process almost invariably terminates in pulmonary tuberculosis, and par- ' Cohnheim contencls that coal particles do not produce irritative changes in the lung, and that the latter are due to irritating substances inhaled with the particles of coal. PNEUMONOKONIOSIS. 537 ticularlv is this true of cases that follow the inhalation of mineral and vegetable dusts {i:ide infra). (2) Chalicosis. — Changes similar to those previously described are in- duced in the pulmonary connective tissue by the inhalation of stone- dust by those who follow certain occupations, such as stone-cutting, knife- and axe-grinding, and millstone-making. The irritating proper- ties of this form of dust cannot be denied, as shown by the great dispo- sition in this subvariety of pneumonokoniosis to the formation of fibrous nodules and diffuse areas of sclerosis in the lungs. The nodules have a gray center and a darker periphery ; they are exceedingly dense, and sections are made with much difficulty. The cut surface may present a grayish and distinctly glistening apj^earance. (3j Siderosis. — This term implies a collection of iron oxid in the lungs, also due to the pursuit of certain occupations (dyeing, iron- smithing, etc.). Cases of much the same nature are caused by the in- halation of vegetable dusts by grain-shovellers, cotton-spinners, cigar- makers, etc. The pathologic changes are identical with those in anthra- cosis, though the color-appearance is red instead of black. Symptoms. — Rarely the onset is marked by the symptoms of acute, followed by those of chronic, bronchitis ; but in a vast majority of in- stances chronic bronchitis gradually develops after long exposure to the action of the exciting cause. The symptoms of emphysema are soon superadded, the patient now suffering from dyspnea, and less frequently from asthma. The sputum is diagnostic in anthracosis, being quite dark ; in chalicosis a microscopic examination is essential to show the particles of silica ; while in siderosis the expectoration presents a red- dish color. Apart from the foreign particles, the sputum is for a long period of years muco-purulent in character, and later it often contains the tubercle bacillus. The physical signs are not distinctive, being identical with those met with in chronic bronchitis associated with emphysema, and followed by those of interstitial pneumonia, and sometimes by those of cavity. The diagnosis is to be made both from the history and from a gross or microscopic examination of the sputum. It may be confirmed by the invariable presence of the signs of bronchitis and emphysema, as well as by the effect of removal to an atmosphere free from dust. In the later stages the detection of infallible evidences of phthisis only serves to corroborate the earlier diagnosis of pneumonokoniosis. The prognosis is favorable in hygienic surroundings until the more advanced stage is reached. The condition favors the invasion of new growths flympho-sarcoma, or cobalt-miners' disease; vide infra). Treatm.ent. — A change of occupation or several hours of exercise in the open air daily for those who are exposed to dust in work-rooms should be advocated. The active treatment is the same as for chronic bronchitis and em- physema from other causes, and is to be appropriately modified when pulmonary tuberculosis develops. 538 DISEASES OF THE RESPIRATORY SYSTEM. NEW GROWTHS OF THE LUNGS. CARCINOMA OF THE LUNG. All varieties of carcinoma have been met with in the lung, but, with rare exceptions, carcinoma of this organ is secondary to similar growths in other parts of the body. To explain its origin it may safely be assumed that the primary new growth involves a vein or lymph- channel, and that the latter carries the germ of the disease to the lung. It is also to be recollected that it may result from extension, or by contiguity from neighboring organs (as the esophagus, mamma, pleura, or mediastinum). Ktiology. — The causes of primary carcinoma of the lung must be, in the main, identical with those of carcinoma in general, and are as yet unknown. Most cases occur in middle-aged persons, and, while sex has no influence upon the appearance of the primary form of the disease, the secondary form is more frequent in the female than in the male. In the female secondary carcinoma of the lung is often preceded by car- cinoma of the breast. We may also regard hereditary influence as a potent predisposing factor. Secondary carcinoma of the lung is most commonly consecutive to primary carcinoma of the bones, and of the digestive and urinary tracts. Pathology. — The pathologic varieties of the primary form are scirrhous, encephaloid, and epithelioma, and of these the latter is the most common. Primary carcinoma is usually unilateral, the tumors at- taining to a massive size and frequently involving the greater part of one lung. Their favorite seat is in the upper part of the right lung, though the pleura is quite often invaded by the carcinomatous process. Less frequently there is pleurisy with sero-fibrinous exudate, which may be hemorrhagic. Carcinomatous involvement of the cervical, bronchial, and tracheal lymph-glands is quite usual, and rarely even the inguinal glands become implicated. Secondary earcinomata are, as a rule, multiple, and may be miliary in size. They are disseminated widely throughout both lungs, though in the rarest instances they may be unilateral. In the softer varieties the central portion of the tumor-mass may undergo fatty degeneration, with subsequent discharge through adjacent bronchi. Symptoms. — The symptoms of carcinoma of the lung vary accord- ing to the location and extent of the disease. Among the most marked symptoms belongs pain, particularly Avhen the pleura is implicated. As a rule, for a considerable period of time the symptoms of bronchitis obtain, and later the breathing-space is diminished sufliciently to excite dyspnea and cyanosis. With the increase in size of the new growth compression of the heart, aorta, and large veins may result, whereupon disturbances of the circulation will arise. The new growth may exert pressure on the esophagus, causing dysphagia ; or upon the recurrent laryngeal nerve, causing aphonia and hoarseness ; or on the trachea or a main bronchus, followed by the symptoms of stenosis of those organs. There are cough and expectoration, the latter fre([uently containing blood-corpuscles with mucus, and resembling in appearance currant- jelly; the sputa may also rarely exhibit a grass-green color, due to trans- formation of the blood-pigment. In carcinomatous lungs putrefactive changes sometimes take place, and if so the expectoration and breath SARCOMA OF THE LUNG. 539 emit an offensive odor, while a microscopic examination of the sputum frequently discloses the presence of carcinomatous elements. The well- known cancerous cachexia invariably develops. Physical Signs. — These will naturally depend upon the extent and location of the ncAV growth. Inspection. — If the lung-tissue be exten- sively involved, the walls of the thorax become unduly prominent and fixed over the seat of the tumor. Indeed, the tumor may, though rarely, protrude between the ribs. The intercostal spaces are widened, and the superficial veins, in view of the fact that they cannot empty themselves into the internal veins, appear engorged ; from the same cause edema afi"ecting the thorax, neck, face, and arms may be noted. Swelling of the lymph-glands in the neck or axilla is often witnessed, and is a symptom of high importance. On palpation the tactile fremitus may be found to be diminished or absent. The p>ercussion-note will be flat, since the air-vesicles and smaller bronchi are replaced by the solid growth. On auscultation friction-sounds are the rule. The respiratory sounds may be greatly enfeebled or absent; but if the carcinomatous tumor communicates with a wide-mouthed bronchus, bronchial breathing may be audible, and the usual physical signs of lung-cavity may be developed. The signs of general bronchitis are present in most instances, being most pronounced in the secondary or disseminated form of the disease ; in the latter variety the lung may shrink, forming a condition in which retraction of the chest-walls on the affected side must ensue. If pleurisy with effusion occurs as a secondary event, the detection of the charac- teristic cancer-cells in the contents of the pleural cavity will show the precise nature of the thoracic affection. Diagnosis. — The following symptom-group will pretty well estab- lish a diagnosis : A peculiarly shaped dull area (as when it extends under the sternum), perhaps a marked prominence over the site of the tumor, enlarged and hard lymphatic glands in the vicinage, and more or less of the compression-symptoms — circulatory, nervous, bronchial, or trachial stenosis. In rarer instances the diagnosis may be made by the occurrence of metastasis to the chest-wall. Again, the discovery of cancer-tissue in masses accidentally detached gives reliable indication of the disease. The differential diagnosis between pulmonary carcinoma and pul- monary tuberculosis can be made Avith positiveness only by a careful microscopic examination of the sputum. From fibroid induration of the lung it is easily discriminated, owing to the history and slower course of the latter affection. Prognosis. — This is bad, as death may occur suddenly from abun- dant hemorrhage or more frequently from either exhaustion or asphyxia. The duration of the affection varies from six months to a year, or, rarely, even two years. Treatment. — The treatment must be addressed solely to the relief of pain and other subjective symptoms. SARCOMA OF THE LUNG. Primarv sarcoma of the lung is rare, but in instances of generalized sarcomatosis the lungs show larger or smaller nodules " in almost every 540 DISEASES OF THE RESPIRATORY SYSTEM. case " (Birch-Hirschfeld), occurring in connection -with osteo-sarcoma of other organs or in lympho-sarcoma of the cervical glands. Secondary sarcoma, occurring in consequence of invasion of the root of the lung by sarcomatous disease of the post-bronchial glands, is also a not uncommon condition. Neoplasms occurring among the cobalt-miners of Schneeberg were described by Hesse and Tragner as lympho-sarcomata — slowly groAving masses that attained to a large size and gave metastasis to lymph-glands, pleura, liver, and spleen. In a majority of these cases there was an asso- ciated pneumonokoniosis, which had probably predisposed to the new growth. HYDATID CYST OF THE LUNG. Hydatids in the lungs may either be primary or secondary, the former variety being exceedingly rare, and the latter somewhat less so. Almost invariably the echinococci are developed in other organs — the liver in particular — and find their way to the lungs, either by direct perforation through the diaphragm or by entering through the blood-current. The etiology and pathology will be considered at sufficient length in connection with Hydatid Cysts of the Liver. Symptoms. — Tlie clinical manifestations are quite varied, even though the cyst may entirely conceal itself. It is important to recollect that similar involvement of the liver usually coexists ; and in addition to the symptoms of the latter affection there may be pain in the chest, dyspnea, considerable cough, and, rarely, blood-stained expectoration. The physical signs, when present, are as follows : Diminished vocal fremitus, defective expansion, dulness on percussion with an absence of the respiratory murmur, and later signs of cavity-formation may appear. A positive diagnosis of hydatid cyst of the lung can be made only when the scolices, pieces of membrane, and the booklets of the echinococcus are demonstrable in the sputum. Besides being evacuated into the bronchi, the cysts may rupture into the adjacent serous sacs (pleura, peritoneum, pericardium), or externally, the latter being the most favorable mode of termination. Unless they are discharged early by ulceration into the bronchi or externally, they are apt to excite in- flammation of the adjacent lung-tissue and tubes, accompanied by an active febrile movement and an aggi'avation of the symptoms before de- tailed : these complicating conditions may assume a dangerous form, or the patient may, if the growth attains large dimensions, become asphyx- iated. Prognosis. — The affection is always attended with great danger, and is of more serious import when secondary to involvement of the liver than when primary. Treatment. — When it can be shown that the growths are situated at the periphery of the lung operation should be carefully considered. The physician stands powerless to do more than to relieve urgent symp- toms in special cases and to support the vital functions. DISEASES OF THE PLEURA. 541 V. DISEASES OF THE PLEURA. PLEURISY. {Pleuritis.) Definition. — An inflammation, either local or general, of one or both pleural membranes. The disease, as shown by postmortem exam- inations, is of great frequency. Varieties. — Pleurisy has been variously classified. Etiologically, the distinction between primary and secondary forms of the disease should be made, as well as a division into tuberculous, carcinomatous, septic, etc. Pathologically, all cases may be summarized under the following heads : Localized and generalized and dry (plastic) pleurisy and pleurisy Avith eifusion (sero-fibrinous, purulent, hemorrhagic). They may also be classified according to their duration into acute, subacute, and chronic pleurisies. I shall describe the following forms, which are based partly upon their etiologic and clinical course, though mainly upon their pathologic manifestations — viz. («) acute plastic pleurisy ; (h) sero-fibrinous pleurisy ; (c) purulent pleurisy (empyema) ; and (d) chronic adhesive pleurisy. Bacteriology. — In all forms of the disease the direct causes are various micro-organisms or their irritating chemical products. Con- spicuous among these is the bacillus of tuberculosis, even, though rarely, found in the pleuritic exudate. Inoculation of guinea-pigs with the latter by Eichhorst gave positive results in 15 out of 23 cases, and by La Damany in 47 out of 55 cases. Although rarely containing bac- teria, Netter, Prudden, and others have found in the exudation of fibrino-serous pleurisy the streptococcus pyogenes, the staphylococcus, the typhoid bacillus, and the diplococcus of pneumonia. The micro- organisms most commonly present in empyema are the micrococcus lanceolatus and the streptococcus, the former especially in the pleurisy associated with pneumonia (in two-thirds of the cases occurring in children — Levy), and the latter in those independent of pneumonia, particularly in adults. Among other bacteria that have been found rarely in the effusion are the colon bacillus, the proteus vulgaris, the gonocoGcus, Friedldnder s bacillus, and various saprophytic bacteria. Except in the case of the pleuritic exudation (usually purulent) in pneu- monia, in which the diplococcus is alone present in about one-half of the cases, the afore-mentioned micro-organisms are generally found in asso- ciation. ACUTE PLASTIC PLEURISY. {Dry, Fibrinous Pleurisy.) Pathology. — The lesions are usually circumscribed, the part in- flamed being intensely injected. It has lost its natural lustre, and instead has a dull, non-glistening surface "like a tarnished mirror," due to a slight fibrinous exudate. Minute ecchymoses are seen at dif- ferent points. Later the exudate may become more copious, when the 542 DISEASES OF THE RESPIRATORY SYSTE3L pleura presents a rough, shaggy appearance. On account of the fric- tion between the two pleural membranes in high grades of dry plastic pleurisy, the exudate may be very thick, and its color-appearance is then yellowish- or reddish-gray. This sheeting of fibrinous exudate entangles in its meshes numerous embryonic round cells, out of which blood-vessels and connective tissue are developed. The opposing sur- faces of the pleura adhere. Occasionally, in the lighter grades, the disease does not advance to firm adhesion, and in such instances the products of the exudate undergo fatty degeneration and are absorbed. The respiratory movements are but little disturbed in these cases. etiology. — The affection may be (a) primary or (b) secondary, (a) By the primary form is meant an inflammation of the pleura occur- ring in previously healthy persons. It is exceedingly rare, and doubt- less many instances of true secondary pleurisy are regarded as belong- ing to this category. Aschoff's studies of 200 cases of pleurisy showed 41 to be idiopathic. Of great etiologic prominence is exposure to cold and Avet, and next to this stands mechanical injury. It is more com- mon in men than in women, and especially during the time of active life, on account of the greater degree of exposure of the fornier than the latter sex. In almost all instances a careful search will disclose the existence of some diathesis (tuberculous, gouty, rheu- matic) that may be properly regarded as the favoring cause. The changeable weather of the Avinter and spring augments the propor- tion of cases during these seasons as compared Avith summer and autumn. [b) The secondary form of dry plastic pleurisy arises from extension of acute and chronic inflammatory affections of the lungs and other neighboring organs. Hence it frequently follows croupous pneumonia, someAvhat less frequently broncho-pneumonia, and more rarely still hemorrhagic infarct, abscesses, and pulmonary carcinoma and gangrene. AYhen pleurisy occurs on the right side it must be recollected that it may have originated in hepatitis. Plastic pleurisy sometimes arises in acute articular rheumatism, to which it may essentially belong. It is an almost constant accompaniment of chronic pulmonary tuber- culosis, and may, though rarely, even constitute the primary lesion (primary tuberculous pleurisy). The disease may appear as a com- plication in chronic alcoholism and in chronic Brights disease. Finally, inflammation of other serous membranes, as of the pericardium and peri- toneum, by direct extension through the lymphatics of the diaphragm, may invade the pleura. Symptoms. — The affection may vary in intensity betAveen the ex- tremes of mildness and great severity, though, as a rule, Avell-marked local symptoms attend the onset. Among the latter a sharp '"'■ stitch " in the side, that is usually referred to the nipple, is the most prominent. The pleural pain is increased by inspiration as Avell as by voluntary motion of the affected side, and hence the patient assumes a fixed position in Avhich he favors the affected side by leaning tOAvard it. There is a dry, distressing cough that is restrained for obvious reasons, and the respiration is somewhat hurried, painful, and jerking in character until the exudation is poured out, Avhen relief from this and other local symp- toms ensues. ACUTE PLASTIC PLEURISY. 543 The general svmptoms are not pronounced, and, save in compara- tively rare instances, do not correspond Tvith the local signs. The tem- perature is not typical, rarelv exceeding 103° F. (39.4° C), and more often it is below 101° F. (38.3° C). The pulse is usually small and tense or soft in character, registering from 90 to 120 beats per minute. Not infrequently the cases are so mild as to be attended by few, if any, subjective symptoms. The patient may complain of ill-defined, uneasy sensations in the affected side, but does not discontinue his usual occu- pation. On the other hand, the worst cases of acute plastic pleurisy — which, fortunately, are rare — manifest violent symptoms : there is a distinct chill, a speedy development of high fever (104° F. — 4.0° C), and profound prostration, and the general and local symptoms are pro- portionately aggravated. The illness then is often a fatal one. Physical Signs. — On inspection the movements of the chest-wall on the affected side are observed to be much restricted, particularly during the first day of the affection. During a later ])qy\oqI paJpation confirms the results of inspection, while p)ercussion yields a normal note. Aus- cultation renders audible a grazing friction-sound, which, though audi- ble, is most intense at the end of inspiration. With the occurrence of fibrinous exudation palpation detects over the corresponding area a diminution of the tactile fremitus. On percussion there is, as a rule, a slight though variable degree of dulness ; and on auscultation the crepitating or rubbing friction-sounds are heard both on inspiration and expiration, being intensified by deep breathing. These sounds frequently endure for a day or two after the other symptoms have disappeared. Very rarely the plastic exudation may be so extensive as to cause compression of the lung, in which instance the breath-sounds may become bronchial in character ; and I have known a case of this sort to be mistaken for lobar pneumonia. In addition, the breath-sounds wdll be feeble and distant. Diagnosis. — By exercising ordinary care the clinician can scarcely mistake other thoracic affections for dry pleurisy, the latter being diag- nosticated to a certainty by the presence of the characteristic friction- murmur. Intercostal neuralgia may present features not unlike those of acute pleurisy. In both affections there is frequently a history of exposure, followed by severe chest-pains that are excited by coughing and deep breathing. In neuralgia, however, there are painful pressure- points, and the pleuritic friction-sound does not occur. Pleurodynia may also give a history very similar to that of acute pleurisy, but the presence of the characteristic physical signs of pleurisy are absent. Prognosis. — The duration of the affection varies from a few days to three weeks, and the immediate outcome is favorable as a rule. It cannot be doubted, however, that a primary attack predisposes to subse- quent attacks, and thus, as a result of repeated seizures, pleural thicken- ing and intrapleural adhesions often arise. Lung-expansion may in this manner be restricted, with the gradual development of interstitial pneu- monia as a consequence. Acute plastic pleurisy is not infrequently a terminal condition in serious forms of illness (e. g. septicopyemia and chronic nephritis). Treatment. — The first object in the treatment is to relieve the pain, and this can best be accomplished by the hypodermic use of mor- 544 DISEASES OF THE RESPIRATORY SYSTEM. phiu. The inflammatory process is best controlled by absolute rest in the recumbent posture, allowing the patient to assume that position which gives him most comfort. I am also in the habit of administer- ing moderate-sized doses of ijuinin (gr. iv — 0.259 — three times daily). After the exudation has appeared, the iodids of iron and potassium, in combination, may be employed. Locally, nothing is so effective as cold in the form of the ice-Avater bag or Leiter's coil, preceded, in robust patients, by the local abstraction of blood (.^iij to vj — 96.0- 192.0) by leeches. At the end of one week the morphin may usually be discontinued. During convalescence the patient should be instructed to take deep inspirations several times in succession, not less than a dozen times each day, with a view to obviating so far as possible the pleural adhesions and other unfavorable consequences. Symptomatic anemia may be present at this time, and should be met by iron given internallv. At this time iodin may be used locally with great benefit; I have not, however, seen any favorable results from blisters. For the pain which continues in the side after all detectable physical signs have disappeared the use of the constant current over the seat of the pleur- isy for twenty minutes at a time gives almost instantaneous relief (Loomis). SERO-FIBRINOUS PLEURISY (PLEURISY WITH EFFUSION, SUBACUTE PLEURISY). Pathologfy. — During the first stage of sero-fibrinous pleurisy the changes are the same in character as those met with in dry pleurisy, though of severer grade, and usually involving the greater portion of the pleura on the side affected. There is an abundant exudation of serum, and usually the entire pleura becomes coated with a fibrinous exudate, that varies greatly in thickness and arrangement. The latter is thin and smooth in .some instances, though more frequently it forms a thick layer, presenting a shaggy surface on the one hand or an irregular, honeycombed surface on the other. Lymph in the form of flocculi is rather abundant in the serous effusion. The interlobu- lar pleural surfaces are also invaded as a rule, in consequence of which they become adherent. The fluid exudate varies greatly in quan- tity (J to 8 pints — 4 liters), is often of a citron color, and is, in the ma- jority of instances, clear or slightly turbid. Rarely it is of a dark- brown color. Unless adhesions between the pleural surfaces have previously existed the effusion gravitates to the most dependent portion of the pleural cav- ity. Microscopically, there are found leukocytes, red blood-corpuscles, endothelial cells, threads of fibrin, and, rareW, crystals of cholesterin and uric acid. The composition of the fluid is almost identical with that of blood-serum, and on boiling it is found to be rich in albumin. Spon- taneous coagulation may take place on standing. Changes in the Xeighhoring Organs. — So long as the normal retrac- tility of the lung is not overcome by the fluid that collects in the pleural cavity, the latter does not produce positive intrathoracic pressure, and hence does not produce displacement of adjacent organs. It may be assumed that until the pleural sac is at least one-half filled with sero- SEBO-FIBBINOIJS PLEURISY. 545 fibrinous exudate the natural contractility of the lung is not destroyed. At this period there may be a slight displacement of the mediastinum toward the opposite side, due to traction exerted by the normal retrac- tility of the sound lung. Obviously, large eflfusions must in a mechani- cal manner displace the pleural membranes, thus causing compression of the pulmonary structures lying above the eftusion. A very copious eflfusion may push the lung up and back against the vertebral column and convert it into a small, flat, bloodless, and airless mass (atelectasis). While a total absence of air in the collapsed lung is due chiefly to com- pression by the fluid, to some extent, however, the air may be absorbed by the vessels or even by the eff"usion (Strlimpell). Together with compression of the lung by the efixision, pressure is also exerted by the latter against the mediastinum, causing displacement of the heart. The mediastinum also loses the normal traction-force of the lung upon the affected side, and hence the lung on the sound side draws the mediastinum toward itself by its own retractile energy. Osier shows that even in the most extensive left-sided eff"usion the heart's apex is not rotated, but that the normal relative position of the apex and base obtain, though the apex is in some instances lifted, and in others the heart lies more transversely. The right chambers of the heart occupy most of the anterior part of the organ, showing that the displacement of the mediastinum with the pericardium and its contents to the right involves no appreciable twisting of the heart itself. Downward displacement of the diaphragm takes place in extensive eff'usion, and shows itself on the right side by the lowering of the liver to a variable distance below the inferior costal border ; on the left side large effusions produce pressure-displacement of the stomach and the transverse colon, and, to a slighter extent, of the spleen. It must be recollected that adhesions may prevent displacement of any of the adjacent organs. Ktiology. — In the present state of our knowledge the causal factors are identical in nature with those producing dry plastic pleurisy. It is highly probable that the degree of severity is dependent upon the pre- vious condition of the patient, whether he be suffering from some other aff"ection or not, and upon the amount of specific poison gaining access to the pleura. The affection may be i^rimary, but is much more often secondary ; and this fact may be explained by reference to any of the specific micro-organisms producing the affection. Direct Causes. — Many of the cases follow quickly upon exposure to cold or wet or an injury to the thorax. I thoroughly agree with those authors who contend that about three-fourths of the cases of sero- fibrinous pleurisy are induced by tuberculous infection of the pleura. The tuberculous process may invade the pleura primarily, but more often it is secondary to tuberculosis of the lungs ; less frequently, though oftener than is generally supposed, it is secondary to tubercu- lous peritonitis. In these instances the tubercle bacilli probably find their way from the peritoneum to the pleura by traversing the lymphat- ics in the diaphragm. Resinelli believes that pleurisy with effusion may be the direct result of neoplasms of the ovaries. I am con- vinced that a large percentage of apparently primary cases of tubercu- 35 546 DISEASES OF THE RESPIRATORY SYSTEM. lous pleurisy have their origin in a circumscribed and more or less latent tuberculous focus in the lungs. It is not improbable also that tuberculous processes in other A'iscera may furnish the tubercle bacilli for secondary pleural infection. Moreover, the fact that many cases of sero-fibrinous pleurisy recover does not disprove their tuberculous nature. The affection is not infrequently secondary to acute articufer rheu- matism, -which is itself most probably a microbic aifection. It also arises as a complicating condition in the course of various acute and chronic affections of the chest, as pericarditis and catarrhal pneumonia, and may develop in acute infectious diseases, as typhoid fever or lobar pneumonia. The typhoid bacillus of Eberth has also been knoAvn to provoke pleurisy (Bozzolo, Fernet, and others).^ It may occur as a com- plication in the chronic affections of various viscera (chronic nephritis, cirrhosis and carcinoma of the liver). The predisposing causes are the same as for the dry plastic form. Symptoms. — The description here refers particularly to primary sero-fibrinous pleurisy, and it is important to recollect that when second- ary to other acute and chronic affections characterized by great bodily weakness the pleuritic symptoms may be more or less completely veiled. With few exceptions the onset is insidious, the symptoms being quite mild ; but rarely there is a sudden onset with active symptoms (risor, high fever). In the majority of instances the patient first ■complains of a sfitch-Iike pain in the side; this is rarely pronounced, l)ut is aggravated upon deep breathing and upon any muscular exertion. Dyspnea soon arises and gradually increases in intensity. Cough may be present or absent, and in some instances is attended by a scanty mucoid expectoration that may rarely be blood-streaked. The constitutional symptoms are of correspondingly slow and gradual development. From the commencement of the attack a moderate febrile movement at night may be observed, and the pulse will be found to be frequent, small, and compressible, or, more rarely, tense. At the time of the patient's first visit to his physician he may give a history of having gradually lost flesh and strength for a period of weeks together, though he may not have been obliged to abandon his vocation. He looks pale, his countenance wears an anxious expression, and he is without appetite. These cases frequently drag along from two to four weeks before con- sulting a physician, the local symptoms going unnoticed, and the patient making complaint only of weakness, anorexia, headache, etc. Sometimes the more acute symptoms characterize the period of invasion, and, after lasting a few "days, exhibit a decided remission ; but at another subsequent period there may be a sudden recurrence of the local and general phenomena, and particularly of the dyspnea. The pleural cavity, which may have been one-half or two-thirds full, now becomes completely filled. Special Symptoms. — Pain. — Chest-pain is an almost constant but not highly characteristic symptom, and, though usually among the earliest symptoms, it may not be present until a few hours or a day after the commencement of the affection. It may be described as a sharp, shoot- ing pain, and is popularly termed a " stitch in the side." It may, how- ever, be tearing or dragging in character. Its intensity is not a safe in- 1 Annual of the Universal Medical Sciences, 1892, vol. ii. p. 12. SERO-FIBBINOUS PLEURISY. 547 dication of the severity of the disease. It is usually referred to a small spot below the nipple or to the mid-axillary region ; exceptionally, how- ever, it is more diflfuse, and in my experience it has not infrequently been retrosternal or referred to limited areas below the inferior costal border. When absent it may be excited by coughing, sneezing, deep inspiration, and stooping. With the appearance of the effusion the pain diminishes, and, as a rule, soon disappears. Dyspnea. — The respiration is shalloAv, catching in character, and hurried in consequence of the severe pleural pain ; in copious effusions, that render one lung almost or wholly functionless, the dyspnea may become intense, even attaining to well-marked orthopnea. It reaches its most pronounced form in persons who have previously been robust, and in those in whom the effusion has developed rapidly. On the other hand, when the pleural sac fills slowly dyspnea may be absent, except on exertion. This symptom appears frequently before the effusion takes place, and is then due partly to the fever and partly to the pleuritic pain. Following marked disturbances in the respiration, cyanosis ap- pears and may become quite pronounced. Cough and Expectoration. — Little need be added to what has already been stated. When there is present much expectoration it is most fre- quently due to associated bronchitis or to pulmonary tuberculosis ; there may, however, be a total absence of expectoration, and in such instances the exciting cause of the cough is probably the pleuritis. Both the cough and expectoration are apt to be increased during the process of resorption of the exudate as the result of a catarrhal bronchitis that is prone to develop in the re-expanding lung. Fever. — The rise of temperature is not rapid as a rule, nor does it reach a high point (101.5° to 103° F.— 38.6°-39.4° C). At the end of a variable period — usually one to three weeks — the temperature falls I)y lysis, and soon touches the normal. The temperature may be of the continued type in many acute cases. In subacute forms the temperature may rarely \-ise above 101° F. (38.3° C), or may, finally, assume a hec- tic type. The surface-temperature of the affected side is from one-half to two degrees (.4°-1.6° C.) higher than that of the normal side. Pulse. — The pulse is quickened, beating 100 or more per minute, and its volume and tension are diminished. Irregularity both of the volume and rhythm of the pulse may also be observed. These pulse- characteristics are to be attributed to the pressure of the effusion upon the heart and great vessels. G-astro-intestinal Symptoms. — Loss of appetite is commonly present, and more rarely nausea and occasional vomiting may be met with at the outset. Constipation is the rule. Renal Symptoms. — The amount of urine is diminished both during exudation and while the exudate remains at the same level. The daily quantity may not exceed eight or ten ounces, but the specific gravity is increased, rano-ino- from 1018 to 1028. Rarely, the quantity is increased Avith existino- effusion. An increase in the daily amount of urine ex- creted is frequently the first sign of commencing absorption of the exudate, and the rapid resorption of the copious effusion may greatly auo-ment the flow of urine to 80 or 100 ounces (2.5 to 3 liters) daily (Strlimpell). The cause of the diminished secretion of urine is, in the main, diminished arterial pressure. 548 DISEASES OF THE RESPIRATORY SYSTEM. Physical Signs. — The physical signs of sero-fibrinous pleurisy differ with the camount of effusion present, and also Avith the particular stage of the affection : those of the first stage, however, are identical with the signs pointed out in connection with dry plastic pleurisy, and need not be restated here. We will note the physical signs (1) during the stage of effusion, as well as (2) those presented when resorption of the effusion has taken place. (1) Stage of Effusion. — When the pleural sac is only partly filled there is noted, on inspection., but little change in the thoracic contour. The respiratory movements are, however, restricted, owing to mechani- cal hindrance to the lung-expansion. In the majority of instances the effusion increases until positive intrathoracic pressure and noticeable bulging in the middle and lower third of the chest-wall on the affected side take place ; the intercostal spaces below are widened and more or less nearly effaced. The apex-beat of the heart is displaced, being visible in right-sided pleurisy to the left of the vertical mammary line in the fourth and fifth interspaces, and in left-sided pleurisy to the right of the right mammary line, or even beyond, in the third and fourth in- terspaces. The apex of the heart may take a position behind the ster- num, when no impulse Avill be visible. Palpation. — The limited movement of the chest is readily appreci- ated on palpation, and in large effusions the chest-wall is practically fixed. The separation of the ribs and the obliteration of the intercostal spaces are easily made out in the same manner. Edema of the chest- wall is rarely present, and fluctuation almost never. An important and early physical sign is the diminished tactile fremitus, which is soon abolished, except in infants, in whom it may be excited on crying. This is a less valuable sign in women than in men, owing to the differ- ences in the vocal vibrations in the two sexes. In copious effusions tac- tile fremitus may sometimes be obtained when bands of adhesion, which serve as a medium for the transmission of vocal fremitus, connect the pulmonary with the costal pleura. The apical .impulse can also be readily located by palpation. The displaced spleen or liver can be read- ily felt through the abdominal wall, and must not be mistaken for an actual enlargement of these organs. Mensuration. — It must not be forgotten that in right-handed adults the right side is, normally, slightly larger than the left ; and it is only after the effusion is considerable in amount that the cyrtometer shoAVS any alteration in the tlioracic contour or an enlargement of the affected side. The tape, however, exhibits the difference in expansive motion of the two sides early, or Avhen there is a moderate amount of fiuid. At the end of expiration the circumference of the affected side will be found to be one or two inches greater than that of the left side, Avhile at the end of inspiration the difference Avill be but slight. The cyrtometric tracing also shows a discrepancy betAveen the horizontal outlines of the tAvo sides. Percussion. — At first the percussion-note is impaired, either poste- riorly or in the infra-axillary region, and a little later there is dulness, tending toAvard flatness (deadness), with increasing effusion. The resist- ance to the pleximeter-finger becomes greatly augmented. In cases in Avhich the effusion rises to the fourth rib anteriorly there is dulness over SEBO-FIBRTNOUS PLEURISY. 549 the fluid above and absolute flatness below. Since both, the flatness and dulness are due to the fluid, it is obvious that the upper level of the latter must, whenever free, change with the posture of the patient ; hence the limit of dulness will be higher in the sitting than in the re- cumbent position. When the pleural sac is filled or when the effusion is confined by adhesions, the latter sign is not obtainable. Displace- ment of pleuritic fluid when the patient's position is changed and also Avith the movements of the diaphragm has been noted with the fluoro- scope (Bergenia and Carriere). If the upper level of the fluid reaches the lower border of the third rib, the percussion-note above the line of dulness is tympanitic or vesiculo-tympanitic {Skoda s resonance). In copious exudations the cracked-pot sound may be elicited immediately below the clavicle in the usual manner, and " Williams s tracheal tone " may sometimes be obtained in large exudations. This may also be obtained near to the spine on the affected side or at a point correspond- ing to the seat of the compressed lung. When the patient is sitting or in the erect posture the upper limit of dulness in large effusions is not a horizontal line, but is highest at the spine and falls as we proceed to the front, which is its lowest point. The upper line of dulness in moderate effusions begins " relatively low down in the back, passes upward from the vertebral column, and soon turns upward and proceeds obliquely across the back to the axillary region, where it reaches its highest point ; thence it advances in a straight line, but with a slight descent, to the sternum " (Ellis). This curved line resembles the italic letter S (Garland). On the right side the flatness is con- tinuous with that of the displaced liver ; on the left it passes into and may obliterate Traube's semilunar space. Auscultation — -The signs of the first stage have already been de- scribed {vide Plastic Pleurisy). With the appearance of the effusion the breath-sounds become weak, distant, and have a bronchial quality. Soon the respiratory sounds over the affected side will be entirely ab- sent, except near the upper level of the fluid posteriorly, where distant bronchial breathing is audible. The latter sounds may exhibit a metallic or amphoric quality, and may be accompanied by rales (pseudo-cavernous signs). The latter are more frequently met with in children than in adults, and often give rise to a false diagnosis. Above the level of the fluid there is broncho-vesicular breathing, and on the opposite side in- tensified breath-sounds may usually be noted. In pneumonia with pleural effusion there may be loud and persistent bronchial respiration over the exudate. The vocal resonance may manifest a nasal or metallic qual- ity, simulating somewhat the bleating of a goat {Laennec's egophony). This is best obtained near the upper level of the fluid in large effusions, and at or above the angle of the scapula w^hen the effusion is moderate. (2) Stage of Resorption. — With resorption of the fluid there is a de- crease in the size of the affected side, together with a return of the nor- mal appearance of the intercostal spaces and the respiratory movements. In many instances there is positive retraction, leading to thoracic defor- mity with displacement of neighboring organs toward the affected side ; and this retraction may be either general or circumscribed. The infe- rior intercostal spaces are more or less narrowed ; the shoulders droop ; the nipple approaches the median line ; the spine may be curved, the convexity being directed toward the sound side (quite rarely toward the 550 DISEASES OF THE RESPIRATORY SYSTEM. affected side); and the scapula projects from the chest- wall on the af- fected side. In children, and even in adults, the lungs and thorax grad- ually expand in order to overcome this chronic deformity. On the other hand, the extensive adhesions between the pleural membranes produce permanent shrinkage of the thorax and embarrassment of respiration. Palpation. — The tactile fremitus closely follows the fluid as it sub- sides from above downward without any extreme degree of thickening of the pleural membranes, though cohesion of their surfaces may pre- vent its return over the lower segment. The inspiratory movement of the chest-wall gradually returns, but not to its former limit. Mensuration shows a steady diminution in the size of the side in- volved, which finally becomes smaller than its fellow. Percussion. — The dull or flat note gives way to normal percussion- resonance, proceeding from above downward in a gradual manner ; but the latter is not renewed over the lower portion of the pleural cavity for a long period after the exudation has disappeared. The abnormal areas of flatness due to displacement of organs (liver, spleen, heart) also disappear. Auscultation discloses most important signs during the stage of re- sorption. The breath-signs reappear at first above, and then lower down, until the base is reached. With commencing subsidence of the fluid the respiratory sounds are feeble and distant, but later they resume their natural distinctness ; and partly as a result of the revival of the natural muscular tonicity, and partly in consequence of the disappear- ance of the fluid, the two roughened pleural surfaces come in contact and play upon one another, giving rise to a rubbing, creaking friction- sound on auscultation. These friction-murmurs may persist for months after the eff"usion has been absorbed. Occasionally the lower portion of the compressed lung remains permanently inexpansile, and usually in such circumstances the upper portion of the lung is the seat of com- pensatory emphysema, which is recognizable by the customary physical signs. By auscultation we may note the return of the heart-sounds to their normal position. Special Clinical Forms of Acute Sero-fibrinous Pleurisy. — The separate varieties are dependent upon the nature of the efiusion and the character of the etiologic factors, and in this connection the main clinical features of a few special types may be briefly described. They are as follows : (1) Tuberculous Pleurisy. — This is, in the majority of instances, second- ary to pulmonary tuberculosis. On the other hand, the primary lesions may be situated in the pleural sac and give rise to (1) Acute sero-fibrinous j)Iewiv/ (with the usual course) ; (2) Subacute pleurisy (with insidious course), leading to tuberculous invasion of the lungs ; and (3) Chronic adhesive pleurisy, in which the course and physical signs correspond with those that will be depicted in a special section on Chronic Pleurisy. The morbid lesions are similar to those met with in other forms, plus the specific tubercles, which may be exceedingly numerous (miliary tubercles) on the one hand, or confined to a few circumscribed areas on the other. This variety of pleurisy has no special etiologic connection Avith empyema, and the eff"usion is usually sero-fibrinous and often blood- stained. Brief reference should be made to those instances in which tubercu- 8ER0-FIBRIN0US PLEURISY. 551 lous pleurisy is followed by tuberculous pericarditis or peritonitis, or both. The two latter aiFections will be considered elsewhere. Suffice it to state here that tuberculosis of the serous membranes usually pursues a chronic course, lasting a year or more, and exhibits Avidely varying degrees of intensity in its symptoms in different cases, and from time to time in the same sufferer. We must grant that tuberculous pleurisy may pursue a favorable course with apparent recovery, though too often, after a variable interval of time, tuberculous symptoms are manifested. (2) Diaphragmatic Pleurisy. — This term is applied to those instances in Avhich the diaphragmatic portion of the pleura is involved, either alone or in part. There occurs an exudate that may be either plastic or sero- fibrinous, though rarely large in amount. The iym'ptomsi are acute, and the pain, which is lancinating in character and situated in the epigastric region, is the most prominent feature. Geuneau de Mussy ^ holds that pain along the tenth rib, extending from the anterior extremity to the sternum and xiphoid cartilage, is pathognomonic. It is increased by deep inspiration and by pressure over the insertion of the diaphragm at the tenth rib, and often abates when effusion takes place. Dyspnea is a marked symptom in most cases, and the patient may be forced to assume a stooping or sitting posture, the respirations being superficial, purely thoracic, and "catching." Cough, nausea, and even vomiting, may occur. In a case under my own care vomiting, due most probably to associated peritonitis, Avas a troublesome symptom. The constitutional features are quite pronounced, and particularly the fever, Avhich exceeds that met with in other forms of pleurisy. The patient's anxiety is extreme. The effusion may be purulent, and if so bulging of the lower intercostal spaces, folloA\'ed by edema, may occur. The physical signs are for the most part negative. (3) Encysted Pleurisy. — This term has reference to effusions that are circumscribed in consequence of adhesions between the pleural mem- branes. There may be tAvo or more pouches, Avith or Avithout communi- cation. This so-called encapsulated pleurisy may occupy any part of the chest, and is exceedingly variable in extent. The symptoms and physical signs are rarely trustAvorthy for diagnosis, but should usually afford ground for suspicion, and hence should lead in every instance to the employment of the exploratory puncture. (4) Interlobar Pleurisy. — This variety is usually secondary to, or associated Avith, the ordinary type of acute sero-fibrinous pleurisy. The serous surfaces, dipping betAveen the lobes, are involved in the inflam- matory process, and the fluid becomes encapsulated in this position in consequence of interlobar pleural adhesions. It is more frequent on the right than on the left side, and its favorite seat is near the root of the lung, betAveen the upper and middle lobes. Osier ^ met AA'ith a case folloAving pneumonia in which there was betAveen the lower and upper and middle lobes of the right side an enormous purulent collection that looked at first like a large abscess of the lung. Fistulous connection with a bronchus often occurs, and the purulent expectoration that folloAvs may be the first symptom to attract the attention to the process of sup- puration in the thorax. Prior to the occurrence of this accident the patient gives evidence of indisposition Avithout definite symptoms. The ^ Arch. gen. de Med., 1853, vol. xi., quoted by Fox. '^ Practice of Medicine, p. 567. 552 DISEASES OF THE RESPIRATORY SYSTEM. patient may or may not give a clear history of antecedent pleurisy. These cysts contain, as a rule, but a small amount of fluid, and do not cause much bulging of the intercostal spaces. Indeed, in a case of my own at the Philadelphia Hospital there was actual retraction, though the aspirating needle showed the presence of effusion.' (5) Hemorrhagic Pleurisy.— By this term is meant an admixture of Fig. 47.— lUustrating pleurisy with effusion : 1, compressed lung-tissue, giving dull tvmpanv on per- cussion ; 2, fluid exudation obliterating intercostal spaces ; 3, depressed liver ; 4, displaced heart. blood with the exudate in acute sero-fibrinous pleurisy, in (quantities suf- ficient to be detectable by the unaided eye. The condition must be sep- arated from hemothorax. The causes of hemorrhagic pleurisy are — (1) Tu- berculous infection, either of the miliary or the chronic (circumscribed) form, following tuberculous disease of the lung ; (2) Carcinoma of the pleura ; (3) Bright"s disease and cirrhosis of the liver ; (4) Adynamic states of the system associated with malignant forms of acute infectious diseases (pneumonia). (5) Advanced age and alcoholism are among the contrib- uting conditions. ' International Clinics (1894), vol. i. p. 39. SERO-FIBBINOUS PLEURISY. 553 In a certain proportion of the cases no assignable cause can be found, and if the condition be observed for the first time after aspiration, the fact that it may have been engendered by an accidental Avound of the lung must be remembered. Diagnosis. — In diagnosticating pleurisy our attention must be directed chiefly to the physical signs. Unfortunately, in view of the fact that the rational symptoms are often ambiguous, a physical explor- ation of the chest is apt to be neglected. The chief difficulties are encounteifed in distinguishing this affection from conditions in which the lung is either consolidated, retracted, or comj3ressed by solid new growths, etc. Chief among the former is croupous pneumonia, and I have tabulated below the most important distinctions between it and pleurisy. The reader will be further aided by comparing Fig. 47 (which shows the physical conditions in pleurisy) with Fig. 17, on page 150, which shows the physical conditions in pneumonia. Pleurisy with Effusion. Primary Lobar Pneumonia. Onset marked by chilliness, persisting for a few days. The pain is sharp, " stitch-like," and strictly localized. Cough frequent and irritating ; no ex- pectoration, or catarrhal. Sputum shows presence of pneumococcus. Moderate fever of continuous type ; de- cline by lysis. Systemic prostration (moderate). Countenance pale and anxious. Herpes does not appear. Rational Symjytoms. Onset acute, rigor, lasting one hour. Acute pain, similar, but soreness more diffused. Cough accompanied by rusty or bloody expectoration. Absent. Intense fever -. decline by crisis from the fifth to the ninth day. Prostration marked. Countenance congested ; mahogany flush on the cheeks. Herpes quite common. Physical Signs. Inspection. Marked distention of the thorax. Palpation. Diminished or absent tactile fremitus. Percussion. Flatness, with great resistance to the pleximeter-finger. Shows displacement of neighboring or- gans. If the sac be partly filled, there is a change in the line of flatness on change of position. Auscultation. Diminished or absent breath-sounds, bronchial breathing frequent, but dif- fused and distant and unaccompanied by rales, as a rule. Vocal resonance diminished or absent: egophony. Friction-sound in early and late stages. Aspiration. Yields serum. Xone. Marked tactile fremitus (absent only when a bronchus is plugged). Dulness less complete, less resistance, and sometimes a tympanitic note. No displacement of neighboring organs, if uncomplicated. Absent. Harsh bronchial breathing and presence of rales in first and third stages, unless a bronchus be plugged. Bronchophony loud, unless a bronchus be blocked. Xo friction-sound, except crepitant r&les in the first stage. Yields a few drops of thick blood. 554 DISEASES OF THE RESPIRATORY SYSTE2I Consolidation of the lung, due to tuberculous infection, may be dif- ferentiated from pleurisy with effusion by means of the physical signs contrasted in the foregoing table, by the history of the case, and by the discovery of the tubercle bacillus in the sputum. Hydrotliorax presents physical signs that simulate strongly those of pleural effusion. Hydrothorax, however, gives the history of cardiac or renal disease, is oftener bilateral, and is unassociated with a rise in temperature or with the pain or friction-sounds peculiar to pleurisy. In hydrothorax the withdrawn fluid has a specific gravity below 1015, while that of the pleural exudate is above 1017. Tionors and cr/sts of the thorax will give complete dulness, will dis- place the heart, and compress the lung on the affected side, thus caus- ing an absence of the respiratory murmur, etc. But the history of the case, the situation of the dulness (usually over the upper or middle parts of the lung), the absence of uniform distention extending to the base, and the exacrg-erated tactile fremitus and vocal resonance will serve to distinguish these aff'ections from pleurisy Avith eff"usion. Echinococcus cyst of the liver, or abscess of this organ, pushing up- ward, will cause retraction or even compression of the lung, and hence will also produce most of the physical signs of pleurisy with effusion. The former aff'ections can be discriminated only by a correct appreciation of the history, by the presence not infre(|uently of a friction-sound on auscultation, and by the immovable, fixed upper convex, boundary of dulness. If doubt remains, an exploratory puncture should be made, and the fluid withdrawn should be subjected to a chemical, microscopic, and bacteriologic investigation. An enormous pericardial effusion may be mistaken for a pleural eff"u- sion on the left side. In the former, however, there is commonly a his- tory of rheumatism, and dyspnea is the most urgent symptom, while the heart-sounds are greatly enfeebled ; moreover, the heart is not dis- placed to the right as in pleural eff'usion. Again, flat tympany is ob- tained in the posterior portion of the axilla and good pulmonary reson- ance at the base in the postero-lateral region of the chest, diff"ering from the results of percussion in pleuritis. For practical purposes it is desirable to distinguish the tuberculous from the rarer forms of pleurisy. This is sometimes possible by paying due regard to the previous history of the patient, including hereditary taint, by noting certain clinical peculiarities (such as associated dis- ease of other serous membranes and of the lung and bilateral inflam- mation of the pleura), and by the results of an examination of the exudate. In dubious cases the guinea-pig should be inoculated with the exudate, and if the patients are tuberculous positive results may be confidently expected. Duration and Prognosis. — This depends largely upon the cause. The course of acute sero-fibrinous pleurisy is not definite, but is made up of two parts — the febrile followed by the non-febrile stage. The fever lasts from one to three weeks, and is due to inflammation ; it corre- sponds to the period when the effusion occurs, and the appearance of a non-febrile period indicates the subsidence of the inflammatory action. The eff'usion may be poured out rapidly, and is removed by absorption not less rapidly ; more frequently, however, the eff'usion takes place SERO-FIBBINOIJS PLEURISY. 555 rather gradually, and the same is true of resolution. Again, large effusions may persist in consequence of a purely mechanical hindrance to resorption ; and finally, the course may become subacute or chronic in consequence of the development of empyema. The continued absence of bacteria in the pus speaks for tuberculosis. Such facts as these con- stitute an explanation for the great differences in the duration of the cases. Simple sero-fibrinous pleurisy, including the hemorrhagic variety, unless it appears as a complication in the later stages of some other grave disease, has a comparatively favorable prognosis. Death rarely ensues suddenly, -^vithout adequate lesions to explain its occurrence. Moreover, the fact that a sero-fibrinous effusion may be converted into a purulent one is not to be forgotten. Again, the crippling influence upon the lung-tissue of previous attacks, oAving to resulting adhesions, must be borne in mind, since chronic bronchitis and emphysema often supervene. Treatment. — In the first stage the treatment is the same as for dry or plastic pleurisy. During the second stage, that of effusion, the objects of treatment are threefold : (1) To limit the extent and intensity of the inflammatory process ; (2) To accomplish the removal of the effusion : and (3) To support the strength of the patient. (1) To Limit the Extent and Intensity of the Inflammatory Process. — To this end tAvo classes of agents are employed — namely, (ci) Internal, and (5) External. Among the latter are counter-irritants, as sinapisms and iodin, by means of which gentle but constant counter-irritation is to be main- tained. Another agent of great Avorth is cold, applied by means of the ice-bag or ice-Avater bag, and if the temperature rises to 102° F. (38.8° C.) cool spongings of the surface of the body, together with the use of the ice-cap, will be found highly useful. Roberts recommended keeping the affected structures at complete rest by fixing in a mechanical manner the side affected. For this purpose strips of adhesive plaster must be firmly and evenly applied to the chest, and by this means the pain is relieved and the amount of inflammatory product poured out is greatly limited. The internal remedies embrace quinin, the salicylates, and opium. Opium and quinin are potent in controlling inflammation of serous membranes ; the former being given preferably either in the form of suppositories or hypodermically, and the latter in divided doses, in cap- sule, folloAved by a feAv drops of mineral acid, administering gr. xvj to XX (1,036-1.296) daily. ^ I have observed good results from the salicy- lates (oj-ij — 1.0-8.0, daily), which have been warmly advocated by Fiedler, Koester,^ and others, as valuable in mitigating or even aborting the inflammation of the pleurie, and thus in limiting the amount of effusion. It must not be forgotten that the effusion is due to an inflam- mation, and not to a simple transudation. The use of mild diaphoretics and diuretics, together Avith rej)eated small doses of salines, also aids in reducing the inflammation in the pleura. With a subsidence of the inflammatory process the temperature falls, and, Avhen the latter reaches a point near to the normal, our efforts should be directed toward the 1 International Clinics (1892), vol. i., second series. ^ Annual of the Universal Medical Sciences (1893), vol. i. (A-31). 556 DISEASES OF THE RESPIRATORY SYSTEM. fulfilment of the second leading indication, (2) the removal of the effusion. Little is to be accomplished by local means, though iodin, per- sistently employed, sometimes does good. The following ointment may also be tried : ]^. Ung. ichthyol. (12 per cent.), Ung. iodini comp., da. 3vj (24.0); Ung. belladonnse, q. s. ad 5ij (64.0). — M. Sig. Apply twice daily. Blisters are not admissible. Mild hydragogue cathartics, and especially the salines, after the Matthew Hay method (/. e. 3ij to Sss — 8.0-16.0, in the smallest possible amount of water, on rising in the morning), stimulate absorption from the pleural cavities by draining the blood of a certain amount of serum. Unirritating diuretics may also be employed, but I have found no appre- ciable advantage from their use. Free diaphoresis (from the use of pilo- carpin) sometimes assists in the absorption of the exudate, but it should not be employed in the presence of feeble heart-action or marked dis- placement of the organ. Among measures to promote absorption, the best, in my own experience, is the following combination : I^. Potassii iodidi, oj (4-0); Syr. ferri iodidi, oij (8.0); Syr. sarsap. comp., 5J (32.0); Ess. pepsiucTe, q. s. ad sij (64.0). — M. Sig. 3J (4.0) every four hours, diluted; the dose to be doubled at the end of four days if well borne by the stomach.^ The patient should be put upon a dry diet in order to increase the plasticity of the blood, which is thus induced to absorb the liquid exu- date from the pleural cavity. The modus operandi of this treatment is different, but the effect aimed at is the same as when saline purgatives are given. The exudation, however, defies all efforts at removal in about 33 per cent, of the cases, and in such the withdrawal of the liquid by aspiration (thoracentesis) must be practised. The indications for thora- centesis arise at two different periods in the course of pleuris}^ with effusion : (1) During the febrile stage, while efforts are being directed to com- bating the inflammatory process. The object during this stage is to avert imminent danger to life, and not merely to remove the fluid. The conditions demanding immediate thoracentesis are — {a) when one pleural sac is completely filled or when Skoda's resonance extends from the clavicle downward no farther than the second interspace ; (h) in double pleurisies, when both sides are half filled, since death may occur from rapid filling of one or the other side ; {c) in cases of copious effu- sions, upon the first signs of involvement of the unaffected side, such as moist rales, broncho-vesicular breathing, and impaired resonance ; {d) the appearance of serious symptoms, such as orthopnea or syncopal attacks with cyanosis ; {e) marked displacement of the heart, especially if one or more murmurs develop in the organ. ' Tlie author has employed this formula in more than 60 cases with very good results. SEBO-FIBRINOUS PLEURISY. 557 (2) The indications for aspiration during the second or afebrile period, when the main object is to remove the exudate, are — («) if no diminution in the quantity of liquid effusion takes place one week after the temperature has reached the normal ; (h) in subacute cases, in which there is little, if any, temperature from the beginning; aspira- tion should not then be withheld longer than three weeks. The operation is free from danger if carried out under antiseptic pre- cautions and if a modern aspirator is employed. The instrument should always be tested before it is used. The patient rests in bed in the semi-re- cumbent posture, the arm of the affected side being brought forward with the hand placed on the opposite shoulder, so as to separate the ribs from one another. The point of puncture is in the sixth interspace on the right- hand side and the seventh interspace on the left, in the mid-axilla, or just beloAv the outer angle of the scapula in the seventh right and eighth left interspaces, respectively. An assistant draws up the skin from the interspace, while the operator uses the fore finger of his free hand as a director. The needle should be introduced with a quick thrust, hug- ging the rib below the interspace, but endeavoring to avoid striking its periosteal covering. The fluid may not be obtained at the first opera- tion, and the reasons for this failure are several. The costal pleura may be excessively thickened, or we may meet Avith a much-thickened fibrous band. Again, the fluid may be encapsulated ; and, lastly, the needle may become blocked. Under these circumstances repeated trials should be made. The amount of fluid withdrawn at one time should never be large (sxij to xxiv — 384.0-768.0), though a relatively larger quantity may be taken during the febrile stage than during the afebrile, since in the latter instance the lung has been compressed for a longer period of time. The fluid is allowed to drain away slowly, a small needle being used, so as to invite the lung to expand in a gradual manner. If this precaution be not taken, the paretic pulmonary capillaries are apt to become the seat of sudden fresh congestion, followed by edema, and often by a speedily fatal termination. Thoracentesis is to be repeated at intervals of several days if nature does not take up the Avork of absorption, fol- lowing the first operations. If during the operation incessant cough, dyspnea, a tendency to syncope, marked thoracic constriction, or sudden intense pain be developed, the needle must be withdrawn instantly. Thoracentesis should not be resorted to in cases in Avhich croupous pneumonia is associated, and never in very aged and excessively feeble persons. (3) To Support the Strength of the Patient. — The poAvers of the sys- tem are to be maintained by a nutritious diet, bodily rest, and other hygienic measures. The lighter forms of solid food may be allowed whenever they are found to agree, and it is important to promote the digestive poAver, should the latter be Aveak, by the administration of suitable remedies. During the stage of convalescence, therefore, tonics (strychnin, quinin, and arsenic) are to be administered. The dietary should be liberal, though composed of AA'holesome articles. Gentle exer- cise in the open air is to be encouraged, and massage of the muscles of the aff"ected side tends to re-establish their usual vigor. To bring about the best possible chest-expansion nothing is so good as light gymnastic 558 DISEASES OF THE RESPIRATORY SYSTEM. exercises, together with the methodical practice of deep inspirations for a minute or two at intervals of three or four hours. I am of opinion that the management of the third stage, or that of convalescence, is similar to that of tuberculosis. EMPYEMA (purulent PLEURITIS). Definition. — A suppurative inflammation of the pleura. Pathology. — On opening the pleural sac after death we may find a thick, creamy pus, though more frequently it is sero-purulent and sepa- rated into two layers — an upper, clear, greenish-yellow serous, and a lower, thick, purulent layer. In a smaller proportion of cases the exu- date is fibrino-purulent. The odor emitted from the purulent collection is either sweetish or fetid {e. g. when due to wounds), and, when the condition is associated with gangrene of the lung or pleura, horribly oftensive. Microscopic examination shows that the inflammatory prod- ucts are identical with those of purulent inflammation in general. The pleural membranes are the seat of a more intense inflammation than in acute sero-fibrinous pleurisy, and are greatly thickened (1 to 2 mm.). They present a granular suppurating surface, and both visceral and costal pleurae exhibit perforations, and the latter, quite frequently, erosions. Histologically., the altered membranes consist of new connective tis- sue, neAv blood-vessels, and numerous leukocytes. l^tiology. — The following are the chief circumstances under which empyema arises : (1) As a sequel of the acute, sero-fibrinous variety. However clear the eff'usion may be, it always contains corpuscular ele- ments, which in the further progress of certain cases undergo coincident increase in numbers until the effusion presents a milky aspect, when it is said to be purulent. Thoracentesis may be responsible for this change, though never if performed under rigid aseptic precautions. (2) In children the effusion early becomes purulent in many instances, and in some cases may be so from the start. (3) Secondary to the acute and chronic infectious diseases (pyemia, scarlatina, pneumonia, tuberculosis, and dysentery most frequently ; typhoid fever, measles, whooping-cough rarely). (4) The disease may follow malignant affections of the thoracic organs (lungs, esophagus), or tuberculous pulmonary cavities which perforate into the pleura. (5) Injuries to the chest may set up empyema (fracture of the ribs, stab or other penetrating wounds). Bacteriologic investigation has shown that the organisms most fre- quently present are the micrococcus lanceolatus {meta-pneumonia), strep- tococcus, staphylococcus, and tubercle bacillus. The cases due to pneu- mococci usually pursue a fovorable course. The leptothrix pulmonalis is often found in putrid effusions. Clinical History. — The symptoms vary with the cause. The on- set may be characterized by acute symptoms, such as rigor, followed by high temperature and signal prostration, and in the affected side there may be severe pains, aggravated by deep breathing and bodily move- ments. EMPYEMA. 559 If the exudate becomes gangrenous, a typhoid state develops early, and the case is apt to prove fatal in the course of a few weeks. It is quite a common event for the acute symptoms that characterize the in- vasion to be replaced at the end of a week or more by the more obscure rational symptoms of chronic empyema. The latter, however, may de- velop very insidiously as a secondary affection. The rational symptoms in a well-marked case should always excite a suspicion of the presence of the affection, but cannot set the question of diagnosis at rest. The local symptoms (pain cough, and expectoration) are of a mild character ; the dyspnea, however, that is usually present may be more or less in- tense. I have on more than one occasion found an utter absence of these symptoms. The general symptoms are those of septic infection — diurnal chills occurring at irregular intervals, followed by great parox- ysms of fever and profuse sweating — and such patients lose flesh and become pale and weak. The temperature is higher than in pleurisy with effusion, and is intermittently, though irregularly, elevated. Peptonuria is a symptom of purulent pleurisy that is not wdthout diagnostic value. It, however, also occurs in suppuration associated with the third stage of pulmonary tuberculosis, and in suppuration due to other causes. While not indicative of empyema, however, it serves sometimes to eliminate sero-fibrinous pleurisy. The urine also con- tains indican in excess in the various suppurations, at least from time to time, if not constantly. Blood-examination invariably shows leukocytosis. If the pus is not removed artificially, it frequently breaks into the lung, penetrates it, and finally discharges through a bronchus. Pneu- mothorax now tends to supervene. Traube contends that necrosis of the pulmonary pleura may allow of the soaking of the pus through the spongy lung-tissue into the bronchi, without the establishment of a fis- tulous connection between the latter and the pleural sac, and hence without the formation of pneumothorax. Besides rupture into the lung and external rupture, empyema may perforate through neighbor- ing organs, as the esophagus, pericardium, stomach, and peritoneum. In rare instances the pus burrows along the spine behind the peritoneum and the psoas muscle, reaching, finally, the iliac fossa and simulating psoas or lumbar abscess. Physical Signs. — These are, for the greater part, identical with those of pleurisy with effusion. Attention Avill therefore be called only to such as are more or less distinctive of the affection. Slight edema of the chest-wall over the seat of effusion, especially in children, is often present, and if the pleural sac be not aspirated, the abscess may point externally and evacuate itself spontaneously. In the latter event a. jjro- trusion between the ribs shows itself: this may be the seat of fluctua- tion, and present an inflammatory appearance prior to its rupture, with subsequent discharge of its contents. The opening is usually found in the fifth interspace in front, and less frequently in the third and fourth interspace^ or below the angle of the scapula behind. The upper level of the fluid does not change so readily on changing the posture of the patient, but requires a longer period of time. Baecellis sign, or the transmission through a serOus exudate of the whispered voice, is sometimes an aid in the discrimination of pleurisy 560 DISEASES OF THE RESPIRATORY SYSTEM. with eifusion from empyema. According to my own observation, though it is not invariably propagated by hirge serous exudations of the pleura, it is yet detectable in a large majority of instances, whilst I have never found it to be obtainable in chronic empyema. Pulsating Pleurisy. — Pulsation synchronous with the cardiac beat in pleural effusion has received various designations {pxlsating empyema, empyema necessitatis, pulsating pleurisy). The latter term is the most appropriate one, in view of the fact that its course takes place not only in empyema necessitatis, but also in empyema (which manifests no tend- ency to point externally) and rarely in sero-fibrinous pleurisy. Its etiology is not definitely known. The principal causal factors, however, seem to be — (1) a copious effusion; (2) paresis of the inter- costal muscles, inducing relaxation of the thoracic wall : (3) a somewhat forcible heart-beat (Henry). The rational symptoms of empyema are present. The physical signs are also identical with those of the latter affection, with the pulsation superadded. There are instances in which palpation alone detects the systolic pulse in the pleural effusion. With rare exceptions the effusion occupies the left pleural sac. The pulsation may be limited to two or three interspaces or it may be visible over the entire antero-lateral aspect of the chest : pulsation at the back, however, is rare. Differential Diagnosis. — An absolute distinction between empy- ema and pleurisy with effusion rests solely upon the results of an aseptic exploratory puncture. For this purpose the needle attached to the ordi- nary hypodermic syringe, or. preferably, the surgeon's exploring-needle, may be employed, withdrawing but a very small (|uantity of the fluid, which, if purulent in character should be examined bacteriologically. Pulsating pleural effusion simulates closely aneurysm of the thoracio aorta. When pulsation occurs in empyema, however, it is seen to be to the left of the normal course of the aorta : the rational symptoms and usual physical signs of purulent pleural effusion are usually present also, while the vascular symptoms and signs of aneurysm of the aorta (thrill, bruit) are absent. Prognosis. — Empyema is a serious disease, but, obviously, the out- look will be modified by the special etiology. Spontaneous ab.sorption may occur, though it is extremely rare. The discharge of the contents of the pleural sac through the bronchial tubes is a comparatively favor- able event, some cases in which this occurs recovering, while in others death follows in consequence of the sudden inundation of the bronchi. An empyema may, in rarer cases, empty itself externally with favorable issue (empyema necessitatis). Evacuation of the pleural cavity is often followed by a continuous discharge of pus for an indefinite period. As a result of the long-continued suppurative process, death may take place by slow asthenia. It must not be forgotten, however, that an unfavor- able termination may be, in part at least, ascribable to certain associated affections (phthisis, pericarditis). Double empj'ema, fortunately a rare condition, is exceedingly grave. Among children the outlook is much more favorable than among adults. The prognosis has been rendered less serious by the applica- tion of surgical principles in the treatment of the disease. In all cases in which recovery ensues there is a progressive obliteration of the pleural E3IPYEMA. 561 cavity, owing to adhesions, which finally become universal and lead to marked retraction of the affected side (^pleu7'itis retrahens). Treatment. — The treatment of empyema is chiefly surgical. In a child the condition may terminate in recovery without operation, and hence may, at this period of life, be allowed to run for tAvo or three weeks, thoracentesis being resorted to if suffocation be threatened. In an adult, however, if the purulent effusion be copious, aspiration should be per- formed at once as a temporary means of relief. Empyema following pneu- monia may terminate favorably after one or more tappings ; but unless eontraindicated by an unfavorable general condition of the patient, such as is met with in the closing stages of pulmonary tuberculosis, free incision should be made Avithout delay. The pleural sac should be opened in the fifth or sixth interspace to the left of the mammary line, the incision being from 2 to 3 cm. in length. Resection of a rib (Estlander's opera- tion) is advocated, but if the drainage afforded by free incision be complete resection is unnecessary. It is only indicated when, by approximation of the ribs, the free exit of the pus is hindered (Yerebeyli ^). Opinions are divided as regards the value of irrigation of the pleural cavity. When the pus emits an offensive odor irrigation with a disinfecting solution is imperative. Carbolic acid should, however, not be used. In rare instances accidents arise during irrigation (sudden collapse, convulsions), and I have repeatedly observed a dangerous, and in one instance a fatal, collapse as the result of irrigation in children. The careful insertion of a roll of iodoform gauze is a method to be preferred to irrigation, except when the effusion is stinking. For further details in the operative treatment of empyema the reader is referred to text- books on surgery. Every effort should be made to favor obliteration of the cavity during post-operative treatment. The indication is to bring about the best possible degree of re-expansion of the compressed lung, and in order to accomplish this the method advised by Ralston James has been practised Avith great success in the surgical wards of the Johns Hopkins Hospital. The patient daily for a certain length of time, in- creasing gradually with the increase of his strength, transfers water by air-pressure from one bottle to another. The bottles should be large, holding at least a gallon each, and by an arrangement of tubes, as in the Wolff bottle, an expiratory effort of the patient forces the water from one bottle into the other. In this way expansion of the com- pressed lung is systematically practised. The abscess-cavitv is gradu- ally closed, partly by the falling in of the chest-wall and partly by the expansion of the lung.^ In long-standing cases, in which the lung cannot expand on account of thick bands of adhesion, the pleural layers can- not be brought into juxtaposition without more or less sinking in of the chest-Avall. This retraction of the thorax is probably hastened by timely resection of one or more ribs, the amount of bone to be removed depending upon the " expansive power of the lung and elasticity of the thorax." The duration of empyema is longer than in pleurisy with effusion, and the former affection tends to exhaust to a greater degree the powers of the system than the latter ; hence the physician's attention should be ^ Quoted in Annual of the Universal Med. Sciences, 1892, vol. i. sec. A. ^ Osier's Text-book of Medicine, p. 60-5. .36 562 DISEASES OF THE RESPIRATORY SYSTEM. directed chiefly to the support of the vital forces, modified to some extent by the special etiology in the individual cases. CHRONIC PLEURISY (CHRONIC ADHESIVE PLEURISY). Definition. — Chronic inflammation of the pleural layers — [a) with eff"usion, and [b) without efiusion. (a) Chronic Pleurisy with Effusion. — This sub-variety may follow acute sero-fibrinous pleurisy, and less frequently it has an insidious develop- ment. The morbid lesions, including the character of the exudate, may also be identical with those of the acute or subacute forms of the affec- tion. Fibrin and serum are present in varying relative proportions, the latter, however, as a rule, in preponderating proportion when compared with the composition of the exudate in acute pleurisy. The secondary consequences of copious acute effusions also are met with — /. e. displace- ment of adjacent organs (liver, spleen, heart) and unilateral dilata- tion of the chest. When the fluid is either absorbed or removed and the case ends in recovery, marked contraction of the affected side re- sults, since the lung, which is covered by thick, organized bands of adhesion, cannot re-expand. Symptoms. — But for slight dyspnea upon muscular exercise the subjective symptoms are frequently wanting. The pulse is compressible and accelerated, as a rule, and there is a trifling rise of temperature in the evening hours. If the effusion becomes purulent, hectic fever develops, leading to asthenia, and the latter con- dition eventually terminates life. Death may also be due to secondary suppurations (abscess of brain, etc.). In most cases occurring in chil- dren the effusion early changes to pus. The physical signs do not difter from those in acute sero-fibrinous pleurisy. The duration of the cases varies from three months to several years, or intercurrent pulmonary tuberculosis may shorten the course of the affection. (6) Chronic Dry or Adhesive Pleurisy. — (1) This may succeed to the acute or chronic sero-fibrinous pleurisy. If the liquid portion of the exudate is absorbed, the pleural membranes come into more or less close apposition, being separated only by fibrinous elements that become organized into a layer of firm connective tissue. Hence the two layers of the pleura, that are greatly thickened, cannot be separated, owing to the firmness of the adhesions. In most cases the autopsy shows the latter condition to be most pronounced at the base, while the lung is found to be compressed and the seat of fibroid change. If it follows the acute form, the extent of retraction is slight, since there are no dense fibrous bands to prevent a fair degree of lung-expansion ; if it succeed the chronic form, however, or empyema, the extent of retraction and flattening will be quite marked. The exudate may undergo cal- careous degeneration, and occasionally little pouches of fluid may be found between the false bands. There is a large class of cases that are dry from the onset {idio- pathic dry chronic pleurisy), and this variety may either be a sequel of acute plastic pleurisy or primarily tuberculous. The condition is very commonly met with at autopsy in subjects who during life had never presented symptoms of pleurisy Avith effusion. The plastic exu- date, however slight, invariably tends to become organized, with result- CHRONIC PLEURISY. 563 ing fibrinous adhesion of the two layers of the pleura. Most generally the adhesions are circumscribed, and if tuberculous in origin are most frequently apical and often bilateral. Under these circumstances small caseous masses and little tubercles may be found embodied in the some- what thickened pleura. General synechia is, however, not rare, par- ticularly unilateral. Sinnptoms. — Definite rational symptoms are rarely present, and the physical signs lack uniformity or may be entirely negative. In other cases of a mild grade the main characteristics are restrained mobility of the affected side and feebleness of the respiratory murmur. In rarer cases the weakness of the breath-sounds is out of all proportion to the expansive motion of the chest. In still another category — composed of a considerable number of instances — certain physical signs are quite pronounced. Inspection reveals decided contraction, Avith immobility of the affected side and a compensatory distention of the healthy side. The heart is displaced, and the apex-beat may be missing (e. g. when the heart is drawn or pushed behind the sternum, or over- lapped by the emphysematous lung). The spinal column is curved, the scapula dislocated, the shoulder ill-shapen and drooping, and the lower part of the thorax shrunken, W'hile the ribs are obliquely placed and closely approximated, or even overlap one another. The tactile fremitus is decreased or absent over the lower portion of the chest, and there is impaired percussion-resonance or dulness over the same area. The breath-sounds on auscultation are exceedingly feeble, and in some instances an occasional dry, leathery, or creaking friction-sound is audible. Rarely, and particularly if the case be tuberculous, vasomotor symp- toms arise in chronic pleurisy, such as unilateral flushing or sweating of the face, or dilatation of the pupil. Doubtless some of the instances belonging to this affection merge into the pleurogenous type of cirrhosis of the lung, and fatal complica- ting conditions may arise in connection with the general circulation. Thus I have observed in one instance enlargement followed by dilatation of the right ventricle, and in turn by general dropsy, with fatal result. Treatment. — In the treatment of this affection two objects must receive especial attention : (1) the removal of any effusion that may be present ; and (2) the improvement of the nutrition of the patient. The first indication is presented only by a limited number of the cases, and the rules for meeting it have been stated in the treatment of sero-fibrin- ous pleurisy and empyema ; the second indication is presented by all cases. Careful regulation of the diet is of the utmost importance : it must be generous, with modifications to suit special diatheses (as the gouty or tuberculous), if they be present. Lung-gymnastics are most useful if methodically pursued. The method of Ralston James (pre- viously described) richly deserves a trial in suitable cases. It is to be borne in mind, however, that in old cases efforts at overcoming the lung-pressure will be unsuccessful. Climato-therapy is advantageous for this class of sufierers, particularly if the slightest tendency toward tuberculosis exists ; and in my own experience low% mountainous eleva- tions combined with purity of atmosphere have given the best results. Of medicines little need be said. It is especially important to promote 564 DISEASES OF THE RESPIRATORY SYSTEM. the digestive power of the patient to the greatest possible extent. In cases in which the digestive function has been feeble I have observed excellent results from a brief stay at any well-regulated seaside resort or in the country. We may also try, with a probability that the eifect Avill be beneficial, small doses (3j — 4.0) of cod-liver oil, three times daily after food, or the following formulae : i^. Acidi muriat. dil., 3ijss(10.0); Pepsini pur., 3ij (8.0) ; Tinct. nucis vom., Siss (6.0); Glycerini, 3iss (48.0); Aquae, q. s. ad gij (64.0). — M. Sig. oj (4-0), well diluted, ten minutes after each meal. Intercurrent catarrh of the stomach may sooner or later become a troublesome feature, and in combating it lavage is frequently our most effective measure. PNEUMOTHORAX. ( Sero-pneumothorax ; Fyo-jvieumotliorax.) Definition. — A collection of air in the pleural cavity. Since the latter, as a rule, contains at the same time serum or pus, the terms sero- and pyo-pneumothorax are frequently employed to describe the same condition. Pathology. — When the pleural sac is punctured air usually escapes, accompanied sometimes by an audible hissing sound. The pleural sac in pure pneumothorax is greatly distended, and the lung is impacted against the spinal column. Other organs (spleen, heart) are also dis- placed, owing to positive intrathoracic pressure. The heart is not ro- tated, however, and the relation of its parts is maintained much as in the normal condition (Osier). The air may occupy but a portion of the pleural cavity, on account of previous firm adhesions {circumsc7'ibed pneiimothora.1-). The point of perforation, as a rule, can be easily found, and frequently corresponds to the seat of rupture of the tuber- culous cavity or superficial caseous mass. In other instances the cause of pneumothorax cannot be discovered. Inflation of the lung under water may reveal the a])erture, which is usually small, by the escape of air-bubbles at the seat of puncture. Occasionally a fistulous connection between the pleural sac and the bronchi can be traced. Simple pneumothorax is, however, of rare occurrence. The air that gains admission into the pleural sac is laden -with micro-organisms (vide Bacteriology, p. 541), which set up various forms of inflammation, ac- companied by eipially various exudations. Hence the cavity is usually filled, in part, with an eft'usion that is purulent or sero-i)urulent. as a rule, and rarely serous or sero-fibrinous. The gas in cases of pneumothorax may be of bacterial origin ; this contains substances not found in air, such as II, IlgS, or mai'sh-gas, and gas-forming organisms (b. coli). Htiology. — The predisposing m^uences are — (a) age — the condition PNEUMOTHORAX. 565 occurring in adults as a rule, though instances are also observed in young children ; (b) sex — males suffer more often than females ; (c) the left side is affected nearly twice as often as the right ; (d) emphysema^ in which the superficial air-sacs are dilated and atrophied, rendering the latter liable to rupture from excessive muscular exertion. The exciting causes are — (1) Perforation of the lung and pulmonary pleura (the most frequent cause), arising in one or other of three Avays — (a) From the rupture of a tuberculous cavity into the pleural cavity. This accident rarely occurs at the apex of the lung, but commonly near the upper border of the lower or middle lobe ; and less frequently near the lower border of the upper lobe. A caseous focus immediately be- neath the pleura may also, during the process of softening, puncture the pleural sac and invite the entrance of air. From this cause we sometimes see pneumothorax developing during a very early stage of pulmonary tuberculosis. It cannot occur, hoAvever, except in cases in which previous adhesions have failed to form at the point of perforation. {h) As the result of necrotic processes, in connection with certain other lung-affections, as gangrene, broncho-pneumonia, suppurating bronchial glands, abscess, and echinococcus cysts, (c) From rupture of the normal air-sacs in consequence of severe muscular effort (S. West, DeH. Hall). This accident is sometimes ascribable to the violent paroxysms of cough in pertussis. (2) Some cases of empyema, by perforating the visceral pleura, the lungs, and bronchi. (3) Perforations of the pleura in malignant disease and abscess of the esophagus. (4) A peripheral bronchiectasis may open the pleural space and thus establish a communication between it and a bronchus. (5) Pyo-pneumothorax may be of subdiaphragmatic origin, consec- utive to J) ^ff oration by malignant disease or ulcer of the stoynach or colon. (6) Pneumothorax may be occasioned by gases resulting from the action of a gas-forming bacterium on the pleural exudate. (7) Wounds causing direct or indirect perforative lesions of the lungs. Fractures of the ribs may produce laceration of the visceral pleura, and afford an opportunity for the ingress of air into the pleural sac. Symptoms. — The earliest symptoms vary according to the cause or causes that produce the condition. When it develops, as it does so often, in the course of pulmonary tuberculosis, the onset is sudden, marked by agonizing pain in the side, by intense dyspnea, and frequently cyanosis. The dyspnea is often accompanied by a sense of impending suffocation. The severity of the pain and the degree of oppression depend largely, however, upon the amount of air that gains entrance into the pleural sac or is formed from the exudate, the rapidity Avith Avhich it enters, and the condition of the pleural cavity as regards the presence or absence of previous pleuritic adhesions. If the orifice be large and valvular, the air cannot escape, but rapidly accumulates and forces all the air out of the lung by compression ; the patient then sinks rapidly into collapse from shock, and sudden death ensues. Fortunately, the latter event is rare. The respirations are frequent (60 or more per minute); ih.Q pulse is also frequent and feeble, sometimes reduced to a 566 DISEASES OF THE RESPIRATORY SYSTEM. thread ; and cold sweats are not uncommon. The temperature at first is apt to fall one or two degrees beloAv the normal, owing to sudden col- lapse ; /e?'^r, however,. follows almost invariably', and frequently is of the hectic type. Its cause is pleuritis, often of a purulent form, and if this be the case, the dyspnea may be due in part to the increasing effusion. The patient now also suffers from the grave symptoms of empyema above described. Edema of the hand of the affected side is sometimes present Fig. 48.—]. Air in the pleural sac ; 2, fluid exudate at base of pleural sac ; 3, compressed portiuu of lung; 4, displaced heart; 5, depressed spleen; 6, mediastinum pushed toward the right. as an early manifestation, and, as a rule, rapidly disappears (Weil). When pneumothorax develops in the last stages of phthisis acute symp- toms may be entirely absent. Physical Signs. — These are marked (see Fig. 48). Inspection shows marked distention and immobility of the affected side; also some degree of distention with unnatural mobility of the healthy side. Palpation shows the tactile fremitus to be diminished above and greatly diminished or wholly absent over the effusion below. Edema of PNEUMOTHORAX. 667 the chest-wall can frequently be made out. The impulse-beat of the heart is found to be feeble and displaced. On, percussio7i a deep and full, or modified tympanitic note {hell-tym- pany) can usually be elicited over the area corresponding to the contained air, and the excessive tension in the pleural sac, due to the enormous amount of air it contains, may cause an elevation in the pitch of the note even to dulness. The "cracked-pot" sound is audible when the air in the pleural cavity freely communicates with the external air. Wintrich's sign, or a change in the pitch of the percussion-sound Avhen the mouth is open or closed (being raised when the mouth is closed and lowered when open), may also be observed. In pyo-pneumothorax a flat note is elicited from the base upward as far as the fluid extends, and there is a more marked temporary change in the upper level of flatness than in pleurisy with change of posture. Modifications in the pitch of the percussion-sound result from an alteration in the form as well as in the dimensions of the air-space. Owing to displacement of the heart, there is, as a rule, resonance over the normal cardiac region, and particularly Avhen the patient assumes a recumbent posture. The liver and spleen, according to the side affected, are displaced downward to a greater degree than in simple pleural eifusion. Auscultation discloses a greatly weakened or altogether suppressed respiratory murmur when collapse of the lung is incomplete. Amphoric breathing is audible in cases of open pneumothorax, and bronchial rales possessing a metallic quality are sometimes heard, as well as metallie tinkling on deep inspiration or on coughing. The metallic tinkling is caused frequently by drops of fluid falling from above upon the surface of the eflusion ; less frequently by a re-echoing of vibrations of moist bronchial rales communicated to the air in the pleural chamber. The vocal resonance is enfeebled, as a rule, and evinces the same metallic quality. The so-called coin-test is a pathognomonic sign, and is elicited in the following manner : An assistant places one coin on the front of the chest and taps it with another while the ear of the examiner is placed on the thorax posteriorly, where will be heard the intensified echo of the coin-sound thus produced. Another most characteristic sign is the so-called Hippocratic succussion, which is elicited by placing one ear upon the patient's chest while the latter's body is shaken, and a distinct splashing sound is heard. Diagnosis. — When the attack is of ordinary severity, pneumo- thorax is diagnosticated by the history of one or other of the causal factors, together with certain physical signs that do not belong to any other affection {coin-sound^ succussion-splash). It is only when the air and fluid in the pleural sac are encapsulated that it may become difficult to eliminate {a) a large pulmonary cavity ; {h) excessive gaseous distention of the stomach ; {c) an abscess below the diaphragm into which air has entered [pyo-pneumotliorax 8ubp)hrenicus) ; (d) a diaphrag- matic hernia ; (e) emphysema ; and (/) pleurisy Avith effusion. (a) A Large Pulmonary Cavity. — The "cracked-pot sound" and Wintrich's sign are more frequent in cavity than in pneumothorax, and the former condition does not tend to dislocate the adjacent organs. There is no response to the coin test aiid an absence of the succussion- 568 DISEASES OF THE RESPIRATORY SYSTEM splash ; both of which signs are often present, even in circumscribed pyo-pneumothorax. Tabulated, these points of difference are — P\0-PXEL"MOTHORAX. LaRGE PlLMOXARY CaVITY. Immobility and bulging of the inter- Immobility, flattening of the chest, and spaces. The apes-beat is usually dis- depression of the interspaces. Apex- placed, beat not displaced. Diminished vocal fremitus. Fremitus usually increased. Percussion-note deep and full. The effu- Percussion gives tympany or a ''cracked- sion sinks to the base, and yields fiat- pot sound," and Wintrich's change of ness. the outline of which changes with sound as a rule, the posture of the patient. Respiratory murmur and vocal resonance Bronchial breathing is heard, and the usually absent. Amphoric breathing vocal resonance is increased. Crack- may be heard if the opening in the ling, gurgling rales, cavernous or am- lung is patulous. The coin- sound and phoric breathing.and pectoriloquy may Hippocratic suceussion - splash are be present. Absence of bell-tympany noted. and succussion-splash. (b) The possibility of excessive gaseous distention of the stomach is to be eliminated by the history of the case and by the happy results af- forded by the application of the therapeutic test, evacuation of the stomach and bowels. (c) Subphrenic Abscess containing Air. — This is exceedingly rare, and occurs relatively oftener on the right than on the left side (Leyden). Its leading causes are ulcers of the stomach or duodenum, followed by circumscribed peritonitis, perforation, and abscess, the latter occupying a position immediately beneath the diaphragm and above the liver. The gases that gain admission to the abscess-sac from the intestines force the diaphragm upward, and thus cause retraction or even compression of the lung. The symptoms and signs are now identical with those of circum- scribed pyo-pneumothorax. limited to the base. A knowledge of the steps in the production of subphrenic abscess ; the absence of cough and expectoration, and of marked, displacement of the heart; and the presence of bulging of the hypochondrium, of striking depression of the liver, and of Pfuhl's sign {I'icle p. 877), are indications favoring sub- phrenic abscess. ((/) Diaphragmatic Hernia. — This either results from a severe injury or is congenital, and the most valuable point of difference between hernia of the diaphragm and pneumothorax is the peculiar cause of the former. The next most valuable point is the fact that the hernial protrusion may return suddenly to its normal position, whereupon the patient will be re- lieved ; the condition may then reappear not less suddenly. The third distinctive feature is the presence of rumbling sounds in the protruded bowel. All other signs and symptoms of one affection may have their counterparts in those of the other. (g) Pneumothorax may be confounded with emphi/sema by the care- less observer ; but the latter affection is slow in onset, free from serious shock, is bilateral as a rule, and does not exhibit the distinctive physical signs of pneumothorax (metallic tinkling, coin-sound, succussion-splash). In pleurisji with effusion hyper-resonance may be noted above the fluid, but it lacks the bell-like tympany of pneumothorax. Over the same area there is diffuse, distant, bronchial breathing (at times slightly am- phoric), whilst the metallic tinkling, coin-sound, and succussion-splash are totally wanting. HYDROTHORAX. 569 Prognosis. — This depends largely upon the cause. The cases at- tributed to advanced phthisis usually reach a fatal issue in the course of one, two, or more weeks, and rarely they run a very rapid and fatal course. On the other hand, the pulmonary condition is at times favor- ably influenced by its occurrence. FolloAving empyema, pneumothorax sometimes takes a favorable course. It is fraught with especial danger when it is the resultant condition of some acute lung-disease (gangrene, abscess, broncho-pneumonia). Treatment. — The leading indication is the alleviation of the pa- tient's sufferings by a prompt resort to morphin, and it often becomes necessary to administer it hypodermically. If the patient's previous strength has been moderately good, the question of operative interven- tion should be seriously considered, the nature of the surgical proced- ure then depending upon the character of the eff'usion. If this be sero- fibrinous, aspiration, as in simple pleurisy, must be performed to relieve the urgent dyspnea ; if purulent, permanent drainage should be pro- cured for the same indication. A costal resection may be advis- able. When pneumothorax develops late in phthisis radical measures are not to be thought of, and the physician must rely upon aspira- tion (when necessary) to relieve urgent symptoms. We may also tap the air-chamber above the fluid Avith a fine needle, Avith a vieAv to lessen- ing the excessive tension. Unverricht has recently reported good results from a somewhat novel mode of treatment. When there is a pulmonary fistula present, he inserts a tube into the pleural sac. This alloAvs free entrance of air, the lung collapses completely, and the fistula has a chance to heal. For the dyspnea, atropin administered hypodermically is valuable ; for the feeble cardiac action, alcoholic stimulants, aromatic spirits of ammonia, strychnin, ether, and other cardiac stimulants should be employed. Locally, cutaneous irritants may be applied (turpentine stupes, mustard pastes). HYDROTHORAX. [Dr02jsy of the Pleura ; Thoracic Dropsy). Definition. — A collection of transuded serum in the pleural cavity. Pathology. — Hydrothorax is generally a bilateral condition. The transudate is a clear, amber-colored liquid that is free from fibrin, but may contain cholesterin and a few endothelial cells. It has an alkaline reaction, a comparatively Ioav specific gravity (1009 to 1012), and is non- inflammatory. The pleural surfaces are usually smooth, though some- times decidedly pale and edematous. The mechanical effects of h3^dro- thorax upon the lungs and other thoracic and abdominal viscera are similar to those of the exudates that accompany inflammation of the pleura, though they are rarely so marked as in sero-fibrinous pleurisy. Ktiology. — Hydrothorax is a secondary affection, and is usually connected Avith one or other of the various forms of general dropsy (hemic, renal, cardiac). The cases that are due to blood-impoverish- 570 DISEASES OF THE RESPIRATORY SYSTEM. ment are more numerous than is generally indicated by writers upon the subject, and not infrequently is hydrothorax symptomatic of either chronic dysentery, chronic diarrhea, leukemia, pernicious anemia, car- cinoma, malaria, syphilis, or scurvy. Strictly local causes may also induce it, as carcinoma of the pleura, or the compression of the superior vena cava or of the thoracic duct by a tumor. Symptoms. — The subjective symptoms are attributed to the mechan- ical eflFects of the fluid, and the causal affection may have symptoms quite in common ; these are dyspnea (often culminating in orthopnea), cyanosis, asthmatic seizures, irritative cough, and a feeble circulation. The general symptoms arise from the primary affection. Physical Signs. — The physical signs are much the same as in pleurisy with effusion — with this difterence, that they are more often present on both sides of the chest. Hydrothorax is often unilateral, however, and an enlarged right auricle may be the cause of this condition in some instances. The right side is the one usually affected. I have also ob- served that quite frequently the two sides of the chest exhibit great variations as to the relative amount of fluid contained.^ Prognosis. — This depends upon the nature of the primary disorder that causes the dropsical transudation. Treatment. — The treatment of hydrothorax has intimate relations with the indications presented by the underlying affection. If the meas- ures directed toward the removal of the general dropsy, of which hydro- thorax is a part, are unsuccessful, and the amount of transudation in the pleural sac interferes with the functions of the heart and lungs, then aspiration must not be too long delayed, and must be repeated as often as occasion demands. NEW GROWTHS OF THE PLEURA. Almost all instances of new growths developing in the pleura are secondary to primary carcinoma of the lung, the pleura being invaded by the direct extension of the neoplasm. It may also arise by meta- stasis from carcinoma of the lung, mammary glands, etc. The pleura presents circumscribed areas of thickening, or the growth takes the form of papular projections from its surface, and as these enlarge they become pedunculated. Their size varies from that of a pea to that of an orange. The adjacent pleura is inflamed, often adherent, and much thickened, and an effusion into the pleural cavity is often observed. Primary carcinoma, of the pleura is very rare indeed, and E. Wag- ner, who first described it, called it endothelial carcinoma. Most pa- thologists of to-day, however, look upon endothelioma as a variety of sarcoma. It owes its orgin to a proliferation of the endothelial cells of the connective tissue and the lymph-apparatus of the pleura. This in- variably assumes the diffuse form, and by metastasis we have involve- ment of the other organs (lungs, lymphatics, liver). Spindle-cell sarcoma of the pleura, as well as the round-cell variety, is occasionally met with. ' For the differential diagnosis between pleurisy and hydrothorax see Pleurisy, p. 554. DISEASES OF THE MEDIASTINUM. 571 Symptoms. — The subjective symptoms are slight in cases in which there is a single circumscribed carcinomatous mass in the pleura ; but they are quite severe in the diffuse form, particularly when, as com- monly occurs, it is of a secondary nature. The symptoms are now those of plastic or sero-fibrinous pleurisy, in addition to those of pri- mary carcinoma of the lung, and the former may oftentimes more or less completely overshadow the latter. Diagnosis. — The circumstances under which the condition arises often throw the strongest light upon its nature. The symptoms of slowly developing pleurisy, either plastic or sero-fibrinous, following carcinoma of the lung or the breast, and accompanied by the cancerous cachexia, would point strongly to the existence of carcinoma of the pleura. Characteristic cancerous elements may also be found by micro- scopic examination of the fluid obtained on exploratory puncture, and this should never be neglected in suspected instances. The difficulties surrounding the diagnosis of primary carcinoma of the pleura are great and usually insurmountable. The cases are very similar in their clinical manifestations to chronic 'pleurisy witli or loithout effusion. Pain is always a more prominent symptom, however, than in simple chronic pleurisy, and this fact, when combined with evidences of a cancerous cachexia, should excite strong suspicions. The prognosis is wholly unfavorable, and the treatment merely palliative. DISEASES OF THE MEDIASTINUM. The affections of the mediastinum may be divided into four classes : (a) Inflammation, {h) Tumors, (c) Diseases of the thymus gland, and (c?) Mediastinal hemorrhage. (a) Inflammation. — This may afi'ect (1) the glands or (2) the connec- tive tissue. Lymphadenitis of moderate grade is found in association with broncho-pneumonia and the various forms of bronchitis. The con- dition appears in its most pronounced form in the bronchitis of measles, influenza, and whooping-cough, and De Mussy held that enlargement of the glands in the posterior mediastinum is potent in exciting parox- ysms of whooping-cough. According to De Mussy and Guiteras, these glands when greatly enlarged give rise to dulness in the upper part of the interscapular region or down to the fourth dorsal vertebra in cases of influenza and whooping-cough. I have, moreover, been able to con- firm this dictum in cases of influenza, though aware of the fact that many authorities consider it questionable. Tuberculous lymphadenitis is elsewhere described {vide Tuberculosis, page 271). The mediastinal lymph-glands may undergo suppuration in consequence of local specific infection, and, though not recognizable during life, it should be recollected that the condition may lead to perforation into either the esophagus or a bronchus, with serious results. In other instances spontaneous absorp- tion occurs, leaving behind inspissated contents that undergo calcareous chang-e. 572 DISEASES OF THE RESPIRATORY SYSTEM. Abscess of the Mediastinum. — This is of rare occurrence, its most frequent seat being the anterior mediastinum. Of the commoner causes may be mentioned traumatism and the infectious diseases — erysipelas, rheumatism, measles, and small-pox in particular. It may also be the result of an extension of a suppurative process from neighboring struc- tures. Pulmonary tuberculosis is the most potent factor in producing chronic abscess in this situation. Symptoms. — Acute Abscess. — Pain and tenderness in the sternum are the most prominent features, the pain being acute and often of a throbbing character. Cough and dyspnea are usually present. The general features are fever, frequently accompanied by rigors and pro- fuse sweats and considerable physical prostration. The chief physical sign is dulness upon percussio7i, usually found anteriorly and increasing gradually with the development of the abscess. Later, the tumor may reach the surface of the body, and rarely the sternum is eroded. Pal- pation now detects pulsation and fluctuation. The abscess may either find its way downward into the abdomen, or it may perforate the trachea or the esophagus. In chronic abscess the symptoms bear a closer similarity to those of solid tumors than those in the acute form. Fortunately, chronic abscess quite often results in spontaneous cure, in which case it is in part ab- sorbed, and the remainder of its contents become inspissated. In obscure cases an exploratory puncture with a small needle may be safely prac- tised, and with definite results, as a rule. DiagtiosiS. — Acute abscess must be differentiated from solid medias- tinal tumors and aneurysm. The more acute onset and general symptoms of the suppurative process (hectic type of fever, chills, sAveats) and the more rapid course will serve to distinguish abscess from aneurysm on the one hand, and solid tumors on the other. Further, the absence of strong expansile pulsation, diastolic shock, and the aneurysmal bruit aid materially in eliminating aneurysm of the arch. The treatment is mainly surgical. (7*) Tumors of the Mediastinum. — Two forms only demand practical consideration — carcinoma and sarcoma. Hare's analysis of o20 cases gave the following ratio: of carcinoma, 134; sarcoma, 98; lymphoma, 21 ; fibroma, 7 : dermoid cyst, 11 ; hydatid cyst, 8 ; and fewer cases of ecchondroma. lipoma, and gumma. In 48 of the cases of carcinoma and in 33 of sarcoma the tumor occupied only the anterior mediastinum. It is quite probable, however, that sarcoma, and not carcinoma, is the com- moner neoplasm of this region. The clinical term '' cancer '" was formerly used promiscuously by many authors, and the pathologic diagnosis was then difficult, so that statistics are notoriously fallacious. Upon inves- tigating 25 of the older reports of "cancer," Pepper and Stengel found in 13 unquestionable evidence that the growth was sarcoma, while in the remaining 12 they could not, for the greater part, decide to which form the disease belonged. Primary sarcoma may spring from the rem- nant of the thymus gland, from the lymphatic glands, the pleura, or lungs, or from the fibrous tissues of the mediastinum. Primary carcinoma may originate in the esophagus, bronchi, lungs, or rarely in the thymus gland. Secondary mediastinal tumors are most apt to have their seat in the lymphatic glands. Carcinoma is less fre(iuently primary than sar- DISEASES OF THE MEDIASTINUM. 573 coma. Among predisposing causes are sex and age — males being more prone to the affection than females, and the period of chief liability is between the thirtieth and fortieth years. Symptoms. — The earlier symptoms are vague (slight substernal pains, dyspnea, general languor). Later, pressure-symptoms gradually supervene. The pain may or may not be severe, but is invariably accompanied by a feeling of oppression. Its chief seat is in the upper sternal region, but it may radiate to the sides of the chest and even down the arms (in Avhich case it is due to pressure on the brachial plexus). Dyspnea appears early, is constant, and may become intense. It is caused by pressure either upon the trachea, upon a primary bronchus, or upon a recurrent laryngeal nerve. Asthmatic seizures may occur before there is constant dyspnea and before the tumor has reached notable size within the chest. There is cough, which may be paroxysmal and of a brazen character. Aphonia may be present. There may be dysphagia from pressure upon the esophagus, though this is rare. If there is an inflam- mation of the vagus or sympathetic nerve, the rate of the pulse may be either slowed or markedly quickened. Owing to implication of the sympathetic there may be local hyperemias and pupillary inequalities. Oonipression of the superior vena cava or of the subclavian vein may be followed by cyanosis and edema of the parts drained by these vessels, and the early occurrence of venous occlusion and marked dilatation of the superficial veins is quite characteristic. Collateral circulation may be rarely established. Less frequently the inferior cava may also be pressed upon. Physical Signs. — Inspection. — In advanced cases a swelling, usually somewhat irregular and often diffuse, appears in the sternal region. The tumor may cause erosion of the sternum, and a little later occupy a position immediately beneath the skin, Osier ^ being of the opinion that the rapidly-growing lymphoid tumors, more commonly than others, perforate the chest-wall. I saw a case in which the perforation occurred at the right edge of the sternum, precisely at the point at which aneur- ysms of the ascending arch most frequently appear. In the early stages, however, this prominence is not present. Palpation. — When a tumor is present it may pulsate distinctly, and the heart's apical impulse may be detected in various abnormal positions. Tactile fremitus is absent over the seat of the groAvth if the latter be in contact with the chest-wall. On percussion dulness is noted, and this is true even in many instances that do not present a visible swelling. The dull area varies in outline with the size and position of the tumor. Auscultation usually reveals no sounds over the dull area, except a bruit in rare instances. The heart-sounds are inaudible over the tumor-site as a rule, and the breath- sounds and vocal resonance are feeble or absent. To the above physical signs are frequently added those of pleural effusion. The diagnosis of mediastinal growths is made, if at all, principally by exclusion. Aneurysm is differentiated from solid mediastinal tumors with only slight success in many instances. It is most valuable to note carefully the length of time the condition has lasted, since aneurysm runs a 1 Practice of Medicine, p. 579. 674 DISEASES OF THE RESPIRATORY SYSTEM. longer course, on the average, than mediastinal tumor. The tumor ■when due to aneurysm communicates a strong, heaving, expansile pul- sation — a characteristic that is absent or only feebly manifested in the case of solid mediastinal growths. The severe diastolic shock, as noted on both palpation and auscultation in cases of aneurysm, is also absent in solid tumor. The bruit in aneurysm has often a booming quality that does not belong to the bruit of solid growths. Pain is more pro- nounced in aneurysm. The duration of the disease is rarely less than six, and quite as rarelv it is more than eighteen, months. The prognosis is absolutely hopeless, except in the case of benign tumors, which may be removed in some instances. The treatment is directed toward the relief of the most urgent symptoms. Anodynes are required sooner or later, and should not be withheld if indicated. As a routine the preparations of iodin and mer- cury are employed ; but, as these are useless, they are uuAvarranted. Arsenic has sometimes seemed to influence sarcomatous and Ivmphade- nomatous growths favorably, though only temporarily. {c) Diseases of the Thymus Gland. — Nothing is known definitely con- cerning the functions of the thymus gland. Tumors may have' their origin in the thymus gland, and the organ may become enlarged (hyper- trophy, abscess); these conditions are indistinguishable from and asso- ciated with mediastinal tumor or abscess as above described. Jacobi believes that fatal cases of laryngismus stridulus may be rarely ascribable to an enlargement of the thymus gland. C. H. Hunter^ reports two cases of primary fatal laryngeal stenosis occurring in the same family in children aged 19 and 7 months respectively. The ques- tion as to the existence of the so-called asthma thymicum, however, is still sub judice. although the number of sudden deaths in young children reported in connection with various forms of enlargement of the thvmus gland is steadily increasing. The dyspnea, generally fatal, that has been found to be caused by an enlarged thymus is scarcely the result of direct pressure on the trachea. Arnold Paltauf attributes sudden death in cases in which the thymus was found enlarged to hyperplasia of the entire lymphatic system [constitutio lymphatica). Ohlmacber^ noted rn 18 cases of epilepsy a large and apparently functionally-active thymus gland. There was hyperplasia of the lymph-glands throughout the body and of the lymph-follicles of the mucous surfaces. Persons who manifest the hemorrhagic diathesis, or those who suffer from hemorrhagic aff'ections, may also show hemorrhage into the thymus gland — a condition that is identical with that produced by hemorrhage into the mediastinum. There is no treatment for enlargement of the thy- mus, although Siegel in one case, a boy of 2^ years, elevated and stitched the thymus to the fascia over the sternum, with the result that threaten- ing dyspnea disappeared and the child eventually made a good recovery. (d) Mediastinal Hemorrhage. — This term signifies hemorrhage into the mediastinal connective tissue. It oftenest results from the rupture of aneurysms of the arch or of the large vessels within the thorax, or it may be of traumatic origin (wounds, fractures). ' British Med. Jour., April 2, 1898. 2 Phila. Med. Jour., Jan. 1, 189S; Saunders' Year-Boo/: for 1899. PART V. DISEASES OF THE CIRCULATORY SYSTEM. DISEASES OF THE PERICARDIUM. PERICARDITIS. Definition. — An inflammation of the serous covering of the heart. Varieties. — (a) Plastic, or fibrinous; (b) sero-fibrinous, or subacute; (c) purulent ; (d) hemorrhagic ; (e) adhesive. There is also a tuberculous pericarditis ■s\hich has been described dvide Tuberculosis, page 308). Bacteriology.— Rudini's experiments have shown that the staphylo- coccus aureus may be a cause of pericarditis ; but they have not con- clusively demonstrated that it is the specific cause, as is evidenced by the fact that the disease is sometimes caused by other organisms and is found in diseases in which other organisms are active. Moreover, sta- phylococci have not been encountered without demonstrable cause. Among other organisms, the pneumococcus, streptococcus, the bacillus coli, the tubercle bacillus, and probably also a variety of the bacillus pyocyaneus and the gonococcus may be named. ACUTE PLASTIC OR FIBRINOUS PERICARDITIS. Patliology. — The morbid changes are frequently localized, and less frequently are general. At the onset the membrane is smooth, SAVollen, and injected, and punctured ecchymotic spots may be visible ; soon it presents a grayish, roughened appearance in consequence of a deposition of a thin layer of fibrin. In the severer types the fibrinous deposit in- creases in thickness for a time, and the natural movements of the peri- cardial surfaces upon one another sometimes cause the exudate to assume a honevcombed appearance. Most examples that I have seen, however, have resembled the roughened surfaces produced by separating two slices of bread that had been thickly buttered ; the surfaces are grayish-yellow in color. In the later stages the exudation becomes partly organized, and as the result of friction produced between the opposed surfaces by the incessant action of the heart, the pericardial surface may present a villous appearance ; hence the term " hairy heart " which was employed bv ancient authors. For like reasons we may see the exudate arranged in the form of little ridges, forming a " tripe-like membrane." Though 576 DISEASES OF THE CIRCULATORY SYSTEM. invariably present, the amount of serous eflFusion, as the term Avould in- dicate, is never large in (\y\ or plastic pericarditis. Myocarditis may frequently be found as an associated condition. Ktiology. — In each variety of pericarditis there are special contrib- uting factors, so that it is desirable to give its etiology separately, except in the sero-fibrinous and acute plastic types, which have practically the same etiology. The two latter are the more common forms of the disease. Acute plastic pericarditis most fre([uently occurs in young and middle- aged males, and is only rarely a primary process, being secondary to acute articular rheumatism (in more than one-half the cases), to chronic nephritis, and. rarely, to other acute infectious diseases. In the sec- ondarv form the infective agents are transmitted to the pericardium by means of the circulation. It may be caused by direct extension of inflammation from adjacent structures, and in this manner it may be a sequel of simple pleurisy ; more commonly the extension occurs from a pneumonia or tuberculous pleurisy, or the condition may complicate new growths and inflammatory conditions aff"ecting the esophagus and bron- chial glands. It may also be secondary to chronic disease of the aortic valve, the pericardium becoming involved by extension through the walls of the aorta. Finally, it may be the result of traumatism, and this mav cause any of the other forms of pericarditis. Clinical History. — Owing to the fact that acute plastic pericarditis is usually a secondary affection, the symptoms that enable one to recog- nize it are obscured by the disease of which it is a sequel. This is par- ticularly true of that large class of cases that develop in acute articular rheumatism, in which subjective symptoms are often entirely wanting. It is only in the severest types of this sort that the symptoms referable to the heart are well enough marked to arrest the attention. There may be a feeling of distress or constriction with or without slight paiii in the precordium. During the first stage or prior to the pouring out of the effusion the pain is most marked, extending sometimes into the left arm or the back, and at others to the ensiform cartilage or even to the abdo- men. This pain is, rarely, increased by pressure over the pericardium. Palpitation and dyspnea may be present, and the pulse is increased in frequency and strength, as a rule, except in the later period, when it may be weak and slightly irregular, particularly if the muscular tissue of the heart be involved. There is some fever, but the degree of ele- vation of temperature perhaps never exceeds 102° F. (38,8° C). In this class of cases the urinary features depend largely upon the charac- ter of the leadino[ etiolojric factors ; thoucrh in many instances the urine is scanty, high-colored, and acid in reaction. Physical Signs. — Inspection discloses increased vigor of the apex- b^at. Friction-fremitus (due to rubbing of the altered pericardial layers upon one another) may sometimes be felt during the earlier and later courses of the disease or when the membrane is comparatively dry, and is usually most intense near the base, just to the left of the sternum. Percussion gives negative results. Auscultation usually reveals a double friction-sound, sometimes quadruple (locomotive murmur) — a character- istic sign, though one on which sole reliance must not be placed in this disease. The friction-rub is caused partly by the exudate and partly by the dry state of the membrane. Its usual seat of maximum pronunciation ACUTE PLASTIC OR FIBRINOUS PERICARDITIS. 577 is m the fourth and fifth interspaces and the adjacent portions of the sternum — /. e. that portion of the heart which is most closely in contact with the front of the chest (Osier). Another favorite point is the cardio- aortic junction. It is usual to hear the rub over small areas, though oc- casionally it is audible over the whole precordia, and its distinguishing feature is its superficiality, seeming closer to the ear than endocardial murmurs. Pressure ^Yith the stethoscope, which approximates the layers, increases its intensity; though if too much force be exerted, the murmur may disappear entirely. In like manner the friction-sound is influenced by respiration, losing in distinctness on deep inspiration and change of posture. The quality of the sounds, like their position, exhibits great variability. They are sometimes soft ; but quite commonly they are grating or rubbing, and in the later stages I have noticed that they may have a loud creaking quality. Though with few exceptions they are double, and are primarily produced by the rhythmic movements of the heart, they do not always occur synchronously with the heart-sounds, and usually exceed the latter in duration — facts that go to show that the quality, location, or superficial area of a given murmur does not indicate the extent of the lesion. Complications. — There may be an extension of the inflammatory process to the external surface of the pericardium, either from the deeper pericardial structures or from the pleura, particularly the left. This is a complicating condition termed " external pleural pericarditis '" or " medi- astino-jjeriearditis," in Avhich the mediastinal connective tissue is also, as a rule, involved. It is most frequently secondary to tuberculous pleurisy {tuherculo-mediastino-p)ericarditis), sometimes also to pleuro-pneumonia, and rarely to simple pleurisy or plastic pericarditis. The recognition of these combined lesions rests chiefly upon the detection of a friction-mur- mur that is partly dependent upon the cardiac and partly upon the respi- ratory movements. These sounds are most distinctly heard along the left edge of the heart. Momentary arrest of breathing suppresses the pleuritic friction-sound, there remaining merely the sounds produced by the rhythmic cardiac action, and even these may be absent. On the other hand, during forced respiration nothing is audible, as a rule, except the strong pleural rub. In normal respiration the inspiratory movements decrease while expiratory movements increase the intensity of the sounds. During inspiration the p)ulse may become small and slow, owing to the partial occlusion of the aorta, brought about by the traction of fibrous bands of adhesions which pass over the vessel, being at the same time connected with the pleura. When these bands pass from the exterior of the heart-muscle or pleura, they may cause, as first pointed out by Riegel, an absence of the apex-beat during expiration. Instances of this sort are not uncommon. Diagnosis. — Although the presence of a to-and-fro friction-sound is, as a rule, indicative of plastic pericarditis, it is an error to regard it as an infallible sign, since complete calcification of the coronary arteries, as well as excessive dryness of the pericardial surfaces, may rarely produce friction-murmurs. Differential Diagnosis. — The harsh double murmurs due to chronic val- vular lesions can be eliminated if it be recollected that they are more constant, more distant, and that each has an area of transmission beyond 578 DISEASES OF THE CIRCULATORY SYSTEM. the limits of the precordia. The sitting posture, leaning forward, or moderate pressure with the stethoscope, all fail to produce or to increase endocardial murmurs, whether acute or chronic. A double aortic mur- mur is associated with cardiac hypertrophy, the Corrigan pulse, and sys- tolic flushing of the capillaries. Prognosis. — The termination is always favorable as to life. Com- plete resolution does not often occur, but the exudate becomes connective tissue, and agglutinates the two layers of the pericardial sac. The acute may merge into the chronic form, and dry, plastic pericarditis often con- stitutes the first stage of severer grades of the disease. Treatment. — Absolute quiet in the recumbent position should be enjoined. The diet should be composed chiefly of light, easily digested solids, allowing as little drink as is possible, and thus endeavoring to avoid an overfilling of the vessels. With the same object in view, if the patient's strength be good, a half-dozen leeches should be applied over the heart, followed by the use of the ice-bag ; the bowels are to be kept soluble by using stewed fruits or saline laxatives if needful. Calomel in doses ranging from gr. ^ to ^ (0.016-0.032) every hour or two, com- bined with a little opium to prevent purgation, is serviceable. At the beginning veratrum viride may also be cautiously administered, with a view to dilating the arterioles throughout the rest of the body, and thus virtually "bleeding the patient into his own vessels." Later, digitalis in combination with the iodids of potassium and iron should be substituted for the purpose of absorbing the eflTused material. Tonics and a change of air may be required during convalescence. SERO-FIBRINOUS PERICARDITIS. Pathology. — The anatomic changes may be grouped into three stages — the first being characterized by a plastic exudation (correspond- ing with the lesions in dry, plastic pericarditis, though more pronounced) ; the second stage, by a variable amount of effusion composed largely of serum. The exudation usually begins about the origin of the great ves- sels springing from the base of the heart, and ultimately forms a thick covering of fibrin, especially on the visceral layer. The quantity of serous effusion may be from 2 to 10 ounces (64.0—320.0), but occasionally it is as much as 3 pints (l^- liters). The admixture of a slight amount of blood- or pus-corpuscles sometimes occurs in this form of the complaint. The third is the stage of absorption in the most favorable cases. Perfect resolution rarely takes place, but, instead, the liquid effusion is alone ab- sorbed, and the lymph causes firm adhesions of the visceral and parietal membranes. If, as sometimes happens, the serum remains, the acute passes into a chronic condition. The muscular tissue of the heart may become involved by an extension of inflammation from the visceral layer "which lies in contact with it ; it is always the seat of more or less col- lateral edema. The grade of the myocardial inflammation will depend much upon the extent and duration of the pericarditis, though usually it is moderate in the fibrino-serous variety. Btiology. — Tlie disease is most frequently observed to be associated ■with acute rheumatism. Bright's disease, and pulmonary tuberculosis. Sears collected 100 cases of pericarditis, of which 51 were due to acute SERO-FIBRIXOUS PERICARDITIS. 579 rheumatism ; and according to Baumgarten, the former disease arises as a complication of the latter in about one-third of the cases. From per- sonal observation, I am led to believe that exceptionally both sero- fibrinous and plastic pericarditis may occur in the course of rheumatic dyscrasia without the slightest evidence of arthritis. The disease also oc- curs in the course of the eruptive fevers and lobar pneumonia, and from extension of inflammation from neighboring parts. Idiopathic sero-fibrin- ous pericarditis is comparatively rare. (See also Bacteriology, p. 575.) Clinical History. — When, as rarely occurs, a primary pericarditis develops, the initial symptoms common to inflammation of other serous membranes manifest themselves, as anorexia, sometimes nausea and vom- iting, cJiills, fever, increased respiration and pulse-rate, together with local pain. The pain is usually of a dull, aching character, and less fre- quently merely a slight soreness, or it may be absent altogether. Acute pain is experienced only when the pleura is implicated. When pericarditis is secondary to an existing febrile affection there are, in many cases, no subjective symptoms to indicate its presence. In other instances there may be precordial oppression with or without slight pain or a feeling of soreness. Hence the rule should be absolute that in all affections in which pericarditis is likely to arise physical examinations of the heart should be frequently made, and particularly during the height of the disease. Dyspnea comes on simultaneously with the appearance of the effusion and may lead to actual orthopnea. Pressure is exerted upon the left lung if the effusion be large — a fact that explains in part the presence of dyspnea. The cardiac muscle, especially the right ventricle, is also pressed upon by the effusion, thus impeding to a greater or lesser extent the cardio-pulmonary circulation as well as the cardiac diastole. We have here an additional reason why dyspnea occurs, and also why deficient aeration of the blood and a feeble peripheral circulation are found in this complaint. Prior to the occurrence of the effusion the circulation is too actively carried on, the fulse being full and strong. It is clear from the above explanation relative to the mechanical effects of large effusions that during the second stage the pulse is small, feeble, and irreg- ular. When the liquid effusion is not large the heart-action may be ap- parently feeble, Avhile the pulse remains strong — a valuable rational sign. On the other hand, an excessive amount of fluid may cause the radial pulse to become quite small or even to disappear during inspiration (the pulsus paradoxus). Fever is present, as a rule ; the temperature is irregularly elevated, ranging from 101° to 103° F. (38.3°-39.4° C). In favorable cases defervescence takes place by lysis. JS^otous symp- toms, as headache and mild delirium, often appear, and sometimes give place to stupor or even coma. Physical Signs. — Inspection. — The skin-surface and mucous mem- branes are observed to be pale and more or less cyanotic. The neck- veins are prominent, and sometimes exhibit undulatorv movements or pulsations. The face wears an anxious expression ; the respirations are increased, labored, and at times irregular. The decubitus is dorsal ; the head and shoulders are elevated, and the patient may be forced to assume the sitting posture. In young subjects precordial prominence, with efface- ment or even bulging of the intercostal spaces, may result from the pres- 580 DISEASES OF THE CIRCULATORY SYSTEM. ence of a moderate effusion. In adults, however, a large collection is indispensable for the production of this effect. If the lung be shrunken or if there are pleuritic adhesions, expansion of the pericardium, and hence also bulging, will be prevented. The distended pericardium may depress the diaphragm. Elevation of the left nipple in consequence of marked anterior expansive bulging has been observed. In the first stage the apical beat is exaggerated, but as the effusion increases (forcing the heart backward and upward) it is displaced in an upward and outward direction, at the same time becoming weaker as well as more diffused, since with expansion of the sac comes greater mobility of the organ. "When the pericardial sac becomes filled the impulse-beat disappears, for the reason that the fluid now completely surrounds the heart and pushes it away from the chest-wall. Palpation confirms the results of inspection. The apical beat is dif- fused and feeble or lost. When detectable it is found to be displaced upward and to the left. Altering the patient's posture changes the seat of the apex-beat (Oppolzer). and if the shock has been lost, turning the patient on his left side or bending his body forward may cause its return. The cardiac impulse disappears earlier when, on account of myocarditis, the systole is greatly enfeebled. On the other hand, old adhesions may retain the apex-beat in contact Avith the chest-wall, despite the presence of a large accumulation. Hypertrophy of the organ would act in a similar manner, though less potently. A friction-rub can be felt occasionally over the base of the heart even when there is a copious effusion present, and, if absorption takes place, the friction fremitus becomes more marked, simulating that of the first or dry stage. Percussion. — The area of cardiac dulness is greatly increased, and assumes a characteristic triangular outline with the base downward and the apex extending up to the third or even second interspace to the left of, though near, the sternum. The lateral border-lines of dulness obviously diverge from above downward, the right passing to a point corresponding with the right edge of the sternum, along which it runs to the Seventh rib ; the other to the left, finally intersecting the base-line at the left anterior axillary line. The lower level of the fluid, being continuous with the liver dulness, is not definable. Even in moderate effusions there is flatness in the fifth interspace to the right of the sternum (Rotch). The margins of the lungs surrounding the heart may be retracted and the heart carried forward or dilated, owing to the presence of adhesions ; the dull space will then appear larger than is justified by the amount of fluid. Retraction or moderate compression of the lung may, however, give rise to a modified tympanitic resonance to the left of the' flat area. Occasionally the lung is attached anteriorly, and then the heart is crowded backward by the effusion, while the area of flatness on percussion is relatively diminished. The triangu- lar shape of the flat space, noted when the patient is in the sitting posture, is to a considerable extent lost and its area diminished when he changes to the supine position or lies on either side, the effusion obeying the laws of gravitation. When the feeble impulse can be felt by the clinician within the dull area and not at its boundary, he has good evidence of the existence of pericardial effusion. Auscultation. — The characteristic friction-rub of the first stage has SERO-FIBBINOUS PEBICABDITIS. 581 already been described. It may, however, also be audible over the base during the stage of eflfusion, and always returns, after absorption of the fluid, for a brief period. The heart-sounds grow more and more distant, faint, and mufiled, though the second sound, as heard over the extreme base of the organ, may remain clear. Over the area of dull tympany corresponding to the lower antero-lateral portion of the left lung (which, as before pointed out, is more or less compressed) may be heard broncho- vesicular breathing. Course and Duration. — It will appear obvious that the course must vary in individual cases with the cause and severity of the special type of infection. Observation has shown that in one class of cases the three stages (dry, efiusion, and absorption) are passed through in rapid succes- sion, while in another class each stage is proportionately lengthened. The latter form has been termed " chronic " by some and " subacute " by others. The acute may also be followed by the chronic variety. Usually sero-fibrinous effusions complicating rheumatism are absorbed with rapidity once the process has begun, seldom requiring more than two weeks. When recovery is about to occur the temperature falls by lysis ; the dyspnea gradually disappears, and with it the effusion is gradually ab- sorbed. Convalescence is further indicated by a return of the appetite, normal heat of the skin, and a less frequent, full, and regular pulse. In cases that tend to a fatal termination either the fever continues or there is suddenly developed Jiypevpyrexia, as may happen when pericarditis occurs in the course of acute rheumatism ; in such cases the dyspnea is urgent and cyanosis is often marked, with signs of failing circulation. Nervous symptoms^ as extreme restlessness, insomnia, and active delir- ium, may be present. Under these circumstances death usually ensues at the end of a week or ten days. In a fatal case of acute articular rheumatism that I saw, complicated by pericarditis, with hyperpyrexia, death occurred on the sixth day. Complications. — Copious effusion may, by causing pressure upon the recurrent laryngeal nerve, produce paralysis of the vocal apparatus, or, it may press upon the esophagus, and cause difficult deglutition. Rarely acute pleuritis with effusion is a complication, and its occurrence usually lengthens the course of the pericarditis and renders the outcome uncer- tain. When there coexists extensive myocarditis syncopal attacks often endanger the life of the patient. Associated endocarditis and a compli- cating pneumonia may be observed. Prognosis. — In sero-fibrinous pericarditis recovery is the rule under favorable conditions. The outlook, however, becomes gloomy when the above-mentioned complications arise, and particularly when there is hyper- pyrexia in connection with acute rheumatism. Occurring as a secondary event in serious acute diseases, as pneumonia, or in chronic diseases, as Bright's, or organic affections of the heart, the pericarditis often precip- itates a fatal termination. The strong possibility that these cases may only partially recover or assume a chronic form must be recollected in making a prognosis. Diagnosis. — The disease is often overlooked, because unsuspected. Ordinarily the recognition of pericarditis by the characteristic triangular area of percussion-dulness and by the friction-sound is not difficult. Atypical cases or those first seen during the stage of effusion can only be correctly diagnosticated by exclusion. 582 DISEASES OF THE CIRCULATOR r SYSTEM Differential Diagnosis. — Acute pleurisy of the left side may simulate pericarditis with copious effusion, and, as before stated, these diseases may coexist. Acute pain, however, belongs to pleurisy alone. In peri- carditis the characteristic physical signs are elicited over the precordia ; in pleurisy they are apt to occupy not only the anterior but also the axillary and posterior aspects of the chest; hence the percussion-flatness in pleurisy extends to the left, far beyond the boundary-line of the per- cussion-flatness in pericarditis. The pericardial friction-sound has a dif- ferent situation usually from the pleuritic, and the latter is heard syn- chronously with the respiratory movements, while the former is intimately related to the time of the cardiac movements. The friction-murmur of pleurisy ceases if the breathing be momentarily suspended. Encapsulated pleural effusions that are limited in area to the antero-lateral portion of the chest are exceedingly diflicult of elimination, and especially in the absence of pleuritic friction. In the latter complaint, however, the heart- sounds are clear and the apex-beat often pushed some little distance to the right ; on the other hand, in pericarditis the general disturbance is usually greater, while a friction-rub may be detectable over the base. The heart-sounds are distant and muffled. The diaornosis is often aided by a consideration of the previous history and the bearing of any facts thus obtained upon the known etiology of these affections. We encounter intricacies when we attempt to exclude cardiac dilatation, though the fol- lowing brief table will be of assistance in the diag-nosis : Pericarditis with Effcsiox. Cardiac Dii.atatiox. {Pi-evioits History.) Recent history of sout, acute rheumatism, Usual history of chronic valvular disease acute infectious or septic disease, scur- of the heart, vy, chronic nephritis, or tuberculosis. (Clinical History.) Fever and slight pain are usually asso- No fever or pain, as a rule. elated. Nervous symptoms are often present. Absent. {Physical Signs.) Inspection often reveals bulging (more Apex-beat usually visible, wavy, and marked in the young). Apex-beat diffused, pushed up, is feeble, and later absent. Heart's impulse usually absent or occu- Though feeble, the impulse is palpable, pies center of dull area. Friction- fremitus may be present over the base. Percussion shows a triangular flat area, Dull area varies with chambers dilated ; and the boundary-line above changes it is coextensive with a wavy impulse, on altering the position. There is dull does not extend so high (except in mi- tympany in the axillary or subscapular tral stenosis), and does not vary with region. change of position. No dull tympany. Ausrultation shows the first sound distant First sound clear, short, and sharp. No and muffled ; a double friction-rub is friction-murmur present, but an endo- often present over the base. cardial murmur or murmurs may appear. Treatment. — The management of the first (or dry) stage is identical with that detailed in discussing the plastic variety. During the stage of effusion the patient should be kept at absolute rest in the recumbent pos- ture, and mental excitants should be rigidly prohibited with a view to PURULENT PERICARDITIS. 583 minimizing the labor of the heart. The diet is to consist mainly of easily digested albuminous articles ; fluids are not to be given in large amounts, since this tends to overfilling of the vessels, increases the arte- rial tension, and delays absorption. Local Measures. — Flannel should be kept over the precordia, so as to avoid exposure and undue chilling. The ice-bag or Leiter's coils (to be used in the first stage) should be cautiously employed during the second stage, until the temperature has defervesced considerably, thus indicating a sub- sidence of inflammation in the pericardium.^ Subsequently, if absorption does not proceed satisfactorily, blisters may be applied over the pre- cordia ; but should the patient's general condition be decidedly bad, an absorbifacient containing iodin, lanolin, and ichthyol may be substituted with advantage. The tlierapeutic measures must be chosen with sole reference to the primary disease, which the physician must continue to treat while he attempts by other means to relieve certain symptoms and promote absorp- tion. For example, if the pericarditis be due to rheumatism, the use of the salicylates must be' persevered in, and opium may be added to quiet restlessness and procure relief from pain. In my own experience absorption has been best promoted by the use of the double iodid of potassium and iron, or of iron and manganese. These agents are seldom contraindicated unless they are badly borne by the stomach. Diuretics and saline purgatives are not without value, but do good only in the later stages. Depressing measures of whatever sort are not to be re- sorted to unless the circulation be good. If the pulse be small, Aveak, and rapid, with marked cyanosis, stimulants are indicated and are to be given in moderate quantity ; the pulse Avill then be found to grow stronger and the dyspnea and cyanosis less marked. Strychnin and the salts of ammonium will be found to be useful. Digitalis and strophan- thus are not to be thought of when myocarditis is associated ; at other times they often improve the peripheral circulation and increase the urin- ary secretion. When the breathing becomes greatly embarrassed and the circulation fails, as shown by the feeble, broken, rapid pulse and the cyanotic hue of the lips, eyelids, and finger-tips, cardiocentesis is indicated, and in sero-fibrinous effusion aspiration has, in recent years, given good results if not too long delayed. If the slightest doubt arises as to the character of the fluid, a preliminary puncture with a hypodermic needle should be made. The point for puncturing is the fourth interspace, 1 inch (2.5 cm.) from the parasternal line, or the fifth interspace, 1|- inches (3.7 cm.) from the left edge of the sternum. The operation must be per- formed with the strictest asepsis, and the amount of liquid withdrawn at any one time should not exceed two or three ounces. It is better to re- peat the puncture several times than to remove the pressure too suddenly from the damaged heart. Of 60 cases of paracentesis for pericarditis of diff'erent varieties, collected by Roberts, 24 terminated in recovery. PURULENT PERICARDITIS. (Empi/ema of the Peri car divtn.) Pathology and Btiology. — The condition often follows the sero- fibrinous form. Septic and tuberculous processes involving the pericar- ^ If the pericarditis be secondary to an acute febrile disease, this fact must modify the method here recommended accordingly. 584 DISEASES OF THE CIRCULATORY SYSTEM. dium are also apt to cause purulent effusion, and many of the cases that arise in the course of the acute infectious diseases belong to this category. The pneumococcus has been found in the pus (Shattuck and Porter). The membrane is much thickened and presents a gray, granular surface, and the myocardium underlying the visceral layer is softened, fragile, and pale-looking (fatty). Clinical History. — The local subjective symptoms and physical signs are the same in kind as in the former variet3% but the amount of exudation is frequently less. At the onset rigors often occur, and may be repeated at varying intervals. The temferature-curve is of the sup- purative type ; the 'puUc is small, rapid, and irregular ; and jyln/sical prostration is pronounced. Purulent pericarditis runs a comparatively rapid and an almost uniformly unfavorable course. Diagnosis. — The chief clinical features are often referable to the primai-y or causal disease ; hence in every instance in which purulent pericarditis is apt to arise a physical exploration of the chest is impera- tive. The purulent character of the effusion cannot readily be ascer- tained, as a rule ; but the history of an affection having etiologic impor- tance, the observance of rigors, and the presence of the fever-curve pecu- liar to suppuration would all point strongly to purulent effusion, and should lead to aspiration with the hypodermic needle — a harmless procedure if carefully performed, and one that almost constantly gives reliable results. Treatment. — It is within the physician's province to treat the pri- mary disease assiduously, but not pericardial empyema. Incision (after preliminary resection of a rib — Brentano), irrigation of the sac, and drainage by a strand of iodoform gauze are advisable and feasible measures. HEMORRHAGIC PERICARDITIS. In purulent pericarditis the effusion may be hemorrhagic, and par- ticularly when it is of tuberculous origin. In non-purulent tuberculous pericarditis also the exudation is apt to be hemorrhagic. In the non- purulent instances that are due to chronic Bright's disease or that occur in the aged the effusion is sometimes blood-stained ; and future observa- tion may show that the hemorrhagic variety is of more frequent occur- rence than has hitherto been supposed. In ordinary serous pericarditis there is apt to be present more blood than in serous pleuritis. M. T. Ferrier has found 5 examples in 9 collections. Sears found a pure growth of pneumococci in the exudate from a case of hemorrhagic peri- carditis. This etiologic variety scarcely calls for separate clinical con- sideration. ADHESIVE PERICARDITIS. ( Chronic Pericardii is.) Pathology and Btiology. — Chronic pericarditis follows the acute forms, and, as in the case of the latter, it may be partial or general. The effusion may rarely remain as a permanent condition, though not infrequently a clear history of the preceding acute attack is wanting. In most instances the opposed surfaces of the membrane are either univer- sally or over a limited area firmly adherent. The amount of new con- nective tissue present or the degree of thickening of the layers varies greatly, and is dependent upon the type of the primary acute attack. If ADHESIVE PERICARDITIS. 585 the latter is of mild grade — as, for example, in the case of the sero-fibrin- ous variety complicating rheumatism — then not much thickening is en- countered in the resulting chronic form. Chronic tuberculous pericarditis is not uncommon, and may be pri- mary, though more commonly it is secondary, in its origin. The disease may be chronic from the time of onset. I have noticed that often more or less effusion prevails. The layers become enormously thickened, and total obliteration of the sac by agglutination of the surfaces is not infrequent. In the dense exudate that remains after complete absorption of a peri- cardial effusion calcareous depositions occur, forming a bony casing, which either partially or totally encircles the organ. The external surface of the pericardium may become united with adjacent tissues. The myocardium is the seat of atrophic and degenerative changes. Symptoms. — Autopsies frequently discover an unsuspected adhesive pericarditis. Hypertrophic dilatation of the chambers usually develops sooner or later, and is due to adhesions that interfere with the free action of the organ as well as with its systole. When present the subjective symptoms point to a giving way of the right ventricle, as shown by the presence of venous stasis and dropst/. The pulse is rapid, of low tension, and irregular, and, though not diagnostic, the pulsus paradoxus is noted. Pericarditis Callosa (Galvagni ^). — A form of chronic fibrous pericar- ditis which comes on insidiously during childhood and is exceedingly difficult of diagnosis (vide infra). Pericarditis callosa is characterized principally by facial cyanosis, slight edema, full and tortuous jugular veins without pulsation. The typical physical signs of pericarditis are wanting also. On the other hand, a congestive cirrhosis of the liver may supervene and lead to ascites. Physical Signs. — Inspection. — Depression or pitting of the intercostal spaces over the position of the heart ma}^ be noticed. Synchronous with the systole there is also a retraction of the chest-Avall in the apical area, and less frequently over the whole precordia, the latter being an unerring sign of universal adhesions. The degree of systolic recession is slightly influenced by the respiration, inspiration increasing it, except adhesions exist between the pericardium and the adjoining pleura, and it is best appreciated on palpation. When the apex-beat is not palpable, the systolic pitting over its site may be due to atmospheric pressure. During the diastole the heart forcibly rebounds, causing the so-called diastolic shock, which is of great diagnostic importance when associated Avith marked systolic retraction. Though not always visible, it can be readily felt on palpation. Friedreich's sign (the sudden collapse of the jugulars during diastole) may frequently be observed, but I have also noticed this in cardiac dilatation without adhesions. Prior to the onset of dilatation the apex-beat may be forcible and visible over an increased area, indicating hypertrophy; but after the myocardium is weakened (from interference with its nutrition) and dilatation comes on, the impulse-beat is faint or wanting, and in marked systolic retraction may be seen to be vibratory. The fixed position of the apex-beat when the patient is turned over upon his left side is a strong confirmatory sign. Percussion. — The area of cardiac dulness is increased, especially up- ward and to the left, owing to the associated hypertrophy and pleuro- ^ University Med. Mag., March, 1899 ; Clinique moderne, ami. iv., No. 341. 586 DISEASES OF THE CIRCULATORY SYSTEM. pericardial adhesions, and, since the adhesions between the pleura and the pericardium do not allow the lungs to overlap the heart during inspira- tion, the upper and left lines of dulness remain fixed (C J. B. Williams). Auscultation. — When dilatation reaches a high degree the auscultatory signs peculiar to that condition appear. In many cases no murmurs are detectable, but in a third group loud murmurs, quite independent of any value as regards cardiac lesions, are audible ; these murmurs may be due to the vortiginous movements in the endocardial blood-current occa- sioned by the jogging cardiac action. The murmur of tricuspid regur- gitation, from a breakdown of the right ventricle without apparent exciting cause, is most significant. Differential Diagnosis. — The condition is apt to be confounded with clironie myoearditii^ and shnple hypertropldc dilatation. As before stated, chronic pericarditis may be associated with effusion, and it is important to distinguish such instances from the adhesive form, if we Avould institute a proper treatment. In chronic pericarditis with moderate effusion the seat of the apex-beat is higher and less un- dulatory, and when the amount of effusion is large the impulse is absent and there is bulging. Adhesive pericarditis with hypertrophy causes bulging in young subjects, but the apical beat is retained. In pericar- ditis with effusion the upper and left limits of dulness are not stationary, and there is an absence of systolic retraction and diastolic concussion. Course and Prognosis. — The hypertrophy that comes on early in consequence of the obstruction offered to cardiac action is compensatory, and this harmonious balance may be maintained for a long period of time with apparent comfort. After myocardial degeneration, followed by atrophy or dilatation, has occurred, the condition becomes quite serious, and death usually ensues amid signs of extreme cardiac dilatation. The treatment must be ordered chiefly with reference to the nutri- tion of the heart-muscle, following the principles noted in dealing with the management of valvular affections of the heart. If chronic effusion be present early, operative measures are to be warmly advocated. HYDROPERICARDIUM. {Dropsy of the Pericardium.) Definition. — A condition in which the pericardium contains a serous transudation, while the membrane itself shows no signs of inflammation. Btiology. — {a) Hydropericardium is usually associated with general cardiac or renal dropsy, of which it forms a component part. Under these circumstances it develops late, and frequently follows hydrothorax, on account of which condition it is liable to be overlooked. It may also occur suddenly in chronic nephritis, and particularly in the scarlatinal variety, {h) It arises not infrequently from local mechanical causes, as the pressure of mediastinal tumors, aneurysm, or thrombosis of the car- diac veins. Symptoms. — No subjective symptoms are present, save perhaps dyspnea, and the diagnosis rests upon the history and the physical signs. None of the latter, however, are particularly significant. They point to HEMOPEBICABDIUM—PNEUMOPERICABDIUM. 587 the presence of fluid, and the area of percussion-dulness assumes the same form and exhibits even greater change, with alteration of the patient's posture, than in pericarditis. No friction-murmurs are heard and no bulging of the pericardium is observed. It is rare indeed, I have found, to see an excessive amount of serum in the pericardium at the postmortem. The symptoms and signs of hydrothorax generally precede and accompany hydropericardium, and the latter condition tends to intensify the effect of the former. The condition, per se, is rarely of serious import. Osier remarks : " Naturally there are in the pericardial sac a few cubic centi- meters of clear, citron-colored fluid, which probably represents a post- mortem transudate." In rare instances the transudate has a milky appearance {chylo-pericardiuni). The treatment suitable for cases of general dropsy, as a rule, aff"ords relief. In large serous accumulations aspiration should be practised. HEMOPERIOARDIUM. By the term " hemopericardium " is meant hemorrhage into the peri- cardial pouch — 'a, rare event. Among the causes are — (a) perforation by aneurysms of the aorta and the coronary arteries into the sac ; (h) rupture of the heart, due to injuries or cardiac aneurysms and fibrous formations from myocarditis; (c) direct injuries, especially stab- and bullet-wounds. The symptoms and course depend greatly upon the nature of the exciting cause. The most frequent factor, rupture of an aneurysm, proves quickly fatal from overcrowding of the heart. In rupture of the heart-muscle there is sometimes a slow outpouring of blood, Avith a correspondingly slow course, varying from a few hours to a couple of days in duration. The physical signs of effusion come on with dyspnea and failing circula- tion, which lead to cardiac exhaustion and death. The blood-stained effusions, before considered, that are met with in certain forms of peri- carditis, are not to be regarded as instances of hemopericardium. PNEUMOPERICARDIUM. [Air in the Pericardium.') In this complaint, besides air or gas, there is usually present pus, and less frequently blood ; hence an appropriate term in most instances would be pyo-pneumopericardiuvi. When the pericardium is perforated puru- lent pericarditis results. The causes are the following : (a) wounds ; {h) a fistulous connection between the adjacent air-containing organs and the pericardium as the result of diseased processes, such as pulmonary tuberculosis or empyema ; (c) rarely decomposition of liquid pericardial effusions. The symptoms are equivocal. In the main they do not diff"er from those of pericarditis with effusion, excepting that dyspnea is more intense than in the latter aff"ection. By attention to the physical signs 588 DISEASES OF THE CIRCULATORY SYSTEM the distinction from pericarditis can rarely be made. In pneumoperi- cardium there is tympanitic percussion-resonance over the precordia, though the fluid, when present, gives rise to a boundary-line of dulness. The change of the patients posture decidedly alters the area of the tym- panitic note. On auscultation may be heard loud, rasping, friction- sounds having a metallic quality, intermingled with churning, splashing noises, or the so-called '• water-wheel sounds." I have, however, met with two cases in which the heart-sounds were exceedingly feeble. Pneumothorax when encysted in close proximity to the heart, displacing the latter organ, must be eliminated. The latter complaint gives cardiac dulness in an abnormal position and a metallic sound synchronously with the respiratory movements — two signs diagnostic of pneumothorax that are absent in pneumopericardium. The ^jrognosis is grave, death coming on most commonly in a day or two. The admission of air might alone result in a spontaneous cure, as occurs rarely in pneumothorax. The treatment is the same as has been recommended for purulent pericarditis. II. DISEASES OF. THE HEART. ENDOCARDITIS. Definition. — Inflammation of the lining membrane of the heart. The process is usually confined to the valves, though the cardiac layer may also be afi"ected. Varieties. — (a) Simple acute endocarditis ; (b) ulcerative endocarditis ; (c) chronic endocarditis. The pathologic processes involved in the first two, the acute forms, are identical in nature, though they difi"er in severity. I have met with tAvo instances that could be referred to neither sub-variety, apparently occupying a middle ground. SIMPLE ACUTE ENDOCARDITIS. (Endocarditis Verrucosa.) Pathology. — The disease is characterized by the formation of small vegetations on the segments, varying in size from excrescences that are scarcely visible to those the size of a pea. They are found chiefl}^ on surfaces that are opposed to the blood-current, near the margin of the valve, and "forming a row of bead-like outgrowths." Their seat corre- sponds to the point of maximum contact (Sibson), but the mitral valve is much more commonly affected than the aortic. With the segments the chordte tendineiTe are sometimes aff"ected, and very rarely the latter are alone involved. The left side of the heart is much more frequently the seat of acute endocarditis than the right, except during fetal life, when the right side is almost exclusively involved. To account for the greater frequency of occurrence on the left side after birth, it has been suggested that freshly oxygenated blood affords the most favorable condition for the multiplication of the micro-organisms that are concerned in the inflarama- torv process. As corroborating this view, the fact is adduced that during SIMPLE ACUTE ENDOCARDITIS. 589 fetal life the blood in the right chamber is the more completely oxygen- ated. It has also been pointed out that before birth the right side, and after birth the left side, is the more active, and that the active side is apt to suffer on account of higher pressure. Obviously, the vegetations form an obstruction to the current of the circulation as it flo^vs through the valvular opening. In the early stage the membrane in the vicinity of these excrescences shows a bright-red color, which has usually disappeared in fatal cases before they come to autopsy. The histologic changes con- sist in a proliferation of the subendothelial tissue (small-celled infiltra- tion), Avhich forms the principal component part of the vegetation. On this basal mass of granulation tissue there is deposited fibrin from the blood, the latter being separable from the former in acute forms of the complaint. Micro-organisms have repeatedly been found in the fibrinous depositions, but the specific causal irritant has not as yet been discovered. In favorable cases either the vegetation is ultimately absorbed or there remains a small indurated mass. When the vegetations are of consider- able size emboli may become detached by the force of the blood-current, and be carried to the vessels of the extremities and to the various viscera, particularly the brain, spleen, and kidneys, giving rise to embolic infarcts. The latter event is frequently observed in cases in which acute endocar- ditis is engrafted upon chronic valvulitis. Simple acute endocarditis may end in the more serious or ulcerative variety. Here the cellular proliferation proceeds actively, leading to necrosis of the newly-formed tissue and to the production of an ulcer. Much more commonly, however, does the simple form terminate in chronic (sclerotic) valvulitis with deformity. iJ^tiology. — The most frequent cause of acute endocarditis is acute articular I'heumatism, which induces the disease in not less than 40 per cent, of the cases. In young subjects suffering from rheumatism the liability to the complaint is particularly pronounced. The severity or mildness of the rheumatic attack does not, however, influence the appear- ance of the cardiac complication. Cases of acute endocarditis of rheu- matic origin are met Avith in which the arthritic phenomena are secondary. It may complicate tonsillitis when the latter is due to or associated with rheumatism. In sijecific fevers it is also encountered, and found to be common in scarlet fever, but rare in typhoid fever, diphtheria, measles, erysipelas, variola, and varicella. It is not uncommon as a complication m pneumonia and pulmonarg tuberculosis, and Osier, as the result of 100 autopsies in cases of pneumonia, found it present in 5 instances, Avhile in 216 postmortems upon phthisical cases it Avas present in 12 instances.^ It has frequently developed in the more serious forms of chorea, and inter- current acute endocarditis may result from chronic diseases attended with emaciation and general weakness or suppuration, such as ulcerative carci- noma, gleet, gout, chronic Bright's disease, and diabetes. Lastly, acute endocarditis may occur as a secondary event in pre-existing sclerotic endocarditis, when it is termed acute recurrent endocarditis. In chronic endocarditis the liability to the acute form is greatly increased by the puerperal state, and also, though to a lesser extent, by pregnancy. Bacteriology. — All cases of acute endocarditis are probably micro- organismal in character. The disease, however, is the result of various 1 Text-hook of Medicine, Osier, pp. 628, 629. 590 DISEASES OF THE CIRCULATORY SYSTEM. microorganisms or tlieir toxins, whose action is assisted by the friction between the blood current and the surfaces of the valves. Indeed, the disease has of late been excited by injecting into the blood the streptococ- cus pyogenes, staphylococcus aureus, and other micrococci. Frankel and San_o-er affirm that the staphylococcus pyogenes aureus is the chief specific acent in causing acute endocarditis, but this view needs confirmation. Clinical History. — It is only occasionally that definite subjective symptoms, as precordial pain (sometimes extending down the left arm), di/spnea, and cardiac palpitation., are complained of by the patient. If fever have been present, as is common, the temperature usually rises rather abruptly. In the vast majority of instances the condition is discov- ered accidentally. This being true, its frequent occurrence in acute artic- ular rheumatism, and its occurrence in the other diseases mentioned under " Etiology," should be kept in remembrance. The symptoms of embolism are rarely observed. F. Billings reports a case Avith multiple emboli. The physical signs by which acute endocarditis is recognizable are dependent upon the valvular insufficiencies caused by the morbid lesions previously described. Hence there must be not a small proportion of mild cases, including those in which the valves are not affected, that give rise to no distinct physical signs. On inspection the area of visible impulse may be seen to be increased, though, as a rule, it is normal. The impulse is sometimes forcible and often irregular during the initial period, but later it becomes less distinct and more feeble. Palpation confirms the result of inspection. I have found the impulse to vary at each visit, with a general tendency to lessen in intensity in the later period of the disease. A very weak impulse is indicative of associated myocarditis or of the poisonous effect of a severe type of primary infection. In recurrent endocarditis the apical impulse is often heaving, on account of pre-existing compensatory hypertrophy, and its area is exceedingly variable. A systolic thrill is sometimes felt. On percussion the area of the heart's dulness is found to be almost uniformly normal, except in cases of intense myocardial involvement, when acute dilatation of the chambers may supervene, giving rise to an increased area of percussion-dulness in the transverse direction. In re- current acute endocarditis the area of dulness corresponds to the increased area of the apical beat. Auscultation. — Acute endocarditis is usually attended Avith a soft blowing, systolic murmur, which, owing to the fact that the mitral seg- ments are the favored seat of the disease, is heard muth more frequently at the apex than at the base. The point of maximum intensity of this murmur is often movable, but its area of transmission is limited. In rheumatic endocarditis this murmur is preceded by a prolongation of the first sound, and it may be rough in character, and associated with accentuation of the aortic second sound, later with a valvular pulmonary second. The murmur is sometimes heralded by a feeble or muftled first sound, with apparent intensification of the second, suggesting ventricular dilatation as the cause of the murmur. In acute endocarditis affecting the mitral valves aortic murmurs may coexist, but their true nature is more than doubtful. There is also a short, low-toned, and double sys- tolic murmur over the tricuspid orifice in a small proportion of the cases ; this is due most probably to a relative incompetency. When acnte endocarditis arises in connection Avith chronic valvular disease, the aus- SIMPLE ACUTE ENDOCARDITIS. 591 cultatory signs of the latter are but little changed, and hence an assured diagnosis is not possible. Complications. — There may be developed by direct extension sec- ondary myocarditis, a disease that Avill receive separate consideration. The diagnosis is based principally on the physical signs, though these are by no means trustworthy. The points gained by careful, inspection and palpation are of especial diagnostic importance, as is also the previous history of the patient. Differential Diagnosis. — The soft bellows murmur is often present in acute febrile diseases in -which the autopsy fails to reveal the lesions of acute endocarditis. The functional murmurs that arise in the specific fevers, however, are principally heard over the aortic area, while those occurring in endocarditis are commonly heard over the mitral area. Leube ^ points out that if the dulness is slightly increased to the left and there is fever ; in fact, if there is infectious disease present, a diag- nosis must be made of acute insufficiency of the ostium mitralis occurring in the course of acute endocarditis. The distinction between simple acute endocarditis and pericarditis should be categorical, in view of the manifold differences between their signs. But the fact that these two affections may be associated, more especially when they are of rheumatic origin, must be steadily borne in mind, and also that when combined the signs belonging to the endocarditis are not open to observation, owing to the pericardial friction-sound, and later the presence of the effusion. I have found, however, that, fortunately, endocarditis usually precedes pericar- ditis. The murmurs present must be called accidental if the area of car- diac dulness is normal, the second pulmonary sound not accentuated, and if the murmur be heard only at the pulmonary cartilage, or at this point and at the apex, and, at any rate, more distinctly at the pulmonary car- tilage (Leube ^). The elimination of old endocarditis or chronic valvular disease — a matter of importance — may be accomplished by attention to the character of the murmur in acute endocarditis, as well as to its limited area of diffusion, and by the absence of the signs of hypertrophy and of marked accentuation of the second pulmonary sound. A relative insufficiency distinguishes itself by a pure systolic murmur, loud and not invariably uniform, by a weak cardiac impulse, a slight ac- centuation of the second pulmonary sound, and a comparatively small and often irregular pulse. It is met with in excessive dilatation of the left ventricle, in anemia, " and particularly in certain changes of the valvular muscles, due to myocarditis " (Leube). Prognosis. — The immediate dangers are few, and depend largely upon the primary disease. Li many instances, however, acute endocar- ditis initiates permanent lesions of the valves. Treatment. — Prophylaxis. — The prevention of acute endocarditis in rheumatism has been dealt Avith in discussing the latter disease. No known direct measures can prevent the development of this condition in the course of the specific fevers, though absolute rest in bed and protection of the body against "cold" may diminish somewhat the tendency to it. The Attack. — The sick-room should be free from draughts, though well ventilated, and flannel is to be applied to the chest. The diet may be liberal, but should be composed chiefly of milk and other light nutritious substances. Stimulants are required in most instances, and ^Deuisch. Archivf. klin. Med., Nov. 5, 1896. ^ Loc. cit. 592 DISEASES OF THE CIRCULATORY SYSTEM. in abundance should the heart be failing. Digitalis is to be employed cautiously if at all. When the myocardium is involved, its use is not without danger ; under these circumstances the drug increases the sufferings of the patient by throwing the inflamed and weakened car- diac muscle into firm contractions. The salts of ammonium, particu- larly the carbonate, should be given continuously with a view to obvi- ating intracardial coagulation of blood ; and should the latter accident occur despite all efforts to prevent it, the carbonate, together with strych- nin and alcoholic stimulants, should be freely administered. I am con- vinced that in endocarditis due to acute articular rheumatism it is wise to continue the exhibition of the salicylates, though in moderate doses, pro- vided that the heart is guarded by the use of stimulants. During con- valescence from an acute endocarditis the patient should be kept at rest, so as to minimize the strain upon the affected valves ; even after he has apparently recovered, and particularly should the murmur still be present, perfect quiet is to be enjoined for a period of several weeks. ULCERATIVE ENDOCARDITIS. {Mali(/iiant or Infections Endocardiiis.) Malignant endocarditis is variously characterized, though usually either by perforative ulceration, by suppuration of the valves, or by both, giving rise to the physical signs of acute endocarditis. These develop amid the symptoms of some severe primary infectious or septic disease. There is at hand sufficient clinical evidence to warrant the assumption that ulcerative endocarditis also occurs, though very rarely, as a primary affection. Pathology. — {a) Valvular Endocarditk. — In its early development the valves are the seat of vegetations (such as are met with in simple acute endocarditis) which later undergo necrosis. The latter process manifests a tendency to spread, destroying more or less of the endo- cardium. In the interior of the vegetations the process of suppuration not infrequently takes place, and the abscesses thus formed rupture and produce various lesions according to their size and situation. The vegetations take on a grayish- or yellowish-green appearance. Histo- logically, they are composed of granulation tissue, veiled by granular and fibrillated fibrin that contains numerous micro-organisms. At the base there is usually developed more or less reactionary inflammation. After rupture the blood-current may enter the abscess-cavity, and, if there be no complete perforation, the endocardium will be pouched out, and an aneurysmal dilatation of the valve will result. Ulcerative lesions ai-e most frequently observed. They may be mere erosions of the endo- cardium, but, as a rule, are penetrating in character and often result in complete perforation. I have seen repeated instances in which the three classes of lesions above depicted were all present. Osier, in an analysis of 209 cases examined by him with a view to ascertaining approximately the relative frequency with which the different parts of the heart were affected, obtained this result : Aortic and mitral valves together, 41 ; aortic valves alone, 53 ; mitral valves alone, 77 ; tricuspid in 19, pul- monary valves in 15, and the heart-wall in 33 instances. In 9 instances the riorht heart alone was involved.^ ' Text-Book of Medicine, p. 631. ULCERATIVE ENDOCARDITIS. 593 {h) Malignant mural endocarditis gives the same set of changes as the valvular form ; indeed, the latter may be combined with the former throughout. It is a comparatively rare condition, as is shown by the foregoing figures of Osier. The ulcerative process may invade the chordae tendinese and the valves, and may perforate the septum or even the ventricular wall itself. The vegetations are detached in small or large masses, and are conveyed by the circulating medium to various distant organs, especially to the spleen and kidneys, less frequently the intestines, meninges of the brain, and the skin. Their site is determined largely by their size, and they may be so large as to plug vessels of the caliber of the external iliac. When found in the lungs they may originate in endo- carditis affecting the right heart. These emboli, containing, as they do, the agents of inflammation, form suppurative infarcts that may be either white or red in color. The detached vegetations are sometimes so laden with irritants as to cause rapid softening of the coats of the vessel at the point where they become arrested, with consequent aneurysmal dilatation directly opposite their seat. As to number, the infarcts vary greatly in different cases ; thus there may be only one or two, as in a case in my own knowledge in which the spleen alone contained two small infarcts, or there may be more than a thousand minute abscesses widely scattered throughout the body. l^tiologfy. — It is to be kept in remembrance that the condition is, with few exceptions, most probably a secondary one. This explains why the lesions peculiar to simple acute endocarditis usually precede and accompany those of the ulcerative form. Bacteriology. — The specific irritant is probably the strejjtococcus i^yo- genes (Frankel and Sanger) ; hence the diseases in Avhich ulcerative en- docarditis occurs as a complication merely furnish the opportunity for the invasion of the streptococcus. The bacillus diphtherige, however, as well as the staphylococcus, the bacillus coli, the bacillus anthracis, the pneumococcus, the gonococcus, and other organisms, have been found in some cases in the absence of the streptococcus. In purely septic diseases ulcerative endocarditis forms but a part of the serious general condition. Here the cardiac element serves to facil- itate the generation and rapid diffusion of the poison ; and, since the latter is prone to attack the valve-segments, the morbid lesions within the heart not rarely' constitute the chief pathologic factor in septico- pyemia. Instances, however, are met with in which the segments pre- sent slight changes. Predisposing Affections. — The malignant form occurs, in connection with acute articular rheumatism, in about 10 per cent, of the cases in which acute endocarditis appears. In lobar pneumonia the ulcerative type is common, occurring almost as frequently as the simple variety, and was found by Osier in 11 out of 23 cases. The septic processes that arise from the puerperal state or from gonorrheal infection may also be complicated with ulcerative endocarditis. Among many other diseases that furnish occasional instances of this serious complication are measles, scarlet fever, typhoid fever, erysipelas, small-pox, chorea, tuberculosis, and chronic Bright's. Clinical History. — That form of ulcerative endocarditis which is a more or less prominent factor in septic diseases has been considered in 38 594 DISEASES OF THE CIRCULATORY SYSTEM. connection with septicemia. Malignant endocarditis being usually a secondary event, its clinical features must not be confounded with those of the primary affection. It is, however, often impossible clearly to separate the symptoms of the former from those of the intercurrent afiection. I shall describe first the common typhoid form. Local symptoms are often entirely wanting, or, Avhen present, consist merely in slight precordial pain and oppression, and are not sufficiently well pronounced to arrest attention. Subjective symptoms are, however, connected with other organs than the heart, and are due to the irritating effects of emboli that occupy the various organs of the body. G astro-intes- tinal disturbance, as shown by the occurrence of vomiting and diarrhea, is common. Pain that is ascribable to local peritonitis over the spleen, and sometimes also over the liver, is observed. Hematuria and dimness of vision are also frequent concomitants, and are due to renal and retinal hemorrhages. The urine may be scanty and albuminous. The more gen- eral features that are the result of the local embolic processes and, in part, of the valvular lesions, are serious and -for the most pnrt typhoid in character. The onset is usually signalized by a severe rigor that may be repeated at intervals varying from one to several days, and the disease often presents an irregularly remittent fever-curve, often touch- ing a high mark (105° or 106° F.— 40.5° or 41.1° C). I saw a case recently in which the febrile movement pursued the continued type for seven weeks. The pulse is rapid and irregular, though frequently be- coming slow within a brief period. The patient rapidly emaciates, and from the earliest development is profoundly prostrated, and nervous symp- toms, as headache, mild delirium, followed by somnolence, and sometimes even coma, appear. Profuse sweating sets in and persists, and as a result the skin may be covered by sudamina. An ecchymotic eruption due to cutaneous emboli is also common, this being often found associated with a papular or a diffused roseolar rash. Physical Signs. — These may be negative as regards the heart. In the majority of instances, however, a systolic murmur is present, which, when associated with other clinical indications that point to this affection, is valuable for diagnosis, and especially so if developed while the patient is under treatment for the primary attack. The second sound is some- times accentuated even when no organic lesions have previously existed. The physical signs of pneumonia and pleuritis (particularly the latter) may not infrequently be noted. Cases occur in which gangrenous in- farcts of the right lung give rise to signs of localized consolidation ; the spleen becomes considerably swollen, as can be easily demonstrated by palpation, and is quite tender as a rule ; and the liver is likewise mode- rately enlarged and slightly sensitive. Cerebral Variety. — In a small though decisive percentage of the cases all the clinical features of acute suppurative meningitis are presented, and sometimes to the almost total exclusion of ^symptoms pointing to the primary disease or to the more typical typhoid form of ulcerative endo- carditis. For a description of the symptoms that characterize the cere- bral form the reader is referred to the discussion of Purulent Meningitis. Recurrent Malignant Endocarditis. — By this term is meant an acute ulcerative endocarditis coming on in the course of chronic valvular dis- ease. As has been pointed out, simple acute recurrent endocarditis is ULCERATIVE ENDOCABDITIS. 595 common, though difficult of recognition. The latter condition, as Avell as the lesions in chronic valvular disease, predisposes to secondary infec- tion by the streptococcus and other organisms. The onset is usually abrupt and marked by a chill. The patient has fever, which may be quite high (104° F. — 40° C, or over), and may present either an irreg- ularly intermittent or a truly intermittent curve. The latter is often asso- ciated with recurring chills. In either of the above groups the course is likely to be acute. In some cases the character of the pre-existing mur- mur is changed, becoming louder and more decidedly blowing ; in many other instances, however, there is no appreciable alteration in the murmur. The condition may arise suddenly, amid the signs of failing compensa- tion, as in a fatal case reported by Dr. H. P. Loomis,^ in which the patient was semi-conscious, cyanotic, and suffering from intense dys- pnea and general dropsy. It was impossible to diagnosticate the cardiac lesions by the murmur present. Occasionally these severe intercurrent feb- rile attacks end in recovery, and such cases probably belong to the benign form, though closely simulating the malignant in their clinical characters. There is a third group of cases that run a subacute or even chronic course, Avith more moderate elevations of temperature, or, as rarely hap- pens, none at all. Mullin of Hamilton has reported a case that lasted more than a year. Here the other clinical phenomena, especially those referable to the heart, are often scanty and indefinite. Diagnosis. — It is of paramount importance to consider the previous history and all the circumstances under which individual cases occur. These points, together with the symptoms attending the onset and the first three or four days of illness, more particularly the severe rigor, early high temperature, and profound prostration, the sweatings, the various embolic phenomena, and the presence of cardiac symptoms, are often adequate for a certain diagnosis. With a clear history and the presence of the more characteristic general symptoms (in particular, the signs of embolism), a correct diagnosis is possible, even though cardiac murmurs be absent. Instances in which no data can be found to explain the occurrence of the disease are especially puzzling, and these will re- main unrecognized if at the same time the lesions in the heart fail to be manifested by special symptoms. The existence of a chronic valvular affection would, in itself, under the latter circumstances afford strong probability of the presence of recurrent malignant endocarditis if the other significant clinical symptoms mentioned above were present. Differential Diagnosis. — There is a group of cases in which either the history fails to furnish the essential causal factors on the one hand, or there is an absence of definite heart-symptoms on the other ; this group cannot sometimes be separated from cases of typhoid fever. The sub- joined table will, I feel, be found valuable as an aid in eliminating the latter disease from the typhoid form of malignant endocarditis : Ulcerative Endocarditis. Typhoid Fever. Previous or associated disease, as acute Previous health good. History of an rheumatism or pneumonia. epidemic. Very rarely a primary affection. No Always idiopathic, with a prodromal prodromes observable. stage. ' Transactions of the New York Pathological Society, 1890. 596 DISEASES OF THE CIRCULATORY SYSTEM. Ulcerative Endocarditis. Typhoid Fever. Ushered in suddenly by a severe rigor, Invasion marked by slight recurring •which may recur. chilly sensations. (Severe chill very rarely.) The fever rises rapidly. More gradually, in step-like fashion. Profound prostration as early as third Profound prostration not earlier than day. seventh day. The fever is markedly irregular from Less so, especially in the first week. time of onset, as a rule. Embolic symptoms (hemiplegia, etc.) may Extremely rare. appear. Cardiac symptoms, especially loud sys- Sometimes a soft systolic murmur. tolic murmur, often present. The blood usually shows signs of septic The blood shows a decrease in the num- leukocytosis. ber of leukocytes. Widal reaction and characteristic erup- Both symptoms usually present and diag- tion absent. nostic' Prognosis. — Most cases that run an acute course terminate in death, and when supposed instances of malignant endocarditis recover they are usually to be regarded as being of benign character. Subacute or chronic varieties, however, such as are most frequently met with in connection with organic heart-disease, sometimes reach a favorable issue. Treattnent. — This is largely supportive. The feeding is to be pushed vigorously, and concentrated forms of liquid food should be given at regular^ brief intervals. Arterial stimulants in liberal quantities are also demanded, and in addition quinin, sodium salicylate, and antiseptics may be tried. For the embolic symptoms the salts of ammonium give sli^^ht promise of beneficial results, and I prefer the carbonate for this purpose. Antistreptococcic serum has recently been used, and has proved efficacious in certain cases. It is obviously of no avail in instances in Avhich the streptococcus is not the causative agent. Moritz treated a case with antistaphylococcic serum, with a favorable issue. CHRONIC ENDOCARDITIS. (Chronic Interstitial Endocarditis.) Two clinical varieties are met with — one following the acute form, the other beginning as a chronic inflammation. Pathology. — The lesions may be limited to the valvular endocardium (their most common seat), or the mural endocardium may also be involved. In not a few instances the lesions are confined to the edges or bases of the segments, and when seen in the early stages there may frequently be observed merely a slight thickening of the free border of the leaflets ; in most cases small prominences appear near their free margins. The endocardium looks opaque and its normal elasticity is lost quite early. When the auriculo-vcntricular valves are aifected the primary seat of inflammation is the auricular face, but when the semilunar valves are dis- eased the morbid changes begin on the ventricular side and implicate the Aurantian body. Extension of the morbid process to other and all parts of the valvular curtain is common, and it is in cases of this sort that the greatest degree of shrinking and crumpling occurs. The most character- istic lesions consist of inflammation and exudation, Avhich produce cohe- ^ The septic form may simulate malaria in its general course. The points of dis- similarity may be found in the discussion of Septicemia. CHRONIC ENDOCARDITIS. 597 sion of the segments, roughen the surfaces, and lead to the deposit of fibrin upon them. The Imtologic alterations consist in a proliferation of the endothelial and a round-cell infiltration of the subendothelial connective tissue. Organization of these products of inflammation into connective tissue, with resulting induration and contraction, is the necessary subse- quent pathologic event. In old cases calcification of the diseased struc- ture is frequent. The shrinking shortens the curtains or curls their free edges, and produces insufiiciency in either case, since on dropping into the plane of the valvular orifice they fail to close it perfectly. Valves thus deformed may also obstruct the blood-stream. As before mentioned, cohesion of the invaded segments takes place, particularly at their bases, and may extend upward for a considerable distance, leading to constric- tion or stenosis. Involvement of the semilunar (aortic) segments in the ways previously described opposes an obstruction to the outflowing blood-current on the one hand, and, owing to the inability of the segments to eff"ect perfect closure of the aortic orifice, allows on the other hand a diastolic reflux of blood into the left ventricle. The aortic ring to which the semilunar segments are normally attached becomes sclerosed, and finally the seat of atheromatous changes, either fatty or calcareous. Again, chronic inflam- mation of the intima of the aorta produces a similarly thickened condi- tion of this layer in spots, followed by atheroma. These changes are most prone to take place in the course of the ascending arch of the aorta or just above the aortic segments. The fact of really vital importance in this connection is that from the aorta and sub valvular rino- the diseased processes before described may extend to the coronary arteries. Hence sclerotic and atheromatous alterations are found frequently in association with organic valvular defects. The great clinical significance of the implication of these vessels will be emphasized hereafter. Much less commonly similar lesions are noted at the orifice of the pul- monary artery. A similar involvement of the auriculo-ventricular valves also causes regurgitant and obstructive deformities at the mitral orifice, and in advanced cases the chordae tendinese, and even the papillary muscles, are almost invariably invaded by direct extension from the valves. As these structures undergo marked thickening with subsequent contraction, they become shortened and rigid, causing an actual narrowing of the cardiac orifice. In mitral stenosis during the early stages or in the mildest types a more or less complete ring of vegetations encircles the mitral orifice on its auricular aspect. The margins of the orifice also become hardened and roughened, these changes frequently extending to the valvular curtains and the chordae tendineae. Under such circum- stances the thickened valve could not, during the ventricular diastole, be forced back against the ventricular wall, but would occupy a nearly cen- tral position. Owing to cohesion of the free edges of the valvular struc- tures and to contraction of the chordse tendinese drawing the leaflets tow'ard the apex of the heart, the transition from this condition to the formation of a hollow cone {funnel mitral) is accomplished by natural, easy stages. Extensive union of the segments along their free margins may reduce the aperture to a mere button-hole slip {button-hole mitral) as viewed from the auricular aspect. The last two forms of lesions are far less commonly met with at the aortic orifice, though they occur rarely in 598 DISEASES OF THE CIRCULATORY SYSTEM. moderate degree ; on the other hand, curling of the valvular edges is far more commonly seen at the aortic than at the mitral orifice, if we except the cases that occur in children. The curtains of the thick, rigid valves may also jDermanently occupy the plane of the orifice, presenting a small ring-like opening [aunidar mitral). Fatty degeneration leading to the formation of necrotic (atheromatous) ulcers is common ; and calcareous deposits are frequently seen in old cases, either in localized areas or coextensive with the diseased tissue, converting the entire valve into a calcified mass, with loss of the valvular outlines. In chronic mural endocarditis the lesions exhibited are grayish-white, slightly elevated patches that are usually found to invade the underlying muscular structure to a greater or a less extent. Under such conditions of the valves the deposit of fibrin would be greatly favored, and the presence of an ulcerative surface or of a fibrous deposit on the valves affords a ready and satisfactory explanation of the occurrence of embo- lism in these cases. Emboli may also become detached from cardiac thrombi or from thrombi formed in the peripheral veins. For anatomic reasons the favored seats of embolic processes are, as in acute endocar- ditis, the spleen, brain, and kidneys, and irritants that cause acute endo- carditis find here a tissue-soil whose capacity for resistance to invasion is greatly lowered. Chronic mural endocarditis and chronic myocarditis are, as a rule, due to the extension of the inflammation from the valves, though the ventricular endocardium may be invaded independently of the valvular affection. In one instance of mitral stenosis I observed an enormous calcareous mass partly in the sub valvular tissue and partly in the wall of the ventricle, the segments remainingr altogether intact. In advanced stages of most cases of chronic endocarditis myocardial degen- eration occurs. It takes the form of fibroid change or fatty degeneration, or both. Aortic-valve involvement, especially when complicated with ath- eromatous change in the coronary arteries, is most prone to these forms of myocardial disease. Chronic endocarditis may be said, with the rarest exceptions, to persist until death, although Musser has reported two cases in which the murmur of chronic endocarditis disappeared during life. The effect of valvular deficiencies upon the several cardiac cham- bers and the muscular structure of the heart will be most advantageously studied when the individual lesions of the segments are considei'ed. Ktiology. — There can be no doubt that most cases of organic heart- disease occurring in children and young adults are caused by primary acute rheumatic endocarditis ; and, although the latter affection cannot in truth be said to terminate invariably in chronic endocarditis, it probably does in most instances. This result, in my opinion, is more frequent in children suffering from acute endocarditis than in adults. On the other hand, not a few cases of chronic endocarditis originate in a very mild grade of acute valvular inflammation, which may be, though itself mute, reinforced by a rheumatic diathesis. Indeed, acute endocarditis may be the sole expression of rheumatic disease. Not less than one half of all cases of organic val- vular disease are caused by rheumatism, and more than one half of the total number occur between tiventy and thirty years of age. Acute endo- carditis complicating other acute infectious diseases than rheumatism (e. g. measles, chorea, pneumonia) may also be followed by the chronic variety ; but it is quite questionable whether this occurs as frequently as in the case of acute endocarditis of rheumatic origin. AORTIC INCOMPETENCY. 599 The second variety, in which slow interstitial changes occur from the beginning, is dependent upon — {a) biologic. irritants (e. g. syphilis, malaria, and chronic rheumatism) ; (5) chemical irritants (uric acid, alcohol, lead) ; and {e) mechanical influences. Doubtless the influence of repeated strain- ing efforts is the most potent cause of this class of cases. Heav_y muscular labor increases constantly the tension in the arterial system, and this acts injuriously upon the valve-segments, setting up a gradual sclerotic change. In like manner, arterial sclerosis and BrigMs disease may cause chronic interstitial endocarditis by maintaining a persistent increase in the vas- cular tension, though the fact that these aff"ections may in turn result from the action of some of the leading causes of organic heart-disease must also be recollected. Trauma has produced in valves previously healthy a sudden, incontestable proof of valvular paresis or laceration that has persisted in a few well-attested cases. This accident is, of course, much more frequent in cases in which the valves have been already dis- eased, and particularly if they have been the seat of ulcerative processes. The predisposing causes of organic valvular disease may be discussed briefly. Hereditary influence, as pointed out by Yirchow, is especially potent in persons in whom there is hypoplasia of the heart and aorta (e, g. in chlorosis). It may be said that any malformation of a valve is certain to throAV an undue strain upon certain portions, and hence is likely to be followed by interstitial change. Osier, in 17 cases of bicuspid aortic valve, has reported the segments to be uniformly sclerosed. The cases of supposed hereditary transmission are doubtless, however, for the most part, due to the causes mentioned above, and particularly to rheumatism. Age exerts a predisposing influence, its effects, however, varying with the valve implicated. During fetal life this is on the right side of the heart in a vast majority of cases ; during childhood, adolescence, and early adult life, when the infectious diseases and rheumatism are frequent, it is the mitral valve in most instances ; and finally, during middle and espe- cially during advanced life the aortic segments are especially involved. I have, however, found aortic disease to be more common in young adults than most writers are ready to admit, and that it is favored especially by an occupation involving muscular strain (e. g. blacksmiths, draymen, sol- diers during campaigns). Sex jDer se has little if any effect, though, owing to the greater frequency of certain well-known causes of valvular disease (chorea and rheumatism) in girls and young women, females may be more frequent suff"erers than males. AORTIC INCOMPETENCY. {Aortic Insufficiency ; Aortic Regurgitation.) Definition. — The failure of the aortic valves to prevent a return flow of blood into the ventricle, owing, as a rule, to a diseased condition of the aortic leaflets (sclerosis) that is followed by crumpling and attended with contraction, shortening, or curling of the edges, and finally calcification. Patliology. — The aortic orifice may be enlarged (relative insuf- ficiency), and here the normal cusps fail to eifect complete closure of the 600 DISEASES OF THE CIRCULATORY SYSTEM. orifice. The cusps of the diseased aortic valves sometimes adhere to the intima of the aorta, and laceration of the semilunar segments, which are the seat of diseased processes (particularly ulceration), is sometimes found post mortem, and may be the chief factor in determining the develop- ment of the condition. This accident may, though rarely, occur as a result of a severe straining effort in the case of valves previously healthy. Occasionally, also, the principal factor in the production of this valvular lesion is a congenital malformation of the segments whereby they are rendered very prone to chronic endocarditis in consequence of the undue strain to which they are subjected. The lesions that give rise to stenosis may coexist with simple aortic incompetency, and. though the latter con- dition frequentlv occurs alone, stenosis is often combined with recfui'ori- tation. Mechanical Influence of the Lesion. — The reflux current passes from the aorta backward through the imperfectly closed semilunar valve into the left ventricle during the diastole of the heart or while the left ventri- cle is being filled by the normal blood-flow from the auricle. It is clear that over-distention of the left ventricle must result at once from two simultaneous influx currents of blood, with a tendency to an increasing dilatation, especially since the lesion itself is steadily progressive. To expel the increased amount of blood from the left ventricle demands in- creased cardiac power, and the over-exertion causes dilatation., followed bv a compensatory hf/jjertrophy. Dilatation and hypertrophy of the left ventricle develop pari passu until the left ventricle reaches enormous dimensions, forming the cor bovinum, which weighs 1000 grams or more (30 to 50 ounces). Under these circumstances the arterial system is overfilled at each ventricular systole. In the very early stage the reflux of blood from the aorta into the ventricle tends to lessen the volume of the circulating medium in the arterial tree, but this depleting influence is successfully counterbalanced by the augmented column of blood thrown from the ventricle during cardiac systole. Hence the requirements for bodily nutrition are, for a longer or shorter time, satisfied. The abnor- mally large amount of blood that is thrown into the arteries with undue force subjects them to increased tension, and as a result arterio-scle- rosis, leading sometimes to atheroma, is commonly developed, and pre- sents its ulterior dangers (aneurysm, apoplexy). The coronary arteries are similarly involved, their caliber being reduced, and particularly at the point of origin. Soon or late the blood-supply to the heart-muscle may become inadequate, and nutritional disturbances now manifest themselves in fatty and fibroid degeneration of the cardiac muscles ; these pathologic changes are attended with secondary dilatation, which soon predominates over the hypertrophy. The imperfect blood-supply to the ventricular tissue may be accounted for, in great measure, by the narrowed lumen of the coronary vessels, and also in part by the inelasticity of the walls of the latter and by the inefiiciency of the aortic recoil. Furthermore, it is to be recollected that, in obedience to the laws of nature, overuse of any single group of muscles, while productive of marked hypertrophy in the first instance, is followed eventually by atrophy and loss of power. In consequence of the increased tension to which they are constantly sub- jected the mitral leaflets may become the seat of sclerotic endocarditis, and this may lead to the development of mitral insufl5ciency (usually of AORTIC INCOMPETENCY. 601 mild grade) ; or there may be a displacement of the mitral segments in the direction of the auricle, thus creating incompetency at this orifice. There is to be observed in many instances a marked degree of fatty degeneration of the papillary muscles, which also exhibit more or less flattening. Again, secondary dilatation may produce relative insufiiciency at the mitral ori- fice. When incompetency has been established here, impeded pulmo- nary and general venous circulation, together with the secondary lesions in the left auricle, pulmonary vessels, and right ventricle that are cha- racteristic of mitral incompetency, are the necessary result. The blood- current through the mitral ring may be retarded, owing to the simultane- ous influx into the left ventricle from the aorta, thus causing pulmonary congestion without organic change in the segments. Special Etiology. — (1) Acute Endocarditis. — Incomplete resolution of the acute form of endocarditis leads to progressive chronic valvular dis- ease. In the young it is caused with comparative frequency by rheu- matic endocarditis. Aortic regurgitation may also arise, though rarely, in the course of acute endocarditis, as, for example, when the latter is attended with destructive ulceration. Such instances usually terminate in speedy death. (2) Chronic Infectious Irritants. — I have found syphilis to be a factor (though rarely the sole cause) in a considerable percentage of cases. Aortic regurgitation is a frequent complaint in sailors and soldiers, among whom it is worthy of notice that syphilis is particularly common. (3) Chemical Irritants. — (a) Uric Acid. — In chronic and irregular forms of gout the irritating qualities of uric acid give rise to interstitial endocarditis and arterial sclerosis. It is quite probable that chronic rheumatism has a similar influence, though brought about in a somewhat different manner, (h) By favoring the accumulation of uric acid in the blood, lead-poisoning may be indirectly responsible for the disease, (c) Alcohol by its persistent irritant action may excite chronic valvulitis. (4) Augmented Aortic Tension. — The excessive functional activity of the heart occasioned by the immoderate use of cardiac stimulants (alcohol) tends to raise the blood-pressure above the normal point, and thus sclerotic endocarditis may be developed very slowly. The effect of occupation in causing this disease, by increasing the vascular tension, is more notable than in the case of alcohol, though both of these factors are found not infrequently to be present in the same case. It is unde- niably true that strong-bodied men in the middle period of life and engaged in such occupations as entail strain — "not a sudden, forcible strain, but a persistent increase of the normal tension to which the seg- ments are subject during the diastole of the ventricle " (Osier) — are the most frequent suff"erers from aortic incompetency. (5) From personal observation I feel convinced that chronic endo- carditis (affecting the aortic valves) may be secondary to aortic end- arteritis as the result of direct extension. It must be borne in mind, how- ever, that arterio-sclerosis is also often secondary to chronic valvulitis. (6) Relative insufficiency is caused, in rare instances, by pronounced dilatation of the ascending portion of the arch near to the valve, or by an aneurysm just beyond the aortic orifice. Among the more effective predisposing factors are age and sex. The disease occurs much more often in males than in females, chiefly on 602 DISEASES OF THE CIRCULATORY SYSTEM. account of the fact that a greater percentage of the former than of the latter are engaged in occupations that are causally related to the dis- ease. As to age, a preponderating proportion of the cases arise during advanced middle life, and a comparatively smaller number at a more advanced period than in young adult life. Symptoms. — So long as the hypertrophy of the left ventricle suc- cessfully overcomes the otherwise injurious consequences of the valvular defect the harmonious balance of forces is maintained, and there is an almost entire absence of symptoms. I have observed, moreover, that compensation does not fail so early in young subjects as in those more advanced in years, or at a period of life when aortic incompetency is often a sequel of atheroma combined with hypertrophy and dilatation of the left ventricle. "With the development of marked hypertrophy severe muscular exertion and strong mental excitement will, by exciting over-action of the powerful heart, bring on a train of symptoms as throh- hing headache, vertigcu and tinnitus aurium. The clinical manifestations of arterial anemia, particularly of the brain, and also those of general arteriosclerosis, fre(juently coexist. The patient's countenance exhibits pallor, and he complains of headache, flashes of light before the eyes, and dizziness. Dilatation of the peripheral vessels often leads to hot flushes and drenching sweats. Cases exhibiting the latter symptoms have been mistaken for jjhthisis. Dizziness is often distressing, and is most marked upon rising quickly from the recumbent to the erect post- ure. Shortness of breath may come on early, but this rarely happens except upon inordinate exertion or great mental excitement — conditions that cause strong cardiac action and prohibit the discharge of blood from the left auricle into the left ventricle, thus causing pulmonary congestion. Oppression in the precordial region and cardiac palpi- tation are commonly present, as is a dull aching pain ; the most constant seat of the latter is the precordia, but it radiates not infre- quently to the shoulders, and thence down the arms, particularly the left. Genuine angina pectoris may be a concomitant. I have also seen a couple of instances of aortic regurgitation in which severe pain was located in the left shoulder-joint, the condition simulating very closely rheumatism. Following immediately upon failure of compensation the cardio-pul- monary circulation is retarded, and there is increased di/sjmea, the latter symptom being greatly intensified by undue exertion and at night. There may be cough, and not rarely hemoptysis, though less frequently than in simple mitral disease. Later on, general venous congestion of a moderate grade follows pulmonary congestion, and the dyspnea now becomes severe. It is nocturnal, and often compels the patient to assume a semi-erect posture in bed. In the later stages the symp- toms, particularly those of venous stasis as shown by cyanosis and malleolar dropsy, are due to mitral incompetency, followed by fail- ure of compensation. Edema of the feet rarely goes on to general anasarca. In aortic incompetency a higher grade of symptomatic anemia is reached than in any other cardiac lesion — a recent blood- count showing 2,800,000 red corpuscles to the c.mm. Hence slight edema of the feet may be due solely or in part to anemia. The in- tercurrence of acute endocarditis, as evidenced by prostration and AORTIC INC03IPETENCY. 603 irregular fever, is observed, and not infrequently as a terminal condition. The symptoms of cerebral, splenic, and renal embolism may arise. Prob- ably sudden death ensues, as the result of involvement of the coronary arteries, with greater frequency in this than in all other forms of val- vular disease combined ; and yet this accident is by no means of fre- quent occurrence. Instances of aortic incompetency, in which nervous 'plienomena^ as peevishness, irritability, or melancholia, manifest them- selves, are too common to be looked upon as mere coincidences. Many patients are doubtless led to commit suicide because of their cardiac lesion when other and erroneous explanations are given to account for their acts. Physical Signs. — Inspection brings to light an enlarged area of the apex-beat ; this is displaced downward, being visible in the sixth and seventh interspaces and to the left, and most marked between the mammary and anterior axillary lines. The entire precordial zone may be distended, particularly in young subjects, and the systolic pulsation is usually more or less heaving in character. The carotids throb for- cibly, as do the temporals, brachials, and radials, though less vio- lently. These abnormal pulsations are due chiefly to hypertrophy of the left ventricle, though frequent factors of lesser influence are asso- ciated — an arterio-sclerosis and a regurgitant blood-stream from the aorta into the left ventricle. The impulse becomes difiused and wavy with the progressive enfeeblement of the left ventricle, and venous pul- sation due to tricuspid insufficiency may be associated with arterio-pul- sation later in the affection. Epigastric throbbing may also be noticed, and on gently rubbing a spot upon the forehead an alternate paling and blushing appear (Quincke's capillary pulse) ; this may also be noted in the finger-nails. It is not peculiar to aortic insufliciency, however, and may be observed in cases of decided neurasthenia and in anemia. Very rarely the pulse-wave is propagated from the capillaries to the veins of the hand and back of the foot, giving rise to a visible venous pulsation. L. Webster Fox informs me also that the retinal vessels are often seen to pulsate in this disease. On palpation a forcible heaving impulse is usually felt. AYhen, how- ever, dilatation predominates over hypertrophy, the impulse is weak and undulating. A diastolic thrill just to the left of the mid-sternum may be detected in many instances, and a presystolic thrill is also dis- coverable very rarely. The pulse is characteristic; it is quick, jerking, and full, but, upon striking the finger, recedes abruptly, and is known as the Corrigan or ivater-liammer pulse. This sudden collapse of the pulse is most decided when the arm is held in a vertical position. Its distinctive characters are not always appreciable after compen- sation is lost. A glance at the sphygmographic tracing will show a sudden rise and fall, with absence or delay of the secondary wave {vide Fig. 50). Percussion. — Cardiac dulness is coextensive with the impulse, ex- tending downward to the eighth rib, and to the left as far as, or even beyond, the anterior axillary line. Later, enlargement of the left auricle may cause dulness upAvard and to the left of the sternum. En- largement of the right ventricle causes an increase of dulness to the right. When the dilatation exceeds the hypertrophy the area of dul- 604 DISEASES OF THE CIRCULATORY SYSTEM ness will be much extended transversely and slightly upward, the apex now being more rounded/ On auscultation a diastolic murmur with its seat of greatest pronuncia- tion is audible at, or a little below and to the left of, the aortic cartilage and is transmitted down along the left edge of the sternum ; this is pro- duced in the left ventricle. From the xiphoid it may be transmitted to Fig. 49.— Normal pulse-tracing. the left as far as the spinal column. It may be heard in the vessels of the neck and, very rarely, in the radials. A. Borgherini affirms that the special direction taken by the regurgitant current determines largely the variable position of the murmur and the variable size of the heart. The rhythm of the murmur can be most readily determined by auscul- tating over the base, for while the pulmonic second sound is usually Fig. 50.— Pulse-tracing in a case of aortic regurgitation (William Hoffman). audible at the apex (the murmur appearing to follow it), it is not so when, as sometimes happens, the murmur is quite loud. The first sound is often dull, indefinite, and Avidely diifused, owing to hypertrophy of the left ventricle. In quality this murmur is usually soft, blowing (long- drawn), and fretjuently musical ; sometimes, however, it is somewhat rough and loud. Associated inurmurs. — In most instances a systolic murmur, brief and harsh in character and transmitted into the vessels of the neck, is also discovered over the aortic region (double aortic). The presence of the murmur with the first sound is not diagnostic of actual aortic stenosis. It is more often due to a mere roughening of the semilunar segments or of the intima of the aorta. In advanced cases a soft systolic murmur is commonly heard at the apex ; it is readily distinguished from the diastolic murmur by its rhythm, and is occasioned in most instances by a relative mitral incompetency. Still another mur- mur, of rare occurrence, is rolling in character and generally presystolic in time, and may be heard at the apex over a limited surface-area. This may be accounted for by the presence of excessive dilatation of the left ' A dilated aorta with tliickened walls — a condition sometimes a.ssociated with aortic regurgitation — may also give rise to abnormal dulness under the manubrium and to the left of the sternum. AORTIC STENOSIS. 605 ventricle, in consequence of which the mitral leaflets must remain free in the blood-stream during the diastole, and here they set up vortiginous movements that cause the presystolic (Flint) murmur. Duroziez dis- covered a double murmur in the arteries (femoral), Avhich is quite fre- quently present, and, in view of its duplex character, possesses con- siderable diagnostic import. Traube has described another arterial phenomenon of interest — a systolic sound in the leg, somewhat resembling a heart-sound, but exceedingly short and sharp. It is probably due to sudden systolic distention of vessels that were previously empty. The diagnosis demands the presence of a diastolic murmur, the signs of left ventricular hypertrophy, the peculiar arterial pulsations, and the characteristic water-hammer or Corrigan pulse. The diastolic murmur may be absent. For the differential diagnosis see Aneurysms of the Arch, Hyper- trophy, Dilatation of the Heart, etc. AORTIC STENOSIS. Definition. — A narrowing or stricture of the aortic orifice, due to thickening or adhesion of the valve-segments, and causing an obstruc- tion to the flow of blood into the aorta. Simple aortic stenosis may be met with, though it is a great rarity. Its development is soon followed by more or less valvular incompetency, and hence these affections often coexist. It may be secondary to aortic insufficiency; but this is rare, the conditions in the latter disease being unfavorable to the development of the former. Special etiology. — Rarely rheumatic endocarditis, and still less commonly other forms of acute endocarditis, cause union of the semi- lunar segments, with resulting stenosis. The most common immediate causative factor is a slow sclerosis of the aortic valve, followed by cal- careous deposits. The more or less immobile, rigid valves obviously narrow the aortic orifice and oppose a barrier to the outflowing blood- current from the left ventricle into the aorta. The aortic ring may be the seat of changes similar to those just described, resulting in a moderate grade of stenosis, though the leaflets themselves remain intact. The lesions are most frequently to be regarded as a part of the general process of arterial sclerosis, which is most marked in the region of the thoracic aorta; and sometimes, as Peter contends, they are distinctly secondary to sclerotic changes at the root of the aorta. The coronary arteries may be the seat of changes similar to those noted in aortic regurgitation. The condition is also rarely congenital. Males who have reached advanced years are especially prone to aortic stenosis, for the reason that atheromatous processes belong peculiarly to that sex and period of life. Mechanical Influence of the Lesion. — To propel the normal volume of blood through the constricted aortic orifice requires increased strength. on the part of the left ventricle, and, as a consequence, the latter hyper- trophies. This hypertrophy develops very slowly, and keeps pace with the 606 BISEASES OF THE CIRCULATORY SYSTEM progress of the valvular lesions. The undue ventricular tension sometimes induces more or less sclerotic change in the mitral valves. Hypertrophy of the left ventricle eventually gives way to extreme dilatation, and also to relative mitral incompetency with its unfavorable influence, first upon the pulmonary and, secondly, upon the general venous circulation. Symptoms. — The symptoms date from the commencement of failure of compensation, often many years after the onset of the disease. Their first appearance will be found to follow some unusual muscular eff"ort or the operation of some depressing influence, as the too free use of to- bacco or alcohol. They are due to disturbances of circulation arising from a gradual secondary dilatation of the left ventricle, which is now unable to propel the normal quantity of blood into the arterial tree. Hence anemia, especially of the brain and peripheral parts of the body, becomes pronounced, and is evidenced by such symptoms as syncope, dizziness, headache, and pallor. Since aortic incompetency usually mani- fests itself secondarily, the clinical features of both aifections are sooner or later variously commingled. In cases in Avhich mitral lesions develop they are overcome by compensatory enlargement of the right ventricle : the latter chamber may at a later period become dilated, in which event tricuspid regurgitation and the symptoms of general venous engorgement appear. As in the case of aortic regurgitation, so in an aortic constriction, slight edema of the feet is common as a terminal symptom ; marked dropsy, however, is uncommon. From the fibrous deposits on the segments, as well as from any small clots behind the valves, emboli are apt to become dislodged by the forcible blood-stream and be conveyed to the brain (cerebral embolism), to the spleen (splenic embolism), to the kidneys (renal embolism), or to other organs. Physical Signs. — Inspection. — The apex-beat is gradually displaced downward and to the left, owing to left ventricular hypertrophy. It is, as a rule, slow, forceful, and heaving, but less frequently it may be lack- ing in strength. It may be enfeebled, diminished in area, or even absent, owing to associated emphysema. Palpation discloses the forcible and heaving impulse-beat, unless emphysema be present, when the heart and its movement may be con- cealed and the apex-beat become impalpable. A marked systolic thrill, Fig. 51.— Spliygmogram of aortic stenosis, from a man aged sixty years. with the seat of greatest intensity in the aortic region, is quite gener- ally present. I have frequently felt this thrill in the apex region, though not so intensely as at the base. The pulse, in this disease, is small, regular, not compressible, and of normal or slightly lessened fre- quency. The sphygmographic tracing shows slowness of the ascending curve and a gradual formation of the descending line [vide Fig. 51). MITRAL INCOMPETENCY. 607 Percussion. — Though there is developed in all cases hypertrophy of the left ventricle, the area of cardiac dulness is almost entirely depend- ent upon the degree of emphysema, if any be present. In the absence of this condition the dulness is increased to the left and downward, and especially so when insufficiency of the valve supervenes. Auscultation. — A systolic murmur, harsh in quality, most audible at the aoi-tic cartilage (the second right), and transmitted into the carotids, is present in typical aortic stenosis. When non-compensation is ad- vanced the murmur is neither so rough nor so loud, and quite late it may be missing altogether. The second sound is faint or inaudible on account of the diminished blood-tension in the aorta and the character of the valvular lesion. As aortic incompetency is commonly associated, a regurgitant or diastolic murmur is also heard, forming a double or see- saw murmur, the stenotic bruit more or less completely masking the regurgitant. A soft, bloAving apical murmur (with the systole) is not infrequent in the advanced stage or after relative insufficiency of the mitral valves has appeared. The diagnosis demands the concurrence of the following signs : a systolic thrill, most marked at the base ; a tense, small, somewhat slow pulse ; indications of left ventricular hypertrophy (unless emphysema be present) ; a rough, loud, systolic murmur at the aortic cartilage and propagated into the vessels of the neck. Differential Diagnosis. — A calcareous plate lying on the intima of the aorta and a markedly roughened condition of the aortic segments are conditions frequently mistaken for aortic stenosis, since they give rise to a murmur possessing many of the characteristics of the one above described. These murmurs, however, are seldom musical, Avhile the murmur of aortic stenosis is often distinctly so ; moreover, the second sound is decidedly accentuated, while in aortic stenosis it is faint or absent. In chronic BrigMs disease with arterial sclerosis and left ventricular hypertrophy a murmur of maximum intensity may be devel- oped at the base ; but here the urinary symptoms, together with inten- sification of the second sound, are sufficient to establish a positive dis- crimination. In aortic regurgitation a systolic murmur frequently co- exists, but it cannot be reckoned as indicating actual stenosis unless it has a musical quality and unless a systolic thrill can be felt on palpa- tion. In chlorosis and other forms of anemia basic murmurs are con- stant concomitants ; the anemic murmurs are soft and distant, and not harsh ; the intense thrill and ventricular hypertrophy are absent also. The venous hum may also be heard in the veins of the neck. MITRAL INCOMPETENCY. {Mitral Reg^lrgitation ; Mitral Insufficiency.) Definition. — Imperfect closure of the mitral valve due to rupture or contraction of the mitral leaflets. It is also caused by dilatation of the left ventricle and by a diseased condition of the chord* tendinese. Pathology. — This is the most frequent form of organic disease of 608 DISEASES OF THE CIRCULATORY SYSTEM. the heart. Thomas G. Ashton,^ from clinical observation of 1012 cases of heart-affection, comprising all the difl'erent varieties, found that 54.4 per cent, were instances of mitral regurgitation. The predominating lesions are of three kinds : (a) Acute or chronic endocarditis, leading to contraction and deformity, particularly curling, of the margins of the valve ; {h) contraction or weakening of the chordse tendinea? ; and {c) relative insufficiency from excessive dilatation of the left ventricle (the segments being healthy). Adhesion of a segment with the walls of the ventricle occui's rarely, but may result in incompetency. Mechanical Influence of the Lesion, — The mitral leaflets normally close, and prevent the reflux of the blood from the left ventricle into the left auricle with each cardiac systole. Hence incomplete closure of the mitral segments allows a portion of the blood to return into the left auricle during the systole. This regurgitant wave meets and offers an obstacle to the normal blood-current coming simultaneously from the pulmonary veins into the left auricle. It is clear that vortiginous move- ments must result under these circumstances and give rise to a murmur. The double blood-current, entering the left auricle during the systole of the left ventricle, causes over-filling (hence dilatation) of the left auricle, and thus induces compensatory hypertrophy of its walls since its labor has been increased. During the next diastole the abnormally large contents of the auricle stream under increased pressure into the left ventricle, producing over-distention (dilatation) of that chamber. This increased volume of blood in the ventricle is not all expelled into the aorta, but a portion of it returns into the left auricle. Thus the left ventricle, in consequence of its increased labor, becomes hypertro- phied as well as dilated. Under these circumstances the volume of blood that is poured into the aorta remains about normal, and hence the arterial tension for a longer or shorter period is also normal. Soon the cardio-pulmonarv circulation becomes impeded. The blood that returns into the left auricle must, by reason of pressure, off"er increased obstruc- tion to the outflow of blood from the pulmonary veins, and the pressure in the latter must, in turn, be similarly increased. The current of the blood through the pulmonary capillaries and branches of the pulmonary artery is thus retarded, owing to the gradual accumulation that takes place in a backward direction. The walls of the lung-vessels are the seat of a sclerotic process, and present an abnormal obstacle to the passage of the systolic wave from the right ventricle to the distal end of the cardio-pulmonary arc ; in consequence of this the right ven- tricle becomes dilated and hypertrophied. The abnormally increased tension in the pulmonary vessels is shown by the accentuated pulmonic second sound. Thus the right heart compensates the lesion in the left, though to supply an adequate amount of blood to the peripheral arteries the left ventricle must maintain its proper degree of hypertrophy. As soon as this harmonious balance is disturbed, either as the result of in- crease in the degree of incompetency or of failure of muscular power, the progress of the blood from the right auricle to the right ventricle is hindered. Increased pressure in the right auricle produces dilatation of its chamber, with subsequent general venous congestion as a natural backward eff'ect {vide Tricuspid Regurgitation). It is now seen that ^ Medical Neus, June 30, 1894. MITRAL INCOMPETENCY. 609 wlien the right heart fails a lessened amount of blood reaches the left ventricle, and hence an abnormally small amount finds its way into the aorta ; this fact explains the presence of the low arterial tension late in the disease. Hypertrophy of the left ventricle in this disease has also been attributed in part to the augmented tension in the general capillary vessels that is occasioned by the venous stasis. Special Htiology. — (a) Rheumatic endocarditis is the most fre- quent cause, though mitral regurgitation also results less frequently from acute endocarditis due to other causes. (6) It may be a part of a general arteriosclerotic process, this group of cases being caused, not rarely, by syphilis and alcohol, (c) A diseased condition of the eolumnce carnece or chordce tendinece, if it contracts them or weakens their struct- ures so that the free edges of the segments pass beyond the plane of the orifice, produces insufficiency, (c?) It rarely arises in the course of aortic valvular disease (a secondary mitral affection), and is then excited mainly by undue tension of the blood in the left ventricle. Here the lesion is of a mild grade, as a rule, (e) It is frequently occasioned by enlargement of the left auriculo-ventricular ring, resulting from excessive dilatation of the left ventricle, as in aortic incompetency, aortic stenosis, long-continued fevers, and the graver anemias (relative incompetency). (/) Ulcerative eiido carditis, either by perforating or producing rupture of the valve-curtains or by destroying the chordae tendinese, may bring about mitral incompetency. Among predisposing factors age and sex are worthy of special mention, the incompetency occurring with greatest relative fre- quency in young adults (from twenty to thirty years of age, according to Ashton's figures), and somewhat more commonly in males than females. Sj^mptoms. — During Compensation. — In healthy persons the com- pensatory forces keep pace with the valvular lesions for an indefinite and usually lengthy period, during which time there may be an entire absence of symptoms. When present they are dependent upon dis- turbances of the cardio-pulmonary circulation that are occasioned by trivial causes, such as excitement, going up stairs, or other forms of active physical exertion. Under these circumstances the force of the regurgi- tant current is increased (by the hypertrophied left Ventricle), thus pro- ducing more or less pulmonary congestion that may proceed to edema of the lungs or hemoptysis. The condition is usually a temporary one, and is attended by dyspnea, palpitation of the heart, a short, hacking cough, and expectoration of a frothy serum that may be blood-stained. The relation existing between the severity of the dyspnea and the degree of active physical exertion is positive and vital. Shortness of breath may be the sole feature during a long period. The rational symptoms rarely warrant a suspicion of the existence of mitral disease until compensation has failed, but the patient's appearance often indicates heart-disease. The face is pale and the features peaked, the eyes, lips, and ears are dusky, and the minute vessels of the cheeks are prominent. Clubbing of the finger-nails is observed most frequently in the vounc^. After Failure of Compensation. — Failure of compensation*^ implies failure of' the right ventricle to cope efficiently with the augmented ten- sion in the pulmonary circulation, with accompanying congestion of the lungs, followed by engorgement of the systemic veins. The latter process begins at the right heart and proceeds toward the periphery, involving 39 610 DISEASES OF THE CIRCULATORY SYSTEM. the viscera, mucous membranes, and extremities until it is universal. The pulmonic sj/mpfoms above detailed are now more marked, particu- larly the dyspnea (which may be constant), cough (with expectoration of alveolar epithelium containing brown pigment-granules), and cardiac palpitation with arrhythmia. Pain is rare unless stenosis coexists. G-eneral venous engorgement manifests itself by an enlargement of the liver and of the spleen, in the features of gastro-intestinal catarrh, in hemorrhoids, in marked cyanosis of the surface, and in the passage of a scanty albuminous urine containing tube-casts and blood-corpuscles. Dropsy follows, beginning in the feet and progressing upward, until finally the trunk and the serous sacs are involved. By stimulation the heart may be reinforced, and all of the unfavorable symptoms disappear in consequence, but this is not for long, as a rule. I have at present under observation a case in which not less than half a dozen instances of broken compensation have occurred at intervals of six to eight months, all of which have been successfully overcome.^ In all cases, however, there comes a time when compensation cannot be restored, and the end is reached by an uninterrupted downward course. Physical Signs. — Inspection. — The precordia is prominent, particu- larly in children, and the area of the apex-beat is enlarged, later becom- ing diffuse and wavy. It is carried to the left and doAvnward, corre- sponding with the degree of hypertrophy of the left ventricle. A pul- sating epigastrium is in frequent association, particularly after dilata- tion of the right ventricle appears. With the failure of the right heart also come wavy pulsations in the cervical veins, and occasionally a mild grade of jaundice. Palpation sometimes discovers a thrill at the seat of the apex-beat, that is synchronous with the first sound. The impulse during the stage of full compensation is forceful and heaving, but Avith the beginning of failure of compensation it grows feeble and irregular, and late in the affection is excessively weak and arrhythmic. The pulse bears a defi- nite relation to the apical impulse ; it is commonly regular and full during the compensatory period (though at times the tension is slightly lowered), but becomes small, easily compressible, and exceedingly irreg- ular during the period of broken compensation. One meets with cases in which irregularity appears during the period of fair compensation. Percussion. — The dull area is increased to the left, extending fre- quently to the anterior axillary line : and also to the right, frequently from I to 1 inch (1.2-2.5 cm.) beyond the right sternal margin. Dila- tation of both ventricles exerts a widening influence ; hence cardiac dulness is increased more laterally than vertically. Auscultation reveals a systolic murmur, with greatest intensity at the apex (see Fig. 52). Occasionally, this murmur is also conducted to the tricuspid and pulmonary valves. It is rarely loudest in the fourth or third space in the vertical nipple line. Balthazar Foster first called attention to the fact that the murmur of mitral regurgitation may be loudest at the base of the heart, and at times audible only in that situa- tion — an occurrence that has since been confirmed. It is sometimes audible in the recumbent posture and inaudible in the erect. From the 1 Neglect of hygienic precautions and intercurrent complaints of various sorts often determine the occurrence of failure of compensation. MITRAL IJ^ COMPETENCY. 611 apex it is transmitted to the left as far as the angle of the scapula, ^-ith progressively diminishing clearness. It has a blowing quality, and fre- quently ends in a musical tone. Loudness implies strength of con- traction (Broadbent). Over the third left costal cartilage, and fre- quently at the apex, there is heard the accentuated pulmonic second sound,"^ due to the increased tension in the pulmonary vessels that is engendered by the hypertrophy of the right ventricle. Combined murmurs may be heard, and not infrequently a rough, rolling, or rum- bling presystolic murmur is detected. A frequent late occurrence is the secondary dilatation of the right ventricle, causing relative tricuspid insufficiency with its characteristic soft, low-pitched, systolic murmur, heard best at the ensiform cartilage. A spurious diastolic murmur may Fig. 52. — 1, Seat of greatest intensity ; 2, direction of chief transmission ; ?>, boundarj- line of rela- tiTe dulness ; A, boundary -line of absolute dulness (modified from Sahli). be noted, though rarely, when the sounds are timed with the pulse. This is due to a weak systole that fails to cause a radial pulse. Diagnosis. — In the presence of the following group of features the diagnosis is set at rest : A marked broadening of the area of cardiac dulness ; a systolic, apical murmur that is conveyed to the left axilla and may be heard even at the back ; and a decided accentuation of the pulmonary sound. Obviously, the latter sound becomes feeble after dilatation of the right ventricle has occurred. A systolic thrill is of the highest diagnostic importance, but is unfortunately absent in perhaps a majority of the cases. Free regurgitation through the mitral orifice may be safely inferred when the following signs are concurrent : 612 DISEASES OF THE CIRCULATORY SYSTEM. (a) An absence of the sound of mitral-valve tension, a murmur replacing the first sound ; {b) accentuation of the pulmonic second sound ; (c) an enlarged area of the left cavity ; (d) an enlarged area of the right cavity (Sansom). Differential Diagnosis, — There are two organic lesions of the heart that are sometimes mistaken for mitral incompetency, since both are ac- companied by a systolic murmur — the one aotiic ste7iosis, and the other tricuspid regurgitation. How to distinguish mitral from tricuspid in- competency is a question that Avill receive due attention when the latter disease is considered. Aortic stenosis generates a systolic murmur, but it is loudest over the base, and is transmitted through the great vessels of the neck ; while the mitral systolic is most intense over the apex and is transmitted far to the left. In mitral incompetency the pulmonary second sound is accentuated ; in aortic stenosis it is not. In mitral in- competency both ventricles are enlarged, as shown by percussion and other signs ; in aortic stenosis the left is chiefly enlarged during almost the entire course. In mitral incompetency a thrill, most marked over the apex-beat, may be felt ; in aortic stenosis a thrill, rough and having its chief seat at the base, is common. Additional minor points of dis- tinction are furnished by the peculiarities of the pulse, the age of the patient, and other etiologic factors. Functional and other harmless murmurs are often confounded with mitral insufficiency. The considerations on which the greatest depend- ence is to be placed in the differentiation are to be found in the sub- joined table : Mitral Incompetency. Functional and Harmless Murmurs. History. Previous history of rheumatism or other History of causative factors of one or disease causally related. other form of anemia, of debility, or of Graves' disease. Frequently there is definite knovrledge of No such association, rheumatism and orfjanic lieart-disease, in combination in the same individual. Physical Signs. Inspection. — Dusky lips, ears, etc. ; later Pallor of skin and mucous surfaces com- wavy pulsation in veins of neck. mon. Palpation. — Finger-tips placed over apex- Finger not lifted by the impulse, which beat forcibly lifted. Pulse-tension some- often cannot be felt. Pulse-tension pro- what lowered and not prolonged. Im- longed and arterial pressure increased pulse displaced. generally. Impulse not displaced. Percussion. — Evidence of dilatation of Dilatation of right auricle, but only in both ventricles. about one-half of the cases, giving rise to dulness above or to the right of the right edge of sternum. Auscultation. — A systolic apex-murmur Soft systolic murmur at apex (may be, (often musical), with characteristic area though rarely, transmitted to axilla), of transmission. This murmur, unlike usually preceded by or associated with the functional, is often heard behind, a basic systolic murmur and a venous between the spine and the scapula. hum in the veins of the neck. To differentiate the murmur of relative mitral incompetency is diffi- cult, though in many instances it can be accomplished with reasonable •certainty. It rests ujson two points : (a) the character of the murmur, MITRAL STENOSIS. 613 which is, as a rule, softer and less intense than that due to valvular lesions ; and (b) the antecedent history of the patient. Thus, relative insufficiency of the mitral segments probably exists in patients in the middle period of life, in whom the previous history furnishes such etiologic factors as chronic gout, syphilis, or alcoholism ; or in persons who exhibit arterio-sclerosis or organic disease of the aortic valve and an apex-systolic murmur. On the other hand, if the signs of mitral regurgitation occur in a younger subject or in one who has been afflicted with acute rheumatism, it is highly probable that the mitral-valve seg- ments are the seat of chronic endocarditis of rheumatic origin. Again, if present in chronic renal disease, with concurrent symptoms of high arterial tension and of left ventricular hypertrophy — accentuation of the aortic second sound, a mitral systolic murmur — it is to be ascribed to relative insufficiency. Compression of the edge of the left lung by the ventricular systole may produce a spurious murmur. I believe that a rare sequel of mitral incompetency is mitral stenosis, owing to the con- traction of the mitral orifice, with, in some instances, cohesion of the free edges of the cusps. MITRAL STENOSIS. Definition. — Constriction of the left auriculo-ventricular orifice, due to either thickening or adhesion of the segments. With few ex- ceptions adhesions of the free borders of the valve or of the chordae tendinese obtain. Special Pathology and Btiology. — It is to be recollected that the constriction may be almost inappreciable, and yet an uneven, rough- ened surface be presented, producing a murmur as the blood-stream enters the ventricle ; on the other hand, a high degree of constriction may be encountered. Thus, in the funnel-shaped form of mitral stenosis the aperture may be so small as scarcely to admit the passage of a goose- quill. When moderate in degree the tip of the index finger is admissi- ble ; in the button-hole form the slit may be so narrow as not to allow an object larger than a shirt-button to pass through it. ^he funnel variety is common in children, and is occasionally a congenital condition (possibly hereditary), while the button-hole variety is comparatively rare in child- hood. In adults, however, the funnel-shaped constriction is rare, while the button-hole valve is quite common ; in 62 postmortem examinations only 3' showed funnel-form contraction (Hayden and Fagge). Mitral stenosis is, as a rule, dependent upon a mild or limited endocarditis that is usually of rheumatic origin. It is more common in young adults and in children after the fifth year than in older persons, and a greater inci- dence is shown m females than in males, for the reason that the aifec- tions that are causally related to endocarditis are more frequent in females (rheumatism, chorea, chlorosis). The endocarditis of measles and scarlatina may also lead to narrowing of the mitral orifice, and I quite agree with Osier in the belief that Avhooping-cough, owing to the great strain that it imposes upon the heart-valves, may be account- 614 DISEASES OF THE CIRCULATORY SYSTEM. able for certain cases. In adults arterio-selerosis and chronic nephritis may act as causes. Ball-thrombi have been found in the auricle. Mechanical Influence of the Lesion. — On account of the obstruction of tbe blood-stream at the mitral orifice during diastole the task of the left auricle becomes greater than normal, and in consequence of this its avails hypertrophy. They may be found to be one-fourth or even one- half inch (1.2 cm.) in thickness, the normal thickness being only three- twentieths of an inch (3.7 mm.). Dilatation of the auricle comes on early, since this chamber cannot take on much hypertrophy owing to lack of muscular structure, and in the later stages its walls become extremely thin. For a varying period of time the increased power due to hypertrophy of the left auricle and the increased resistance to the circulation that is the result of the mitral lesion are exactly balanced. At a comparatively early period, however, the auricle can no longer main- tain this equilibrium ; and then, owing to retardation of the current from the pulmonary veins to the auricle, the vascular tension in the lungs ^and right ventricle is increased. The right ventricle, in seeking to overcome the obstruction, becomes greatly hypertrophied and dilated, and late in the disease tricuspid incompetency supervenes with its usual sequences. The hypertrophy of the latter chamber counterbalances the lesion during the greater part of the period of compensation. For a brief time the left ventricle exhibits no abnormal proportions. Later and at autopsies its cavity is found smaller and its walls thinner than the normal, these conditions being due to its abnormally light labor. The apex of the heart is formed almost exclusively by the greatly enlarged right ven- tricle. If the left ventricle be hypertrophied, it is owing to the existence of associated mitral incompetency. Symptoms. — The subjective symptoms are scanty and of slight value in forming the diagnosis. During the period of full compensation there may be an entire absence of symptoms except on going up stairs or on attempting some unusual muscular effort, when dyspnea appears. The vegetations previously described are sometimes quite friable, and when so may be swept from the valves into the circulation and give rise to the phenomena of cerebral embolism (aphasia and hemiplegia). The same conditions may arise, and in the same way, from recurring endo- carditis, to which such patients are specially liable. The patient in well-marked cases presents an anemic appearance : a stitch-like pain in the apex-region is freijuently present, and active exertion, by overtax- ing the left auricle, induces cardiac palpitation and dyspnea. After failure of compensation the symptoms referable to the pulmo- nary system are almost identical with those manifested in mitral incom- petency. Owing to the pulmonary engorgement the dyspnea is constant, and is increased by exertion. After severe or prolonged physical exer- cise congestion, followed by edema of the lungs, may supervene, attended by a copious blood-stained, serous expectoration. True hemoptysis may arise from time to time. The increased tension in the pulmonary vessels being practically constant, sclerosis, followed by atheromatous degenera- tion of their walls, is a frequent occurrence, and may accidentally result in pulmonary apoplexy. Intercurrent /f6n7g attacks (due usually to re- curring endocarditis) are common, particularly in the later stages, and are attended with marked aggravation of the circulatory disturbances. MITRAL STENOSIS. 615 Among other things, mitral stenosis differs from mitral incompetency in that general anasarca is rare, though enlargement of the liver and other evidences of portal congestion (including ascites) are not wanting. Physical Signs. — Inspection. — The apex-beat is not displaced un- less there be excessive enlargement of the right ventricle or associated hypertrophy of the left. There is usually present a visible pulsation in the second left intercostal space, and sometimes in the third and fourth interspaces, occasioned by increased tension in the pulmonary artery ; and there is also a diffuse impulse along the right border of the sternum. Epigastric pulsation is common. A prominence having its seat over the fifth and sixth left costal cartilages and the lower half of the sternum is observed, particularly in children. After failure of compensation the impulse is feeble and undulates, with engorgement and pulsation of the jugular veins. Palpation discovers a presystolic thrill in a great proportion of cases. In certain instances active physical exertion may render this appreciable, or when in the recumbent posture on the left side the ele- vation of the arms may accomplish the same result. It is, however, absent in rare instances before failure of compensation occurs, and more frequently by far after the latter event. This fremitus is best felt over the third and fourth (less frequently the fifth) interspaces, just within the nipple, and during expiration. It commences after the second sound (during the diastole) as a purring fremitus, increasing steadily in volume and intensity, and terminates abruptly with the severe shock of the new impulse. The fremitus is pathognomonic, and may be relied upon in the absence of the murmur. The heart's impulse is most forcible over the lower portion of the sternum and along the right border, being due to the enlarged right ventricle ; in a smaller proportion of cases, in the Fig. 53.— Sphygmograms in a case of mitral stenosis treated by extract of convallaria, and sub- sequently by digitalis : A, before treatment, showing the interpolated pulsations ; B, after treat- ment (bansom). fourth and fifth interspaces to the left of the sternum. The radial pulse is small, compressible, and markedly irregular as the propulsive power of the right ventricle diminishes. The sphygmographic tracing is not- ably irregular {vide Fig. 53). Percussion shows an extension of heart-dulness to the right, fre- quently 5 centimeters (2 inches) beyond the sternal margin, as a result of hypertrophy of the right ventricle, and upward as high as the sec- 616 DISEASES OF THE CIRCULATORY SYSTEM. ond rib on either side of the sternum. Increase in the cardiac dulness to the left also occurs not infrequently, and is attributable to excessive enlargement of the right ventricle, though more often of the left ven- tricle in consequence of associated mitral insufficiency. Auscultation reveals a rough, presystolic murmur, -which may be characterized as churning or rolling, acquiring increased intensity toward its termination. Its point of greatest pronunciation is just above and about one inch within the normal apex-beat. The area of trans- mission is generally quite limited, not exceeding a couple of inches in any direction. Griffith, however, has shown that the murmur is not seldom widely transmitted. This murmur sometimes exhibits atypical characters : it may be brief and low-toned, and may be audible on one occasion and then disappear for a considerable period. After the right ventricle becomes weak the murmur may lose its characteristic sudden termination, or may entirely absent itself either temporarily or per- manently. In most cases the clear, accentuated first sound is retained, even though the murmur disappears. Improvement in the muscular power of the heart as the result of judicious treatment may cause the murmur to reappear, and I have seen such an occurrence in a case asso- ciated with mitral incompetency at the Philadelphia Hospital. For purposes of diagnosis, nothing is so vitally important as the time or rhythm of the murmur, and in his examination the observer must there- fore palpate the heart, and not the radial pulse, while practising aus- cultation. The finger as well as the ear will thus become sensible of the systolic shock which replaces the cardiac impulse, and it will be noted that the murmur terminates at the same moment. In cases in which the impulse cannot be felt the finger should be placed over one or other carotid, since here the pulse is practically synchronous with the systole. In most cases the murmur occupies only the latter half of the diastole, though occasionally the whole of the long pause. Owing to the presence of right ventricular hypertrophy the pulmonic second sound is greatly accentuated, being distinctly audible at the apex, while the aortic second sound is often absent or feeble. Reduplication of the second sound is not rare, and is characteristic. Secondary Murmurs. — As previously pointed out, the murmur of mitral stenosis may succeed that of mitral incompetency, but this is comparatively rare. Mitral stenosis may follow aortic valvular disease, but in the vast majority of instances it is a primary affection. Secondary murmurs are not uncommon, however. Among these the bruit of mitral incompetency is relatively frequent. After compensation is ruptured the murmur of tricuspid insufficiency usually becomes audible at the lower end of the sternum and persists until the end. In so-called '''■relative mitral sfeywsis" associated with primary dilatation of the left ventricle, which holds the orifice open, there occurs also a mitral regurgitant murmur, while that of stenosis may be absent. Diagnosis. — The distinctive features of mitral stenosis are — (1) A presystolic thrill at the apex. (2) An increase in the precordial dul- ness upward and to the right. (3) A murmur which (a) has its seat above, yet near, the normal apex-beat ; (b) is usually localized ; (c) is presystolic in time, terminating abruptly with the systolic shock (sharp TRICUSPID INCOMPETENCY. 617 impulse) ; and (d) is rough and vibratory in character. (4) A marked accentuation of the pulmonic second sound. Differential Diagnosis. — When the murmur of mitral stenosis is very brief, it is difficult to eliminate a mere roughening. In the latter con- dition, however, there is no increase in intensity of the murmurs on ex- ertion or when the arms are uplifted, and there is no right ventricular hypertrophy. From simple mitral stenosis the lesion of 77ntral incom- petency is easily distinguished by its systolic rhythm, greater area of transmission, and by the soft, more blowing character of its murmur. A combination of the two lesions, however, is a more frequent occur- rence than that of pure mitral stenosis ; and under such circumstances it is with great difficulty that the two murmurs are separated. The presence of the systolic murmur is distinguishable by its synchronism with the impulse or carotid pulse, and by its area of transmission to the left as far as the axilla. If now the stethoscope be applied just above and to the right of the normal apex, a limited superficial area will be found where a presystolic murmur is distinctly heard. Points can also usually be found where a continuous bruit, covering a portion of the period of diastole and of systole, is audible. The presystolic murmur is sometimes, and especially after failure of compensation, entirely veiled by the systolic. In aortic regurgitation the presence of a presystolic thrill and mur- mur has rarely been recorded, and Fisher, Phear, and others have called attention to their presence in adhesive pericarditis as well as in simple dilatation. When, as is usual, a purely diastolic murmur is also present in the aortic area, together with strong correlative evidence ojf aortic regurgitation, the diagnosis of mitral stenosis must be made with ex- treme caution and reserve. TRICUSPID INCOMPETENCY. {Tricuspid Regurgitation.) Definition. — An imperfect closure of the tricuspid valve, due either to a dilatation of the right ventricle that is secondary to mitral or lung- disease, or, less frequently, to an inflammatory shortening of the valves. Pathology and Ktiology. — As a primary disease tricuspid in- competency is rare. It, however, is not uncommonly due to chronic organic changes, though originating in fetal endocarditis. After birth this variety is most common during childhood, and the frequency of occurrence is in inverse ratio to the age. At any period of life, how- ever, chronic affections of the lungs or organic disease of the left side of the heart may, by augmenting the tension in the right ventricle, pro- duce chronic interstitial changes in the tricuspid segments. These lat- ter, however, are usually of mild grade. I have observed in autopsied cases of chronic bronchitis associated with emphysema, and in pulmonary tuberculosis, that the chief reason why extensive lesions of these valves are seen so rarely is to be found in the fact that dilatation of the right ventricle is soon followed by relative insufficiency, and thus the strain 618 DISEASES OF THE CIRCULATORY SYSTEM. is in great part removed from the valves themselves. And yet, accord- ing to the statistical studies of Byron Bramwell, the tricuspid valve is implicated in 50 per cent, of all cases of acute endocarditis, notwith- standing the rarity of sclerosis of these segments. He suggests that the afute form frequently results in cure because of the relatively diminished right intraventricular tension. In rare instances one of the leaflets has been ruptured by straining. The relative tricuspid in- sufficiency, produced in a manner analogous to mitral insufficiency, is an exceedingly common secondary condition in affections of the lungs and heart that cause hypertrophy and dilatation of the right ventricle (mitral incompetency and stenosis, emphysema, sclerosis of the lung). Secondari/ Alterations. — In tricuspid leakage every systole of the right ventricle is accompanied by a reflux of venous blood through the imperfectly closed tricuspid orifice into the auricle, and thence into the veins. This causes venous stasis and gives rise to visible pulsation, and in this manner the engorged pulmonary circulation is relieved to some extent. A necessary unfavorable consequence, however, on account of the reflux current from the right ventricle, is the lessened blood-supply to the pulmonary arteries, even though the latter are found to be en- gorged. The already hypertrophied and dilated right heart now under- goes further enlargement in the same manner as in the hypertrophy of the left ventricle following mitral incompetency, though not to the same extent. In mitral incompetency the right ventricle compensates the mitral lesion after failure of the left auricle, but there can be no such effective compensatory reinforcement after failure of the right auricle in tricuspid incompetency, since the right heart is not reanimated by a fellow as is the left. The blood-stream flowing into the right ventricle during the period of diastole, however, is abnormally large, owing to moderately increased tension. When the right ventricle fails to main- tain the pulmonary circulation, progressive dilatation of its chamber occurs, with a proportionate thinning of its walls until its dimensions are enormous. Symptoms. — In most instances the indications of the primary or causal aftection must be noted, though these are often more or less screened by the more characteristic features of the disease under con- sideration. The symptoms of tricuspid incompetency point to passive congestion of the lungs and engorgement of the systemic veins, and they have been described in connection with mitral lesions. Cardiac dropsy is common, though present in by no means all cases. Frederick Taylor ^ contends that ascites is absent frequently, because the liver acts as a diverticulum to accommodate the excess of venous blood. Physical Signs. — Inspection. — Venous pulsation, caused by the back- ward blood-wave from the right ventricle at each systole, is a path- ognomonic sign. It is confined to the lower portion of the jugular veins so long as the valve that lies above the jugularis remains closed, but soon this yields, and then the veins seem to pulsate through their entire course with each cardiac systole. This is best seen Avhen the patient is in the semi-recumbent posture, and is more marked in the right than in the left side. The subclavian and axillary veins may also be seen to pulsate, but rarely. The veins appear to be everywhere en- 1 Lancet, Nov. 22, 1890, p. 1126. TRICUSPID INCOMPETENCY. 619 gorged, producing a cyanosis that is more noticeable if the breath be held when in full respiration. Tricuspid incompetency may be shown by pressing on the vein Avith the finger rather firmly, commencing just above the clavicle and passing upward, thus emptying it of blood. If, now, the right ventricle be capable of producing a return wave suffi- ciently powerful to overcome the valve in the external jugular, pulsation is seen to take place — also from below — in the vessel slowly and in- creasingly until the vein, as far as the point compressed, becomes filled. The vein fills "by jets synchronous with the heart-beat" (Sansom). Again, an impulse may be communicated to the jugulars from the underlying carotid artery ; if this be the true explanation in any given case, the light pressure upon the vein below does not arrest the pulsa- tion above, as is the case in tricuspid incompetency. Not rarely there is noticeable a feeble presystolic venous pulse, due to the weaker contrac- tion of the right auricle as compared with that of the right ventricle {cinadiclirotic venous pulse). The area and seat of the apex-beat vary with the nature of the primary affection : in mitral incompetency, for example, the beat is displaced to the left and downward, while in un- complicated mitral stenosis no appreciable displacement occurs. To the right of the sternum an undulatory pulsation is seen, due to contraction of the right auricle and ventricle, but this is not characteristic, since it may take place in simple mitral stenosis without tricuspid regurgitation. Epigastric pulsation is almost invariably observed. Palpation detects the heaving impulse of the right ventricle in the upper epigastric region. Rhythmic expansile pulsation of the veins of the liver is quite characteristic and is usually detectable. To obtain this sign the patient should lie on the back with the arms raised, and the examiner should place the palm of his left hand over the right mid- axillary region, and that of the right hand over the upper abdomi- nal region. He will thus be enabled to feel an expansile pulsation of the liver synchronously with the ventricular systole. This is to be carefully distinguished from mere systolic depression of the organ due to the impulse of an enlarged right ventricle, transmitted through the diaphragm and left lobe of the liver to the epigastrium. Popoff and others have also noted an inequality in the radial pulses in tricuspid regurgitation. This is probably due to the pressure of the enlarged auricle. Percussion. — The extent and form of precordial dulness are variable according to the nature of the causative disease, but a dulness extending far beyond the right edge of the sternum is especially characteristic. Auscultation. — A systolic murmur having its seat of greatest inten- sity at the base of the ensiform cartilage {vide Fig. 54) is almost con- stantly audible. The area in which it is best heard varies according to the intensity of the murmur. It is clearly conveyed to the left one inch beyond the left sternal margin, and to the right and upward for an equal distance beyond the limit of cardiac dulness. It is soft in character, short, and often faint. Additional murmurs, due to primary lesions, are often heard, and usually at other orifices. The pulmonic second sound is accentuated. Diagnosis. — I believe that the most valuable symptom for diag- nosis is the venous pulse, whether observed clearly in the neck or de- 620 DISEASES OF THE CIRCULATORY SYSTEM. termined positively by bimanual palpation of the liver, as before described. Either of these signs alone suffices. The murmur is gen- erally audible, and when so is a most valuable aid to the diagnosis. The differential diagnosis between mitral and tricuspid regurgitation is easy when either exists alone, if it be remembered that the seat of greatest pronunciation, the area of transmission, and the acoustic char- acter of the respective murmurs are widely different. But it is ex- FlG. 54. -1, Seat of greatest pronunciation ; 2, chief direction of conveyance ; 3, boundary-line of absolute dulness ; 4, boundary-line of relative dulness (modified from Sahli). tremely difficult to discern precisely a faint tricuspid murmur when it develops secondarily to the more pronounced murmur of mitral incom- petency. If a careful observation of the murmur fails to establish the diagnosis of tricuspid insufficiency, as sometimes is the case, absolute reliance should, in my opinion, be placed upon the venous pulse when present, and the absence of the latter sign should exclude this disease. TRICUSPID STENOSIS. This is a rare condition, occurring as a congenital and an acquired disease with about equal frequency. As a primary, independent dis- ease tricuspid stenosis is very rare, being usually seen in association with organic disease of the left side of the heart. The lesions of mitral and tricuspid stenosis are observed to be combined most frequently, PULMONARY INCOMPETENCY. 621 ■while those of tricuspid stenosis and aortic insufficiency coexist less frequently. The morbid changes are practically identical with those of mitral stenosis, the right auricle becoming dilated, and this being fol- lo"ft'ed by general venous stasis. The effect of tricuspid stenosis upon the right ventricle is the same as that of mitral stenosis upon the left ventricle. The right ventricle, however, is usually hypertrophied, OTving to the obstruction in the pulmonary circulation that results from the combined valvular deficiencies. Special Etiology. — The fact that mitral and tricuspid stenosis fre- quently have a common cause, acting concurrently, can scarcely be doubted in view of their frequent association and pathologic identity. Hence the statement that rheumatic antecedents are furnished by the history in from 30 to 40 per cent, of the cases of tricuspid stenosis need excite no surprise. As in mitral stenosis, so in tricuspid, sex is a po- tent factor, the statistics of Bedford, Fenwick, Herrick, and of Leudet (which embrace a total of 160 cases) showing a ratio of 5 to 1 in favor of the female sex. Symptoms. — The symptoms are those of the combined affections. Physical Signs. — Inspection sometimes reveals a feeble venous pulse in the jugulars, due to right auricular systole, and hence presystolic in time. Palpation may detect a presystolic thrill over the body of the right ventricle. Percussion may enable the observer to indicate the enlarged right auricle. Auscultation gives usually an audible pre- systolic rolling murmur, which is best heard over the lower sternum and along its right border. The above physical signs are to be relied upon in uncomhined cases, which are exceedingly rare. On the contrary, it is difficult in the extreme to differentiate the signs of tricuspid stenosis from those of the lesions with which it is almost uniformly associated — viz. mitral stenosis and aortic insufficiency. PULMONARY INCOMPETENOY. {Puhnono.ry Regurgitation.) This is an exceedingly rare complaint that results from acute (ma- lignant) or chronic endocarditis after birth ; it is also rarely due to a congenital malformation. In the latter form union of two of the seo'- ments is often observed ; in the former, the usual sclerotic processes, with the occasional adhesion of one or more segments with the pulmo- nary artery wall, may be noted. The effect of the lesion is to cause hypertrophy and dilatation of the right ventricle. The physical signs furnish no diagnostic characteristics. There is developed a diastolic murmur Avhich is most audible in the second pulmonary interspace, and is transmitted to the lower sternal region, simulating the murmur of aortic regurgitation. The water-hammer pulse and marked hypertrophic dila- tation of the left ventricle are present in the latter complaint, however, and are absent in pulmonary regurgitation. In pulmonary insufficiency, on the other hand, hypertrophy and dilatation of the right ventricle en- sue. Preble reports a case of relative insufficiency of the pulmonary cusps ; at the autopsy aortic and mitral insufficiency were also found. 622 DISEASES OF THE CIRCULATORY SYSTEM. PULMONARY STENOSIS. A QUITE frequent form of congenital 7nalformatio7i of the heart is the narrowing of the pulmonary orifice. In the rarest cases it is of post-natal date, and may result in induration, contraction, and fusion of the segments. In one of Osier's cases the orifice " was only two milli- meters in diameter, with vegetations of acute endocarditis on the seg- ments." I saw one case in which the pulmonary artery near the valve was contracted to one-half its normal caliber. Myocarditis with result- ing contraction of the conus arteriosus may cause pulmonary stenosis, and some of the cases that originate during adolescence and later in life are due to atheromatous change, while others possibly are the result of chronic endocarditis, direct violence, and ulcerative endocarditis. The lesion is compensated by an hypertrophy of the right ventricle, follow- ing which dilatation and tricuspid incompetency may appear. Sjnnptoms. — Cyanosis and distention of the systemic veins are observed. Physical Signs. — A systolic tlirill may be felt at times over the base. There is considerable enlargement of the right ventricle, as elicited by percussio7i and palpation, and a systolic murmur of greatest distinct- ness is audible, as a rule, in the third left space near the sternum. It is harsh, superficial, and transmitted a short distance upward and to the left. Occasionally this murmur is heard best at the aortic valve, but it is never conveyed to the vessels of the neck, and hence is easily distin- guished from the aortic systolic murmur. Its harsh character and loud- ness would serve to obviate confusion with functional or anemic murmurs that are sometimes heard here. The pulmonic second sound is weak, and, not rarely, there is a diastolic murmur of the same character, indi- cating pulmonary regurf/itation. Broadbent asserts that a temporary systolic murmur due to severe exertion may be observed, and I have noted a systolic murmur in the pulmonary area in young adults of remarkably vigorous build and unusual endurance. Sansom holds that disease of the pulmonary artery (contrary to other forms of organic heart-disease) predisposes markedly to pulmonary tuberculosis. I have at present under my care a tuberculous patient in whom there is a double murmur audible at the pulmonary orifice. COMBINED FORMS OF CARDIAC DISEASES. It may be asserted safely that in more than one-half of all the cases combined lesions or murmurs are exhibited before the fatal termination. As I have already stated, stenosis of an orifice when due to valvular disease is associated with incompetency of the corresponding valve. Thus aortic stenosis is constantly combined with or followed by aortic incompetency, and in like manner mitral stenosis by mitral incompetency. The association may also have reference to lesions at two or more dif- ferent valves ; and according to the elaborate table of F. J. Smith, the CHRONIC VALVULAR DISEASE. 623 relative frequency of the chief murmurs found in combination is as follows : Aortic diastolic and systolic and mitral systolic, 16.55 per cent. Aortic stenosis and mitral stenosis, 6.12 " Aortic diastolic and mitral systolic, 5.21 " Aortic diastolic and systolic and mitral presystolic and systolic, 3.77 " When two lesions coexist at the same valve, the one may compensate, in part at least, for the other, as, for example, in the case of aortic ste- nosis in association with aortic regurgitation. Here the stenotic deficiency lessens the reflux current from the aorta into the left ventricle during the diastole ; hence the latter receives a correspondingly diminished amount of blood. During the contraction of the ventricle the distending force in the aorta is diminished, both on account of the narrowincr at the aortic orifice and the relatively lessened contents of the hypertrophied ventricle. Similarly, in dominating mitral incompetency an associated mitral stenosis by lowering the strength of the regurgitant current ren- ders the conditions more favorable. Relative insufficiency at the mitral valve, following aortic insufficiency, may prove salutary in its effects by preventing over-distention of the left ventricle, and also the over-filling of the arterial tree and the possible rupture of the blood-vessel. On the other hand, mitral incompetency is sometimes secondary to aortic stenosis ; and when so the latter defect may hasten the unfavorable ten- dencies in the former. Relative tricuspid incompetency, secondary to mitral disease (a fre- quent combination), usually results in the development of a serious impediment to the systemic venous circulation, and often heralds a speedily fatal issue. It is probable that in advanced mitral disease the occurrence of a slight leakage at the tricuspid valve may be the means of obviating disastrous consequences to the right ventricle in case of undue strain. Physical Signs. — These are confusing, but a systematic analysis often leads to the correct inference. That one of the valvular lesions pre- dominates over all others is a fact of paramount importance for the solu- tion of these cases. The chief lesions can usually be determined by noting the seat, the area of transmission, and the character of the most pronounced murmur; and more important still is the correct timing of any murmur that may be audible. The secondary alterations in the heart frequently coincide with the predominating murmur, and it will therefore be an aid to the observer to recollect the familiar fact that mitral murmurs are often secondary to aortic, and that tricuspid mur- murs point to the coexistence of mitral disease. Unquestionably, a single observation of these cases, however carefully made, is often profit- less, whilst repeated observations may be productive of tangible results. Complications of Valvular Disease.— Most of these have already been spoken of at sufficient length, but to restate them col- lectively in this connection may prove useful to the student and phy- sician. They are — (1) acute endocarditis (including the ulcerative form) ; (2) acute pericarditis ; (3) pleurisy ; (4) pneumonia ; (5) nephritis, followed by uremia ; (6) local or general arterial sclerosis ; (7) chronic 624 DISEASES OF THE CIRCULATORY SYSTEM. gastric or intestinal catarrh -with intercurrent acute attacks ; (8) embolic processes; (9) angina pectoris; (10) edema of the lungs; (11) hysteria, neurasthenia, epilepsy, and insanity ; (12) rupture of the skin of the ex- tremities in consequence of excessive edema, with erysipelatous inflam- mation ; (13) synovitis, a not uncommon complication, fever, swelling of one or more of the joints, and pain are the usual symptoms. The muscles of the extremities may also be involved simultaneously. It is highly probable that these manifestations are to be ascribed to rheuma- tism, though they are also met with in ulcerative endocarditis. (14) Febrile paroxysms occur at varying intervals of time, and are due to a variety of causes, as rheumatism, acute endocarditis, and pericarditis. Ulcerative endocarditis may also occur and be attended with an irregular type of fever. Course and Duration. — When valvular disease consists in rupture of a segment the course is brief and usually proves quickly fatal. Apart from these exceptional instances the duration is measured by months, or more often by years or even decades. Statements applicable to all cases cannot be made, however, owing to the wide differences in diff'erent cases. Among the circumstances aff'ecting the duration I would men- tion in particular the patient's mode of life, the hygienic conditions under which he lives, his occupation, mental condition, and the severity of the morbid processes. Every experienced physician has doubtless met with a small class of cases that have terminated fatally in from six months to a year, having developed in that period all of the serious phenomena and complications of the more chronic forms of organic heart-disease. In the preponderating proportion of cases, however, the course is exceedingly slow, and often cases have existed many years before they have finally been recognized. In numerous instances the patient follows his usual avocation, which may even be laborious, for years, and without discomfort. In other cases the symptoms, as dysp- nea on exertion, are so slight as not to excite suspicion. Facts such as these render it obvious that while the period of com- pensation is long, its exact limits are indeterminable. In 12 instances of chronic endocarditis that have developed under my observation (some having lasted ten or twelve years) only 3 have reached the stage of broken compensation. The progress after faihire of compensatio7i is more definitelv known, since frequent opportunities for observation are afforded. At this time the cases also exhibit wide differences respecting their duration ; in my own experience they have varied from two to three months to as many years (rarely even longer), depending much on the patient's mode of living. The course may be shortened by severe external injury, intercurrent acute illness (especially febrile disease), vicious habits, straining efforts, and the like. Prognosis. — The detection of a cardiac murmur should not alone lead to a gloomy prognosis. Says Osier: ''With the apex-beat in the normal situation and regular in rhythm, the auscultatory phenomena may be practically disregarded." Individual cases require separate and careful consideradon. It is well not to advance positive assertions until all the circumstances that may influence the prognosis of any given instance have been well weighed. Observation of a case for some weeks and months enables the physician to speak with greater CHRONIC VALVULAR DISEASE. 625 confidence and knowledge concerning the probable outcome. Prior to the occurrence of disturbances of compensation the prognosis is meas- urably favorable. After this pivotal event the prognosis as to life becomes wholly unfavorable, though the end is not necessarily near at hand. Disturbances of compensation that are attended with marked arrhythmia, urgent dyspnea, and general dropsy may, under proper treatment, admit of even complete relief. Later on, however, restora- tion of the balance of forces becomes only partial, and finally the above- mentioned symptoms become more pronounced ; Cheyne-Stokes' breath- ing may then develop, and after a prolonged and distressing struggle for breath the patient succumbs. Death may also occur suddenly from cardiac paralysis. Among ominous and yet common complicatio7is and intercurrent aiFections may be cited again extensive edema of the lungs, pneumonia, typhoid fever, embolic processes, ulcerative endocarditis, acute endocarditis, obstinate gastritis, and nephritis. On the contrary, favorable indications are sound general health, good external condi- tions (absence of poverty,. hunger, etc.), strong and regular action of the heart, absence of arterio-sclerosis, of excessive hypertrophy, of rheumatic antecedents, and any vices of life. Age influences the prog- nosis to some extent. In children under ten years the lesions are usu- ally somewhat more rapidly progressive than in adults, and the compen- satory hypertrophy is developed with corresponding rapidity ; hence the period of failing compensation is reached earlier. This mav be said to be a broad general rule, and I have found that it is one to which there are many exceptions. Among other reasons for the more gloomy prospect when heart-disease occurs in young children are the followino- : the mitral valve is generally implicated, the liability to rheumatic inter- currences is great, and children, unless carefully controlled, overtax at play the reserve cardiac power when indulging in running and other forms of exercise. After the twelfth year the prognosis becomes more favorable. Sex is also a modifying prognostic factor, women bearing valvular lesions better than men, apart from the influence of childbear- ing, though even this is an influence the significance of which has been greatly magnified by many writers. To explain the more favorable out- look in women we have two main facts — viz. a less laborious as well as a more quiet life, and a diminished liability to arterio-sclerosis and in- volvement of the coronary vessels. The particular valve involved has some influence on the prognosis. Aortic regurgitation gives, on the whole, a rather favorable proo-nosis, particularly in those cases that begin in early adult life, grantino-. of course, that the patient regulates wisely his manner of livino;. Under such circumstances the lesion may be compensated for manv years or even decades. The increased vigor of the left ventricle as compared with the right is conducive to longevity in this disease. After failure of compensation, the prognosis is less satisfactory in aortic reo-uro-itation than in mitral regurgitation, since restoration of compensation is not as readily accomplished in the former as in the latter variety. In the lesion under consideration a chief danger arises from associated arterio-sclerosis — a rather frequent occurrence in advanced life— and from implication of the coronary arteries. Much depends upon the condition of the latter vessels. When their lumen is narrowed starva- 40 626 DISEASES OF THE CIRCULATORY SYSTEM. tion of the heart-muscle quickly ensues, followed by myositic degenera- tion. Blocking of one of the branches of the coronary artery is the most frequent cause of sudden death in this affection. In aortic stenosis equally favorable predictions are warrantable when the disease is un- complicated. Mitral regurgitation, when a primary lesion, is propitious, except in the very young, and not infrequently the progress of the morbid process is apparently arrested. In a considerable proportion of cases the dis- ease does not materially shorten the life of the sufferer. In a larger percentage, however, there is special liability to a renewal of the causa- tive affections (e. g. rheumatism) and to pulmonary conditions of serious import, producing exacerbations and permanent aggravations of the disease. The gravity of these intercurrent complaints is also increased by the existence of the cardiac lesion. Failure of compensation at once renders the prognosis decidedly unfavorable. In mitral stenosis com- pensation of the right heart fails somewhat earlier than in mitral insufficiency, and hence the accidents and conditions referable to the lung (diffuse pulmonary apoplexy, edema) are not so long delayed as in the latter disease : this is also true of the later, more serious manifestations. I have learned by experience that mitral stenosis is better borne by Avomen than by men, and better during adolescence and early adult life than during more advanced years. The congenital forms are comparatively benign. It should not be forgotten that mitral stenosis causes sudden death more frequently than any other form of organic disease of the heart except aortic regurgitation. Tricmpid incompetency, whether secondary to disease of the lung or of the left side of the heart, is extremely grave. It is usually indicative of dila- tation following hypertrophy of the right ventricle. Compensatory hy- pertrophy, however, can be re-established, and sometimes repeatedly. Treatment. — This falls naturally into three subdivisions : (1) pro- phylaxis ; (2) management during the stage of compensation ; (3) treat- ment of the stage of non-compensation. (1) Prophylaxis. — It can scarcely be doubted, as shown by the statis- tics of Sibson, that complete rest and protection of the surface during an attack of acute articular rheumatism lessen the average percentage of cases in which acute endocarditis develops. When the latter com- plication occurs in acute rheumatism the patient should keep to his bed for some time after all rheumatic symptoms have disappeared (two to six weeks) or until the improvement in the cardiac condition has ceased absolutelv. This precautionary measure will often lessen the extent of the ensuing chronic endocarditis, and also increase the proportion of perfect recoveries. Suitable dietetic and medicinal treatment must necessarily be combined. When the physician is cognizant of hered- itary predisposition to organic heart-disease, or has to deal with the arthritic diathesis (gouty or rheumatic) or the alcoholic habit, he can fref}uently. by timely advice and hygienic suggestions, direct his pa- tient to adopt measures that will obviate the occurrence of valvular disease. All persons predisposed by heredity or otherAvise should be told of the probable effect of muscular strain, alcohol, and other excit- ing factors ; too often, however, when he sees his patient for the first time the physician is confronted by an incurable malady. CHRONIC rALVULAE DISEASE. 627 (2) Management during the Stage of Compensation. — Three main ob- jects are to be accomplished: (a) The avoidance of every agency that tends to aggravate or maintain the lesion or lesions. Under this head the detection and removal of all causal factors is imperative. Thus, if the patient's avocation entails undue muscular effort, it must be aban- doned ; violent exercise, as running up flights of stairs, heavy lifting, or straining at stool, is also dangerous and must be prevented. If alcohol has been a factor, it must be discontinued ; if syphilis, it must be treated specifically. If there be. present a rheumatic or gouty taint of the system, it must be overcome as far as possible by special meas- ures. The recognized causes of rheumatism, as fatigue and exposure, must be avoided, particularly if the patient be comparatively young. Emotional excitement and mental over-exertion injuriously affect the car- diac lesion; therefore tranquillity of mind should be insisted upon, though moderate and systematic mental exercise has no risks for the patient. In the case of children at school careful supervision of their studies as ■well as of their recreative -exercises is essential. Fright and sudden emotion must be avoided if possible. The use of tea, coffee, and tobacco should be rigidly prohibited. (b) The diet of the patient demands careful regulation. Only a very moderate amount of food, composed for the most part of readily digested albuminous articles (milk, eggs, the lighter forms of meats, and stewed fruits), is to be taken, since overloading the stomach will disturb the action of the heart ; particularly is this true at night. The carbohy- drates may be allowed only in limited quantities, since they are apt to decompose and form gases that distend the stomach and intestines. For the same reason the coarser and more indigestible food-stuffs should be avoided. Small meals at brief periods is a plan of feeding that I can highly commend. The amount of liquids taken should not exceed the actual requirements of the patient, inasmuch as over-filling of the blood- vessel system increases the work of the already overburdened cardiac forces. Alcoholic beverages should not be used as a rule ; but if the patient has been moderate in the use of alcohol, and particularly if he be advanced in years, light wines may be allowed in moderate quantity to aid digestion, (c) Carefully regulated exercise is beneficial, but it must be gentle and should be taken out of doors. As before intimated, a good general muscular development is an aid of no mean value to the conservative powers of the heart. Oertel, with a view to assisting the compensatory forces of the heart, has recommended graduated physical exercise ; he advises that patients be instructed first to ascend low ele- vations, and later mountains of a considerable height, the object being to bring about full compensation. Great caution is to be exercised by the physician, however, since this method has been found to be inapplicable to a large percentage of cases. Cardiac distress, pjalpitation, and dys- pnea are complained of by this large group of patients if other than the gentlest forms of exercise be undertaken. With respect to exercise, then, the sensations and experiences of each patient must be consulted before the physician can advise judiciously. Woollens should be worn next to the skin during both the warm and the cold seasons. The skin should be kept clean by daily sponge baths, and if these be followed by friction of the surface, the bodily nutrition will be improved and the 628 DISEASES OF THE CIRCULATORY SYSTEM. liability to intercurrent attacks of bronchitis greatly lessened. The bowels should be moved each day, and usually the use of stewed fruits suffices to accomplish this end ; if not, salines, Rochelle or Carlsbad salts, and the bitter waters (Friedrichshall, Hunyadi-Janos) must be brought into requisition. In winter a Avarm climate may prove ad- vantageous, though long journeys are often illy borne, owing to the fatigue induced thereby. If, despite the measures above indicated, the patient becomes anemic or his nutrition is notably impaired, a suit- able change of air,' or the use of (juinin, mineral acids, arsenic, small doses of mercury, and cod-liver oil, is to be recommended. Digitalis should not be employed when compensation can be preserved in other ways. (3) Treatment of the Stage of Non-compensation. — The principal object to be kept in view in this stage is the reinvigoration of the exhausted cardiac muscle, and thus to relieve the impeded circulation. Sudden death may, though rarely, occur from the blocking of a branch of the coronary artery or from acute dilatation. Failure of compensation, however, begins gradually as a rule, the condition often existing without marked or characteristic symptoms ; but its early recognition is import- ant from the stand-point of therapy. Increased dyspnea on exertion, and nocturnal seizures of shortness of breath and irregular action of the heart (arrJiz/thmia), are among the earliest clinical features. The latter symptom may have been present before, and particularly during active exercise in mitral disease, but now it is more marked, and may be con- stant. The patient's nutrition often suffers, and he is pale and rather feeble. Absolute quiet, liberal feeding with suitable food, and iron may in a little while restore the impaired cardiac tone. If this treat- ment fails, by the end of a fortnight a small dose of digitalis should also be exhibited (5 minims — 0.333 — of the tincture three times daily); the latter should be promptly withdraAvn upon the disappearance of the symptoms. Decided indications of lost compensation are marked dys- pnea and arrhythmia ; the canter rhythm ; an irregular, small, compres- sible pulse ; and cyanosis, with or without the presence of dropsy. The object now is the maintenance of the blood-pressure at an adequate height by the following means : (a) Absolute 7\'st in bed. This diminishes greatly the work of the heart, and thus enables it to regain lai'gely its former vigor. Rest joined with careful yet liberal feeding and attention to the bowels will often restore disturbed compensation in from one to two weeks. In 4 cases recently treated at the Medico-Chirurgical Hospital this method succeeded admirably. (b) Cardiac stimulants and tonics. Of these, when occasion demands, the most important is digitalis, and this may be tried in any case in which dilatation exists. By stimulating the pneumogastric, by increasing the blood-supply to the heart-muscle, by causing the systole to be more com- plete and the period of diastole to be lengthened, digitalis becomes an in- valuable aid to the nutrition of the cardiac muscles. In addition, the heart contracts more regularly and the blood-pressure in the peripheral circulation is raised. As a result of the use of this drug the tissue-calls ^ Observation and experience have confirmed my belief tliat sea-air during the warm season and high altitudes at all times are injurious in their eti'ects in valvular disease of the heart. CHRONIC VALVULAR DISEASE. 629 upon the cardiac forces from the outlying portions of the body are satis- fied and the reserve energies of the heart-muscles are maintained. In mitral disease the influence of digitalis is most beneficial, the pulse becoming slower, of better tension, and more regular while the urine increases in amount. In mitral incompetency its good efi"ects are ascrib- able in part to the powerful contractions of the left ventricle, whereby the normal blood-stream from the ventricle to the aorta is greatly in- creased. On the contrary, the patient's condition is occasionally aggra- vated by the drug, because " the leak is increased as much as the normal flow " (Hare). Digitalis exercises its most beneficial influence by ren- dering the systole of the right ventricle more energetic, the blood-press- ure being raised in the pulmonary circuit and left auricle ; this fills the left ventricle better during diastole and " resists reflux through the mi- tral orifice in the systole" (Broadbent). In mitral stenosis digitalis, by lengthening the period of diastole, allows time for the blood to pass from the auricle through the narrowed mitral orifice into the ventricle. Slight toxic eifects may sometimes result from digitalis, the pulse becoming thread-like and irregular, and the urine scanty. Under these circum- stances the drug should be discontinued. In aortic regurgitation digitalis exercises as great, if not as wide, an influence as in mitral disease : the theoretic view% however, that by pro- longing the diastole digitalis causes overfilling of the left ventricle rests on too slender a foundation to be regarded as a valid objection to its use. It may, hoAvever, produce excessive hypertrophy, in which case it should be promptly withheld. The symptoms due to secondary mitral regurgitation digitalis meets by reinforcing the ventricles, 'particularly the right. In all forms of organic heart-disease, though most frequently in aortic regurgitation, nausea and vomiting sometimes follow the ad- ministration of digitalis : when this is the case it should be stojDped and other cardiac stimulants substituted or the dose reduced to the point of tolerance, when it may be continued if adequate to maintain a proper efi"ect. When secondary dilatation comes on in aortic stenosis digitalis is needed to increase left ventricular poAver. The dose is to be calcu- lated according to the degree of existing dilatation. When tricuspid incompetency is secondary to mitral disease striking results are obtained from the use of digitalis (supra); but when it exists alone — e. g. follow- ing emphysema or cirrhosis of the lung — digitalis often fails. The cardiac contractions, if they have previously been irregular, may become somewhat more regular,'but the precordial distress will often be increased, while the circulatory disturbance, as evidenced by the objective signs, Avill remain unrelieved. If dropsy he slight or absent, 10 minims (0.666) of the tincture or 2 to 3 drams (8.0-12.0) of the infusion, three or four times daily, will suflSce. If symptoms of decidedly unfavorable imi^ort be present, including marked dropsy, the dose should then be larger (of the tincture, minims x to xv — 0.666 to 0.999; of the infusion, gss — 16.0 — every two or three hours) for tAvo or three days, when the dose must be diminished or given at longer interA^als. Quantitative estima- tions of the urine should be made during the use of the drug, and if the effect be good the daily amount Avill often be greatly increased ; if bad, there Avill be a diminution rather than an increase in the amount. There are not a few patients in whom the symptoms of commencing failure of 630 DISEASES OF THE CIRCULATORY SYSTEM compensation recur as soon as the drug is discontinued. To such digi- talis may be administered continuously or until toxic symptoms are mani- fested. I believe that the solid preparations (powder and extracts) can be taken for longer periods than the liquid forms without exciting unto- ward symptoms. This suggestion should be followed particularly in cases that are seen at long and irregular intervals of time. Evidences of fatty degeneration and atheroma are not contraindications to its use, but are signals for the observance of extreme caution. It should, however, be a rule never to be broken to discontinue the digitalis when the symptoms of disturbed circulation have vanished. When it fails of its effect or is not well borne, and when, as often happens, the arrhythmia is not favor- ably influenced by it, the physician is compelled to resort to other car- diac stimulants. These are numerous, and, whilst their good effects are not comparable to those of digitalis in every respect, some of them seem to meet certain indications that are not met by this drug. Among the more important are nitroglycerin, strophanthus, strychnin, cocain, spar- tein, and caffein. Nitroglycerin in small doses is at the same time a car- diac stimulant and an arterial relaxant, and hence is more often useful in aortic than in mitral valvular disease. In larger doses, when left ven- tricular hypertrophy is excessive, as may occur when general arterio- sclerosis is associated with aortic regurgitation and also (though rarely) aortic stenosis, it is highly useful, widening the blood-paths, and causing less powerful contractions of the heart. Strophanthus should be em- ployed in instances in which digitalis must be interrupted, since the action of these two remedies upon the heart-walls is very similar. The tincture is usually employed, the dose (varying with the indications of each case) being from 4 to 10 minims (0.266-0.666) every three or four hours, and in controlling the irregularity or intermittency of cardiac action it is sometimes better in its influence than digitalis. Many cases of marked arrhythmia will not yield to either when but one is given ; and in such I have occasionally obtained good results from digitalis and stro- phanthus in combination. Caffein citrate is also a good cardiac stimu- lant, but is superior as a diuretic. It should be stated that, rarely, stro- phanthus, like digitalis, does harm rather than good, being sometimes badly borne by the stomach. Under these circumstances I have em- ployed, both in hospital and private practice, the following combination : I^. Caffein. citrat., .^j (4.0) ; Strychninfe sulphat., gr. ^ (0.021) ; Spartein. sulphat., gr. ij (0.129). Ft. capsul?e No. xij. Sig. One every three or four hours. The above prescription is not only a good heart-tonic and stimulant, but also an equally good diuretic. Spartein is a potent diuretic and heart-stim- ulant when employed in doses of gr. -g- to ^ (0.010-0.016) every four to six hours, and is especially serviceable in organic heart-affections when dropsy as a symptom and nephritis as a complication exist. Strychnin, when given hypodermically in full dose, gr. g^j- to y^- (0.002-0.004), is the most eflicient cardiac stimulant known to medical science. It should be em- ployed in this manner in cases in which there is sudden failure of heart- power with the development of serious symptoms. Given in doses of CHRONIC VALVULAR DISEASE. 631 average size, per os, its effects in chronic valvular disease are not very striking. Atropin may be advantageously combined with it. When the indications are urgent and the above agents are not avail- able, diffusible stimulants, as ether or ammonium, may be used until more suitable remedies can take effect. Cocain simulates strychnin in its action. The dose is gr. ^ (0.016) every four hours, and the drug may be given with digitalis in pill-form. Later, systemic tonics are often de- manded by the anemia and other constitutional indications, and here iron and quinin should be joined with strychnin. Unquestionably, the value of iron in full doses as an aid to the completion of the work of restoring broken compensation has been and is still scarcely appreciated by the profession at large. When iron disagrees, arsenic may be given instead. In many cases of failure of compensation the restoration of the balance of the cardio-systemic circulation can be greatly assisted by deflecting the over-filled venous system. There are two ways of attaining this end : (a) Venesection. — When the right heart is over-distended, as shown by its very feeble efforts at contraction, and the Avhole venous system is intensely engorged, as shown by marked cyanosis and orthopnea, bleeding directly from a vein is not only warrantable, but often imperatively de- manded in order to save life. From 16 to 30 ounces (473.0-887.0) may be removed safely, and the heart's action will almost immediately be obserA^^ed to grow stronger and more regular, and the pulse fuller and of better tension. As before intimated, the form of dilatation of the right ventricle that follows emphysema is disinclined to yield to digitalis. In such instances, following the suggestion of Osler,^ I have obtained bril- liant results from free bleedings. (5) Depletion hy purgation affords less pronounced relief to the heart, though it is of the greatest value in cases in which a moderate grade of cyanosis and dropsy exists. As in the case of venesection, a feeble, irregular pulse is not a contraindication to the use of purgatives, since the latter remove directly a considerable portion of the heart's burden. The purgative to be used Avill vary with different cases. I select at the outset Rochelle or Epsom salts, employing them after the method of Matthew Hay — ^. e. from 1 to 2 ounces (32.0-64.0) of Rochelle or 1 to 1^ ounces (32.0-48.0) of Epsom salts, in concentrated solution, to be given from a half to one hour before breakfast. Watery evacuations (three to six in number daily) usually follow the administration of the saline ; but, unfor- tunately, one meets with many patients in whom it produces symptoms of marked catarrhal irritation. Next to salines, the most satisfactory results have been obtained from the use of elaterium ; I often combine this with podophyllin and belladonna. I have never seen good results from the use of mercurials Avhen the object has been to procure venous de- pletion, but they are of service in dropsy, and particularly in ascites. Schott of Nauheim has introduced a special plan of treatment that is applicable to most forms of valvular disease, simple dilatation, and nervous affections of the organ. The beneficial effects are principally attribu- table to the salt, which acts as a cutaneous stimulant, and to a slighter degree to the gaseous ingredients of the bath. Greene^ regards the warmth and moisture as the important features. Twenty-one baths are 1 For illustrative cases from Prof. Osier's wards, see article by Lentler, Medical Neivs, July, 1891. - Jour. Amer. Med. Assoc., Oct. 15, 1898. 632 DISEASES OF THE CIRCULATORY SYSTEM given in one month, dropping one every fifth, fourth, third, and second days. The water contains sodium chlorid, calcium chlorid. and carbon dioxid, and the temperature ranges from 82°-9o° F. (27.7°-35° C). The first bath lasts seven or eight minutes ; the time is then gradually lengthened, the temperature lowered, and the carbon dioxid increased. After the bath the patient is rubbed and allowed to rest for an hour. Artificial Nauheim baths are successfully employed in certain Amei'i- can hospitals at the present time. They are prepared as follows : Five pounds of sodium chlorid and eight ounces of calcium chlorid are dissolved in one half bath (30 gals. — 114 liters), the temperature of the Avater being 95° F. (35° C). In a few days the bath is charged with carbon dioxid by adding sodium bicarbonate (1 lb. — 153,6) and HCl (jlb. — 226.8), the latter just before the bath is taken. The effects are to lower the pulse- rate, to decrease the size of the heart, to stimulate the nerves, and, indi- rectly, the cardiac nutrition. There is also a tendency toward improve- ment of the skin and an increase of the urine. Gentle resistance exercises (consisting of all the more reasonable move- ments that a person naturally makes, and resisted by an attendant) form an important element of the treatment, since they tend to stimulate the muscles and nerves and propel the blood from the congested veins. The Nauheim treatment is not suitable in aortic regurgitation, aneurysm, or fatty degeneration of the heart, although the movements alone are bene- ficial in these conditions and may be employed to the exclusion of the baths. Individual symptoms freijuently become so conspicuous as to demand special treatment. (1) Dyspnea and Orthopnea. — When these conditions are caused by engorgement of the pulmonary vessels, the cardiac stimulants above detailed usually afford relief. Frequently the patient cannot lie down, in which case a suitable bed-rest often gives immediate comfort and support. For the severe attacks of nocturnal dyspnea (amounting some- times to orthopnea), particularly^ when accomi)auied by cardiac palpita- tion, the subjoined formula has proved itself of great benefit : ^. Sodii bromidi, gr. xv (0.972) : Tr. opii deod., Tdx-xx (0.666-0.999).— M. Sig. To be taken in one dose at bed-time. In the late stages of heart-disease morphin, given hypodermically. is to be preferred in combating this symptom, and is entirely free from the usual objections to the habitual use of the remedy. Its influence for good is inestimable. Dyspnea may also be produced by associated bronchitis, edema, emphysema, and hydrothorax — conditions that must be treated according to the customary rules. Frequent physical explorations of the chest should not be omitted. Hydrothorax demands aspiration, and this repeatedly in some instances.^ In valvular disease (particularly aortic), owing probably to coronary arterio-sclerosis, paroxysms of severe dyspnea (cardiac asthma) are apt to arise. These are best overcome by nitroglycerin in ascending dosage in combination with sodium bromid at bed-time, to be repeated as needful. ' When the chambers of the heart are greatly dilated care must be exercised in insert- ing the aspirating needle, lest the left ventricle be entered. CHRONIC VALVULAR DISEASE. 633 (2) OougJi. — Cough is common after failure of compensation, and is due to bronchitis resulting from stasis in the pulmonary vessels. In mitral disease it may come on before the rupture occurs. Beyond the treatment directed to the causal condition (the cardiac failure) nothing is needed to relieve the cough. It should be remembered, however, that these subjects are very liable to suffer from catarrhal bronchitis due to cold, and that unless the condition be promptly controlled, the compen- satory power of the heart will suffer. (3) Hemorrhage may take place, and generally from the lungs, though it may also proceed from the nose, stomach, bowels, or uterus. In a recent case of double aortic and relative mitral insufficiency attended w^ith marked dropsy, rather copious hemorrhages occurred from the bowel, but with apparent relief to the patient. The hemoptysis, which is a rather frequent accompaniment of mitral lesion, is rarely excessive, and is probably always beneficial. I would advise against active treat- ment unless the hemorrhage is actually copious in amount. (4) Palpitation may be due to different causes, the recognition of which in each case is important. At times undue hypertrophy maintains a constant throbbing and distress in the precordial region, the former being distinguished by the strength of the impulse and by the full, tense pulse at the Avrist. Palpitation is best met by the use of the tincture of aconite, ttlj-iv (0.066-0.266, every four hours. With the aconite I frequently associate the bromid with excellent effect. An ice-bag to the precordia is worthy of recommendation. Unless the patient's dis- comfort is significant, however, this symptom does not call for active treatment. The administration of a saline purge not infrequently serves to quiet the heart. The patient may suffer from pure nervous palpitation, in w^hich case the diet and the condition of the stomach must be care- fully looked to, while for the throbbing the bromids of ammonium and sodium, together with preparations of valerian, are the most reliable. (5) Anginose Pains. — These are seen in aortic incompetency accom- panied by sclerotic vessels, and more especially in mitral stenosis. When dependent upon rigid blood-vessel walls nitroglycerin should be tried ; if the attacks be severe, amyl nitrite by inhalation deserves a trial, and, this failing, morphin and atropin may be employed hypodermically. The latter measures, as a rule, promptly relieve the patient's suffering. Local measures alone are sometimes sufficient when the pain is only moderately intense, and the ice-bag or Leiter's coils may be tried. The sedative effect of a blister (4 by 6 in. — 10 by 15 cm.) has more often proved effectual in my experience, though its use should be limited to patients whose general strength is not materially impaired. (6) Pain referred to the stomach, and less frequently to the abdomen also, occasionally assumes prominence and is relieved with great diffi- culty. It is dependent, in part at least, upon obstinate subacute gas- tritis, and I have quite recently seen an instance of the sort verified by autopsy. Among many drugs tested in this case, opium alone gave relief. Usually the pain results from gaseous distention of the stomach and bowels, and is not intense, a mild laxative frequently bringing- relief. Should this fail, however, trial should be made of the carmin- atives in combination with some antiseptic agent, as salol or creosote. (7) G-astric Symptoms. — Soon after compensation is broken the ap- 634 DISEASES OF THE CIRCULATORY SYSTEM. pearance of mild symptoms of catarrh of the stomach may be said to be the rule, and these yield to simple measures in addition to the cardiac stimulants and laxatives already indicated. But there are not a few instances in which such symptoms as gastric distress and uneasiness, constant nausea with frequent vomiting, particularly after food, occur and assume a distressing phase. Such patients cannot, as a rule, take digitalis or strophanthus by the mouth ; they sometimes, however, do Avell on the capsules before adduced composed of strychnin, spartein, and caffein. When the latter cannot be borne I employ hypodermically digitalin and strychnin or caffein citrate, the latter being made soluble by the addition of sodium benzoate in solution. Cases of this class reach an early fital termination, as a rule. The symptoms may be partly due to gastric catarrh coupled with hepatic engorgement, and partly to uremic intoxication. (8) Nervous Symptoms. — Insomnia and internal restlessness are almost constantly present at some period in the course of heart-disease, and notably in the more advanced stages. The restiveness is rendered more distressing on account of hideous dreams and cardiac palpitation on awaking. For these phenomena stimulation often answers a better purpose than sedation. Hoffman's anodyne (3j — 4.0 — well diluted), spirits of chloroform (TTLxv — 0.999), or ether (3ss — 2.0), taken in whis- key (5J — 32.0) are serviceable. The elixir of ammonium valerianate is also of value when given in full doses. I formerly employed sulfonal in combination with camphor monobromate when a hypnotic was required to afford sleep. Recently, the use of trional (grs. xv) in combination with sodium bromid (grs. xx) was found more satisfactory. Paralde- hyd and chloralamid are among the remedies of choice in the treat- ment of this symptom, but I have had no experience with their employ- ment. In the later stages there is no objection to the use of morphin hypo- dermically. Headache due to uremia may fre({uently be a troublesome symptom in connection Avith sleeplessness, and in such cases morphin is the remedy par excellence : it is to be supplemented by free purgation and cardiac stimulants. Should the right heart be found flagging, venesection may be practised. (9) Dropsy. — Among the symptoms re((uiring special treatment in advanced valvular disease dropsy easily assumes the lead. As above pointed out, rest with attention to the diet and state of the bowels will often restore defective compensation even when accompanied by a mod- erate degree of dropsy. In the severe grades of failure of the balancing forces the cardiac stimulants and purgatives before mentioned often suffice to remove the dropsy for a considerable period of time. Later, however, it becomes obstinate, and refuses to yield to any of the known methods of treatment. The therapeutic indications, so far as the symp- tom under consideration is concerned, are for the use of diuretics and purgatives. Diaphoretics, particularly the hot-air and vapor baths, are not to be thought of, since they tend to depress the already weakened heart. While describing the action of digitalis as a cardiac stimulant, incidental allusion was also made to its action as a diuretic. In view of the fact that it raises the blood-pressure in the peripheral vessels and capillaries by contracting their walls, and because of its stimulating CHROXIC VALVULAR DISEASE. 635 effect on the heart, digitalis in large doses becomes a most efficient diu- retic in cardiac dropsy. When the renal secretion is not free under its use, or when for some good reason it cannot be taken, 1 have frecjuently found that a combination of strychnin, spartein, and caifein (vide supra) will excite free diuresis. Nitroglycerin may also be prescribed, espe- cially in cases presenting evidences of advanced arterio-sclerosis. An unirritating yet highly eifective diuretic mixture in these cases is the following : ^. Potassii acetatis, 3J (4-0); Inf. digitalis, sij (64.0).— M. Sig. 5SS (16.0) every three hours. Purgatives are of the utmost value. Frequently, after a few copious Avaterv evacuations as the result of the action of hvdraD;oo:ue cathartics, a free discharge of urine can be established, when before the latter event it has been impossible. Salines and elaterium, with podophyllin and belladonna, are agents that have been already recommended as purga- tives (to deplete the venous system), and these should be first employed in the order named. Compound jalap powder may also be combined with the elaterium. A course of calomel, folloAved by salines until free catharsis is set up, is valuable from time to time. Mercury is especially applicable when the liver is much enlarged and ascites is a marked fea- ture, or when the history of syphilitic infection is obtainable. It may be combined with cardiac stimulants and other diuretics ^as follows : I^. Pulv. digitalis, Pulv. scillje, ad. gr. xij (0.777); Hydrarg. mass., gr. xxiv (1.555) ; Ext. bellaclonnse, gr. ss (0.0324). M. et ft. pil. No. xij. Sig. One every three or four hours. When efforts at relieving the dropsy by means of medicines fail, then the most dependent parts of the body, or those most swollen, should be scarified under strict aseptic precautions. Fine silver trocars with rubber tubes attached (Southey's tubes) may be inserted and the liquid allowed to drain off in a gradual manner. Means to Prevent Recurrence of Broken Comjjen.sation. — When the compensation has been successfully established, the after-treatment must be prosecuted with vigor for at least a year. The cause of the rupture of compensation is most probably fibroid and fatty degeneration of the cardiac muscle, and hence the mere restoration of the compensatory power of the heart does not imply a complete cure of the impaired mus- cular structure of that organ. Much can be done, however, to overcome the tendency to degeneration by the peristent use of hematinics and other tonics, as iron, cod-liver oil, arsenic, and mercuric chlorid, the latter two in small doses. I have obtained excellent results from the use of the following prescription in these cases : ^i. Liq. arsenici chlor., ITlxlviij (3.186) ; Tinct. ferri chlor., gss (16.0); Hydrarg. bichloridi, gr. ss (0.0324); Glycerini, q. s. ad fgiij (96.0).— M. Sig. 3j (4.0) after each meal, well diluted. 636 DISEASES OF THE CIRCULATORY SYSTEM. This preparation may be taken indefinitely with occasional brief inter- ruptions. The patient should lead a very quiet life, and follow rigidly all hvgieuic rules that tend to prevent the production of valvular disease. Appropriate diet, it should be emphasized, is not inferior to appropriate medication in its salutary effect. Should the faintest evidence of failure of the right ventricle manifest itself, the patient must be put to bed immediately, and the foregoing treatment is to be carried out. I am inclined to the view that the plan herein advocated not only renders the course of recurring attacks of failing compensation milder, but that, in a considerable proportion of the cases, the much-dreaded recurrence is thus prevented. CARDIAC THROMBOSIS. Pathology. — True cardiac thrombi are seen most frequently on the right side of the heart, in the auricular appendices, and, less commonly, in the right ventricle near the apex. They are of firm consistence, and are tightly adherent to the endocardium, considerable force being re- (juired to dislodge them. The color, while generally grayish-brown or red, varies with the age of the thrombus, being more colorless as it be- comes older. Cardiac thrombi may be pedunculated or sessile, and their contour is, as a rule, more or less rounded. Recklinghausen and others have observed globular masses, the so-called "ball-thrombi." in the auri- cles, without the slightest endocardial attachment. They vary greatly in size, from a mustard-seed to a hen's egg, and sometimes exhibit cal- careous degeneration. Cardiac thrombi may occur singly or in groups of considerable numbers. From the cavity in which they have their primary seat they may project into other chambers of the heart, or from the left ventricle into the aorta for a considerable distance. It is evi- dent that fragments detached by the blood-stream from these cardiac blood-concretions will tend to lodge in various viscera and in the per- ipheral tissues, and set up embolic processes. Examined microscopically, degenerate round cells and detritus are revealed, but pus-cells are not seen. Secondary degenerative changes, and later softening, may take place in the central portions of a thrombus, and these areas may contain a reddish-brown liquid. Ktiologfy. — The causes of cardiac thrombosis are to be found chiefly in some previously diseased or injured condition of the endocardium, though sometimes alterations of the blood constitute a factor of consid- erable importance. The condition may occur in the course of both acute and chronic diseases, in which the intracardiac conditions favor the formation of a blood-clot. Hence it is seen in connection with organic diseases of the heart in which the valvular and often the mural endocardium are roughened, and the obstructive and regurgitant lesions at the various valves cause retardation in the blood-current. Chronic obstruction in the lungs may contribute to the result by slowing the cir- culation in the heart. Cardiac thrombosis has been observed in many CARDIAC THROMBOSIS. 637 of the acute affections, and almost invariably there is a loss of endocar- dium, due to inflammatory action (endocarditis) at some point in the cavities of the heart. This becomes the seat of the fibrinous deposit which is subsequently imperfectly organized. Among the most import- ant of these acute primary diseases are rheumatism, diphtheria, lobar pneumonia, and pyemic and puerperal conditions. It may be questioned whether, given a healthy endocardium, as contended by some Avriters, slowing of the circulation alone suffices to cause true cardiac thrombi. Symptoms. — These will depend very much upon the rapidity with which the thrombus is formed, as well as upon its seat and dimensions. Thrombi invariably lack definiteness, and, as their effects are largely mechanical, signs of obstruction to the cardiac circulation and failure (more or less gradual) of the cardiac muscle are developed. The fulse becomes weak, rapid, and irregular ; dyspnea, vertigo, and attacks of syncope are frequent; and later cyanosis may appear. It is probable that at times the liquefied products of a clot may be absorbed, producing blood-poisoning. When the thrombus is formed rapidly the symptoms are suddenly developed and the course is rapid. Rarely a valvular ori- fice, an efferent vessel, or the coronary artery may become blocked and instant death follow. Since the right heart is the most frequent seat of these thrombi, pulmonary embolism, attended with its usual symp- toms, is a common event. When portions of a clot are broken off and swept into the systemic circulation, the clinical phenomena of cerebral, splenic, or renal embolism are exhibited. The physical signs consist of a feeble impulse Avith marked arrhyth- mia ; the area of dulness is somewhat increased to the right, and often upward ; and the heart-sounds are greatly enfeebled and quite irregular, with marked change in any murmurs that may previously have been audible. A systolic pulmonary murmur may rarely be engendered. Diflferential Diagnosis. — It is important to distinguish true car- diac thrombi, such as are above described, from the less dense and usu- ally darker clots that are formed either immediately before or after death. The latter may seldom show an attempt at a very low grade of organization, and may present a somewhat decolorized appearance, but they do not adhere firmly to the endocardium. Moreover, antemortem and postmortem clots, as the latter may be appropriately termed, have a different causation from true thrombi. For instance, they are apt to form in diseases in which the fibrin-factors of the blood are greatly increased, as in pneumonia. Perhaps a more potent causal element is the progressive weakening of the heart-muscle, resulting in partial ex- pulsion of the contents of the right ventricle; the blood that remains in the chamber is merely whipped up, and the deposition of its fibrin must thus be greatly favored. Such heart-clots may be generated if the endocardium be healthy, and cannot be separated positively from true cardiac thrombi by clinical observation. The prognosis is uniformly bad and sudden death may be expected. Treatment. — Beyond measures calculated to meet the symptomatic indications nothing can be suggested. 638 DISEASES OF THE CIRCULATORY SYSTEM. HYPERTROPHY OF THE HEART. [Hypertrophia Cordis. ) Definition. — Hypertrophy is an increase in the muscular structure of the heart, evidenced usually by an increased thickness of its walls. It is almost invariably associated with dilatation of the chambers. Pathology. — When the two processes — hypertrophy and dilatation — coexist, they cause great enlargement of the organ. To this condition the term '•'• ecceritric hypertrophy'' has been given. Hypertrophy with- out dilatation receives the name '■^simple hypertrophy,'' and hypertrophy with diminution in the size of the cavities was formerly described as ''''concentric hypertrophy," but this term should now be regarded as ob- solete, inasmuch as the condition is due to postmortem contraction of the ventricles. The increase in size may affect either the whole heart, one chamber on either side, one whole side, or but a single cavity {general iindi partial hypertrophy^. The process may also be limited to a minute division of the heart (circumscribed hypertrophy). Owing to its important physio- logic function the left ventricle is more frequently enlarged than the right, and oppositely the right auricle is more frequently involved than the left. The toeight of the normal heart in a man of average size is approximately 9 ounces (255.0); in a woman it is 8 ounces (226.0). In bilateral hypertrophy, however, the weight of the heart may be greatly increased ; hearts weighing from 15 to 25 ounces (425.0—710.0) are seen in moderate grades of hypertrophy, and those from 40 to 50 ounces (1134.0-1420.0) in extreme cases {cor bovinum). Measurements show- ing the thickness of the walls also indicate the degree of hypertrophy ^ and the exact seat of the enlargement when not general. The normal diameter of the left ventricular wall is from 8 to 12 mm. {\—^ in.) ; that of the right ventricle, from 5 to 7 mm. {^^ in.) ; that of the left auri- cle, about 3 (^ in.), and of the right, 2 mm. {-^ in.). Suffice it to state in this connection that under conditions of cardiac hypertrophy the normal thickness of the various cavity-walls is usually doubled, not in- frequently trebled, and, rarely, even quadrupled. In cases in which there is a concomitant dilatation the walls may appear thinned, while the measurement will show them to be in reality thickened. The shape of the heart is also altered according to the seat and ex- tent of the hypertrophy. If both ventricles are enlarged, the apex is widened and appears flattened ; if only the left ventricle is involved, the apex is lengthened and is more or less pear-shaped ; and if the right ventricle alone is hypertrophied (as in mitral stenosis), it may form the largest part of the apex, which will be less conical than in health. The papillary muscles and columnte carneae are greatly thickened, and, particularly in the eccentric form of hypertrophy, they are often decidedly flattened. In this form the septum frequently shows increased thickness — a condition that I have never observed in simple hypertrophy. The muscular trabecuUie generally assume greater prominence on the right than on the left side. The muscular structure is usually of a ^ Measurements should not be attempted until the rigor mortis has been overcome by soaking the organ in water. HYPERTROPHY OF THE HEART. 639 deeper red color and also firmer than normally. The hypertrophied left ventricle can, as a rule, be lacerated readily, -while the right, as first pointed out by Rokitansky, may be tough and leathery. As the heart continues to enlarge it sinks lower in the chest-cayity ; this is not, however, owing to an increase in size alone, but more particularly to an increase in weight. In hypertrophy of the heart there is a multiplica- tion of muscular fibers, to which alone the enlargement of its walls is attributable. i^tiology. — Hypertrophy of the left ventricle (sometimes termed general hypertrophy) results from obstructions to the arterial circula- tion of whatever sort. These may be classified, according to their seat, into — (1) Lesions of the Heart. — {a) Aortic incompetency and aortic stenosis ; (U) Mitral insufficiency ; {e) The fibroid form of myocarditis ; ((.?) Pericardial adhesions, particularly in the young. Late in life the heart may become atrophied. In such cases the adherent pericardium exerts a counter-traction force during the systole, and thus the Avork is increased beyond the capacity of the normal heart, with consequent hypertrophy. In valvular disease the augmented tension in the ven- tricle induces the hypertrophy. Hassenfeld ^ has recently shown that hypertrophy of the left ventricle occurs only when the visceral arteries exhibit an extreme degree of sclerosis, or when the thoracic aorta is sclerotic. In cases of pure contracted kidney all the chambers of the heart are hypertrophied ; but when extreme arterio-sclerosis is present also the left ventricle is disproportionately enlarged. (2) Abnormal Conditions of the Blood-vessels. — {a) Narrowing of the aorta — e. g. congenital stenosis, external pressure, and the development of an aneurysm ; (h) General arterio-sclerosis, by raising the pressure ; [c] Increased arterial pressure, due to contraction of the peripheral vessels in consequence of the local action of certain chemical and biologic irri- tants (lead, Bright's disease, gout, syphilis). In all of these cases, whether the blood-pressure is raised in larger or smaller vessels, increased car- diac action is essential to meet the demands of the system-circulation. Attention should be called to the causes of the so-called " primary idio- pathic hypertrophy." The main causal conditions are — (1) Prolonged physi- cal exertion, as in certain occupations (blacksmiths, locksmiths, dray- men, and athletes). (2) Constant over-distention of blood-vessels, as in the case of excessive beer-drinkers {heer-heart). Here the direct action of the alcohol upon the heart-muscle must also be taken into account. (3) Functional disturbances (neuroses), constant over-action of the heart, and even paroxysmal tachycardia, tea, cofi'ee, and alcohol may give rise to primary and general hypertrophy. Idiopathic hypertrophy of the heart is undoubtedly due to increased activity, which"^ may be due to a variety of irritating influences acting upon the heart-muscle (De Domen- icis ^). Excessive bicycling causes hypertrophy, particularly if arterio- sclerosis exists. Primary congenital hypertrophy of the heart is attribu- table either to circulatory disturbance (Simmonds ^) or, as Yirchow holds, to a diffuse myomatous neoplasia of congenital orisiu. Hypertrophy of the right ventricle develops secondarily to" any condi- tion that ofi'ers obstruction to the pulmonary circulation or to the blood- 1 Deutsch. Arch.f. klin. Med., Dec. 9, 1897 ; PhUa. Med. Journ., Jan. 22, 1898. 2 Wien. klin. Woch., May 22, 1897. ^ Munchener med. Wock., 1899, ^'o. 4, S. 108. 640 DISEASES OF THE CIRCULATORY SYSTEM. current through the right ventricle. Among them may be mentioned — (1) mitral incompetency and stenosis ; (2) emphysema, bronchitis, col- lapse of a portion of the lung, contraction of a lung from pleural ad- hesions, and cirrhosis of the lung : (3) right-sided valvular lesions, par- ticularly obstruction at the pulmonary orifice ; (4) it is doubtful whether, on account of the normal situation of the right ventricle, pericardial adhesions induce hypertrophy of this chamber. Hypertrophy of the Auricles. — Hypertrophy with dominant dilatation of the left auricle occurs in mitral disease, and especially in mitral ste- nosis. The right auricle hypertrophies, though not invariably, when the blood-pressure in the pulmonary vessels is pronounced from any cause. Stenosis of the tricuspid orifice is occasionally the sole cause of thicken- ing of the right auricular wall, which also becomes hypertrophied in tri- cuspid incompetency. Symptoms. — There is usually an entire absence of subjective symp- toms when compensation is efficient. When present, their intensity varies with the degree of the hypertrophy, which is then pronounced, as a rule, and often already attended by incipient dilatation. They may be local entirely, though frequently general as well. Of the former, precordial discomfort and uneasiness from the violence of the impulse occur. They are most annoying when the patient is in the recumbent posture on the left side and when the hypertrophy is dependent upon nervous causes. Pain and palpitation are seldom complained of except by neurasthenics and patients suffering from enlargement due to tobacco or excessive muscular exertion. Decided aggravations of the local mani- festations may follow the operation of influences that create a demand for increased cardiac action, such as undue mental emotion or excite- ment, physical exhaustion, active bodily exercise, and gourmandizing. The general symptoms, when present, may fluctuate or even intermit. Those most frequently observed are fulness in the head, often amounting to actual headache, tinnitus aurium, carotid pulsations, flushing of the face, flashing of light before the eyes, and often prominent eyeballs. These symptoms are attributable to the increased vigor of the cerebral circulation. Remote Effects. — General or total hypertrophy promotes high ten- sion throughout the arterial tree. Endarteritis and arterio-sclerosis are, as a conse(iuence, frequent consentaneous developments in advanced cases, especially when the cause of the enlargement has been increased tension in the peripheral vessels, as in Bright's disease. With a circu- lation too forcibly carried on, as in hypertrophy, the sclerotic vessels are overstrained, and are apt to rupture. The break often occurs in the brain {apoplexy) or in the lung {puhnomary apoplexy), and hemoi'rhage from the lung (hemoptysis), due to left ventricular hypertrophy, is more common, I believe, than is supposed. Some of the symptoms are due to the cause or causes of the hypertrophy. Physical Signs in Left-sided Hypertrophy. — Inspection — In females and in young children with yielding ribs there is visible bulging. The intercostal spaces are much broadened and the apex-beat covers an in- creased area, the extension being downward and to the left. The whole body of the patient, and even the bed on which he may be lying, may share visibly in the cardiac impulse. Palpation. — In pronounced grades the impulse may be felt as low HYPERTROPHY OF THE HEART. 641 down as the seventh interspace and as far to the left as the axilla. In simple hypertrophy it is carried downward to the sixth intercostal space and outward to a point near the anterior axillary line. The impulse is slow, forcible, and heaving, the "thrust" lifting the fingers of the ex- aminer. In eccentric hypertrophy (hypertrophy with dilatation), though heaving and forcible, it is somewhat more abrupt, as in cardiac dilata- tion. Over the aortic orifice a short diastolic impulse may also be felt occasionally (double impulse). Pressing the fingers into the second and third right spaces will detect an impulse if the aorta be dilated. The pulse in pure hypertrophy is full, strong, regular, and of normal rate ; it is also prolonged, owing to increased tension. In eccentric hyper- trophy it is more abrupt, soft, full, and somewhat accelerated. Percussion. — This defines only approximately the degree of enlarge- ment, as the hypertrophy may take a backward direction or there may be more than the usual overlapping of the heart by the lung. Traced upward, dulness may terminate in the second interspace, whilst to the left it may extend 1 or 2 inches (2.5-5 cm.) beyond the mid-clavicular line. When hypertrophy is of moderate extent the left limit of dulness corresponds with the results of palpation and inspection ; but when it is of immoderate extent the extension of dulness does not keep pace with the systolic impulse, which is diffused to points beyond the limits of contact of the heart with the thoracic wall. If concomitant hyper- trophy of the right ventricle be present, dulness will also extend to the right (vide infra). Auscultation. — The sounds vary with the grade of the morbid proc- ess and the variety. In simple hypertrophy of marked type a pro- longation of the first sound is always appreciable, and usually it is duller than the normal. I'he second sound (aortic) is intensified, clear, and often ringing. The degree of accentuation depends partly upon the vigor of the left ventricle, though chiefly upon the condition of the blood-vessels. Reduplication of the second sound, due to high tension, is common (e. g. in Bright's disease). The first sound may also be du- plicated. In dilated hypertrophy the first sound is clearer and more abrupt, while the second is less marked or even faint. Modification of these sounds occurs when hypertrophy is due to chronic valvular disease. Hypertrophy of the Right Ventricle. — One or more of the causal fac- tors that produce augmented tension in the pulmonary vessels are pres- ent, and, if properly appreciated, will throw light upon the condition. There may be an absence of all symptoms if the hypertrophy exactly balances the result of the obstructive forces, and this state may be main- tained for a long period of time. Undue exertion, however, soon leads to temporary dyspnea in many cases. When secondary to emphysema or cirrhosis of the lung the symptoms occasioned by the latter diseases, such as cough and dyspnea, may completely veil any symptoms that may be due to the hypertrophy. Discomfort in the cardiac region should, however, arouse suspicions of the existence of the latter con- dition. When dilatation of the ventricle supervenes, as is usual, and the clinical evidences of tricuspid incompetency develop, then pulmo- nary symptoms, due to venous congestion, are prominent ; these are bronchial catarrh, shortness of breath, and the like. Later, general cyanosis and edema appear. As pointed out in the discussion of Mitral 41 642 DISEASES OF THE CIRCULATORY SYSTEM. Stenosis with permanently heightened tension and overgrowth of the right ventricle, the lung-vessels becorae atheromatous and the lung- tissue the seat of brown induration. Owing to the fact that the scle- rotic vessels are easily ruptured, hemoptysis — a not uncommon event after sudden great exertion — is to be expected: intense pulmonary congestion and apoplexy may also be met with in hypertrophy with dominant dilatation. Physical Signs. — These have been in the main detailed in sj)eaking of affections of the mitral valve. Inspection discloses bulging of the sixth and seventh left costal cartilages and of the lower sternum. In the angle between the ensiform cartilage and the seventh rib an epigas- tric impulse may be visible, but more commonly the impulse is in the sixth interspace, close to the left edge of the sternum. It is also very generally seen to the right of the sternum, in the third and fourth interspaces, and particularly is this the case in eccentric hypertrophy, forming a highly characteristic sign. The apex-beat is therefore diffuse, the radial puhc is small, and in dilated hypertrophy it is increased in frequency, and is small, unsustained, and irregular. Percussion shows the extension of cardiac dulness to a point an inch (2.0 cm.) or more beyond the right sternal border. When there is great increase transversely, dilatation is most probably associated and may predominate over hypertrophy. The auscultatory signs are not distinct- ive unless dilatation also exists, when the first sounds are clear and sharp. In simple hypertrophy the first sound is slightly prolonged and lower than in health. Owing to the high vascular tension throughout the lungs the second sound at the pulmonary valve is accentuated, and reduplication of the second sound may occur for the same reason. It must be kept in remembrance that Avhen advanced emphysema is present all the physical signs will be greatly modified, and may even be entirely negative, though the heart be of large size. Under these cir- cumstances venous pulsation in the neck would be diagnostic of dilated hypertrophy of the right ventricle. Hypertrophy of the Left Auricle. — This may be assumed to occur in mitral stenosis and incompetency in order to compensate for these lesions : it cannot, however, be recognized positively by physical signs. When the chamber is at the same time extensively dilated, the dulness may be extended upward to the left of the sternum, passing over the third and even second interspaces. At this point — the second inter- space — a presystolic wave may now be noticeable. Hypertrophy of the right auricle, associated with dilatation, is per- haps more common than its counterpart on the left side. It is secondary to tricuspid incompetency (rarely stenosis) and enlargement of the right ventricle, and hence has the same etiology as the latter conditions. The ]jJi//sicaJ signs are — systolic jugular-pulsation, sometimes a pre- systolic wavy pulsation over the third and fourth interspaces to the right of the sternum, extension of cardiac dulness to the same interspaces, and other signs of tricuspid regurgitation. Diagtiosis. — The recognition of cardiac hypertrophy is possible only by attention to the physical signs. Xext to these, in point of diagnostic value, come the causes, which should therefore be diligently searched for ; the rational symptoms are least in value, though usually HYPERTROPHY OF THE HEART. 643 corroborative. It is difficult to establish a diagnosis, even approx- imately, when extensive emphysema coexists. As before pointed out, venous pulsation in the neck would point indisputably to right ventric- ular enlargement. Differential Diagnosis. — Conditions that cause an increase in the pre- cordial area of dulness, except hypertrophy, must be eliminated. (1) Pericardial Effusion. — A careful analysis of the physical signs and the history will suifice. (2) Aneurysm. — In this affection the enlargement is altogether upward and to the left or right. This fact, joined with the other evidences of aneurysm, should obviate error. (3) Mediastinal groivths also enlarge the dull space mainly upward and to the right or left, though the point of cardiac contact may be increased and the heart carried forward. (4) Dis'placement of the heart does not give a heaving impulse nor an increased area of dulness ; moreover, it usually furnishes its special cause (pleural effusion). (5) Abnormally narrow-chested persons present a considerably increased superficial zone of dulness, partly owing to the position assumed by the lungs and partly (perhaps chiefly) to their imperfect development. Since there is usually an entire absence of all other physical signs of hypertrophy, ordinary caution will exclude the latter complaint. (6) Affections of the Lungs and Pleurce. — Left-sided pleurisy with retraction may, by exposing a large part of the anterior surface of the heart, give rise to signs of moderate hypertrophy. The presence of the former condition, the lack of lung-expansion on deep inspiration, the displacement of the heart to the left and upward, and an absence of the causes of hypertrophy should lead to a correct conclusion. (7) Phthisis and cirrhosis of the lung., with or without pleurisy, may in like manner produce apparent enlargement of the heart. It must also be remembered that cirrhosis of the lung is one of the causes of right-sided hypertrophy, and that the latter condi- tion may therefore be present. Prognosis and Course. — The course that Avill be pursued depends largely upon the stage at which the case has arrived and the character of its special cause. I have repeatedly found ijostmortem evidence of a moderate grade of hypertrophy in persons who died of other affections, and with especial relative frequency in those who had constantly fol- lowed manual pursuits. Simple cardiac hypertrophy, being compensa- tory as a rule, exerts in nearly all instances a salutary influence, and if the processes that constitute the causal factors are not steadily pro- gressive, life may not only not be curtailed, but be greatly lengthened by its existence. Even in organic valvular disease of the heart hyper- trophy prolongs life by overcoming the ill effects of the vaive-lesion and by maintaining the normal circulatory equilibrium. But since in this class of cases the lesion is progressive despite treatment, a limit is reached sooner or later beyond which the increased vigor on the part of the heart cannot be maintained. ^ The nutritive functions becom-e inade- quate in obedience to a natural law, and muscular degenerations then occur, followed by disturbances of the circulation due to cardiac weak- ness and secondary dilatation. It must, however, be recollected that the heart may at no time, in the course of certain cases, fully compen- sate for the causal condition — e. g. as when a valve ruptures with start- lino; suddenness. Failure of the cardiac nutrition at once renders the 644 DISEASES OF THE RESPIRATORY SYSTEM. prognosis unfavorable. The cardiac sounds now give notice that the hypertrophy no longer meets the requirements of the case. The sys- tolic pause grows longer (with abbreviation of the first, sound), and the diastolic shorter. Occasionally, as the result of undue muscular exer- cise, acute dilatation, followed by a speedy termination of life, is observed. I believe that hypertrophy of the left ventricle warrants a more favorable prediction than can be made in hypertrophy of the right, and this for two reasons : first, the increased capacity for work of the left ventricle ; second, the milder character of the many factors that are productive of left ventricular hypertrophy, as compared with those of the right. In special instances, however, the reverse may obtain, as when left-sided hypertrophy is associated with or caused by general arterial degeneration. It may be of advantage to the student and junior physician to recapitulate here a few of the chief points that are prog- nostically favorable as well as those that are unfavorable : Favorable Conditions. — (1) When the hypertrophic development fully compensates the causal lesion ; (2) when the causes are removable or more or less amenable to treatment; (3) when the external conditions under which the patient lives, his habits, and general nutrition are good. Unfavor- able. — (1) When signs of imperfect nutrition of the heart arise ; (2) when evidences of advancing cardiac dilatation (dyspnea, rapid, irregular pulse, edema) show themselves; (3) when poverty, poor food, intemperate habits, and an unhygienic environment are all combined ; (4) when appar- ent cardiac vigor suddenly gives place to dilatation and great cardiac weakness. The treatment Las for its prime objects the establishment of full, and the prevention of failure of, compensation (vide Chronic Valvular Disease). Over-hyj^ertrophy, as indicated by certain cerebral and thoracic symptoms, may require the employment of measures to reduce the con- tractile energy of the left ventricle, although direct cardiac depressants (aconite, and the like) are rarely needed. It requires careful dietetic and hygienic management. Briefly, the diet should be nutritious, but the more concentrated forms of food should be used very sparingly, and the daily quantity should be slightly less than that required in health. It must be non-stimulating, and tea, coffee, alcohol in all forms, and smoking must be prohibited. The physical exercise should be moderate in amount and of the gentlest sort ; and if the patient's occupation tends to stimulate the heart, it must be immediately abandoned. A mild saline purge (^ij to 5ss — 8.0 to 16.0 — of Rochelle salts once daily) is quite beneficial. For relief of the cerebral symptoms (tinnitus aurium, vertigo, fulness) and the precordial discomfort the physiologic relaxants of the capillaries and the arterioles are of great service, particularly when arterio-sclerosis is a traceable cause. Among them nitroglycerin in full doses and veratrum viride are most useful ; the efiicacy of both may often be enhanced by the addition of the bromids. In cases of nervous origin the bromids, Avith preparations of valerian, are the most valuable agents. Nothing, however, is of higher importance than the determination and removal of the cause when possible. After compensation has failed the further treatment is identical with that of cardiac dilatation. DILATATION OF THE HEART. ^ 645 DILATATION OF THE HEART. Definition. — By dilatation of the heart is meant an enlargement of its various cavities. The -svalls of the chambers may in consequence be thinner than in health, but much more commonly they are thicker, as in dilatation -with hjijertrophy. Both hypertrophy and dilatation are rela- tive terms, but the latter has reference to that condition in which the cavities are distended out of proportion to the diameter of their walls. Varieties. — (1) Dilatation with Sypertrophy. — Here there is a pro- gressive increase in the capacity of the chambers until they attain to large dimensions. The cardiac walls continue of abnormal thickness, yet the vigor of the divisions affected may be relatively diminished to a remarkable degree, owing to the weakening influence of the degenerative processes that attack the hypertrophied muscles. In eccentric hyper- trophy the heart-cavities are dilated, but the hypertrophied cardiac walls are sufficiently vigorous to meet the demands of the circulation. This condition should not be regarded as identical with dilatation with hyper- trophy, but frequently merges into the latter, the size of the cavities now being proportionately greater than is the thickness or the functional power of their walls. (2) Dilatation with Thinning of the Heart-tvalls. — The diminution in the diameter of the cardiac muscles may be slight if the capacity of the chambers involved be only moderately increased. Instances of this sort are sometimes seen to follow prolonged fever (typhoid). On the other hand, the process of attenuation may reach a high grade, the greatly thinned cardiac wall being scarcely capable of holding the weight of the contained blood. (3) Dilatatiomoith little or no variation from tlie normal cardiac iv all has also been described by some authors. It is to be observed, however, that stretching of a cavity whose walls are of normal thickness must be attended with thinning of those walls. Pathology. — Dilatation with hypertrophy is generally secondary to valve-lesions, and affects more than one cavity as a rule. It may happen, as in advanced aortic regurgitation, that all the divisions are dilated. The right ventricle is somewhat more frequently dilated than the left, however, for reasons previously adduced. The auricles (espe- cially the left) are more frequently expanded than the ventricles ; hence of all the chambers the left ventricle is least apt to dilate. The extent of the relative increase in the capacity of the cavities is variable, and often remarkable. As an example of extreme dilatation of a chamber, the left auricle in cases of mitral stenosis may be singled out ; I have seen an instance in which this auricle was capable of containing twenty- two ounces of blood. The septum may be seen to bulge when one ven- tricle only is stretched. Extensive dilatation of the chambers produces a dilated condition of the auriculo-ventricular rings, which in turn gives rise to relative incompetency. Other cardiac orifices are found to be similarly dilated. Dombrowski ^ has drawn attention to the fact, first pointed out by Wolf, that the surface of the mitral leaflets greatly ex- ceeds the orifice, and Kirschner and Garcin contend that the anterior 1 " Functional Insufficiency of the Valves of the Left Heart," Revue de Medecine, Sept. 10, 1893. 646 DISEASES OF THE CIRCULATORY SYSTEM. flap alone suffices to close the mitral orifice, " even -when the left heart is considerably dilated." Dombrowski believes that functional incom- petency is due, in many cases, '' to muscular dilatation, producing a separation of the insertions of the papillary muscles, which in systole cannot approach each other near enough to allow the valves to close, the contraction of the papillary muscles only increasing the difficulty." Great dilatation of the left auriculo-ventricular ring is, however, prob- ably an important factor in the causation of relative mitral incompetency. The tricuspid valves, being scarcely competent, normally, are unques- tionably incompetent when that orifice is considerably dilated. The' shajye of the heart is altered according to the seat and extent of the dilatation. When all the cavities are dilated the organ assumes a globular form, while dilatation of the ventricles only produces broaden- ing of the apical region. Condition of the Endocardium and Cardiac Jliiscle. — The muscular tissue generally exhibits degenerations (fibroid, fatty, or parenchyma- tous). Important as is the part played by the ganglia in maintaining the nutritive integrity of the heart by supplying nervous force, our knowledge of the alterations that may occur in them in this condition is as yet very imperfect. Ott and others have, however, found them to be degenerated. Opacity and patchy roughening of the endocardium are common. The pa- rietes and endocardium may, however, have a normal color and structure. Ktiology. — Entering into the causation of cardiac dilatation, there are two essential factors: (1) increased endocardial tension; (2) dimin- ished resistance. These often act together. Broadbent contends that the special feature of dilatation is the imperfect emptying of the ventricles. (1) Increased Endocardial Tension. — It is to be premised that a pri- mary and a secondary form occur, the latter being of greater importance clinically than the former. Primary dilatation occurs from a recent ob- struction to the circulation of considerable magnitude and at any point throughout the blood-vessel system. A good example is afibrded by aortic constriction, in which condition the obstruction of the aortic ring engenders dilatation of the left yentricle by raising the intraventricular pressure ; this is quickly overcome by compensatory hypertrophy. In the vast majority of these instances the nutrition of the muscular fibers eventually suffers, with consequent dilatation. Angiospastic dilatation is a condition due to acute transitory spasm of the vessels (Jacob). ^ Other causes of augmented endocardial pressure have been considered in the discussion of Hypertrophy and Chronic Valvular Lesions. In eccentric hypertrophy dilatation is a compensatory arrangement, until finally the cardiac nutritive functions fail and dilatation at once predom- inates (dilatation with hypertrophy). Compensation has now been rupt- ured. Among the exciting factors that may precipitate this accident may be briefly stated — recurrent endocarditis, intercurrent febrile affec- tions which over-stimulate the heart and tend to impair its muscular tissue, general disturbances of nutrition, and, lastly, physical and mental overstrain. Acute primary dilatation may be brought about by sudden, great ex- ertion, as in ascending mountainous elevations, excessive bicycling, and the like. Under these circumstances the heart palpitates violently, and 1 Zeiischr.f. klin. Med., Feb. 4, 1899. DILATATION OF THE HEART. 647 there are epigastric pulsation and often pain in the cardiac region — evi- dences of dilatation of the right ventricle. Although in these cases the heart's reserve capacity for work has been exceeded, rest followed by quite moderate exercise often restores the conditions to the normal. I have seen acute primary dilatation produced by strong emotion; in such cases sudden contraction of the peripheral vessels occurs, attended with arrest of the heart's action ; this soon gives place to violent palpitation, and rarely to dilatation (angiospastic dilatation). Sudden fright may similarly cause acute dilatation. The remarkable endurance of the athlete and the gymnast is in part owing to the abnormal amount of physiologic cardiac reserve force which they naturally possess, but it is mainly due to the invigorating effect of training. If, however, the training be not so conducted as sym- metrically to develop the entire muscular system, or if the exertion be in excess of the reserve functional power of the heart, then acute dila- tation may suddenly arise. From this accident (cardiac fatigue) recov- ery may take place ; sometimes, however, it initiates organic valvular disease, and thus prohibits the further undertaking of unusual feats. Acute dilatation has been made conspicuous by recent contributions, in which bicycling is assigned as the cause. Apparently idiopathic cases of cardiac dilatation of indeterminate etiology rarely occur. (2) Diminished Resistance owing to Weakened Cardiac Walls. — The occurrences that weaken the cardiac wall are numerous, and not a few lead to acute primary dilatation, such as myocarditis due to acute specific fevers (scarlatina, typhoid, malaria, typhus). It is especially prone to occur in rheumatic endocarditis and pericarditis. The chronic degenerations (fatty, fibroid) impair the contractile power of the heart. Nutritional disturbances of varied origin, such as digestive disorders, ill-ventilation, lack of open-air exercise, and improper or defective food- supply, may induce enfeeblement of the cardiac muscle. Dilatation is met Avith also in diseases of the blood (chlorosis, anemia, leukemia). Clinical History. — In acute dilatation the onset is sudden. It is accompanied by such symptoms as dyspnea and cardiac palpitation (both speedily becoming aggravated), a feeling of coldness, and frequently by pain in the precordial region. The physical signs may be incontestable. They are venous pulsation in the neck, a rapid, feeble apex-beat, and a systolic murmur at the tri- cuspid valves, all of which declare the presence of tricuspid regurgita- tion. In angiospastic dilatation the pain may begin in the extremities, and the second heart-sound may be louder at the apex than the first. Among signs of subsidiary value are a venous turgescence, a marked epigastric pulsation, and a sudden extension of dulness to the right; the pulse is small, irregular, and exceedingly rapid. In the more chronic form which arises from slowly-acting causes, or in that which accompanies eccentric hypertrophy or follows simple hy- pertrophy due to left-sided heart- or lung-trouble, the manifestations that characterize the earlier stages are not at all striking. They indi- cate weak heart- walls, and such chambers expel their contents imper- fectly during systole. Hence with each subsequent diastole the abnor- mal amount of blood contained in them is increased. This blood-stasis, 648 DISEASES OF THE CIRCULATORY SYSTEM. as previously pointed out, often extends from the left heart to the pul- monary vessels, from the latter to the right heart, and finally to the general venous system. Both in the acute and chronic forms, however, failure of the right ventricle more often determines rupture of compen- sation. Obviously, the symptoms must be those of organic diseases of the heart (tricuspid incompetency in particular). Dilatation of the right heart, without tricuspid insufficiency, is a frequent complication of pulmonary tuberculosis (Maisonneuve '). Physical Signs. — Inspection in dilatation of the left ventricle shows the apex-beat to be displaced outward and downward, and a diffuse, weak, fluttering, and often distinctly undulating impulse. The apex- beat will show a greatly diminished vigor in its normal area; or there may be no recognizable point of strongest impulse as in health. Dis- tinct pulsation in the second left interspace is not rare. Its feebleness and diffuse character are confirmed by jjalpation. It may be quick and sharp, though always lacking in power. Walsh first made the capital observation — since abundantly corroborated — that the impulse may be visible, yet not palpable. There may be a mere vibration or an utter absence of the apex-beat in advanced cases. The pulse is small (rarely large), short, often rapid, and irregular. Percussion shows a lateral increase in dulness to the left, to or even beyond the mid-clavicular line, upward to the second rib, and downward as far as, though rarely below, the sixth interspace, except perhaps, in rare instances, in dilatation with hypertrophy. In emphysema the lungs unduly overlap the heart. Dilatation of the right ventricle demands separate consideration so far as the impulse and percussion-dulness are concerned. The normal impulse is largely replaced by the abnormal apex-beat of the right ven- tricle, which advances to the anterior chest-wall. The chief impulse is now seen and feebly felt, as a rule, below the xiphoid cartilage, or, less commonly, to the right or left of the latter. A wavy pulsation is seen to the left of the sternum, over the fourth, fifth, and sixth interspaces and close to its right edge. If dilatation of the right auricle be asso- ciated, as is often the case, a distinct pulsation also occurs in the third right interspace. Dulness reaches to a point 1 inch (2.5 cm.) or more beyond the right sternal border on a level with the fourth interspace. On auscultation variable results are obtained according to the state and diameter of the cardiac walls. When thin and not much disorgan- ized, the first sound is much shorter, sharper, and louder than in health. In advanced cases the systolic sounds may be feeble, though almost always audible in the aortic area (unlike the first sound in hypertrophy). The first closely resembles the second sound, the long pause being short- ened, resembling the systolic pause (^fetal heart-sounds). This form of arrhythmia is a serious indication of failure of the ventricles. The can- ter rhythm is equally common. Irregular and intermittent cardiac action are usual phenomena. Reduplication may occur, but is not frequent. Pre-existing organic murimirs obscure the sounds due to dilatation, and, on the other hand, the dilatation may also alter the murmurs (pre- viously audible), and even cause them to disappear, as, for example, in mitral stenosis. Again, dilatation may induce relative incompetency or superadd a murmur, as in cases of chronic valvular disease at the auriculo- 1 Gaz. hebdom. de Med. el de Chir., Oct. 30, 1898, No. 45 ; Ann^e, No. 87. DILATATION OF THE HEART 649 ventricular orifices. It is interesting to recall here that proper treat- ment may remove a murmur due to relative insufficiency, and that this treatment may, in turn, reproduce an organic murmur. Diagnosis. — This is made readily when there is obtainable a clear history, together with the following characteristic features : a weak, irreg- ular heart-action ; an extended, Avavy impulse ; a small, vigorless, irreg- ular, and intermittent pulse ; often an indistinct apex-beat ; an outward, upward increase in the percussion-dulness on one or both sides, causing the outline to resemble a square ; and a brief, sharp, yet feeble first sound that strikingly resembles the second, which is itself enfeebled. Differential Diagnosis. — Hypertrophy, like dilatation, gives rise to an extended area of impulse and of percussion-dulness ; hence by the care- less observer these conditions are sometimes sadly confounded. From dilatations, in which the diagnosis rests upon the points above enumer- ated, hypertrophy is to be distinguished by symptoms of an opposite nature, such as indicate increased energy on the part of the heart. The latter are — a slow, heaving impulse ; a full, sustained, regular pulse ; an increase in the area of dulness, chiefly outward and doAvnward ; abnor- mal position of the apex-beat ; and the prolonged, dull first and accen- tuated second sounds. To determine the point at which eccentric hyper- trophy ends and dilatation (with hypertrophy) begins is often difficult ; but a careful discrimination must be attempted, and I have already dis- cussed the ushering-in symptoms of dilatation following hypertrophy (chiefly of the right ventricle) in connection with Chronic Valvular Disease. Occurring in left ventricle hypertrophy, dilatation first be- trays itself by a change in the position of the visible apex-beat and the palpable impulse. Thus, the maximum point of the apex-beat of hyper- trophy very early becomes rounded and indefinite, and later is diffuse and wavy. The strong, heaving thrust of the impulse gives place to the shorter, more sudden shock of commencing dilatation, indicating weak- ness. These signs, together with a reduction in the strength and an in- creased frequency or irregularity of the pulse, show the condition to be dilatation with hypertrophy. The prognosis is bad, as a rule, and may be said to be that of the causative factors. Treatment. — This in all essential particulars is identical with the treatment of organic heart-affections after rupture of compensation. The etiology in many cases differs from that of the organic valvular affections of the heart ; and next to rest and the use of cardiac stimulants, the re- moval of the remote and near causes of the dilatation is the most im- portant part of the treatment. Individual cases frequently present special indications ; but in all the work of the heart is increased and the propulsive power of the organ diminished. In cases of non-valvu- lar origin digitalis and other heart-stimulants may be omitted early, as a rule ; though they should be resumed if there be a recurrence of seri- ous indications of dilatation. When the dilatation has been overcome careful attention is to be bestowed upon all the details of the patient's life and sanitary surroundings in order to force his bodily nutrition to the highest point. Every precautionary measure having for its aim the prevention of a recurrence of the dilatation must also be advised and enjoined. 650 DISEASES OF THE CIRCULATORY SYSTEM. MYOCARDITIS. [Carditis.) Definition. — An inflammation of the muscle-substance of the heart. It may be acute or chronic. ACUTE MYOCARDITIS. Pathology and Varieties. — (1) Acute Parenchymatous Myocarditis. — This is characterized by a granular degeneration of the muscular fibers of the parenchyma of the organ, with a numerical increase in their nu- clei. The muscle-structure throughout looks pale, is turbid, and very soft. Many cases of a severe type terminate in fiitty degeneration. (2) Acute Diffuse Interstitial Myocarditis. — Here the primary altera- tions affect the connective tissue of the myocardium ; the histologic changes consist in round-cell infiltration. (3) Acute Circumscribed Myocarditis. — In this variety the degenerative processes result in necrosis of the tissues over large or small areas, with abscess-formation. Though usually multiple, these abscesses vary con- siderably in number, and may rupture either into the various cardiac chambers or into the pericardium. Thus, the purulent contents of the abscess, Avhen there is established a fistulous communication with an endocardial chamber, find their way into the blood-stream and are con- veyed to all parts of the arterial system, frequently setting up, here and there, embolic processes of an infectious nature. The blood in turn enters the abscess-cavity, exerting pressure on the walls, and may either produce an acute aneurysmal dilatation of the heart-wall or occasion fatal rupture into the pericardium. More frequently, perhaps, the con- nective-tissue wall of the abscess yields gradualh* during the ventricular diastole, when the cardiac aneurysm is formed Avith corresponding slow- ness. Occurring in the vicinity of one of the auriculo-ventricular valves, abscesses may cause mitral or tricuspid incompetency. Owing to their tendency to burrow, they may perforate the interventricular septum, thus creating a fistulous connection between the two sides of the heart, and resulting in an intermingling of venous and arterial blood. The abscess may become encysted, then caseous, and finally undergoes a calcareous process. Btiology. — The causes of myocarditis are — [a) endo- and pericar- ditis in the course of rheumatism : it is probable that rheumatic myo- carditis may also exist Avithout involvement of the endo- or pericardium ; {It) the infectious processes in acute specific fevers ; (r) infectious emboli, lodging in the branches of the coronary arteries in connection with sep- ticemia, pyemia, and acute ulcerative endocarditis, and commonly termi- nating in abscesses (circumscribed myocarditis). The first two of these causes give rise to acute diff"use interstitial and acute parenchymatous myocarditis as a rule, although Freund calls attention to the frequency with which circumscribed myocarditis is associated with rheumatism and diseases of the joints. As compared with the female sex. the male suffers much more frequently. Symptoms and Diagnosis. — The symptoms are practically nega- tive. They point merely to great cardiac enfeeblement. When cardiac CHRONIC MYOCARDITIS. 651 weakness, as shown by a rapid, small, compressible, and irregular pulse, and by attacks of cardiac palpitation and syncope, comes on suddenly in the course of rheumatism, septicemia, or other causal affections, myo- carditis may be suspected. Later, signs of venous stasis appear. The mental symptoms may suggest meningitis or salicylic-acid poisoning. The physical signs simulate those of dilatation, and may, indeed, be largely dependent upon the presence of the latter condition. Early the action of the heart is tumultuous ; the sounds on auscultation are short, sharp, and finally very feeble. Murmurs in myocarditis are not rare, and are not necessarily dependent upon dilatation. Kiehl's work shows the dependence of the valves for their complete closure upon a normal state of different portions of the heart-muscles, and thus explains these mur- murs. The special conditions rendering the murmurs audible are great dilatation, softening of the papillary muscle, and abscesses near the valves. The recognition of cardiac aneurysm is made possible by the manner of increase in the percussion-dulness (upward and toward the left) with coextensive pulsati n. The symptoms of visceral or cutaneous embolic processes, combined with a murmur and a septic type of fever, are sus- picious of the existence of circumscribed myocarditis. Their great variability as to presence or absence is an important point, especially in the diagnosis from murmurs due to endocardial changes. The latter usually coexist with an accentuated pulmonary second sound, which in the myocardial murmurs do not appear, owing to weakness of the right heart. The diagnosis of acute myocarditis embraces the elimination of endo- carditis and pericarditis. Prognosis. — The diffuse forms are fatal ; the circumscribed form may, however, end in recovery. Myocarditis may end life suddenly. The treatment is identical with that indicated for endocarditis and pericarditis — diseases of which myocarditis is often a complication. The effects of digitalis, particularly when myocarditis supervenes upon old heart-lesions, are quite unsatisfactory. When myocarditis is suspected as an independent condition absolute rest must be enjoined, the general nutrition maintained, and the more urgent symptoms relieved. CHRONIC MYOCARDITIS. [Fibrous Myocarditis.) Definition. — A gradually developing inflammation of the cardiac interstitial connective tissue, resulting in induration. Pathology. — The characteristic changes may be diffuse, though most frequently they are confined to certain portions of the muscular structure, the left ventricular wall, the septum, and the papillary muscles being the three favorite seats of the process. This is sometimes of ante- natal development, and then its usual seat is near the apex of the right ventricle. The hardened spots take the form of more or less rounded patches or broad lines. In color they are gray, grayish-Avhite, or gray- ish-yelloAV, the latter tint being due to the intermingling of fibers'that have undergone fatty degeneration. Their size is ex'ceedingly variable, some being so minute as to elude detection by the unaided'eye, while others measure 1 or 2 inches (2.5-5 cm.) in diameter. Inflamma- tory induration (contraction, of the conus arteriosus of either ventricle causes narrowing of the pulmonary and aortic orifices, with the usual 652 DISEASES OF THE CIRCULATORY SYSTEM. signs and S3miptoms. Similar changes, by disturbing the functions of the papillary muscles, produce valvular incompetency. Compensatory hypertrophy of the uninvolved portion of the heart is also observed, both the size and weight of the organ thus being increased ; the hyper- trophic enlargement may frequently be accounted for in part by an associated chronic endocarditis. Sometimes, however, the hypertrophy is occasioned mainly by general arterial sclerosis. Dilatation of the ventricles follows, with fresh and grave disturbances of the circulation. Chronic inflammation usually attacks early the intima of the coro- nary arteries, and leads to thrombosis, with the formation of anemic infarcts that subsequently undergo sclerotic changes in the muscle- structure. It is probable that most cases of localized fibrous myocar- ditis have their origin in an obliterating endarteritis. Pasquier offers proof that fibroid myocarditis results from chronic congestion due to stopping of the vessels. The calloused zone may yield to the endocar- dial blood-tension, and thus slowly produce saccular dilatation (aneur- ysm). Microscopiealli/, the affection is characterized by hyperplasia of the interfibrillar connective tissue with subsequent development of new fibrous tissue. Fatty degeneration and atrophy of the muscle-fibers (the latter in consef[uence of compression) are also observed. Fragmentation of the muscle-fibers has also been observed. This occurs as 2b postmortem change, and is due to a softening of the interfibrillar substance (the etat segmentaire of Renant). !^tiology. — The disease is most commonly traceable to the action of one or more of the following factors : an excess in the use of alcohol or tobacco, lead-poisoning, gout, rheumatism, diabetes, chronic nephritis, malaria, and syp>hilis. Thus, it may be produced by many infections and chemical irritants, the latter, in most cases, first causing a sclerosis of the coronary arteries, to Avhich the patchy fibroid degeneration is secondary. Some of the causes of acute diffuse interstitial myocarditis may by their more slightly irritant effect (owing to the minuteness of the dose of the specific poison) lead to the subsequent development of the general chronic form (e. g. rheumatism). Certain irritants that usu- ally engender localized lesions of chronic myocarditis may also affect the entire myocardium '(syphilis, alcohol, gout). Chronic myocarditis may arise in consequence of a direct extension of the infective inflam- matory processes in chronic endo- and pericarditis ; it may also follow injuries of the antero-lateral thoracic region. Sex and age possess a predisposing effect, the disease being more common in males than in fe- males, and after middle life than before that period. The right ventricle is apt to be the seat of chronic myocarditis during fetal life, if at all. Symptoms. — Extensive indurated myocarditis has been met with jjost mortem in numerous instances that have been unattended by per- ceptible symptoms during life. In many of these cases the presence of compensatory hypertrophy accounts for the absence of any symptoms, and it may, therefore, be inferred that mild grades that fail to manifest themselves must frequently exist. The symptoms when present are, almost without exception, untrustworthy for diagnostic purposes, since they bear a striking resemblance to those of the organic valvular dis- eases, minus their more characteristic physical signs. Among the earliest phenomena that point merely to failing heart-power are dys- CHRONIC MYOCARDITIS. 653 pnea, and sometimes also, on exertion, palpitation and a sense of heavi- ness or constriction in the precordia. The patient suffers from marked general debility, and becomes fatigued in consequence of the slightest physical exertion. Me^ital inertia is the rule, and chronic mania may come on and last to the close. Later, more positive disturbances of the circulation gradually arise, and when the breathing becomes more diffi- cult {cardiac asthma) signs of venous stasis affecting the liver, gastro- intestinal tract, and kidneys, and edema finally appear. Two symptoms that are frequently manifested, and not without some diagnostic import, remain to be mentioned : (1) Angiiia pectoris, which is attributable to the sclerosed condition of the coronary arteries. ( Vide Symptoms of Angina Pectoris, p. 672.) It is often followed by some form of arrhythmia. Cases occasionally occur in which recurring paroxysms of angina pectoris, with or without arrhythmia, are the only phenomena of the disease. (2) Qardiac Arrhythmia.— ^vdichjciix^idi is associated as a rule, there being a reduction in the pulse-rate to 50 or even 40 beats per minute. With this decreased rate intermittency is often combined, and various other forms of disturbed rhythm are also observed, though they are less frequent and less significant. Slowing of the pulse does not, howevei', prohibit the cardiac palpitation that is especially apt to arise during ano'inal attacks. Disturbance of the rhvthm may, on the other hand, be entirely absent. Th.Q pulse is slow, irregular, and of low tension if cardiac atrophy be present. Should fatty degeneration be conjoined, the pulse may be quickened and irregular, and this effect likewise obtains when the patient escapes sudden death and the usual dilatation supervenes. Chronic myocarditis may be the sole cause of the pseudo-apoplectic seizures that often terminate life abruptly. Preceding the unexpected attack the patient, usually advanced in life, may have experienced from time to time slight vertigo, syncope, and oppression. These seizures may also be caused by a heavy meal or intense mental or physical exertion, and may consist in a momentary loss of consciousness, paralytic symp- toms then being usually absent. At other times they last a number of hours, and are accompanied by paralysis which outlasts the coma, as a rule, by a few hours only. Convulsive twitchings may be present. During the attack cerebral hemorrhage occurs, and may leave the patient hemiplegic. It is highly characteristic of these pseudo-apoplectic seiz- ures that they tend to recur, sometimes at intervals of a few hours for a day or two, but more commonly at longer intervals during many weeks or months. Physical Signs. — The impulse may be feebly heaving (sometimes ab- sent) ; the apex-beat is displaced downward and to the left, while the dull area is enlarged correspondingly in the same direction. Quite early the heart-sounds may be clear and strong, but subsequently they become weak and muffled. A contraction of the papillary muscles and of the chordae tendine^e may cause mitral incompetency Avith its customary murmur. With the occurrence of dilatation also comes an apical, systolic mur- mur (dite to relative incompetency), with a gallop rhythm of the heart. DiflFerential Diagnosis. — (1) Chronic valvidar disease can, as a 654 DISEASES OF THE CIRCULATORY SYSTEM. rule. Ije eliminated prior to the occurrence of secondary dilatation. During this period murmurs do not occur unless the valvular adnexa (the chordne and papillary muscles) are affected. In the latter event the secondary alterations in the heart, the symptoms, and whole course of the complaint are the same as in certain chronic valvular lesions. (2) Hypertrophy and Dilatation. — In chronic myocarditis hyper- trophy does not usually reach as high a grade of development as in the majority of the organic valvular complaints and other causal conditions. But after the occurrence of dilatation, following indurated myocarditis, the differential diagnosis between the latter and eccentric hypertrophy is purely conjectural. (3) Fatty overgrowth must be distinguished from fibrous myocarditis, and is met with chiefly in brewers, publicans, and butlers. The disease is also found to be specially related to obesity, and sometimes to over- eatino' and drinkincr, combined with indolent habits. These subjects suffer more frequently from bronchitis, emphysema, and nocturnal asthma than patients having chronic m^'ocarditis alone. Slight vertigo is com- mon, but true syncopal attacks are rare, according to my observation. In fatty overgrowth the heart-sounds are weak and decidedly muffled throughout ; the pulse is weak, though regular as a rule. Marked obesity, liowever. often obscures the local signs. Prognosis. — Chronic myocarditis is a fatal disease. Its course and duration, however, are subject to great variations. Among unfavorable surroundings are certain causal and associated conditions, particularly arterio-sclerosis, chronic interstitial nephritis, and diabetes mellitus. On the other hand, if syphilis has been the cause, hope for temporary improve- ment, if not for actual cure, may be reasonably entertained. Sudden death ma\- result from a blocking of a vessel that is the seat of sclerosis. Treatment. — The treatment should be managed according to the considerations pointed out in the treatment of Organic Valvular Dis- ease. Rest of body and mind is imperative. Next to this come the dietetic and hygienic details. Residence in a mild climate in winter and a change to the country or to a moderate elevation in summer are matters of the greatest moment to the Avelfare of the patient. Those rather frequent cases that present, among other complications, such closely united conditions as arterio-sclerosis, gout, and chronic nephritis sometimes do well while sojourning at certain mineral springs, such as Marienbad, Carlsbad, Kissengen abroad, and Bedford or Saratoga at home. These waters must, however, be cautiously used. When dilatation arises cardiac stimulants are called for, but must be used with an unusual degree of caution. Strychnin has proved itself to be valuable if perseveringly exhibited, and here, as elsewhere, digi- talis deserves a trial ; its careless administration, however, may give bad results if the pulse be much retarded or arterio-sclerosis coexist. For the angina pectoris morphin, administered hypodermically, is to be pre- ferred. Recurrences of this distressing symptom may be averted by the cautious use of nitroglycerin, the use of which should, however, be limited to cases that seem to be dependent upon arterial degeneration with high tension. Attacks of syncope are most successfully met by the hypodermic use of the diffusible stimulants (ammonia, ether), and at the same time by putting the patient at rest with the head lowered. DISEASES OF THE CORONARY ARTERIES. 655 DISEASES OF THE CORONARY ARTERIES. It has previoxisly been noted that in pyemia and allied disorders septic emboli may block the branches of the coronary arteries, causing suppurative infarcts (acute circumscribed myocarditis). It has also been shown that one of the chief effects of sclerosis affect- ing the coronary arteries is the production of chronic myocarditis. Sudden blocking of one coronary artery by an embolus causes instant death. In numerous instances in which death has occurred suddenly either thrombotic or embolic obstruction has been the only discoverable 'post-mortem lesion. In others the pathologic evidences of local or general atheroma have coexisted. Ligation or plugging of the coronary vessels in the lower animals causes arrhythmia or even an abrupt arrest of cardiac action ; a partial or even slight reduction in the lumen of the coronary vessels by diminishing the supply of blood to the heart-muscle induces degenerations in the latter. Kronecker found that occlusion of the coronary arteries by injecting paraffin caused the heart to become irregular, even when it solidified in only the smaller branches, and stopped almost at once. The anatomic peculiarity of the coronary arteries in that they are end-arteries is to be noted, since it affords a ready interpretation of the usual effects following total or partial occlu- sion. According to F. H. Pratt, however, the vessels of Thebesius, which extend from the auricles and ventricles to the myocardial capil- laries and coronary veins, may rarely maintain the nutrition of the heart-muscles even after occlusion of the coronary arteries. The blocking of the terminal branches by emboli or by the more gradual formation of thrombi usually produces the so-called anemic necrosis or ivhite infarct — a condition that richly deserves brief descrip- tion : Anemic necrosis {anemic infarct) is met with most frequently in the left ventricle and septum, which receive their blood from the ante- rior coronary artery. The involved areas are small and circumscribed, and present irregular margins that project slightly above the surface. Rarely the infarct is wedge-shaped. Its color is grayish-white or gray- ish-red, while the central portion is often distinctly white and firm ; less frequently it breaks down into a soft detrital mass {myomalacia cordis). When softening does not occur the fibers in the affected area lose their nuclei, becoming first hyaline and subsequently sclerotic. The chief histologic changes are of two sorts : {a) the striae of the muscle-fibers are lost, the latter becoming granular and breaking down ; and (5) the fibers assume a homogeneous hyaline appearance, the nuclei havino- dis- appeared. The symptomatic consequences of the lesions are often obscure and unreliable. Sudden death may take place, and rarely this accident may be due to rupture of the heart. Weak and irregular action of the heart, evidences of embarrassed circulation (especially in the cardio- pulmonary circuit, as shown by cough and dyspnea), and finally an- gina pectoris, are among the principal features observed. Death may ensue in the first attack. The paroxysms are presumed to be due to sudden occlusion of a branch of the coronary artery ; but it should be 656 DISEASES OF THE CIRCULATORY SYSTE3f. stated that occasionally in fatal instances of true angina pectoris a total absence of lesions, including emboli, has been noted. I desire to lay stress upon the medico-legal importance of coronary disease ; it may be the only lesion found in cases of quick death. DEGENERATIONS OF THE HEART. (a) Fatty. — The terra '• fatty heart " includes two pathologically dis- tinct aflFections : (1) Fatty degeneration, in which the cardiac muscle- fibers have been converted into fat; and (2) Fatty overgrowth, in which an abnormal (juantity of fat is deposited in and about the heart. FATTY DEFENERATION, Pathology. — The condition may be either general or localized. Its most frequent seat is in the left ventricle, the papillary muscles and trabeculifi, first appearing as yellowish spots or stripes beneath the en- docardium. The affected portions are light yellow or yellow'ish-brown (faded leaf) in color, due to an associated brown atrophy ; they are also soft and friable, and are easily lacerated. The heart is enlarged, and often decidedly so if the process be general, and its walls lack firmness. The microscope reveals characteristic changes : the strife and nuclei begin to fade, oil-drops and granules appear in the fibers, and finally the latter are occupied throughout by minute globules. Ktiology. — Fatty degeneration has already been mentioned as occurring in both the primary and secondari/ forms of cardiac hyper- trovhy. It is found also in association with fatty change in other oro-ans in severe forms of primary and secondary anemias. It is most commonly encountered, however, in the cachectic states produced by such chronic diseases as carcinoma and phthisis, and in the course of acute infectious diseases of intense type, all of which may produce the condition. In poisoning by arsenic and phosphorus and in pernicious anemia it advances to a high grade. The various lesions of the coronary arteries previously considered bear a marked causal relation. Predisposing causes are — {a) age — it being most common after forty years of age ; {b) sex — it occurs somewhat more frequently in men than in women, notwithstanding the fact that there are predisposing influ- ences at Avork in the latter that do not obtain in the male sex, such as childbirth and amenorrhea ; and, lastly, (c) Avhatever may be its apparent etiology, it is invariably preceded by a defective nutritive supply to the muscle-cells : this may be dependent upon a narrowing of the lumen of the coronary vessels, or upon impairment of the oxygen-carrying power of the blood, as in the anemias. An excessive supply of glucose, gly- cogen, and nuclein may be a factor. Symptoms. — The disease may exist in an advanced form w^ithout noticeable symptoms, though the conditions under which it is most liable to occur afford secure ground for suspicion. The evidences of cardiac FATTY BEQENEBATION OF THE HEART. 657 enfeeblement are usually present, but in pernicious anemia the pulse may even be full and regular. Dilatation is apt to supervene early, owing to the weakened state of the heart ; and hence it is probable that many of the symptoms that have been ascribed to the fatty changes are in reality due to secondary dilatation. Among these are palpitation, dyspnea, a small, irregular^ and somewhat quickened pulse, and cool and clammy extremities. The heart-sounds are weak, as a rule, and the action of the heart often irregular ; later the physical signs of dilatation are almost invariably present. Dropsy, however, is rare in uncomplicated cases. Sometimes sudden, great physical exertion produces equally sudden dilatation, whereupon a canter rhythm and an apical systolic murmur speedily develop. In most instances, however, the symptoms are more gradually brought to light. BreatJilessness on exertion is often a striking feature, and syncopal attacks are sometimes troublesome. The^w^s^, in conse- quence of irritation of the inhibitory center in the medulla, often be- comes greatly retarded, dropping from the normal rate to 30 or 40 beats per minute, and, in rare cases, to 10 or 12 beats. The fatty arcus, senilis is devoid of diagnostic value. There are frequent attacks of cardiac asthma in the mornings, and these are apt to be accompanied at intervals by angina p>ectoris. Disturbance of the intellect, sometimes taking the form of maniacal delusions, may come on and persist. Syncopal attacks occur. Pseudo-apoplectic attacks, such as have been described (vide Chronic Myocarditis), are also concomitants that point to disturbance of the cerebral circulation. Cheyne-Stokes breathing is among the later manifestations, and I have noticed that these symptoms often occur together. Epileptiform attacks resembling p>etit mal maj arise. The diagnosis is sadly obscure. The history, the age of the patient, and the symptoms of cardiac weakness and subsequent dilatation, together with retardation of the pulse, apoplectic attacks, and Cheyne- Stokes breathing, in the absence of precedent hypertrophy merely justify a probable diagnosis. With a clear history and the 'presence of the more significant symptoms, including the signs of dilatation following hypertrophy, fatty changes may be inferred with some de- gree of assurance, although a positive statement of opinion should be withheld. The prognosis is as varied as the etiology. Death may come quickly, though oftener the end is reached in a gradual manner, the signs and symptoms of advanced dilatation dominating the closino- scene. Treatment. — The cause in each individual case should be deter- mined with as much precision as possible, and when ascertained a bold attempt should be made to remove it. This course often places the patient in the most favorable position for the successful treatment of the cardiac condition ; and the method embraces many hygienic and dietetic considerations that assist in improving the nutrition of the cardiac tissue — one of the cardinal aims of a proper system of treatment. An- emia in one form or other plays an important role in the majority of the cases, and the particular variety present in each instance must deter- mine the character of the remedies to be employed. In that laro-e cate- 42 658 DISEASES OF THE CIRCULATORY SYSTEM. gorv of cases occurring in certain cachexias (cancerous, tuberculous) the folloAving formula has given gratifying results : ^. Acidi arsenosi, gr. j (0.0648) ; Ferri sulph. exsic, gr. xxx (2.0); Strychninte sulph., gr. j (0.0648); Quininte sulph., 3j (■^•'-*)5 Papoid, gr. xxx (2.0). M. et ft. capsular No. xxx. Sig. One after meal-time, t. i. d. A frequent, irregular pulse and other signs of cardiac failure indicate commencing dilatation, and under these circumstances digitalis should be employed in small doses. When used with perseverance it is of the greatest service, and in the form of the poAvder or the aqueous extract it may be conveniently combined with the above prescription. I believe that gentle indulgence in physical exercise and light gym- nastics is beneficial, since it tends to invigorate the heart-muscle ; it is to be increased in proportion to the manifest improvement in the patient's condition. It sometimes happens, however, that even gentle exercise is badly borne, and it should then be discontinued. Kinesi- therapy. particularly the milder Swedish method of gymnastic exercises (alternating movements of resistance), increases the contractile power of the heart and at the same time lessens the peripheral resistan ;e, and should be accorded a careful trial. I have been in the habit of advising daily inhalations of oxygen gas in this class of cases with good results. Recourse to massage is also in the line of sound practice, but the sittings should not exceed half an hour in duration at the start. The more p)-o)nini')it si/)nptom>< may require special measures. The syncopal and anginal attacks are to be handled in the manner indicated for the same symptoms in chronic myocarditis. For the pseudo-apoplectic attacks rest in the recumbent posture, with the head slightly elevated, is use- ful. Therapeutic agents, as digitalis, ammonia, and ether, may be used hypodermically to stimulate the heart ; it is also good practice to withdraw from 12 to 24 ounces (355.0-710.0) of blood directly from a vein. If the arteries be hard and tense, nitroglycerin is of distinct service. A strictly horizontal posture and the application of ice to the pre- cordial region often quickly terminate the attacks of cardiac asthma, and spartein sulphate, with nitroglycerin, is worthy of a trial. Hot toddy and other diifusible stimulants are valuable adjuvants. Should these remedies fail, hypodermic treatment by morphin is to be adopted. FATTY OVERGROWTH. Pathology. — The characteristic change consists in a marked in- crease in the normal f\\t, particularly in the auriculo-ventricular fur- rows. This over-production of fat takes place to a greater or lesser extent in every obese person, and may become so excessive as to form a complete enveloping mantle measuring an inch or more in thickness. In these extreme grades the muscular fibers of the organ may, from too great pressure, undergo atrophy and thus become weakened. Dilatation FATTY OVERGROWTH OF THE HEART. 659 often supervenes, and the principal symptoms date from the time of its occurrence. In the cachexias of carcinoma and phthisis, and the general atrophy of old age, fatty overgrowth and fatty degeneration coexist. The diagnosis rests upon the combined presence of marked obesity and cardiac enfeeblement. (For the etiology and differential diagnosis, see p. 654.) Treatment. — I wish to advocate warmly the system of treatment introduced by Oertel, as I have seen excellent results from its employ- ment. It should not be resorted to in chronic valvular disease, in the stage of broken compensation, nor in marked atheroma. Oertel's method comprises three parts : (1) The reduction of the amount of liquid taken with the meals and during the intervals, the total for each day being 36 ounces (1064.0). Frequent bathing (includ- ing the Turkish bath in suitable instances) and pilocarpin are employed to promote free diaphoresis. (2) The diet is composed largely of proteids, as follows : Morning. — A cup of coffee or tea, with a little milk — about 6 ounces (178.0) alto- gether ; bread, 3 ounces (98.0). iVoon.— Three to 4 ounces (90.0-120.0) of soup ; 7 to 8 ounces (218.0- 248.0) of roast beef, veal, game, or poultry, salad or a light vegetable, a little fish; 1 ounce (32.0) of bread or farinaceous pudding; 3 to 6 ounces (93.0—186.0) of fruit for dessert. No liquids at this meal, as a rule, but in hot weather 6 ounces (178.0) of light wine may be taken. Afternoon. — Six ounces (178.0) of coffee or tea, with as much water. An ounce of bread as an indulgence. Evening. — One or two soft-boiled eggs, 1 ounce (32.0) of bread, per- haps a small slice of cheese, salad, and fruit ; 6 to 8 ounces (178.0— 236.0) of wine, with 4 or 5 ounces (120:0-148.0) of water (Yeo). (3) Graduated exercise up inclines of various grades. The distance to be undertaken each day is to be carefully specified and frequently, though gradually, increased. A like plan is to be pursued with refer- ence to the degree of inclination. This is the most important part of the system, since it directly invigorates the heart-muscles. (h) Brown Atrophy. — A form of degeneration in Avhich accumulations of yellowish-brown pigment-granules occur in the muscular fibers. The color exhibited by the heart-muscle is a reddish-brown, and in pro- nounced cases a dark-red brown. Brown atrophy is most commonly seen in the hearts of the aged, though also quite often in cases of chronic valvular disease that have reached an advanced period before the time of the fatal issue. {c) Calcareous Degeneration {Calcification). — Calcareous infiltration of the muscular fibers of the myocardium has been noted, though very rarely. Somewhat more common are the bony callosities that result from the inspissation and calcification of the purulent contents of former myocardial abscesses (vide Circumscribed Myocarditis). {d) Amyloid Degeneration. — This form of degeneration is rarely met with. It is limited to the blood-vessels and interstitial connective tis- sue, the muscular fibers escaping, and its causes are the same as those of amyloid degeneration of other viscera. 660 DISEASES OF THE CIRCULATORY SYSTEM. (e) Hyaline Degeneration. — This is sometimes seen in association with amyloid change. It also occurs independently in prolonged fevers (hi/aline transformation of Zenker). The fibers are swollen, translu- cent, and homogeneous, and their strife almost entirely disappear. CARDIAC ANEURYSM. {Aneurysm of the Heart.) A CARDIAC aneurysm may, in the first place, involve the whole diameter of the myocardium (aneurysm of the walls).^ Secondly, it may merely implicate the valves, together with a few myocardial fibers (valvular aneurysm). Aneurysm of the Walls. — This is not of fre([uent occurrence. Its most common seat, however, is the wall of the left ventricle near the apex ; it is quite generally a sequel to chronic myocarditis, which, as before stated, occurs oftenest at this point. Anything that produces a decided localized weakness of the ventricular parietes (other forms of degeneration and endocardial and pericardial inflammations) may, how- ever, lead to its development. In size cardiac aneurysms are exceed- ingly variable, and may either be very small, or as large as the average- sized head of an adult. As to form, two types should be recognized : {a) an equable dilatation of a part of the ventricular wall, and (h) the sacculated form, which communicates with the chamber by a compar- atively small orifice. Layers of fibrin are often found in these aneur- ysmal dilatations as an indication of Natures attempt at a cure, and occasionally they may completely efface the sac when the attempt is successful. In most aneurysms non-laminated blood-clots are also found. It must not be forgotten that, once an aneurysmal distention has begun, a straining effort may cause a .sudden great increase of the dimensions or even rupture it. The structures adjacent to the gradu- ally formed aneurysm exhibit fibroid overgrowth and other kinds of degeneration, these changes being secondary and most probably con- servative processes. Diagnosis. — Aneurysm of the myocardium has no characteristic features. Usually the symptoms and local signs of chronic myocarditis or dilatation are more or less conspicuous, but the presence of the aneurysm is not even suspected unless certain physical signs develop in the course of the former complaints. These are — a pulsating prom- inence in the apex-region that may even perforate the chest-wall, and a coextensive dulness. The abnormal area of dulness is best appreciated early by stethoscopic percussion, but unless peculiarly circumscribe?(7«Y/s sicca); (er rectum and are detected in the stools. In cases that arise from the action of irri- tant poisons vomiting and purging are well marked and the dejections contain blood-stained mucus. We cannot be certain about the presence of croupous deposits in toxic cases unless they be found in the dis- charges. When phlegmonous enteritis occurs as a complicating condi- tion in infectious diseases, the symptoms are almost completely veiled. The symptomatology of the follicular variety cannot be separated clini- cally from that of follicular ulceration. The treatment is that of the indications presented by the causal conditions or affections in the course of which it occurs. CHOLERA MORBUS. {Cholera Nostras.) Definition. — A self-limiting disease, characterized by a brief course and by serous vomiting and purging, colicky pains, and often muscular cramps. Pathology. — No constant anatomic changes have been noted. So far as observed, they are analogous to those seen in acute gastro-enteri- tis, though cases have terminated fatally in which no morbid lesions were detectable at the postmortem examination. Ktiology. — Among predisposing causes, the age and the season exert the most prominent influence. The condition may appear in sub- jects under two years, when the term " cholera infantum " is employed/ though it is more often met Avith in older children and adults. It is almost invariably seen during the heated term, from the latter part of June to September, being rarely met with at other seasons, and it is especially prevalent during the month of August. Bad hygienic environments, foul air in particular, have a noticeable effect, and, though not as yet absolutely proved, it may be safely inferred from the clinical history and the usual course of the affection that it is of microbic origin. Among other factors are improper food, particularly unripe fruit, cucum- bers, egg-plant, and exposure to cold and wet. Various . organisms (especially the Finkler and Prior spirillum) have been found present. No one variety, however, has been definitely found to be the cause of the condition. Virulent specimens of the bacillus coli communis, and even of the streptococcus, have been noted. Clinical History.— The symptoms are those of an intense gastro- enteric catarrh. The onset is often sudden, and is marked by abdominal pain, vomiting, and diarrhea. At first the vomitus consists of food, and later of a mixture of bile and mucus. The dejections are fecal in char- acter at the onset ; though they soon become watery, and may resemble the rice-water stools of Asiatic cholera. ' This affection is described sepai-ately (vide p. 800). CHOLERA MORBUS. 807 * Physical examination reveals only tenderness on pressure over the abdomen, particularly the epigastric region. General symptoms are not wanting. Cramps in the calves are com- mon. The thermometer mav register a high temperature, though it varies greatly, ranging from 100° to 106° F. (37.7° to 41.1° C). The skin-surface, however, and more particularly that of the extremities, feels cool, and owing to this fact the rectal temperature should be re- corded. The pulse, as the case progresses, becomes rapid and feeble. The face is pale or even cyanotic, the features looking pinched. The extremities lose their plumpness, and the patient usually appears pros- trated and mentally dull. The urine is apt to be scant, high-colored, and sometimes albuminous, and thirst is extreme. Often the picture of general collapse is soon developed. Differential Diagnosis. — The symptoms of cholera morbus re- semble so closely those of Asiatic cholera as to preclude the possibility of a diiferential diagnosis. The dissimilarity between these affections lies partly in the fact that no connection can be established between iso- lated cases of cholera morbus and cases of true Asiatic chlorea when the latter disease is not epidemic. A bacteriologic examination of the stools alone, however, permits a certain discrimination. During a cholera epidemic the distinction between them is made without difficulty (see Diagnosis of Asiatic Cholera). Prognosis and Duration. — The duration of the disease varies from three or four hours to two days. It is rarely fatal, though in persons suffering from such chronic affections as Bright's or cardiac disease, and also in the aged, the prognosis is only guardedly favorable. It is said to be more unfavorable when cholera and dysentery prevail (Loomis). A pronounced algid state should not be looked upon as free from danger. I remember two cases attended with profound collapse that recovered, but in which a condition of marked neurasthenia, indigestion, and func- tional heart-disturbance formed a series of sequelae that lasted for several months. Nearly all cases, however, recover without sequelae. Treatment. — The diet must be rigorously restricted, and predi- gested milk and animal broths are to be prepared as lightly as possible until convalescence has been faii'ly entered upon. The comfort of the patient, as w'ell as the cure of the disease, is much enhanced by keeping the patient at absolute rest. Local measures are useful in combating pain and vomiting. A large mustard-paste applied to the stomach and abdomen, followed by linseed-poultices that are to be worn constantly, has a strong influence in accomplishing the relief of the symptoms before mentioned. If indigestible substances have been taken prior to the attack, prompt though mild laxatives are to be given at the begin- ning of the treatment. For the excessive thirst chipped ice, over which a little brandy has been sprinkled, is effective. For controlling the pain, the nausea, and the diarrhea in this disease we have a remedy par excellence in the hypodermic administration of morphin. The dose should vary (gr. ^ to J — 0.016 to 0.032) according to the severity of the symptoms, and I have rarely found it necessary to give a second dose. Not only are the pain and diarrhea subdued, but the peripheral circulation is also re-established. It has also been recommended to ad- minister opium by the mouth for these symptoms in the form of the solid extract or laudanum, but the results are infinitely more brilliant 808 DISEASES OF THE DIGESTIVE SYSTEM. when the drug is employed subcutaneously. The other points in tne treatment of this affection are identical Avith those discussed under the treatment of Gastric and Enteric Catarrh. INTESTINAL INFARCTION. A FEW instances of occlusion of the superior mesenteric artery by an embolus have been recorded recently. The condition produces hemor- rhagic infarction of the small intestines, and is marked by grave and usually fatal symptoms. Its causes are sometimes obscure. The cases that have come to autopsy have shown intense congestion, Avith a swollen, blood-infiltrated state of the jejunum and ileum. Osier has seen three instances : in one there were numerous vegetations on the mitral valves from which the embolus was probably derived ; in another the superior mesentery was plugged at its orifice ; and in the third the artery was blocked by a portion of the fibrous clot of an aneurysm of the aorta near the diaphragm. The symptoms are urgent. Quite often diarrhea is present from the first, the dejections sometimes becoming blood-tinged. Soon, however the characteristically grave symptoms of intestinal obstruction supervene — viz. great pain, vomiting, and consti- pation, with excessive tympanitic distention of the abdomen. The con- dition cannot be recognized from the symptoms and physical signs on account of their close resemblance to the various forms of obstruction, yet its probable existence may be inferred in the presence of one of the known causal conditions. INTESTINAL ULCERS. DUODENAL ULCER. Definition. — A small, round perforating ulcer of the duodenum, and a counterpart of the gastric ulcer {vide p. 763). Pathology. — The morbid characteristics are so nearly identical in appearance and nature Avith those of peptic ulcer of the stomach that they scarcely demand a separate presentation. The seat of the ulcer is Avith fcAv exceptions above the orifice of the common bile-duct. When these ulcers heal the resulting cicatrix produces stenosis, A\hich in turn leads to dilatation of that portion of the duodenum back of it, and finally of the stomach also. Progressive cicatricial contraction may completely close the ductus communis., and in like manner the pancreatic duct or the portal vein may be occluded. Protective adhesive inflammation betAveen the duodenum and the adjacent parts (pancreas, gall-blad- der, liver) often prevents complete perforation of the duodenal Avail : when perforation does occur, hoAvever, the peritoneal cavity may be opened, causing peritonitis, or a fistulous communication may be estab- lished with the gall-bladder, liver, or pancreas. Rarely the direction of INTESTINAL ULCERS. 809 an abscess resulting from perforation is outward, pointing at the seventh intercostal space. In cases in which the posterior wall of the duodenum has been perforated the abscesses burrow through the mediastinum into the tissues of the neck and open posteriorly near the shoulder-blade (Loomis). The concurrence of a gastric and a duodenal ulcer is not infrequent. Htiology. — Though the duodenal ulcer has, as a rule, the same mode of origin as the gastric ulcer, the fact should be prominently mentioned here that extensive burns of the skin-surface of the body are quite prone to be followed by a perforating ulcer of the duodenum, while gastric ulcers are seldom caused in this manner. To explain this form of ulcera- tion of the duodenum is difficult. It is quite probable, however, as in other forms of duodenal and gastric ulcers, that the circulation is arrested by an embolus (from decomposing masses of blood) at some point in the mucous membrane, the acid gastric juices subsequently digesting the part that is thus deprived of its blood-supply. In confirmation of this view we may mention the facts that these ulcers are rarely situated below^ the point of entrance of the ductus communis into the duodenum, and that the contents of the portion of the duodenum above the mouth of the common bile-duct have their parallel in those of the stomach, the acid secretion remaining unchanged until it becomes mixed with the biliarv and pancreatic secretions. Sir William Gull suggests that the situation of the ulcer depends somewhat upon the fact that the portion chiefly im- plicated is so much more fixed than the rest of the organ that one can imagine its surface becoming abraded during peristaltic movements. The influence of sex and age as causal factors is notable and in striking contrast with their import in gastric ulcer. In the latter dis- ease most instances occur among young females, while in duodenal ulceration they occur, as a rule, in males between the thirtieth and fortieth years. Of 64 cases collected by Kraus, only 6 sufferers were females. In view of the fact that the pathology of gastric and duodenal ulcers is the same, these diflerences respecting their etiology are inex- plicable. The ratio of cases of gastric and duodenal ulcers, however, is about as 30 to 1 in favor of the former. Clinical History. — Perhaps no real distinction between the symp- toms of gastric ulcer and those of its analogue affecting the duodenum can be said to exist in most instances. A probable diagnosis of ulcer- ation of the duodenum has, however, been repeatedly made, and some- times verified by the subsequent autopsy. Inasmuch as the essential symptom in ulceration of the duodenum — viz. melena — occurs not in- frequently without the presence of marked gastric symptoms, there is great danger that the disease under consideration will be mistaken for other affections of the intestine in which this is also a prominent symptom. Under like circumstances, if duodenal ulcer be classed with gastric ulcer, there is great danger that the true nature of manv cases will be overlooked. The difi"erence in the symptomatology in the two forms of ulceration is owing solely to the difference in locality, implying a differ- ence in nervous and blood supply. The distinctive features of this disease may be shown by presenting its leading symptoms by the side of those characteristic of gastric ulcer : 810 DISEASES OF THE DIGESTIVE SYSTEM. Duodenal Ulcer. Usually occurs between 30 and 40 years, except when due to external burns. Males are more frequent suiferers than females, in the proportion of 10 to 1. Onset marked by intestinal hemorrhage, which may recur at intervals of vary- ing duration. The melena may be preceded by or ac- companied by hematemesis, though not generally. Blood in the discharges often is bright red, profuse, sometimes dark, and tarry from the action of acid chj'me when slight, though less marked than when from the stomach. Pain may come on late, two to four hours after meals : more often it is absent. It is localized in the right hy- pochondriac region. Gastric crises of great violence occur without reference to time of taking food. Hemorrhage from the bowels is apt to occur at time of crises. Vomiting less frequent. Jaundice occasionally present from oc- clusion of bile-duct. Less marked improvement after diet has been regulated. Painful point is either in the same areas on the right side or is absent alto- eether. Gastric Ulcer. May occur at any age after childhood. Females are the chief sufferers. Gastric hemorrhage occurs, preceded by other gastric symptoms, as a rule. Blood may appear in the stools, usually after hematemesis. The blood in the dejections is dark and tarry from the action of the gastric juices. Pain paroxysmal, greatly influenced by taking food ; often relieved by vom- iting. Pain sharply localized in the epigastric region, about two inches be- low the ensiform cartilage. Gastric crises come on soon after taking food. Vomiting and hematemesis apt to occur at culmination of crises. Jaundice absent. Usually a marked improvement follows reirulation of diet. Boas claims to have discovered a painful point over the tenth and twelfth ver- tebrae, on the left side. Of the symptoms mentioned under Duodenal Ulcer, the intestinal bleedings and violent crises (in Avhich the pain is referred to the right hypochondrium, and comes on from two to four hours after meals) are the most diagnostic. While hemorrhage is the leading single symptom in this complaint, we must not. in attempting to estimate its significance in any case, neglect to eliminate hemorrhoids, carcinoma, tuberculosis, dysentery, and finally the hemorrhagic diathesis, — all conditions in which melena occurs as a cardinal symptom. Recently many cases have been reported in which there was an entire absence of symptoms until per- foration occurred, followed by rapidly fatal suppurative peritonitis. In regard to these accidents we may refer to what is said in the description of the latter disease (infra). The signs of dilatation of the stomach, for reasons before stated, sometimes follow the healino; of these ulcers, associated usually with chronic gastro-duodenal catarrh, the latter being due to mechanical causes. Rarely, stenosis of the ductus communis takes place as the result of duodenal ulcer ; more frequently tumors either compress or occlude the lumen of the bowel beloAv the mouth of the duct. The symptoms presented differ widely from those due to ste- nosis above the duct, the most characteristic being the continual back- ward flow of bile into the stomach, sometimes attended by constant vomiting of biliary secretions. As in the case of gastric ulcer, in the duodenal form there is at times so much thickenino- about the base of INTESTINAL ULCERS. _ 811 the ulcer as to give rise to the signs of tumor. This is especially true of those instances in which the base of the ulcer becomes attached to adjacent organs ; in such cases the resemblance to malignant disease may be striking. Prognosis. — The risk to life is greater than in gastric ulcer, since there is less tendency to cicatrization. Treatment. — The suggestions made in the treatment of gastric ulcer are entirely applicable to the duodenal form also. Follicular ulcers have already been described under Catarrhal Enteritis (vide p. 793), and they have a similar pathology and etiology. When present in goodly numbers they give rise to a symptom peculiarly their own, and hence may be dignified by a separate though brief mention. The symptoms of the condition arising in the course of chronic enteritis often escape observation for a long time. The most characteristic man- ifestation is the appearance in the stools of conical-shaped masses of mucus resembling "boiled sago." Marked Aveakness and emaciation rapidly ensue. Among children the disease is common and assumes an aggravated form, the little sufferers quite frequently reaching their end as the result of inanition. An unfavorable termination may be due to perforation followed by suppurative peritonitis. The treatment coin- cides with that of chronic enteritis. Stercoral ulcers are the result of the mechanical effect of hard fecal scybala (often enteroliths, due to a deposit of lime-salts) upon the intes- tinal mucous membrane. They occupy the sides or tops of the normal folds in the colon. Symptoms. — There is, as a rule, a clear history of chronic constipa- tion, though the physician may, notwithstanding, be called on account of the presence of diarrhea; this is caused by the retained hardened feces working their way into the rectum. A digital exploration will now clear up the diagnosis. There are tenesmus and colicky pain in the abdomen, the latter symptom being also complained of when no diarrhea is present. The pain often occurs in severe paroxysms that may be attended with the discharge of thready or flaky mucus, pus, and sometimes blood. Physical Examination. — Palpation may in rare instances reveal the presence of a sausage-shaped tumor and sharply localized tenderness over the seats of ulcers. Enteroliths may lie in the intestines for years together, or they may finally be discharged with the stools. The ulceration that is thus caused often passes unrecognized. The prognosis is good if the condition be not overlooked. The treatment consists in thoroughly evacuating the bowels by salines and simple enemata, persistently used. Subsequently these cases are to be managed in the same manner as other non-specific ulcers of the bowels. Simple ulcerative colitis is a not uncommon complaint, and one that is frequently associated with chronic intestinal catarrh. The ulcers may be quite extensive, removing the greater portion of the mucous 812 . DISEASES OF THE DIGESTIVE SYSTEM. membrane, though in several instances I have observed cases at the Episcopal Hospital that were superficial ; these were confined almost solely to the mucosa. The muscular layer of the gut was greatly hyper- trophied and its lumen increased in every instance. The non-ulcerated portions of the mucosa looked, in part, quite pale, and in part quite dark. Polvpoid growths have been observed situated between the ulcers. The etiology is obscure. The disease is met with most frequently in persons past middle life, and it is quite probable that chronic enteritis sustains a causal relation. Those Avhose constitutions have been enfee- bled by previous disease or an unfortunate hygienic environment are the chief sufferers. Symptoms. — The clinical features are ill defined at the onset, and are often erroneously ascribed to indigestion. Diarrhea (lienteric in character) is its most prominent symptom, and with it constipation may alternate. Pus and blood are absent with the rarest exceptions. The general health soon suflFers greatly, the patient becoming weak and emaciated. The course of the disease shows it to be of the subacute type, tending in most cases to become chronic. The diagnosis, apart from a consideration of the symptoms above men- tioned. re(iuires the elimination of dysentery — an easy task as a rule. Prognosis. — This is unfavorable during the earlier stages in the aged. The strong innate tendency of the disease to become chronic must be considered. The treatment embraces («) a careful regulation of the diet, consist- ing in a restriction of the patient to liquids and semi-solids during the acute stage; {b) the administration of a gentle laxative, followed by antiseptics and astringents (bismuth gr. xxx — 2.0 — combined with salol gr. V — 0.324 — every four hours); {<:■) the more serviceable local measures in the form of enemata, among the best being silver nitrate (gr. \ ad 5j — 0.016 to 32.0) or creolin (2 per cent.). Solitary Ulcers. — " Two instances of ulcer of the cecum, both with perforation, have come under my observation, and in one instance a simple ulcer of the colon perforated and led to fatal peritonitis " (Osier). The diffuse catarrhal ulcer is inseparable from acute enteritis ; the cancerous ulcer is alluded to under the latter head. APPENDICITIS. Definition. — A catarrhal, ulcerative, or interstitial inflammation of the appendix vermiformis. It must be confessed that, according to our present views, appendicitis is a surgical rather than a medical affec- tion, particularly from the standpoint of treatment. KnoAving from personal experience and observation, however, that general physicians are constantly meeting with cases of appendicitis, its prompt clinical rec- ognition by the latter is not only a matter of interest, but also of gi'eat practical importance for twt reasons : First, in order that surgical inter- APPENDICITIS. 813 vention can be instituted at the proper moment ; and secondly, because appendicitis is the leading serious disease of the intestinal tract. The term "appendicitis " includes the affections typhlitis (inflamma- tion of the cecum) and peritypMitis (a similar involvment of the connec- tive tissue behind the cecum), for the reason that with few exceptions when the symptoms of the latter affections are presented the ap- pendix vermiformis is the part primarily affected. To the physicians and surgeons of America belongs the credit of having first established the truly important rank of appendicitis.^ Anatomic. — Without any known function the human appendix vermiformis represents the remains of the enormous cecum of inferior animals, especially rodents and herbivora. Clado asserts that the ver- miform appendix is kept in position by two folds of peritoneum, a meso-appendix, which is attached to the iliac fossa, and a second fold, perpendicular to the first, which is attached to the posterior portion of the small intestine.^ A lymphatic gland generally occupies the angle formed by the appendix, cecum, and the small gut ; this receives all the lymphatic vessels of the appendix. The size of the latter varies greatly. Ferguson,^ after measuring 200 appendices, gave as the aver- age length 4:^ inches (11.4 cm.), and as the diameter, that of a No. 9 English sound — about a quarter of an inch (0.62 cm.). Berry's studies, which are partly based upon personal examination of 100 bodies, and partly upon comparison of his own results with those obtained by other investigators, gives the average length in all the observations as 9.2 centimeters (3.6 inches). The caliber is ordinarily of the size of a goose-quill. Very exceptionally, as in a case reported by Swan, there is a congenital absence of the appendix. Its two fibro-muscular coats (external longi- tudinal and internal circular) are thick ; its mucous membrane contains lymphoid elements in abundance. The blood-supply is derived from the ileo-colic artery at the valve, a single branch running to the end of the appendix. Shortly after middle life the cavity of the appendix becomes obliterated. Its blind extremity points most frequently toward the spleen. The appendix may lie behind the cecum, and sometimes partly to its inner side, its tip almost touching the liver or the gall-bladder. In not a few instances it dips downward, passing over the brim of the pelvis. There is no adjacent organ to which it may not become adherent, and in rare instances it is twisted like a loop around the small gut, causinof constriction or even strangulation. Osier mentions one case in Avhich the appendix, with the cecum, entered the inguinal canal, curved upon itself, re-entered the abdomen, and w^as adherent to the wall of an abscess-cavity just to the right of the promontory of the sacrum. Pathology. — Three pathologic varieties are recognized : (1) Catarrhal or Obliterative Appendicitis. — This may be acute or chronic. The term "catarrhal inflammation" is still retained, though scarcely applicable, since, as a rule, appendicular inflammation tends to spread quickly to all the coats, including the serosa. Obliterative ap- ^ The following names will long be connected with this disease : Pepper, Fitz, Mc- Burney, Porter, Willard Parker, Weir, Sand, Bull, Warren, Keen, Morton, Price, J. William White, Deaver, Senn, and many others. ^ Sajous' Annual, vol. i., 1893. ' "Some Points regarding the Appendix Vermiformis," American Journal of Medical Sciences, Jan., 1891. 814 DISEASES OF THE DIGESTIVE SYSTEM. pendicitis is descriptive and in every way preferable. The mechanism of the inflammation is briefly as follows : The mesentery being too short, the exit is too small, and in consequence of swelling of the coats (especially the mucous) the venous return is greatly impeded, then the arterial, followed often by abscess-formation. In the female a branch is supposed to be furnished by the ovarian artery, making a more perfect blood-supply. The appearances are, in the beginning, identical with those of catarrhal inflammations elscAvhere in the bowel. Within twenty-four hours all the layers are swollen, with marked cellular infiltration, causing the appendix to become firm and often rigid. The mucosa may be de- nuded of its epithelium and present a granular surface. The external coat (serosa) is usually hyperemic, and not uncommonly the seat of fresh or old adhesions. The tube may become completely obliterated by pressure, resulting in a union between the granular surfaces, in this manner rendering subsequent attacks impossible (Hawkins). It is in cases in which this fortunate result is not reached, however, that acute appendicitis leads to the chronic form with relapses. Two additional terminations may be observed : First, an obliteration of the lumen may occur near the valve, in which case the appendix becomes dilated, and sometimes enormously so (cystic). The contained liquid may be either serous or purulent. Second, obliterative appendicitis may lead directly to ulceration of the mucous membrane, and often in the absence of a fecal concretion or foreign body. Again, the cystic appendix may ulcerate, with or without perforation. Obviously, the more marked the stenosis of the appendix the less favorable the conditions for natural drainage, and the greater the liability to recurrences of attacks of appendicitis. This variety then may end in resolution, complete oblit- eration, stenosis, or ulceration, and the latter sometimes in perforation. (2) Ulcerative Inflammation. — Like the preceding, this variety may be acute or chronic. It may be a sequel of the obliterative form, and often accompanies chronic obliterative appendicitis. More commonly, however, it is seen in connection with concretions, and sometimes with foreign bodies also. By no means invariably, however, does the pres- ence of these substances excite ulceration of the appendix. Micro- organisms play an important role in this variety {vide Etiology). The submucosa or muscularis usually forms the base of the ulcer. The ter- mination may be in healing, with tendency to stricture. When obliter- ation is complete, dilatation beyond the seat of the latter may ensue. Again, the ulcer may extend in depth until perforation occurs. (3) Interstitial or Parietal Inflammation. — This may be preceded by the obliterative or the ulcerative form, which maybe followed bv anemic necrosis and sloughing. Concretions or foreign bodies are often found, though specific bacteria are of greater etiologic importance. The gravest, most common, and hence the most important lesions are the gangrenous, Avhich are usually limited to a circumscribed part of the tube. Interstitial inflammation has a single termination — perforation — and leads to appen- dicular peritonitis of a virulent and infectious type. It may be that neither necrosis nor gangrene may supervene. AVhen perforation occurs, one or more openings, ranging in size from one to several millimeters, may be observed, while the remainder of the appen- dix may present no abnormalities ; more often, however, it is blood- APPENDICITIS. 815 injected and swollen. The appendix may slough en masse. The histo- pathologic changes may be characterized by intense cellular exudation, necrosis, or purulent inflammation. The muscular coat is hypertrophied ; the arteries show obliterating endarteritis. Conseciuences of Perforation. — A common result of all forms of appen- dicitis is a localized peritonitis, and this is a constant effect of the severer forms, either leading to (a) circumscribed peritonitis or to an (h) acute diifuse peritonitis. {a) Circumscribed Peritonitis. — At first the surface of the peritoneum is opaque and velvety. Soon a fibrinous exudation covers the appendic- ular peritoneum, and quicklj^ establishes adhesions between the appendix and the adjacent parts (abdominal wall, intestinal coils). The process may not proceed any further. Generally, however, it is soon followed by a serous or sero-fibrinous exudation, Avhich becomes sero- or fibrino-puru- lent, and often forms the so-called perityphlitic abscess. The seat of the abscess is always near the tube, and is as varying as the position of the appendix ; its size is also extremely variable, as it sometimes contains enormous amounts of pus. Among the most common locations are — McBurney's point, the vicinity of the cecum, the coils of the small in- testines (near the umbilicus), and, more rarely, in the pelvis below. The pus contained in the abscess is rarely thick, grayish-yellow in color, and emits a fecal odor ; more commonly it is thin, turbid, dark-gray or greenish in color, and has an extremely fetid or even gangrenous odor. The process of gangrenous sphacelation en masse is often completed after the limiting wall of adhesion has formed, when the entire appendix is found free in the pus-cavity. The abscess may be subperitoneal, as when perforation occurs into the retro-cecal connective tissue, and the term "iliac abscess" was formerly applied to these extra-peritoneal purulent collections. They are rare, however, since the early operation has been employed. Their situation and dimensions depend upon the direction taken by the ap- pendix. The latter may pass downward, and the pus is then apt to accumulate in the lower part of the iliac fossa, and may point and finally burst in the neighborhood of Poupart's ligament, with subse- quent recovery. Occasionally under these circumstances a fistula remains for an indefinite period of time. The appendix may touch various abdominal structures, and the pus in following the line of least resistance may cause spontaneous rupture into the rectum, bladder, or the vagina when it points inward ; and into the perinephric region or into the pleural cavity (through the diaphragm) Avhen it points upward ; or even into the cecum or colon. The contents of the abscess may also find their way through the abdominal wall in the vicinity of the umbil- icus. The psoas muscle may conduct the abscess downward, and it may then point at the hip-joint or gain the gluteal regions or the scro- tum, producing the so-called "scrotal appendicitis." The appendix has also been found in a hernial sac. Among the rare lesions to be noted are erosion of one of the arteries of the iliac region (causing fatal hemorrhage) and pylephlebitis. From the thrombi in the mesenteric veins in the latter condition infectious emboli may be conveyed to the liver, giving rise to hepatic abscess ; this occurred in a case of my own at the Episcopal Hospital, Philadelphia. The abscess may also be due 816 DISEASES OF THE DIGESTIVE SYSTEM. to an extension of the thrombo-phlebitis of the mesenteric veins that lead from the appendix to the portal vein. Thrombosis of the iliac veins Avith edema of the corresponding leg may also arise, and these veins ma3^ during the process of healing, become compressed, with a resulting edema of the leg, as I have witnessed in two cases. It rarely happens that suppurative processes are both extra- and intra- peritoneal. {h) Acute Diffuse Peritonitis. — This follows perforation when previ- ous adhesions have not taken place or Avhen, having formed, they yield. Generalized peritonitis may also follow the circumscribed form, the lesions being propagated to the entire membrane by direct extension. The morbid changes are those mentioned in the description of Acute Peritonitis. Since the early operation has been employed peritonitis has been the result, usually, of direct perforation before a limiting wall of adhesion has been formed. Ktiology. — Predisposing Causes. — (a) Doubtless theve ^ve congenital structural defects that aid in the production of appendicitis. Among them are unnatural length, location, and arrangement of the organ, and peculiarities in the development of its mesentery. These factors tend to obliterate the lumen of the canal by producing kinks and twists, thus favoring the collection of material Avithin the appendix, (b) Stric- tures, particularly near the cecal end of the tube, and adhesions due to old inflammation, especially peritonitis, operate in the same manner as the preceding, only with greater power, (c) Fecal concretions are the main cause in nearly one half, while foreign bodies play a small role, having been present in 7 per cent, only of 1400 cases (J. F. Mitchell). The calculi form in the appendix itself (Rochaz). The foreign bodies are very various, and consist of seeds, worms, gall-stones, pills, bristles, and, more rarely, pointed bodies, as fish-bones or pins. The presence of fecal concretions and foreign bodies is often tolerated by the appen- dix Avithout symptoms or local pathologic changes ; hence they are looked upon rather as a predisposing than as an exciting cause of ap- pendicitis, (d) Ulcers (tuberculous, typhoid, and, rarely, actinomycotic) may also produce this affection, (e) Straining Efforts and Traumatism. — Not uncommonly excessive muscular exertion, traumatism, or jarring of the body as in jumping, act as favoring causes. {f)Age. — The dis- ease is especially freo[uent in young adults between the fifteenth and thir- tieth years. It is not very infrequent in childhood, hoAvever, after the third year, and it has even been seen in persons over seventy years of age. {g) Sex. — Appendicitis attacks males oftener than females ; this fact has been explained {vide supra). In the female it is rarely of ad- nexal origin. Adiiesions betAveen the tube and ovary and the appendix may occur, the morbid process then extending to the latter. (Ji) Gastro- intestinal Disturbance. — Indiscretions in the diet may precede a primary attack, and are of paramount etiologic importance in the recurrent forms of the malady. (*') Heredity. — That this plays no mean role in many cases of appendicitis I have long felt convinced. This serves as the explanation of those cases in which rheumatism and uric-acidemia seem to act as causal agents. (./) Evidence to shoAv that influenza and other affections may cause appendicitis is not Avanting. {k) It is not improb- APPENDICITIS. 817 able that poor hlood-sujyply is, after all, the leading predisposing factor, and torsion and the like the active cause. Bacteriology. — While it is true that in many instances there is no apparent exciting cause, yet there are excellent grounds for ascribing specific pathogenic properties to certain micro-organisms. The com- bined results of several experimentalists tend to show that no special organism plays an exclusive role in this disease, but the studies of Hodenpyl indicate that the baciUus coli communis is the bacterium most generally present : it is well known, moreover, that this bacillus becomes pathogenic when it escapes into tissues in which it does not naturally belong. Barbacci emphasizes the etiologic importance of the passage of the intestinal contents into the peritoneal cavity — /. e. the chemical factor. Of other specific bacteria, those of typhoid and tuberculosis are not uncommonly found to be present. The strejytococcus pyogenes may also be found to produce the most virulent infection, and the staphylococ- cus pyogenes aureus, the proteus, and other specific organisms have been found. The great frequency of appendicitis is rendered appreciable by the numerous favoring factors (including the congenital conditions) act- ing upon the appendix, which naturally has an exceedingly low vitality ;, also by the constant presence of one or more organisms that are known to become pathogenic in the presence of a slight lesion. Clinical History. — Doubtless many cases are overlooked because of the extreme mildness of the symptoms. These are often attributed to intestinal indigestion or to a "cold," to which the patient pays little attention unless he displays unusual susceptibility. The onset of acute appendicitis may be slow and gradual, but oftener it is quite sudden. A clear history of some obvious cause (an error in diet or muscular effort) may be obtainable. Again, preceding the onset of the definite symptoms and extending over a day or two, there may have been certain prodromes, as impaired appetite, nausea, consti- pation, or diarrhea. In slow cases the local and general symptoms are at first slight, but gradually increase in severity as the different stages of the disease are evolved. Indeed, in the latter class the patient may go about his customary duties during the attack with ill-defined rational symptoms, while in reality suffering from periappendicular abscess. These patients run two serious dangers — first, spontaneous rupture of the abscess into the peritoneal cavity may occur ; and secondly, the slow septic absorption may suddenly overwhelm the system. As a rule, the sudden cases develop in seeming perfect health, and are sometimes heralded by a rigor or chilliness. The characteristic features of the invasion are abdominal pain, fever, tenderness over McBurney s point, circumscribed resistance, gastric dis- turbances, and, as a rule, constipation. The pain varies in intensity from a mere feeling of soreness to that of the most agonizing suffering. It may be paroxysmal, though oftener it is constant, with moderate exacerba- tions. Severe pain points to an involvement of the peritoneum and signalizes a danger of perforation. At first the pain may be referred to any point in the abdomen ; later it becomes more distinctly localized in the ileo-cecal region. Elevation of Temperature. — The exacerbations may at first touch 52 818 DISEASES OF THE DIGESTIVE SYSTEM. 102°, 103°, or even 105° F. (38.8°-40.5° C), and particularly in chil- dren ; more commonly they range from 100° to 102° F. (37.7°-38.8° C)- The degree of fever is unreliable, however, as a criterion of the severity of the case, since the worst cases may have a subnormal temperature throughout. M E M e M E M E M E M E m;e M E M E M E M E M E M E M E BOWELS - - - - - URINE DAILY AMOUNT F. 101^ 100° 99° 98° — * 97° DATE T. y Irt- }y hi t / A / I /\ UJ \ ' 1 j, v A / ■^ \' A / \| / \i 1 \ / / / / A / / / / \ ' / / Y ' / , V / A J V A \ 1 1 i \ / \ t V A V f V / \/ \l V Z' \- 1 'ER/i TURES , 1 > oI2 13 14 16 17 18 20 21 22 23 24 25 c. Fig. 58.— Temperature-chart of a case of appendicitis. M. M , aged thirty -five vears ; motor- man. Laparotomy, by Prof. E. Laplace, disclosed catarrhal appendicitis with adhesions. An elevation of temperature, however trivial, is most significant, pointing as it does to inflammation as the cause of the local symptoms. The pulse-rate is somewhat higher than the elevation of temperature would lead one to expect, and in bad cases the pulse is usually much quickened. Sometimes, however, it remains at 80 to 90 per minute, and may be full and soft, even though the patient be practically moribund. Fixed tenderness is practically constant on pressure over a limited area, midway on a line between the anterior superior iliac spine and the umbilicus {McBuriieys point), and is a most valuable sign. The seat of the tenderness may rarely be found at other points, depend- ing upon the location of the appendix. I have twice observed it in the lumbar, once in the right hypochondriac region, and once far below the usual point, in the right iliac fossa. It has been found in the umbilical and left iliac regions, in the pelvis, and in the groin. In several instances, although I have found it elsewhere in the early stage, it has shifted to McBurney's point later. On the other hand, it may move from the usual position in cases that are allowed to drag on. When the sensitive area is at McBurney's point, as is the rule, the gentlest pressure often suffices to elicit exquisite tenderness, but when it is situated elsewhere firmer pressure Avith the finger-tips is usually required. Deep pressure always reveals localized tenderness at some point in the abdomen if the case is one of appendicitis. Palpation also detects an abnormal tenseness of the right rectus abdominis muscle. On or about the second day a circiwiscribed induratioyi manifests itself, followed soon by a fulness and swelling tending to obliterate the depres- APPENDICITIS. 819 sions above and in front of the anterior iliac spine. The position of the indurated area varies according to the location of the appendix, but is usually found at or in the vicinity of McBurney's point. Sometimes a resistant mass of the shape and size of an enlarged appendix is palpable. In such cases peritoneal exudation has not as yet occurred to any great extent. In some cases the induration is diifuse at first, but assumes the usual circumscribed form later ; it may, moreover, be so deeply seated as not to be appreciable. The degree of tenseness of the two recti mus- cles — right and left — should be compared, though an absence of tension of the right rectus does not, I feel certain, eliminate the possibility of appendicitis. The results of pe;Ti(Ssw?i furnish no certain guide. As a rule, the note on light percussion differs from that on the opposite side ; on deep percussion a dull tympany or a circumscribed area of dul- ness can be outlined. This deadness may be due in great part to the presence of fecal matter in the adjacent coils of intestine. While at the start the abdomen may be flattened or even retracted, tympanitic dis- tention afterward appears, particularly in the cecal region, giving rise to exaggerated tympany on percussion. Less characteristic, though still of diagnostic worth, are certain other symptoms. At the beginning vomiting usually occurs, unless there be diarrhea, and is attended by more or less nausea ; it may con- tinue throughout the course of the attack. In most cases, however, after a few fits of vomiting the symptom disappears, though it may recur if errors in diet be committed or if peritonitis supervene. During the attack constipation is the rule, though diarrhea, which sometimes precedes appendicitis, may also occur at a late stage as a septic symp- tom. There is anorexia, and the tongue is coated. The decubitus is dorsal, with the right leg flexed. Frequent micturition (early) and re- tention of urine (later) are not uncommon, the urine having a deep color-tint, and sometimes containing albumin. The case may follow a mild course, terminating in resolution Avith recovery ; or it may be of a severe type and develop perforation, Ayith the formation of abscess or difliise peritonitis. As graphically stated by Fitz, it is impossible to obtain statistical evidence on a large scale of the relative frequency of these alternatives, and hence the frequency of treatment of appendicitis by abdominal section. From all available data, however, it would appear that in more than one-half of the cases the course is light and favorable. If not operated upon early, the fever may continue for three to five days, and then subside, with simultaneous abatement of the severe local and general symptoms and with the establishment of convalescence. The same amelioration of the symptoms may be brought about by early free purgation, either as the result of salines or, rarely, spontaneously. In these instances resolution takes place even after invasion of the peri- toneum. Small abscesses may be absorbed, and usually in cases ter- minating in resolution perforation has not occurred. Infection of the peritoneal membrane directly through the appendix is not uncommon. In severe attacks perforation may occur, tvith the development of localized jjeritoneal abscess or generalized i^eritonitis {vide Pathology), and it must be remembered that cases that begin gradually may also show a tendency toward perforation. When this event occurs early in 820 DISEASES OF THE DIGESTIVE SYSTEM. the course of a severe attack or after a protracted mild appendicitis the symptoms of local or general peritonitis are superadded. If early, the symptoms pointing to peritonitis are intense; the abdomen swells quickly, and is exquisitely tender, though the physical signs of a tumor are ab- sent. The temperature often falls, and the characteristic vomiting and circulatory collapse appear. Often the generalization of the peritonitis is marked by less violent symptoms. Starting from the seat of circum- scribed inflammation, the pain and tenderness propagate themselves noticeably from day to day until every portion of the peritoneum has been invaded. Besides progressive augmentation in the local features, including the pain, there is a gradual failure in cardiac power, as shown by the condition of the pulse ; vomiting also returns, and at last becomes fecal. Death results from asthenia, and sometimes suddenly when un- anticipated. If perforation occurs later, suflficient time has been allowed usually for the inflammation to become circumscribed, in which case the localized abscess is generally intra-peritoneal ; it may, however, rarely be extra-peritoneal. The local symptoms intensify, the pain becomes excruciating, and the spot of tenderness may rapidly extend itself in all directions, particularly downward. Vomiting sets in, and may become troublesome, and constipation is absolute, not even gas escaping from the rectum. Retention of urine is common. Physical Signs of Localized Abscess. — Inspection shoAvs distention of the belly, the aff"ected area being prominent, with an obliteration of the natural depression in the right iliac region. Palpation discovers indura- tion and great tension that soon yield to pressure (doughy), and edema of the skin. If the abscess is superficially seated, fluctuation may be appreciated on bimanual palpation. Deep-seated tumors are not vmcom- mon, and then fluctuation is detected with difficulty or not at all. An examination per rertum, with a vicAv to determining whether the abscess has gained the pelvis, is highly important. Counter-pressure above Avith the free hand aids matei'ially. In doubtful cases bimanual pelvic examination should not be neglected. Percussion reveals dulness if the abscess be superficial. A tympanitic note, however, is often elicited, due either to an intervening coil of intestine or to the gas contained in the sac of the abscess. If active peritonitis and septicemia do not develop, the constitutional as well as the local symptoms may abate, and the patient leave his bed, cai-rying Avith him, hoAvever, the abscess. The latter may point some- Avhere in the right loAver quadrant of the abdomen or in the lumbar region. There is also a strong tendency toward spontaneous rupture into the rectum, bladder, vagina, or cecum. Often, preceding the dis- charge of pus into these organs, the latter display marked irritability, particularly the rectum and bladder. There is ahvays the danger that the contents of the abscess may find their Avay into the general perito- neal cavity. The symptoms of hepatic abscess may develop at an ad- vanced stage. The pus may traverse the abdomen in the upAvard direc- tion until it touches the diaphragm, when the symptoms of subphrenic abscess may be manifested. Extension through the diaphragm may noAV occur, causing pleurisy or pericarditis, and a pleuro-fecal fistula may thus be established. The general symptoms undergo a modification, due to the suppurative APPENDICITIS. 821 jjrocess. Rigors or a decided cliilliness may occur. Diarrhea often succeeds to previous constipation, and drenching sweats to a dry skin. Improvement and even spontaneous cure may ensue if spontaneous rup- ture into one of the outlets of the body should occur. The fever (Fig. "m" E M E 1? E M E E M E M E M E M E M E M E M E M ^ M E M E M E M E BOWELS - - - - - - - - - - - - - DAILY AMOUNT c. F. 105° lOi" 103° 102° 101° 100 99° 9S° 97° DATE 11' fn l-r, — m z CO en P m 'r CO L-l U- '■ ^ tj ^ " 1 -4n CO 1 1 1 1 i 1 / -m 1 ' \ 1 \ — ^ — — i >, 1 \ 1 1 -38 1 1 1 J 1 J 1 \ 7 1 1 h / / i 1 1 sl 1 ^ 1 ' / \ \ / \ 1 1 A \ \ / 1 A -,/ / w ( j 1 v V r^ y 1/ 1 \^ 1 i/lORNING M IMi k -^C- __ — 1 |25 26 27 28 29 1 30 31 2 ■ 4 5 6 7 8 9 10 1 Fig. 59.— Temperature-chart of a ease of appendicitis. R. C , aged nineteen years ; carriage- builder. A peritoneal abscess was found, while the appendix was becoming gangrenous. 59) may be either remittent or intermittent, and if the localized inflam- matory process be active, the usual pronounced features of septicemia are predominant in the clinical picture. The latter specially grave con- dition often drifts into an extreme typhoid state with a hopeless course. Diagnosis. — Typical cases of appendicitis are readily diagnosti- cated. Their recognition rests upon a few cardinal symptoms — viz. the acute development of severe pain in the right iliac fossa, coming on in a person previously healthy and usually under forty years of age ; appendicular tenderness, unilateral induration, fever, vomiting, and con- stipation, or, more rarely, diarrhea. Atypical cases, however, may offer difficulty, although Morris affirms that errors in diagnosis are less frequent than in almost any other disease. Often the pain is, for a time, referred to a circumscribed area far removed from the usual site of the appendix, and rarely it continues without a change of situation throughout the attack. In the latter case the local lesions may occupy the usual, though oftener they have an unusual, position. Thus, when the pain is referred "due east," or to the left iliac fossa, with 822 DISEASES OF THE DIGESTIVE SYSTEM. bilateral induration, the appendix will be found in the pelvis (Deaver). In such instances a rectal and a bimanual vaginal examination are im- perative. It should be an unvarying rule in all cases of severe abdom- inal pain to palpate with the finger-tip every square inch of the abdomen if necessary, to find the localized tenderness when it is not found at McBurney's point. The degree of tenderness sustains a close relation- ship to the severity of the local inflammation as long as the condition remains strictly localized, but this relationship is lost when generaliza- tion occurs. With the appearance of a circumscribed induration and of the intense local tenderness and pain it is reasonably sure that per- foration either has occurred or is impending. Perforation, however, may occur without local induration, and even after subsidence of the acute pain and excessive tenderness. Gangrenous appendicitis is most deceptive. The very acute symptoms, including the fever, may disap- pear, and unless the physician be upon his guard the patient will be considered convalescent and be allowed to go about. Rupture of the abscess now occurs unexpectedly into the peritoneal cavity, intestines, or some other direction, or a large-sized abscess develops with the usual signs and symptoms. Differential Diagnosis. — Ti/phlitis, and especially the Massing of Feces in the Cecum. — These are truly rare conditions. According to McBurney, 99 per cent, of all typhlitic abscesses are of appendicular origin, and of 400 autopsies by Einhorn 91 per cent, had this origin. Ball and others have performed laparotomy for ulcerative cecitis, but this condition cannot be recognized during life. Stercoral typhlitis is discriminated from true appendicitis by the precedent constipation, which may become absolute, by the dragging character of the pain, the late-appearing fever, and chiefl}' by the physical signs, Avhich indicate the presence of a superficial, sausage-shaped tumor that is often doughy and extends vertically from a point near the right costal border " south- ward " through the ileo-cecal region. Percussion elicits dulness over the seat of the tumor. The localized tenderness and circumscribed resist- ance of acute appendicitis are wanting, and a thorough emptying of the large intestine usually cures stercoral typhlitis.^ Renal Colic. — The absence of fever and of a localized spot of ten- derness and induration, and the presence of hematuria are points that distinguish this affection from appendicitis. Indigestion. — Digestive disturbances, and particularly pain and vom- iting, accompany appendicitis. When they occur independently of ap- pendicitis, however, they can be relieved, and the appendicular region remains free from fixed pain, tenderness, or tumor. Acute Inflammation of the Gall-bladder., ivith Distention: — This gives rise to a superficial, mobile,- pear-shaped tumor, with or without jaun- dice — features not met with in appendicitis. Osier, however, mentions a case of the sort in which the diagnosis was undetermined until lapa- rotomy Avas performed. Perinephric Abscess. — Without a history indicative of chronic renal disease or of nephro-lithiasis the differentiation cannot be made except by exploratory incision. ^ It is highly probahle that the term "stercoral typhlitis" is synonymous with chronic appendicitis with retahied feces in the cecum. APPENDICITIS. 823 Oarcinoma of the Large Intestine. — This discriminates itself by its peculiar and more chronic history. Acute Peritonitis, due to Ovarian or Tuhal Disease. — When the ap- pendix occupies, not its usual seat in the iliac region, but the pelvic fossa, then the distinctions between salpingitis and appendicitis are not easily drawn. Right ovaritis, owing to the presence of pain, tenderness in the right iliac fossa, and fever, often closely simulates appendicitis. In the former tenderness is less pronounced, and the organs of utero- gestation manifest certain disturbances of function. A clear history, coupled with a careful pelvic examination, will usually complete the clinical separation of these two conditions. Extra-uterine Pregnancy. — In this condition the menstrual history furnishes important information. There is, in addition, profound col- lapse, due to hemorrhage, when rupture of the adhesions occurs. Ele- vation of temperature is absent. The localized tenderness and in- creased resistance are loAver in the pelvis than in appendicitis. Acute Tuberculous Peritonitis. — As in appendicitis, so in tuberculous peritonitis, pain, tenderness, and fever are present, but in the latter the onset is more gradual, and the signs of tumor and increased resistance in the right iliac fossa are absent. Movable dulness may be present in the tuberculous affection, and not in appendicitis until the peritonitis has become generalized. The lungs are generally implicated in tuberculous peritonitis. Acute Intestinal Obstruction. — When this is due to intussusception there may be signs of a tumor, but not at McBurney's point ; the ten- derness over the site of the mass is less intense, while the frequent bloody discharges that are seen in this condition, accompanied by tenes- mus, do not characterize appendicitis. When obstruction is caused by strangulation stercoraceous vomiting is apt to occur, and is absent in appendicitis. Pain, local tenderness, and, not uncommonly, signs of a tumor appear, but elsewhere than at McBurney's point. Some of these instances, however, remain obscure till the diagnosis is set at rest by the celiotomist. Sip-joint Disease. — In both hip-joint disease and appendicitis the dorsal decubitus with flexed leg is noted. If the patient be anesthet- ized, however, full extension of the leg and a normal condition of the hip-joint are easily demonstrable in appendicitis. Typhoid Fever. — Mild cases of appendicitis with accompanying diar- rhea bear a close superficial resemblance to typhoid fever. In the latter affection, however, the onset is more gradual and the fever-type more continuous than in appendicitis. In typhoid the stools are somewhat peculiar, the spleen is swollen, there is dulness of intellect, bronchitis and the characteristic eruption attend, — all features that are absent in appendicitis. The diazo-reaction, if present, would strengthen the diag- nosis of typhoid, and a response to W^idal's test would be conclusive. In appendicitis the local features, and in typhoid the general, are pre- dominant. Dietl's Crises. — In a case of movable kidney which I saw recently all the symptoms pointed to appendicitis. An operation was about to be performed when a sudden subsidence in the abdominal swelling and local induration occurred. The kidney was subsequently detected in an abnormal location (vide Mobility of the Kidney). 824 DISEASES OF THE DIGESTIVE SYSTEM. CHRONIC APPENDICITIS. {Relapsing A2)pendicitifi. ) Relapses occur in nearly one-half the total number of persons who have suffered from a primary attack of appendicitis. In most of these cases there is constantly present a slight local discomfort during the in- terval ; in a small percentage, however, there is an entire freedom from uneasiness. The local symptovis in those having had an antecedent peritonitis are more pronounced than in the first attack, but after a number of recurrences the symptoms are likely to be less severe with each new attack. The most constant symptom betAveen attacks is a sub- acute form of pam that is liable to manifest exacerbating periods with slight fever. Physical fatigue, a strain, and errors in diet causing gastro-intestinal disorder are very likely to induce a relapsing appendi- citis. Chronic appendicitis strongly favors the retention of fecal mat- ter in the cecum, thus forming so-called stercoral typldltis. This asso- ciation was formerly mistaken for primary typhlitis. The characteristics on which the diagnosis is based durino; the attack are similar to those detailed under Acute Appendicitis; the course is, however, somewhat, more condensed than that of the acute form. In the intervals between the attacks the appendix can be readily ap- preciated on palpation., the method employed by Edebohls being prefer- able : " The patient lies upon his back with the examiner at his side ; the latter places his right hand upon the patient's abdomen over the right rectus muscle, opposite the anterior superior spine of the ilium, and presses the left hand upon the right, so that no force is used by the right hand and the tactile sense of its fingers is left undisturbed. The hands are drawn slowly outward, allowing the contents of the abdo- men to slip from underneath them. The coils of intestine can be felt as they escape from under the hand as it presses against the posterior abdominal wall."' In this way the appendix may be felt as an elon- gated tumor of the size and shape of the little finger. If there be only a slight exudation present, the appendix often appears to be immediately beneath the abdominal wall. It may, hoAvever, be deep-seated, even though the exudation with adhesions be absent. Both pain and tender- ness are pronounced, and particularly if pus be present. The results of chronic appendicitis upon the general health and nu- trition of the patient are quite noticeable, and tend to augment as time passes, if the attacks be frequent or the intervals between them grow shorter. The chief symptoms are those of a nervous type ; emaciation and debility are also observed. The associated nervous symptoms are those of neurasthenia. These patients often become introspective and exceedingly irritable, the mental condition being accounted for, to a great extent, by the consciousness that there is ever present the over- hanging danger of a fresh attack with serious possibilities. Differential Diagnosis. — Carcinoma of the Cecum. — This presents many points of similarity to chronic appendicitis. I have under my care at present a lady aged sixty years suffering from chronic appendicitis, whose case had been diagnosticated as carcinoma of the cecum, and for a considerable time my own view coincided with that of my predecessor. ' B. Farquhar Curtis : Twentieth Century Practice of Medicine, vol. viii. RECURRENT APPENDICITIS. 825 The occurrence from time to time, llo^Yever, of relapses, during which the feces Avere massed in the cecum and fever arose, soon indicated the correct diagnosis. Besides the absence of periodic attacks of fever, the general features — loss of flesh and strength, anemia — are more steadily and rapidly progressive in carcinoma of the cecum. The history of the mode of onset also aids in the distinction. Pain, tenderness, and a re- sistant tumor are common to both affections. Hypochondriasis and Hysteria. — Hypochondriasis and hysteria may lead to the manifestation of morbid feelings simulating those of appendi- citis. Such cases may show merely a greatly exaggerated uneasiness, or such an increase of sensibility as to cause the patient to complain of pain in the right iliac fossa. In addition, there may be localized ten- derness. I recently witnessed the removal of the normal appendix from an hysteric female in whose family two genuine cases of appendicitis had occurred not long previously. Hypochondriasis and hysteria dis- tinguish themselves by the antecedent history and by the absence of a tumor-mass and of increased resistance ; there is also an absence of localized tenderness if the patient's attention be withdrawn. In such subjects oxaluria is not infrequent, and it is possible that irritation of the right ureter by the passage of crystals of calcic oxalate, as men- tioned by Cabot, may explain the localizing of the discomfort (Wood and Fitz ^). I recently saw a case of this sort in a neurasthenic med- ical student. RECURRENT APPENDICITIS. When successive attacks occur in the same individual at intervals varying from several months to a year or more, each new attack is spoken of as a recurrent appendicitis. Severe attacks may succeed light ones, or, conversely, mild recurrent may folloAv severe preceding attacks. I recall several cases in which rudimentary appendicitis (indi- cated merely by colicky pain) occurred, and lasted from a few hours to a day or two. Often the illness is too trivial to lead the patient to con- sult a doctor. An absolute diagnosis demands, besides the subjective symptom, pain, the presence of localized tenderness (with or without induration), and elevation of the temperature. In several subjects of recurrent appendicitis formerly under my care the last attack occurred three or four years ago. That each new attack may be the last is always to be remembered. Prognosis. — In forming the prognosis in a given case of appendi- citis the same rules may be followed as in the case of acute infectious diseases. To estimate the severity of the type of infection, however, is not a simple matter. Unlike many of the acute infectious diseases, the height of the temperature and, to a lesser degree, the rate of the pulse are unreliable guides in appendicitis. Broadly speaking, however, in the severer forms the local process exhibits a strong tendency to spread ; the temperature and pulse are relatively high, and there is an intense appendicular intoxication. These are the cases that suppurate or result in perforative peritonitis (often rapidly spreading), and in pericecal abscesses. They are among the gravest of known conditions. Of this fatal group of cases not less than 68 per cent, die before the eighth day. ^ The Practice of Medicine, p. 886. 826 DISEASES OF THE DIGESTIVE SYSTE:\I. The development of fulminant peritonitis or of a peritoneal abscess after perforation is attended by a falling temperature, though subsequently the latter may mount high or become markedly irregular. On the other hand, in the mild forms that are included in the name catarrhal appendicitis recovery is the unvarying rule. These lighter cases often lead to adhesive peritonitis — a circumstance that strength- ens the view that they are of an infectious nature. The temperature is only moderately elevated as a rule, and the pulse-rate correspond- ingly quickened. Both pulse and temperature indicate marked im- provement on the third or fourth day, Avhile the pain and localized tenderness disappear. In this connection the deceptiveness of gan- grenous cases must be recollected {vide supra. Diagnosis). The com- plications that are most likely to arise and other points of prognos- tic significance have been fully stated in the Clinical History. The general mortality of appendicitis is about 14 per cent. (Fitz). Im- proved methods, chiefly surgical, of dealing Avith the disease have, however, greatly reduced its death-rate. The prognosis in chronic appendicitis is most uncertain ; after the patient has survived several attacks it is on the whole more favorable. Treatment of Appendicitis. — Whether imminent danger of per- foration exists or not, the physician who is called to a case of appendi- citis should at once request the services of a competent surgeon. Few surgeons subscribe to the doctrine that all cases demand operation ; but, since it may become necessary to perform celiotomy at any hour there- after, the latter should help to settle the important question : " When is it necessary to operate in the case?" The physician who does not pur- sue the course above recommended falls short of his duty, both toward the patient and toward the surgeon on whose skill he relies to remove safely the source of danger. Surely, in a disease that so often baflles both physician and surgeon, suddenly developing, as it sometimes does, a fatal virulence without previous unfavorable symptoms, they should stand guard together from the moment the case is diagnosticated or ap- pendicitis is strongly suspected. Unfortunately, both the medical and surgical treatment of appendicitis have recently been recommended with great earnestness by their respective advocates. With rare exceptions, prompt surgical intervention should be recom- mended. The indication for an immediate operation is undoubted in all cases of acute appendicitis, whether marked by sudden and severe or mild invasion-symptoms, if seen at the beginning of the attack, and free purgation at the earliest possible moment is not followed by de- cided relief. A waiting policy and medical treatment are also peril- ous in doubtful cases. Obviously, the conditions are less favorable for operation after a case has progressed to the beginning of abscess- formation — /. e. from the third to the fifth day of the illness. It is at this period that the peritoneal inflammation tends to circumscribe itself by the formation of adhesions. Hence, as Richardson states, it is " too late for an early operation, and too early for a safe late operation," since there is great risk of infecting the general peri- toneal cavity. Whether it is Avise to allow the appendix to remain after adhesions have been formed in some cases, and merely to drain, cleanse, APPENDICITIS. 827 and pack the cavity, cannot be discussed here. The mild attacks that develop in the course of chronic appendicitis after numerous previous seizures need not excite alarm. Under such circumstances operation should be undertaken between attacks, Avhen the mortality is practically nil. On the other hand, in cases that have been allowed to drag on un- til general peritonitis has set in. treatment by operation is not advisa- ble. Moreover, the most ardent advocate of immediate operative treat- ment is sometimes compelled to rest satisfied with medical measures. Such cases are those in which there are associated chronic affections (advanced diabetes, Bright's disease), not to speak of those in which the patient declines operation. Hence there is a medical treatment of ap- pendicitis, but it should not be the treatment of election. General Management. — The patient should be kept in bed in a quiet, well-ventilated apartment, and in no affection is the value of absolute rest in the treatment of inflammation greater than in appendicitis. The diet should be liquid and nutritious, consisting chiefly of pancreatized milk and concentrated broths. All articles of food that tend to undergo fermentative changes, and all carbonated drinks, should be prohibited, since they increase meteorism. The patient should be under- rather than over-fed. At the start, and particularly if a sausage-shaped tumor be present, intestinal irrigation, oft-repeated with a view to removing the fecal matter, must be carried forward assiduously. Saline laxatives (Rochelle salts, 3ij — 8.0 — every hour or two, preceded by a dose of castor oil or a few fractional doses of calomel) are to be administered until the evidence of their action upon the bowels has been definitely noted. There almost never exists a contraindication to the use of saline aperients at the onset of the attack, and they constitute the best known means of obviating, as well as limiting, the spread of peritonitis by de- pleting the portal system and emptying the bowels. If commenced early, they may be continued throughout in doses sufiicient to produce two or more daily evacuations. In the event of a development of evidences of peritonitis with pus-formation, salines should be pushed vigorously, unless an operation can be promptly performed. I am aware that many authors advocate withholding purgatives when indications of suppuration appear, but I have yet to see a case in which perforation has followed an active saline treatment. I avoid the use of high enemata in progressive cases, since they are more apt than salines to induce rupture of the sac. As regards the use of opium professional opinion is not united, though a general tendency toward the limitation of its use to the mini- mum amount necessary to alleviate pain is happily noticeable ; unless demanded by excessive suffering it had better be omitted altogether. "When necessary, it is best administered hypodermically in the form of morphin (gr. -^^ — 0.0054-0.0081). The greatest objection to the use of opium is its effect in veiling the symptoms that assist the physician in forming a judgment as to the prospects and progress of the case. Local Measures. — The suspended ice-bag is an excellent means of combating the pain, and often obviates the necessity of an internal use of opium. Instead of the ice-bag, cloths wet in. cold water may be applied and changed every few minutes. In the earlv stage a" few leeches may be beneficial in their effect upon the local' inflammation. Blisters, however, are rarely advisable, and are particularlv objection- 828 DISEASES OF THE DIGESTIVE SYSTEM. able should the patient afterward be submitted to an operation. Mild forms of counter-irritants (mustard-paste) are preferable, though these also render the skin and underlying tissues hard and leathery. Management of Convalescence. — The patient should not be allowed to leave his bed for several days after the disappearance of all symp- toms ; even the mildest forms of exercise should not be undertaken for at least one week subsec^uent to getting out of bed. During convales- cence the diet must be carefully guarded, and the bowels, at all hazards, kept in a soluble condition. It is questionable whether drugs will aid in the absorption of the exudate or assist in resolution. Gentle and per- sistent counter-irritation with preparations of iodin will be found useful. INTESTINAL OBSTRUCTION. {Ileus.) Definition. — An acute or chronic, complete or partial, occlusion of the intestinal canal. Pathologfy and Btiology. — The causes of intestinal obstruction ma}^ be divided, at once most simply and practically, into the (1) acute and (2) chronic forms. In the former variety the narrowing or closui'e develops very suddenly or rapidly, and usually in the small bowel ; in the latter, the large bowel is commonly affected by pathologic conditions that develop slowly and gradually and narrow its lumen ; the latter conditions usually occur in persons of advanced years. Acute. — («) Strangulation. — In the order of frequency, this is first among the causes of acute intestinal obstruction. It is produced most often by bands of adhesion, the result of a former recent or remote peri- tonitis, and is most commonly situated in the right iliac fossa. Incar- ceration of the bowel from flexions and adhesions not rarely follows upon abdominal section for the treatment of pelvic disease in women. The usually free end of Meckel's diverticulum is sometimes attached to the abdominal wall, and may thus cause constriction of a loop of bowel. This diverticulum is the remains of the fetal omphalo-mesen- teric duct, and arises from the ileum about half a meter (1.64 ft.) from the ileo-cecal valve. A similar constricting band is formed by a cord representing one or more of the obliterated omphalo-mesenteric vessels. The adhesive attachment of the free end of the appendix vermiformis may also form an opening through which the bowel may be caught. Internal strangulation (hernia) may be the result of forcing a portion of bowel through a slit in the omentum or mesentery, or into peritoneal diverticula and openings, such as the duodeno-jejunal fossa (Freitz's ret7'o- peritoneal hernia^ or the foramen of Winslow. Diaphragmatic herniiB are not of extreme rarity, and may be either of congenital or traumatic origin. Most cases of intestinal strangulation occur in males during early adult life. {h) Intussusception. — Invagination is the descending " telescoping of one section of the bowel into another," probably caused by a circum- scribed, irregular peristalsis of the intestine. The effect of the latter state in producing invagination may be either a thrusting forward of INTESTINAL OBSTRUCTION. 829 the receiving portion by a contraction of the longitudinal muscular coat (Nothnagel), or a thrusting in'v\'ard and do^vnward of the portion imme- diately above by means of an increased or spasmodic peristaltic action. Thus, a cylindric or sausage-shaped tumor results, varying from a half inch to over a foot (1.3—30 cm.) in length. The layers met with in intussusception are the outer or receiving, called the iJitussuscijneyis, the middle or returning layer, and the inner,, called the intu8susceptu7n. The seat of invagination is most commonly at the ileo-cecal valve, though it is often found in either the ileum or colon alone. Sometimes the in- tussusception occurs and is detected in the rectum. A lateral or partial invagination, more or less chronic, may also occur, due to the attachment of a tumor within the bowel. The intussuscepted portion of intestine is usually the seat of perito- neal adhesions and considerable tumefaction, so that in pronounced cases the parts are so firmly agglutinated that reduction is wellnigh impossi- ble. The engorgement may pass into an intense local inflammation, with final necrosis and sloughing, and even the discharge pe?' rectum of the invaginated portion ; or a fatal termination may be ushered in by perforation of the bowel. Intussusception occurs most frequently by far in children prior to ten years of age, in whom also the disease is more acute than in adults. Males are more subject to invagination than are females. Invagination is asserted to be an occasional consequence of the ope- ration of circular enterorrhaphy and of lateral anastomosis by jjlates (Robinson).^ (c) Volvulus. — Twists of the intestine are met with most commonly at the sigmoid flexure of the colon. An unusually long or relaxed mes- entery predisposes to the condition, so that the axis of twisting may either consist of the mesentery itself or frequently of the bowel. Not rarely the pedicle of the volvulus contains both a twist and a sharp bend in the bowel, causing complete acute strangulation. The latter condition may be pronounced in such cases, or at least be hastened, by the accumu- lation of the intestinal gas and of masses of feces, or by bowel-adhesions to an adjacent stump of omentum (Nieberding). The passive reactive pressure of the coils of intestine and of the abdominal walls tends also to further confine the enormously dilated and twisted loop of bowel to its abdominal state. Knots may be formed by the association of loops of the ileum Avith each other or about the pedicle of a twisted cecum. Here, again, males between forty and sixty years of age have been observed to be especially the subjects of volvulus. Chronic. — (a) Fecal Imjjaction. — Intestinal Concretions. — Accumula- tion of feces (coprostasis) is a common cause of intestinal obstruction, the impaction taking place usually in the cecum or sigmoid flexure. Though not infrequent in children, fecal obstruction is more common in adults (particularly in females), in the hysteric, the demented, and the hypochondriac. Congenital dilatation of the colon may predispose to coprostasis, and an acquired dilatation, which in some cases becomes enormous, is often the result of paresis of a portion of bowel caused by over-distention for a long period of time. The retained fecal masses may become hard, but for some time permit the passage of soft or liquid 1 Med. Record, Aug. 13, 1892. 830 DISEASES OF THE DIGESTIVE SYSTEM. material through the interstices of the accumulation, until finally either complete obstruction takes place or the condition is relieved. So severe may the obstruction prove in some cases as to result in inflammation, ulceration, and even perforation of the bowel. Among other causes of obstruction due to abnormal contents may be mentioned enteroliths. These are intestinal concretions formed of various nuclei, as gall-stones, hardened feces, phosphates of lime and magnesia, various foreign substances, and organic derivatives. Balls of tangled ascarides may mass sufficiently to cause obstruction. Gall-stones not infrequently become impacted in the duodeno-jejunal or ileo-cecal regions after ulceration through the duct, except in the case of very small stones, which enlarge subsequently by accretion. Foreign bodies, as pins, buttons, coins, fruit-stones, may also cause obstruction of the bowel. It is stated that even insoluble mineral medicines, as bismuth or magnesia, have caused obstruction by accu- mulation in the intestines. {h) Tumors. — Tumors cause a form of chronic obstruction that may at any time develop suddenly into the acute type. They may do so either as — (1) ne^v groioths in the Avail of the intestine itself, or by (2) com- pression and traction from tvithout. Again, the intestinal neoplasms may be malignant or benign in nature. Carcinoma of the bowel is at once the most frequent and important of these. It may be either cir- cumscribed and annular, causing a gradual narrowing of the bowel- lumen, or a diffused infiltration of the intestinal wall, commencing either in the mucosa or in its glands (cylindric epithelioma). Its most common seat of growth is the large bowel, about the sigmoid flexure. The mesenteric and retroperitoneal glands are usually secondarily affected. Ulceration of the bowel and catarrhal inflammation of the mucous membrane above the carcinoma may coexist late in life. Sarcoma usually attacks the small bowel, starting beneath the mucosa, and is of the recurrent variety. Regional infection of the mesenteric and retroperitoneal glands {Ldhstein s cancer) is also a usual consequence of sarcoma. It may occur in children or in young adults. Benign tumors may be polypoid, adenomatous, fibromatous, and lipomatous. Intestinal obstruction due to compression or traction may be caused by tumors (omental) or by adhesions of the pelvic viscera. (c) Cicatricial strictures cause chronic intestinal obstruction, as after the healing of various ulcers, the cicatrices of which slowly contract. Cicatricial stenosis of the colon is commonly due to the cicatrization of dysenteric ulcers. In the rectum the stenosis is usually a result of a syphilitic lesion. Tuberculous and, very rarely, typhoid ulceration may be followed by stricture of the small intestine. {d) Congenital stricture is rare, and is more purely surgical than the preceding cases. It is often an occlusion or an imperforate condition of the anus {atresia ani), and is only mentionable in this connection. (e) Paresis of Peristalsis. — This condition — called also adynamic ob- struction — while it is a functional affection, is held to be either a cir- cumscribed or diffuse paresis of the intestinal muscular coat. It is caused by some such inflammatory disturbance as enteritis or peritonitis, or even by the manipulations employed in prolonged abdominal sections. In such cases the obstruction is due to an accumulation of feces and INTESTINAL OBSTRUCTION. 831 gases in the paretic portion of the bowel, causing marked tympanites, vomiting, and constipation. Special Pathology. — The pathologic changes that accompany nearly every form of intestinal obstruction are briefly stated as follows : Accumulative dilatation — with hypertrophy in chronic cases — of the intestine above the seat of disorder, and an emptiness, narrowing, and even atrophy below the obstruction. The affected walls of the bowel are inflamed, and there is a surrounding acute or chronic peritonitis. Catarrhal and sometimes diphtheritic inflammation of the mucosa may develop. Gangrene, ulceration, and perforation of the bowel, with resulting generalized peritonitis, may also ensue. Symptoms. — Acute Obstruction. — There is a suddenly developed ab- dominal pain that may follow some abrupt or severe exertion. Early vomiting and absolute constipation are also conspicuous and important symptoms. If the obstruction is high in the small bowel, distressing hiccough and eructations may precede the vomiting. Except for the possible discharge of the intestinal contents below the seat of obstruc- tion, the constipation is usually complete and obstinate. Accompanying the latter condition there is tympanites, Avhich is most marked in ob- struction of the colon. Intermittent and colicky at first (partial obstruction — Treves), the jjain soon becomes agonizing and constant. Vomiting, also, alternating v^'hh. pai7iful 7'etching, is more constant and severe after several hours. The material at first ejected is gastric and mucous; it then becomes bilious, and finally is characteristically ster- coraceous, due, most probably, to the putrid decomposition of stagnated contents above the obstruction. The constitutional symjjtoms develop early, are intensely threatening to life, and cause rapid and profound depression and collapse. The pinched and pallid features, cool and moist skin, Hippocratic expression, rapid and feeble pulse, the usually subnormal temperature, shallow and accelerated breathing, marked thirst, scanty urine, great anxiety and prostration, — all indicate the gravity and danger of the condition. The physical examination will discover a swollen, extremely tender, and tympanitic belly. Exaggerated peristalsis of the intestine above the obstruction may be visible on the surface of the abdomen. Bor- borygmi, gurgling, and splashing may be heard on auscultation. Chronic Obstruction. — The symptoms are more dependent upon the special causes operating than in acute obstruction. The fact that early in the case only partial obliteration of the intestinal lumen may be rightly inferred in many of the chronic forms of obstruction has given rise to the discriminating term of intestinal constriction. In gen- eral, the clinical history is one of increasing and intractable constipa- tion, sometimes alternating with diarrhea, due to catarrhal inflammation of the mucosa above the obstruction. Paroxysms of colicky pain and, later, augmenting tympanites, vomiting, and jyrostration, attend. These symptoms may merge suddenly into those of the acute form of obstruction. The bowel-movements in chronic obstruction are irregular, infrequent, slight, and sometimes accompanied by pain and tenesmus. The stools consist often of small, hard, ribbon-like, or scybalous masses, and may contain blood and mucus. When the stenosis is in the small intestine the constipation is less apt to occur on account of the fluidity of the 832 DISEASES OF THE DIGESTIVE SYSTEM. contents. Sometimes, and particularly in old people, the rectum be- comes distended with hardened accumulations of feces ; there is in such cases a constant feeling of fulness and a harassing desire to defecate, but the attempts thereat are ineffectual. The pain of fecal impaction may be due either to colitis or to peritonitis, and may be referred to the regions of the cecum or sio-moid flexure. In malignant and in cicatririaJ stenosis there are a prolonged and variable history of constipation, occasional vomiting, localized pain, meteorism. and, in cancerous cases, the development of the characteris- tic cachexia and the progressive emaciation. Physical Examination. — Insjyeetion shows the abdomen to be dis- tended from meteorism, the movements, and contour even, of the coils of intestine in active peristalsis above the seat of stricture being evi- dent. A tumor or the throbbing aorta (excited, perhaps, by pressure of the distended bowel or growth) may be palpated. Tympany and borborygmous noises may also be noted. Diagnosis. — Locality of the Obstruction. — Given the symptoms of a sudden, severe, and exacerbating pain in the abdomen ; of marked, and later feculent, vomiting; of absolute constipation and of tympanites and profound, early, systemic depression, — a diagnosis of acute intestinal obstruction may be easily made. The determination of the seat of trouble, however, is often very difficult. First may be mentioned the differential diagnosis between obstruction occurrinor in the small and in the larjre intestine. It mav be noted of the former that vomiting occurs early, is scanty, and later feculent, while in the latter there is less vom- itino; and the vomitus is seldom feculent. Again, in obstruction of the small gut the distention is both less marked and higher situated, while in that of the large gut tympanites is often quite marked, is more cen- tral, is associated with tenesmus, and sometimes Avith mucus and blood. If the cause of obstruction be a tumor or stricture, the locality may be successfully palpated or the lower limit of the active coils of hypertro- phied intestine may be defined. In stenosis of the duodenum or jejunum, owing to the stagnation and decomposition of albuminous substances, the products of which (indol and phenol) are absorbed and partly excreted by the urine, use may be made of the discovery of increased amounts of indican in the urine for diagnostic purposes. On the other hand, in stenosis of the large intestine the urinary test may be negative, since the albuminous elements of the intestinal contents are absorbed before they reach the stenosed portion of bowel, where stagnation and putrefaction can take place. Examination per rectum with the finger or with the rectal tube, by means of liijuid distention or gaseous inflation of the colon, may enable us to determine the seat of obstruction in certain cases. The detection of a deeply-seated incarcerated hernia (in the abdominal fossae and pouches, diaphragm, or obturator foramen) is often made only postmortem. Nature of the Obstruction. — This is even more difficult of discovery than the preceding. The following causes of obstruction with their differentiation may be referred to in attempting a diagnosis : Strangu- lation often affords a previous history of peritonitis or abdominal sec- tion or of recurrent attacks of abdominal pain, occurring mostly in young adults. Early fecaloid vomiting is common. INTESTINAL OBSTRUCTION. 833 Intussusception usually gives a negative previous history. The sud- denness of the attack, without appreciable cause, occurring in a child, and associated with colicky pain, tenesmus, and the presence of mucus and bloody stools, and of an elongated cylindric tumor in the right iliac or umbilical regions, however, render this condition easy of diag- nosis in some instances. It is to be noted that absolute constipation and meteorism here are unusual. The intussusception may be felt in the rectum. In volvulus it may be helpful to elicit a history of former constipa- tion and flatulence, with evidences of atony of the bowel, in persons of advanced years, along with marked abdominal tympany, tenderness over a distended coil, which may perhaps be outlined (Wahl), a rigid abdomen, and sometimes dyspnea from great gaseous distention. The history in cases of fecal obstruction is nearly always one of obstinate, habitual constipation, and occurs especially in females and neurotic subjects. The onset is gradual ; pain is less acute; and tym- pany and fecal vomiting are less prominent and late in appearance. Fecal masses in the colon and rectum may be palpated, and even in- dented, particularly in the cecal and sigmoid flexures. Dulness is present on percussion, with slight tenderness over the tumor. Obstruction due to large enteroliths or foreign bodies may be only surmised ; especially is this true when symptoms of appendicitis arise. Biliary calculi may give a history of previous attacks of hepatic colic and jaundice. In the chronic obstructive form of stricture of the bowel due to cica- trices or neoplasmata the history of dysentery, tuberculosis, sarcoma, or carcinoma should be considered. The detection of an irregular tumor and the cancerous cachexia point to malignancy. In obstruction caused by intestinal paresis there is generally a history of a previous enteritis, peritonitis, or celiotomy. The abdomen is smooth, though tympanitic throughout, and there is no perceptible peristalsis. Not rarely it will be of therapeutic as well as of diagnostic import- ance to ascertain whether an attack of acute obstruction is primary, or whether it is the terminal exacerbation of a chronic condition, such as carcinoma of the bowel. Here a study of the past history of the patient, as well of the present signs of a probable nature, will afford considerable aid. Differential Diagnosis. — Acute intestinal obstruction must be discrim- inated from acute generalized peritonitis. Acute Generalized Peritonitis. Acute Intestinal Obstruction, Etiology. There is a history of causal conditions or There is a history of previous chronic diseases (ulcer, appendicitis, pelvic in- obstruction or hernia. (The age of fection). the patient if it be intussusception.) Symptoms. An early and considerable rise of temper- No early rise (except in volvulus), but ature ; later variable or may be absent. later with advent of peritonitis. Pain more continuous and diffuse. Pain in short paroxysms and localized. Vomiting is characteristic, but not ster- Vomiting becomes characteristically ster- coraceous. coraceous. Collapse occurs later. Earlier onset of collapse. Slight increase of indican in the urine. Excessive indicanuria, particularly when the small intestine is obstructed. 53 834 DISEASES OF THE DIGESTIVE SYSTEM. Physical Signs. Distention of the abdomen is usually Less marked (sometimes partial), unless general and marked. the obstruction be situated in the lower seo;ment. Visible peristaltic waves absent. Present and pronounced when the seat of obstruction is low. Tenderness general. Tenderness localized. Signs of effusion appear. Less common, due to secondary perito- nitis. Auscultation negative. Loud gurgling and splashing sounds au- dible on auscultation. Prognosis almost hopeless. Not so if operated upon early. It must also be differentiated from acute enteritis, in Avliich (particu- larly when due to toxic minerals) there is more apt to be diarrhea with considerable mucus and blood, an elevated temperature, intense gastric pain, associated with traces of the poison in the vomitus, as well as with its effects on the oral mucous membrane, and an absence of marked tympanites and fecal vomiting. There are also localized pain, tender- ness, and tumor, or there may be collapse. The various forms of abdominal colic, as enteralgia, hepatalgia, and nephralgia, should not be mistaken for acute intestinal obstruction after considering the history of the cases, the character and locality of the pain, and the absence of such symptoms as obstinate constipation, fecal vomiting, early collapse, intense local pain and tenderness. Course, Complications, and Prognosis. — A case of acute ob- struction usually terminates within from two to seven days. The chronic form may last weeks, and even months, with progressive emaciation and anemia, until the superaddition of more or less acute symptoms, lasting from ten to fourteen days. As a rule, the prognosis is wholly unftivor- able, and especially in the acute cases. The chronic forms, due to fecal or other impaction, often recover with the discharge of the disturbing intestinal contents. Life may be prolonged by surgical interference in certain cases if they are taken in their inception. Complications that may occur, as secondary peritonitis, gangrene, perforation, septico-pyeraia, and enteritis, are all grave, and only tend to hasten the dissolution. Treatment. — Whilst the treatment of intestinal obstruction is sooner or later essentially surgical, attention to the medical aspect is frequently of prime importance. The first indications for therapeutic interference in acute obstruction are presented by the pain and the incessant vomiting. The former is to be met by hypodermic injections of morphin, which at the same time tend to arrest the excessive peri- stalsis. For the vomiting no other measures are comparable to gastric lavage and starvation. It is well in most cases to withhold food for some hours to prevent retching and aggravation of the condition. The lavage is strongly advised by Kussmaul. who claims that both the tension above the seat of stricture and the inordinate peristalsis are thus greatly diminished and, exceptionally, cured. It may be repeated every six hours. A diagnosis of intestinal obstruction having been made with- out having learned the cause or character of the obstruction, cathartics should absolutely not be given. If it has been determined that fecal impaction is the trouble, it is still prudent to avoid purgatives until the CARCINOMA OF THE INTESTINE. 835 main mass has been moved, as in many cases there are both paresis and inflammation at the seat of impaction, so that this class of agents would thus be useless, if not harmful. High rectal injections, copious, steady, and regularly repeated, are to be practised, using for this purpose pre- ferably "a warm saline solution of olive oil" (particularly if scybala be present) administered while the patient is in an inverted position by means of a fountain syringe, so that the flow is readily controllable. The abdomen should be methodically kneaded (a valuable adjunct in the procedure) and the patient at times well shaken. This method of treatment, by hydrostatic pressure, can and must be carried forward without undue violence, and if it be unsuccessful, the intestines are to be inflated from a large india-rubber bag with air or hydrogen gas (Senn), of Avhich two to three gallons may be cautiously introduced. Thorough manipulation of the abdomen from below upward, particularly if it be a case of intussusception, may be combined. In the latter con- dition inflation, early and perseveringly applied, cures the majority of instances. In cases of intussusception or strangulation of the bowels these efibrts should be continued for twenty-four hours, when, if the condition is not relieved, immediate operation is to be encouraged and advised. Although the statistics of Fitz show the mortality in cases without operation to be lower (69 per cent.) than with operation (83 per cent.), I am convinced from personal observation that the less favor- able results from abdominal section would not obtain if it were per- formed in due time. To relieve the excruciating tympanites the plunging of a fine trocar and cannula into the intensely distended bowel, as in case of volvulus, may be required. In chronic obstruction the treatment of the underlying or etiologic conditions and various complications is to be conducted on general prin- ciples. Additionally, the patient's dietary is to be arranged with care, and the bowels moved with unfailing regularity, by the use of unirri- tating laxatives and enemata. During the periods of threatening com- plete occlusion, with pain, the methods advocated above for acute ob- struction are appropriate. If total obstruction persist despite medical treatment, surgical treatment — enterectomy, enterotomy, or other opera- tion, as the circumstances of individual cases may dictate — is required. The after-treatment consists in keeping the bowels active and regular by habit, diet, and an aperient pill if needed. Massage and electricity to the abdomen are found useful at this time. CARCINOMA OF THE INTESTINE. ( Carcinoma Intestinalis .) Carcinoma of the intestine is perhaps the commonest cause of chronic intestinal obstruction. The stenosis is usually partial, and is due both to couipression and to direct invasion of the lumen of the bowel by the growth. Primary intestinal carcinoma is rare in comparison with the occurrence of gastric carcinoma. Pathology. — When carcinoma attacks the intestine it is usually in the form of a cylindric-celled epithelioma, although it may assume the 836 DISEASES OF THE DIGESTIVE SYSTEM. various forms as found in carcinoma of the stomach — namely, scirrhous, medullary, and colloid. The growth may be annular or semipolypoid, or it may occur as a diffuse nodular infiltration of the bowel-walls. Ulcera- tion of the surface of the carcinoma may take place, and the glandular structures of the abdominal cavity sometimes reveal metastatic growths. The most frequent seat of intestinal carcinoma is the rectum, and next in order of frequency are the sigmoid flexure, the transverse and descend- ing colon, the papilla duodenalis, the ascending colon, and the lower and middle portions of the ileum. The bowel is dilated above the constric- tion, and is usually filled with an accumulation of fecal matter. The muscular coat is hypertrophied. Below the narrowing the intestine may be small and atrophied. Htiology. — Heredity and advanced age are of chief importance as predisposing causes. "Whether or not antecedent intestinal ulceration mav afford a probable nidus for carcinomatous growths is doubtful. Symptoms. — A description of the course of rectal carcinoma belongs more properly to surgical Avorks. The chief symptoms are progressively increasing distress and radiating pain in the rectum ; these occur, at first, durincr defecation only, but later almost constantly. There may be diarrhea alternating with constipation, and the feces often contain blood and mucus. Gradual bodily ivasting and increasing mental anxiety are associated. Paralysis of the anal sphincter and consequent incontinence may ensue. The symptoms of carcinoma of the bowel above the rectum are often vacrue, and vary according to the portion involved by the neoplasm. With or without an appreciable tumor in the abdomen the clinical his- tory is usually that of chronic obstipation of the intestines. There are irregular attacks of sharp, colicky pains, especially a few hours after eating, distressing defecation, obstinate constipation, perhaps alternating with diarrhea, sometimes vomiting, which may be feculent, and not rarely slight meteorism. The special symptoms of carcinoma of the papilla of Vater are vomiting, jaundice, and colic. The progressive emaciation and debility of the patient are marked. In advanced cases of stenosis the feces are passed in small, compressed lumps resembling sheep's dung. Physical Examination. — Inspection of the abdomen may show the presence of a tumor produced by the carcinomatous growth along the line of the sigmoid flexure or colon : peristalsis may be seen above the site of the carcinoma, communicating its movements to the abdominal walls. Palpation may be resorted to in order to confirm the above, and the growth is then frequently found to be nodulated. Percussion may give either dulness or a muffled tympany over the tumor and for some distance above, on account of accumulated masses of feces. This area of impaired intestinal tympany may be sharply defined by a clear tym- panitic note elicited over the empty bowel below the growth. Diagnosis. — This may rest, in some cases, upon heredity, the age, the evidences of the cancerous cachexia, sharp, radiating abdominal pains, bloody stools, and the detection of a more or less firm and nod- ular tumor. Differential Diagnosis. — {a) Carcinoma of the bowel above the rectum needs to be discriminated from other abdominal tumors. The presence of the following may render the diagnosis of carcinoma during life well- ni'^h impossible : sarcomata, fibromata, myomata, adenomata, and cys- CARCINOMA OF THE INTESTINE. 837 tomata, all of whicli may produce symptoms of obstruction like those due to carcinomatous growths. The cancerous cachexia may be simu- lated by other conditions. The advanced age of the patient and the distressingly rapid and downward progress of the disease will, however, point toward malignancy. Fecal tumors., enteroliths, diXidi foreign bodies may need to be excluded also. Fecal masses have been mistaken for carcinoma, and when it is recollected that such may exist above and overshadow the presence of carcinoma of the intestine, the difficulty in differentiating the two is quite obvious. {h) The portion of the bowel involved by the neoplastic growth is also difficult of definite diagnosis, except when it occurs in the rectum, when the digital and visual examination of the parts, supplemented, it may be, by microscopy, are sufficient. The locality of the tumor as detected by palpation, associated with special symptoms, is of value in arriving at a diagnosis of the diseased portion of bowel. Heulin ^ has studied carefully primary cancer of the duodenum, and asserts that the com- parative frequency of duodenal involvement is due to limited motion of the organ, being thus subject to injury. When it occurs above the papilla of Vater the symptoms greatly resemble those of dilatation of the stomach. An important point separating carcinoma above from that below the papilla is the presence or absence of bile in the vomit, being abs.ent if situated above. When the carcinoma involves the papilla of Vater symptoms of biliary obstruction necessarily follow. A hard nodular mass may sometimes be felt in the lower epigastric region; this coupled Avith increasing gastric dilatation and marked persistent jaundice would indicate carcinoma of the duodenum. It is apparent, however, that carcinoma of the pylorus, of the left lobe of the liver, or of the omentum or mesenteric glands, or a thickened cecum might all be easily confounded with carcinoma of the bowel at various adjacent parts of its course. The injection of filuid into the bowel may be re- sorted to in locating the probable situation of the growth. Thus, if obstruction from carcinoma exists in the sigmoid flexure, liquid will be arrested there and the rectum distended ; while, if the stenosis be high up in the large or small intestine, the colon will be found comparatively emptied of feces and will be distended with the injected liquid. Course and Complications. — Carcinoma of the intestine some- times runs a rapid course, and, symptomatically at least, lasts but a few months or even Aveeks ; in the scirrhous variety, hoAvever, the disease may last two or three years. Intestinal carcinoma may perforate the bowel and cause fatal puru- lent peritonitis, and carcinoma of the rectum may perforate and invade the vagina and bladder, causing purulent vaginitis and cystitis. Or, OAving to extreme distention by fecal accumulation betAveen a cancerous stricture of the sigmoid flexure, for instance, and the resistant ileo-cecal valve, rupture of the colon, folloAAcd by a terminal peritonitis, may result. Extension of the groAvth into surrounding tissues, with ulceration, may lead to cellulitis, phlebitis, and pyemia. The prognosis is almost hopeless. Treatment. — This, from a strictly medical standpoint, is simply 1 Gaz. hebdom. de Med. et de Chir., Feb. 13, 1898; Thhe de Paris, 1897; Saunders' Year-Book, 1899, p. 194. 838 BISEASES OF THE DIGESTIVE SYSTEM. palliative. The diet should be highly nourishing and easily assimilable, but \shen the symptoms of acute obstruction supervene the administra- tion of food by the mouth is contraiiidicated. Attention to the state of the bowels by the use of enemata, or of the aloin, strychnin, and bella- donna pill is necessary in most cases. Opium or cannabis indica for the pain, and stimulants for the depression, may also be serviceable. Lavage of the stomach gives decided relief Avhen decomposing mat- ters tend to cause regurgitation on account of the damming back of accumulated food-detritus. Carcinoma of the bowel may be treated surgically by colotomy, ex- cision, lateral anastomosis of the bowel, enterostomy, and, if the groAvth be situated in the rectum, by extirpation by means of sacral resection [Kraske's operation). HABITUAL CONSTIPATION. ( Costiveness.) Definition. — Chronic fecal retention, habitual infrequency, irregu- larity, difficulty, or insufficiency of the evacuations of the bowels. Although constipation is a symptom, and although habitual consti- pation is frequently a symptom of chronic disease, the causal elements of the latter may be so indefinite and obscure that the former takes on all the individual importance of a functional affection. I describe habit- ual constipation, therefore, as a disease sui generis ("idiopathic"). Htiology. — In the majority of cases habitual constipation is the direct effect of a lack of expulsive or peristaltic power, and also of a deficiency of the hepatic and intestinal secretions. Two sets of causes operate to bring about these conditions of abnormal defecation : General Causes. — (a) Temperament : it has been observed often that people of a nervous and "bilious " or motive temperament, of the dark type — brunets with a predominating nervo-muscular susceptibility — are much troubled with inherent constipation. Anemic brunets — per- sons having pale skin and dark hair combined — are particularly so alFected, although alternating periods of diarrhea may supervene, owing to the hydremic state of the blood. "Torpid liver" and "sluggish bowels " are commonly held to be synonymous with these physical cha- racteristics. (6) Habit : a sedentary life conduces to secretive inactivity. Thus, a lazv life, in which the calls of nature are irre^ularlv attended to or habitually neglected, leads to frequent over-distention of the rectum and paresis, a common cause of chronic constipation. Again, the femi- nine false modesty (so called) that prompts a postponement and suppres- sion of the desire to defecate in public places, as well as the habitual, hurried performance of the act in illy-kept, uncomfortable, and unsani- tary closets, — all these tend to obtund the sensibility of the bowel to fecal masses in the rectum. The accumulation of these fecal masses causes paralytic over-distention. their hardening into scybala, and diffi- culty of expulsion, (c) General bodily iveakness., and diseases, as neur- asthenia, hysteria, anemic brain- and spinal-cord affections (causing inhibitory disturbances of the intestinal nerve-supply), acute fevers, hepatic disorders, especially the presence of jaundice, and the habitual HABITUAL CONSTIPATION. 839 dependence'upon and use of purgatives, (d) Diet: the constant use of concentrated articles of food, as meats, in which little residual mat- ter is left to stimulate the bowel to peristalsis. On the other hand, a very coarse diet may leave such an excess of residue as to cause fecal impaction, (e) Abundant and i^rolonged diuresis and diaphoresis, by causing loss of fluids, also may induce chronic constipation. Local Causes. — (a) Atony of the abdominal 77iuscles from obesity or, in females, as a result of many pregnancies. (6) Atony of the large boivel (the sigmoid flexure in particular) from chronic colitis, (c) Pres- sure by tumors, (d) The presence of intestinal stenosis from external or internal constriction, {e) Congenital stricture or giant groiuth of the colon, with coprostasis (as in Formad's case) (Functional Neuroses of the Intestines, vide p. 846). Symptotns. — In cases in which there is no adequate cause for habit- ual constipation other than a constitutional and perhaps an inherent pe- culiarity there may be the appearance of perfect health. Nothing is complained of save the fact that an evacuation of the bowels occurs too infrequently. It should be borne in mind here, hoAvever, that the term " constipation " is, individually speaking, almost wholly a relative one — i. e. one person may enjoy good health with but one evacuation every other day, another with two passages per diem, while still another must have one stool a day, cceteris paribus, to feel perfectly well. The last is usually considered an average normal state with most people. Persons such as are instanced above, in apparently good health, but observing that they have to defecate less often than many others, sometimes grow anxious, worried, and even hypochondriac, until assured that they are not truly constipated if enjoying perfect physical ease. Symptoms of habitual constipation may be direct or reflex. Direct or local troubles are seen in the feeling of fulness, weight, and pressure in the perineum and abdomen. Flatulence, colicky pains, and alterna- ting diarrhea occur not infrequently. The hurried and inattentive per- formance of defecation gives rise to the so-called '' cumulative constipa- tion," in which the accumulated feces are but partially evacuated with the movement, and the rectum consequently is not emptied. A sense of fulness then remains, and complete relief is not felt in these cases. Reflex and general symptoms are malaise, languor, hebetude, irrita- bility of temper, headache, facial flushing, palpitation, cold extremities, anorexia, vertiginous attacks, paresthesia, menstrual distress in women, sleeplessness, and bad dreams. Pressure on the sacral and visceral nerves may cause neuralgias. The tongue is coated. Palpation of the abdomen often shows the presence of doughy-like fecal tumors at the cecum or at the hepatic, splenic, and sigmoid flexures, or of bologna- like masses at intervening places. In marked cases attacks of nausea and vomiting, with diarrhea, may ensue ; fever may also be present, and typhoid fever even may be simulated (Meigs). Complications and Sequelae. — Hemorrhoids, ulcerative colitis, perforation, and enteritis may be associated with chronic constipation. Not rarely do we have as results dilatation of the colon or sacculation, with the presence, in old people mainly, of enteroliths (calcified scyb- ala) ; also intestinal obstruction and typhlitis, or cerebral hemorrhage or hernia from violent strainino- efi"orts. 840 DISEASES OF THE DIGESTIVE SYSTEM. Diagnosis. — Bearing in mind the relativity of constipation in dif- ferent individuals, the diagnosis is read at sight. The detection of the causes is not difficult, though sometimes tedious. Hypochondriasis or melancholia should be carefully placed either as precedent to or conse- quent upon chronic constipation, the nervous condition often acting to produce the latter, and vice versa. The prognosis is usually favorable, but should be guarded. Treatment. — Hygienic. — Causative factors must, of course, be re- moved, modified, or lessened. Systematic regularity as to time and frequency and sufficiency of movements of the bowels should be en- joined upon and practised by the patient. Exercise is of signal value, and particularly horseback riding or gymnastic motions that bring the ab- dominal muscles into play. Attention to the calls of nature should be esteemed a duty, and proper time and heed must always be given to the completeness of defecation. Young girls especially should be in- structed in this regard. The wholesale swallowing of cathartics is to be vigorously combated. The dietetic regimen, if properly looked after, often avails much in relieving this affection, and foods calculated to be easily digestible, but leaving a moderate residue after digestion, are to be recommended. Such are bread made of unbolted flour, plenty of vegetables and fruits, butter, and such laxative articles as figs or honey. A glass of cold water taken regularly at bed-time and in the morning before breakfast is efficacious and a point of common knowledge. Remedial. — The methods and means offered for the cure of chronic constipation number legion. From the little aperient pill or "peristaltic persuader " to the cannon-ball rolled externally along the course of the large bowel is made up such a list of drugs and measures as to leave un- tenable any plea of lack of resource that may be advanced. Drugs occupy a subordinate part in the treatment of habitual constipation. Indeed, their use should be restricted mainly to those periods when the bowels become unusually obstinate and when a more or less free movement is urgently needed. That the constant use of laxative and purgative drugs tends to a confirmation of the condition, and its ulti- mate resistance to the action of cathartics when circumstances will have required their use, is familiarly known. I have found of value in lithemic and dyspeptic subjects the laxative bitter waters (Hunyadi Janos, Kissingen, Friedrichshall, Carlsbad). Drugs employed to unload a filled bowel may at times be used spar- ingly and in the smallest adequate quantities ; the mildest forms should be selected. Since the constipation is only temporarily relieved by catharsis, the frequent use of strong purgatives in large doses only tends to render the bowel accustomed to their use. Creosote in large doses has recently been highly recommended; it probably relieves the constipation by overcoming the intoxication. Among those laxatives and cathartics most commonly used may be mentioned aloes, rhubarb, Rochelle and Epsom salts, compound licorice powder, castor oil, jalap, senna, mercury, colocynth, and podophyllin. Important adjuncts in combination with one or more of the above are the extract of nux vomica (or strychnin) and the extracts of belladonna, hyoscyaraus, and physostigma. The much-used aloes, strychnin, and belladonna pill can be used for a considerable length of time in the hope HABITUAL CONSTIPATION. 841 of stimulating a normal intestinal and sphincteric activity, and thus in- ducing even a cure in some cases. The formula may be made up as follows : B^. Aloin., gr. iij-v (0.194-0.324); Strychnintfi sulphat., gr. f-i- (0.0216-0.0324); Extr. belladonuc^, gr. ij-ijss (0.129-0162). M. et div. in pil. No. xx. Sig. One pill at bedtime. Sulphur in confection, along with the official pill of aloes and iron, has been recommended for the habitual constipation of anemia. In senile atony of the bowel, with much flatulence, a laxative pill having in combination asafetida or capsicum is often beneficial. The subjoined formulae are also rationally and empirically service- able in chronic constipation : ^. Ext. cascar. sagrad., 3ss (2-0) ; Ext. nucis vomicae, gr. iv (0.259); Ext. physostigmat., gr. iij (0.194) ; Ext. belladonnie, gr. ij (0.129). M. et ft. in pil. No. xx. Sig. One at night, or night and morning. (Aloes, gr. j (0.0648), or podophyllin, gr. ij-iij (0.129-0.194), may be substituted for cascara in the foregoing formula.) Or, I^. Ext. colocynth. comp., gr. xxx-xl (1.94-2.59) ; Ext. hyoscyami. gr. x-xx (0.648-1.29); Ext. nucis vomic, gr. iv (0.259); Ext. gentian?©. gr. XX (1.29). M. et ft. in pil. No. xx. Sig. As above. The meclianical means of relieving habitual constipation, as by enemata, are injurious if long continued, by reason of their irritating effect on the rectal and colonic mucous membrane, as well as on account of their tendency to become incompetent. At times, when the stomach is weak or irritable, a loaded bowel may be relieved by an ordinary enema of soap and water or by one containing -|- to 1 ounce (16.0— 32.0) of castor oil, with 1 or 2 drams (4.0-8.0) of oil of turpentine if there be some flatulence. Glycerin enemata, containing from |- to 2 ounces (16.0-64.0) of the agent, may be used. Suppositories of soap, molasses candy, or glycerin are included in the armamentarium. 3Ias- sage also claims an important part in the relief of habitual constipation. It acts by stimulating the peristalsis and the abdominal muscles, and should be employed at set times in the day preceding a desired evacu- ation of the bowels. The hand of the masseur^ or that of the trained patient even, when systematically used in this way, may be effectual when all other means have failed. The regular rolling of a metal ball along the course of the greater gut may be mentioned for its novelty as well as for its undoubted efficacy. The application of the faradic cur- rent to the abdominal walls or galvanization of the lumbo-abdominal 842 DISEASES OF THE DIGESTIVE SYSTEM. circuit deserves proper trial in many cases. Hydro-therapeutic meas- ures, or cold sponging and baths, are nearly always useful adjuncts in the treatment of this often stubborn affection. DILATATION OF THE COLON. [Ectasia of ihe Colon.) This is usually a chronic condition, though not rarely it is acute. It may also be general, but in the majority of cases it is confined to the colon, and particularly to the sigmoid flexure. The post7no7'tem findings are those of hypertrophic dilatation of the bowel, and rarely (as in a case of Rolleston and Hayward ') ulcerative and catarrhal lesions of the in- testinal mucosa are noted. The sigmoid flexure is prone to become di- lated in subjects in whom it is congenitally elongated. Mya^ believes that the condition is due to a faulty development and not to fetal dis- ease. The most distinctive features are constipation., which generally dates from infancy, and great abdominal distention. In the case of Rolleston and Hayward peristaltic waves were visible upon the surface. The condition may fluctuate, constipation alternating with regular daily movements, and the distention changincr to a normal softness of the ab- dominal parietes in some instances. I have recently seen a case of this kind in a male aged twenty-seven, in Avhora the affection had commenced in infancy. In the treatment of the constipation resulting from congeni- tal ectasia of the colon, lavage of the intestine with a very long tube is superior to laxatives or purgatives. NEUROSES OF THE INTESTINE. Afi in the case of the stomach, these embrace derangements of [a) secretion, {h) sensation, and (c) motion. (a) SECRETORY DISTURBANCES. Unquestionably the intestinal secretion may, through a purely ner- vous influence, be augmented. This manifests itself most frequently in the primary morbid secretion of mucus {mucous colic) and in membranous enteritis. Moreover, the fact that an actual catarrh of the intestinal mucosa may supervene as a secondary event is undeniable. MEMBRANOUS ENTERITIS. {Enteritis Membranacea.) Definition. — A peculiar pathologic condition, chiefly of the large intestine, attended by a morbid secretion of mucus. Pathologfy. — In the truly primary form there are no morbid lesions 1 BritUk Medical Joitnml, May 30, 1896. •^ Lo Speriiiientale, 1894, fasc. iii. p. 215. NEUROSES OF THE INTESTINE. 843 discoverable in the mucosa. Osier states that the membrane is due to a derangement of the functions of the mucous glands the nature of which is unknown. My own view is that this is a secretory neurosis, and that the catarrhal process may develop as a secondary event. Htiology. — Sex has a decided influence ; according to W. A. Ed- wards, not less than 80 per cent, of all cases occurring in adults are noted in w^omen. Hysteric females and those of a highly neurotic con- stitution are the most frequent victims of the disease, which is rare in children. Symptoms. — I have found the condition to be invariably associ- ated with a decidedly constipated habit — a fact that may, in part, ex- plain its occurrence, since time is thus allowed for the formation of the membrane. The most important clinical feature is the passage, at var^/- ing intervals., of long, ribbon-like threads of mucus, or of more or less perfect casts of the gut, the act being attended with tenesmus and severe colicky pains. The composition of the stools has been thoroughly in- vestigated by M. Rothmann and 0. Rothmann and C. Ruge. They " consist of a uniformly turbid ground-substance, which, on the addition of acetic acid, becomes opaque and striped. It is interspersed with a cellular detritus, consisting partly of strongly refractile granules and partly of cellular elements, desquamated epithelial cells, round cells, and peculiar glossy flakes. There are also found cholesterin-crystals, needles of fatty acids, triple phosphates, remnants of undigested food, pigment- granules, many bacteria, and occasional red and white corpuscles." The individual paroxysms vary in duration from one to ten days or more. In one case observed by me the attacks lasted about two days, recurring regularly at the end of every three months. Ordinarily the recurrence is after a shorter interval. Diagnosis. — It is important to make a microscopic examination of the pieces of membrane. If, when thus examined, mucus, cylindric- celled epithelium, a few round cells, and the other elements already mentioned are found present, the diagnosis of mucous enteritis is un- doubted. It is to be recollected, however, that membranes are not passed wuth every attack. Course and Prognosis. — The disease pursues a very chronic course and lasts for many years. The bodily nutrition sufi"ers consider- ably if the attacks are frequent and severe, though, as a rule, this does not occur until a late stage in the afi'ection. The risk to life, it is need- less to say, is slight. (6) SENSORY DISTURBANCES. It may be noted here that the sensory nerves of the intestines, as well as the inhibitory and vaso-motor dilators, are traceable to the splanchnics. Increased sensibility of the sensory nerves produces — ENTERALGIA, {Neuralgia of the Intestine.) etiology. — This is commonly met with in hysteric, neurasthenic, and anemic subjects. It occurs as a reflex neurosis, as in the case of 844 DISEASES OF THE DIGESTIVE SYSTEM cold, gout, and irritative lesions of the pelvic organs (kidneys, liver). Enteralgia is symptomatic of many local affections and conditions that induce direct irritation of the sensory nerve-filaments of the in- testine ; among these are inflammation of the mucosa, foreign bodies, gall-stones, abnormal distention with gas. and enteroliths. Under these circumstances the condition is associated with increased activity of the motor nerves or heightened contraction of the muscularis. forming true intestinal colic. In lead colic it is probable that the lead acts directly upon the nerves or their ganglionic cells. I have repeatedly observed the action of certain exciting causes, and particularly of nervous shocks. Symptoms. — Enteralgia may develop very suddenly, but oftener it sets in less abruptly, and is then attended with eructations of gas, ex- pulsion of flatus, and the like. In the fully-developed attack the pain may attain to great violence, causing the patient to "bend double" or even faint, and its character is variously described as boring, tearing, or cutting. The pain may be confined to a circumscribed spot or may be diff^use. The attacks are sometimes brief, or they may be character- ized by a sudden subsidence. At other times they last for days or per- haps weeks, and then subside gradually. Recurrences are common, but the intervals between the attacks vary extremely in duration. Hypogastric neuralgia is a term applied to neuralgia aff"ecting the sensory nerves lying in the most dependent segments of the intestine. Here the nerve-fibers entering into the hemorrhoidal plexus are involved. It is caused chiefly by tabes, by hemorrhoids, and by the neurotic state so common to females. This form of neuralgia has its seat in the hypo- gastric region, and is accompanied by a distressing sensation of pressure in the rectum and bladder, and by an irresistible desire to go to stool ; pains also radiate to the sacrum, thighs, and perineum. Diagnosis. — The various organic diseases and conditions mentioned under Etiology, in the course of which colic is a common symptom, must be separated from the true neurotic enteralgia. The former are distin- guished from the latter by a group of symptoms peculiar to themselves (fever, aggravation of the pain upon pressure, vomiting, constipation, or diarrhea), and by the usual definite causes furnished by the history. Renal and hepatic colic bear a superficial similarity to enteralgia. The former conditions, however, are distinguished first by the seat and direction of the pain, and secondly by the appearance of jaundice in hepatic colic and of hematuria in renal colic. Rheumatism of the abdominal muscles is easily eliminated, since it is generally combined w^ith rheumatism in other parts of the body ; the pain is also greatly increased upon throwing the muscles into contraction, as in stooping or rising ; finally, it vanishes in response to the action of the salicylates. DIMINISHED INTESTINAL SENSmiLITY. This implies diminished peristalsis or constipation. A greater or less degree of anesthesia of the bowel attends, with a loss of desire to go to stool and an accumulation of feces in the rectum. This is a usual concomitant in many diseases of the brain and cord, with which paraly- sis is associated. Motor innervation may remain intact, and when atony NEUROSES OF THE INTESTINE. 845 of the intestine is absent spontaneous movements of the bowels occur ; when atony is present, however, to a marked degree (motor paralysis), the feces must be artificially removed. (c) DISTURBANCES OP MOTILITY. When the contractility of the muscularis is increased from purely nervous causes the result is — NERVOUS DIARRHEA. This condition presents no morbid lesions. The increased contrac- tility results from an exaggerated irritability of the motor nerves of the bowels. It may also result from morbid processes in the central nervous system and in other organs of the body ; in short, the condition may be a reflex one. Examples of this sort are caused by tabes, by gastric disturbances, as after certain foods and drinks, by dentition, and the like. Most cases, however, are encountered in persons having an abnormally irrita- ble nervous organization — ^. e. the neurasthenic and hysteric classes. In such the effect of mental excitement, of fright, and similar psychic influences is to induce diarrheal evacuations. Symptoms. — The stools vary in number from two or three to twenty-four or more daily. In rare instances they are soft — not truly diarrheal — and formed, yet they may be quite frequent. Blood and mucus, pus, and other morphologic elements are absent from the de- jections. It is characteristic of nervous diarrhea that the stools follow one another in rapid succession, usually during the morning hours, and then discontinue for the greater part of the day. The bodily nutrition is often well preserved. In the diagnosis organic affections of the bowel are to be carefully eliminated. ENTEROSPASM. {Spasm of the Intestine.) By this term is meant a concurrent spasm of both the longitudinal and circular muscular fibers, usually inducing spasmodic constipation, and sometimes total, though temporary, occlusion of the bowel. Its causes are similar to those of nervous diarrhea, and the condition is clinically related to enteralgia. Neither pain nor constipation, how- ever, is a constant feature. The stools may assume the form of a rib- bon or of large rounded masses (sheep's dung), but they are not pathog- nomonic. They may also be covered with mucus. Ewald distinguishes between an idiopathic and a secondary or symptomatic spasm, the lat- ter being a concomitant of basilar meningitis and of chronic lead- poisoning. Another variety affects the rectum (proctospasin), and is generally secondary to some other rectal affection, as fissure of the anus ; it may, however, occur as a neurosis in the hysteric and nervous class of subjects. The diagnosis of true functional enterospasm can only be made after all organic causes that may produce spasm of the bowel have been excluded. 846 DISEASES OF THE DIGESTIVE SYSTEM. CONSTIPATION. This is a common condition as a functional neurosis. It is due to an abnormity of function of the intestinal nerves that leads to a weak- ened peristaltic action, and is met with in hysteria, neurasthenia, and in those suffering from the various forms of psychoses. Central nervous affections often manifest atony of the intestine as a symptom : hence this form is not a disease sui generis. Cases of this class do not respond to any variety of cathartics, whether they act upon the small or large intestine (Ewald). Paralysis of the external sphincters is a common concomitant in a great variety of local (catarrhal) and central nervous diseases. Under these circumstances the act of defecation may be purely reflex, owing to loss of control of the voluntary muscles ; or it may be voluntary, ex- cept when the person affected is not upon his guard, or during mental excitement, micturition, sneezing, and like influences, the latter condi- tion being a mere weakness. Treatment of Intestinal Neuroses. — A suitable change of en- vironment, including an appropriate arrangement of the dietary, is of primary importance, and is uniformly applicable in this class of sufferers. Further, the treatment of special cases has peculiar reference to the character of the nervous derangement. After makino; an accurate diag- nosis a search for the factors of the greatest etiologic importance should be made, and these must then be vigorously assailed. In the secretory neuroses an associated membranous enteritis must be corrected, the digestion must be improved if faulty, and the obstinate constipation overcome. For the latter symptom enemata containing ox- gall, either alone or in combination with salines, are especially service- able. Kussmaul and Fleiner have obtained the best results from reg- ular large oil-enemata administered once or twice daily. During the painful attacks simple enemata. repeated every couple of hours, will sometimes bring speedy relief by facilitating the removal of the scybala, and will assist natures efforts at separating the adherent membranes. Pain must be relieved by morphin. In the sensory disturbances in which the activity of the sensory nerves is increased (enteralgia and hypogastric neuralgia) the treatment may be considered under two headings : first, the relief of the neuralgic pains ; and secondly, the correction of the causes or conditions on which the enteralgia depends. If the pain be severe, opium or morphin may be required. Especially good as an antispasmodic is codein, which may suffice in all save the severer cases. The object should be to give the minimum amount of the opiate that will meet the necessities of the case, with a view to obviating a resultant constipation. In hypogastric neuralgia I have found suppositories containing opium to be little shoi't of magical in their effects. In cases in which there is constipation due to diminished sensibility, with a loss of motor innervation (atony of the bowel), the feces must be artificially removed unless the underlying condition can be successfully overcome. It is especially important that the environment — physical and psychic — be so regulated as to bring about an improvement in the gen- DISEASES OF THE LIVER. 847 eral condition of the patient. It may become necessary to employ tonic preparations of strychnin, iron, or arsenic. The treatment of nervous diarrhea involves the same principles, so far as the indication presented by the peculiar nervous organization is concerned, as in the sensory and secretory neuroses. It is especially important to prevent the Operation of the direct causes — fright, mental excitement. Astringents and intestinal antiseptics are not called for, unless the bodily nutrition be affected thereby. Enterospasm is to be met by the same remedies that are used to control enteralgia. IX. DISEASES OF THE LIVER. ANOMALIES IN SHAPE AND POSITION. Altered Shape. — Occasionally malformations of the liver are met with that materially alter the shape of the organ, either primarily when the result of disease, or secondarily from pressure of adjacent structures. Of the latter class the most important cause is tight-lacing, met with almost exclusively in women and producing the so-called " corset liver." The lower part of the right lobe of the liver is usually the part affected ; the hepatic parenchyma is atrophied, owing to continued compression, and shows deep grooves that correspond to the position of the lower ribs. The connective-tissue capsule and the peritoneal coat are both thickened at this point, the smaller blood-vessels often being entirely obliterated. In marked cases the right lower lobe may become con- verted into a dense fibrous band, with only a vestige of the former liver- structure remaining. Among other acquired causes of anomalies in the shape of the liver may be mentioned deformities of the vertebrae and ribs, or tumors of the ribs or adjacent structures (the pylorus, omen- tum) pressing against the liver. Diagnosis. — Rarely, clinical symptoms are present. " A constant sensation of jjressm^e and pulling is felt in the hepatic region, and sometimes, as a result of venous stasis, there is a temporary but decided swelling of the isolated portion, and, possibly, violent pain and indica- tions of irritation of the peritoneum, such as vomiting and an approach to collapse. Jaundice is rare in consequence of this deformity " (Strlim- pell). The danger of this condition lies in a possible mistaking it for an abdominal tumor (Pepper), amyloid disease, passive congestion, or neiv groivths of the organ (Striimpell). Primary alterations in the shape of the organ may be due to active or passive congestion, hereditary syphilis, hypertrophic or atrophic cir- rhosis, acute yellow atrophy, carcinoma, abscess, or hydatid cyst. The accompanying symp)toms would, of course, be those of the disease caus- ing the deformity. Anomalies of position are not infrequently met with, the organ being displaced upward, downward, or laterally. The most common cause of lateral displacement is found in an abnormal lengthening of the suspen- sory ligament. The organ may occupy the epigastric region or be dis- 848 DISEASES OF THE DIGESTIVE SYSTEM. placed into the lower part of the abdominal cavity, but a change in the posture of the patient or external pressure is often sufficient to replace the liver in its normal position. The symptoms (if present at all) con- sist of a dragging sensation, often amounting to pain that may be severe and referred to the right shoulder. On physical examination palpation may reveal a fissure between the right and left lobes, toorether with a movable tumor presenting the size and normal outlines of the liver, which by manipulation may be returned to the right hypochondriac region. Percussion gives tympany over the normal area of liver-dulness, which changes to flatness when the organ is pressed or falls into its natural position. Displacement upward may result from gastric or intestinal distention, marked ascites, or an abdominal tumor ; while downward displacement may be due to a mediastinal tumor, an emphysematous lung, or a pleural effusion. Diagnosis. — Among the conditions likely to be confounded with movable liver may be mentioned carcinoma of the omentum or of the pylorus^ dermoid cysts, tumors of the ovary and uterus, hydro- or pyo- nephrosis, tumors of the kidney, and chronic proliferative peritonitis. By a careful study of the symptomatology, and in the absence of the normal physical signs over the hepatic area, the different-ial diagnosis can usually be firmly established, although marked fatty degeneration or atrophic cirrhosis may coexist with any of the above conditions and cause marked diminution in the area of hepatic dulness. The treatment of movable liver is merely palliative, and consists in the application of a suitable bandage for preventing the displacement. JAUNDICE. {Icterus.) Definition. — A condition in which the tissues and secretions are stained with bile-pigments. Jaundice is not a disease, but a symptom. The doctrine of a hematogenous jaundice has been successfully over- thrown by the investigations of Stadelmann, Hunter, and others. All forms are due to obstruction (hepatogenous) ; at all events the cases of hematogenous origin must be extremely exceptional. Hepatogenous or ohstruetive jaundice is more commonly seen in — (1) Inflammatory swelling of the duodenum or of the lining membrane of the duct, which is by far the most common factor in its causation, and demands separate consideration (vide infra. Catarrhal Jaundice) ; (2) Foreign bodies within the ducts, as gall-stones or parasites ; (3) Stric- ture or obliteration of the duct ; (4) Tumors within the duct or ob- structing its orifice ; (5) Pressure on the duct from without, as by a tumor of the liver, stomach, pancreas, or omentum ; also by fecal ac- cumulations, displaced organs, a pregnant uterus, enlarged glands in the fissure of the liver, and, more rarely, by abdominal aneurysm ; (6) Low- ered blood-pressure in the vessels of the liver favoring resorption of bile, as in simple icterus of the new-born (Frerichs). CATARRHAL JAUNDICE. 849 CATARRHAL JAUNDICE. {Hepatogenous Jaundice; Icterus Catarrhalis ; Duodeno-cholangitis ; Inflammation of the Common Bile-duct.) Definition. — A condition characterized by a discoloration of the tis- sues from retention and absorption of bile and resulting from a catarrhal inflammation of the lining membrane of the ducts, more especially the larger, and of the duodenum. Pathology. — On examining a liver and gall-bladder in situ the former is usually found enlarged, lighter in color than normally, and of a distinct icteroid tint. On making a longitudinal section drops of bile can be collected on the edge of the section-knife. The gall-bladder is found distended with bile, and on firm pressure a tough plug of mucus is usually expelled from the common duct into the duodenum, after which bile flows into the intestine freely. The mucosa lining the ductus communis is swollen and inflamed, and the catarrhal process may extend to the cystic, and in some cases to the hepatic, duct. As a rule, that portion of the common duct lying in the intestinal wall is more frequently and more deeply involved. If the disease becomes chronic, a formation of connective tissue occurs, owing to the irritation caused by the retained secretion, and atrophy of the liver-cells, with biliary cirrhosis, may result. Suppuration is rare. Toxic (hematogenous) jaundice, so-called, has for its lesion extensive catarrh of the intra-hepatic bile-ducts from their origin. Here duodenal catarrh is not necessary for the production of jaundice. It was formerly assumed that the pigment (hemoglobin) was liberated in the blood ; but Stadelmann and others have shown that the bile containing the poison, or its irritant products (toxins), excite inflammation of the finer ducts. Htiologfy.- — As simple catarrhal jaundice results in a majority of cases from extension of inflammation 4ue to gastro-duodenal catarrh, the principal predisposing causes are as follows : (a) Exposure to cold and wet ; (b) The use of improper foods, under which heading may also be comprised faulty cooking and improper mastication ; (c) The excessive or prolonged use of such irritants as tea, coffee, or alcohol ; (d) Pro- longed anxiety and mental or physical overwork ; (e) Certain acute dis- eases, as pneumonia, relapsing fever, typhoid fever, and malaria (toxic jaundice, vide supra) ; (/) Portal obstruction, occurring in chronic heart- or kidney-disease ; (g) More rarely it has occurred in epidemic form. Symptoms. — Preceding the development of the distinctive features by several days, dyspeptic symptoms are in evidence [vide Gastro-hepatic Symptoms). The principal symptoms in detail are : (a) Icterus, or tint- ing of the body surface may be the first symptom noticed in this condi- tion, appearing usually on the forehead and neck and rapidly spreading over the entire body. The conjunctivae also early become discolored, and the general hue, though variable, is commonly a bright lemon-yellow. In chronic cases the color is apt to change to a bronzed or deep-green tint. (b) Secretions and Excretions. — The urine and sweat are often found to contain bile-pigment, the patient's linen frequently being discolored. In extreme cases the urine may be dark-green in color, while in those of average severity it is of a lighter or deeper greenish-yellow hue. The shaken specimen foams, and the froth has a yellow color-tint. 850 DISEASES OF THE DIGESTIVE SYSTEM. (Jften the presence of bile is detected before any noticeable coloring of the conjunctivcTe occurs. In cases of intense or long-standing jaundice albumin and tube-casts may be present, and the latter may be bile-stained.* Hyaline casts are often found in cases of moderate intensity. The bowels are constipated, and the stools are pale-drab or slate- colored ; they are usually very fetid. Diarrhea, however, may be pres- ent, owing to the production of irritating substances and decomposition. The tears, saliva, and milk are rarely stained with bile-pigment. The expectoration also is rarely tinted, unless pneumonia or some form of pulmonary infiltration coexists. ((') Oireulation. — -The pulse, although not appreciably altered in vol- ume or tension, is usually slow (often 30 or even 20 beats per minute), though this is not an unfavorable symptom. ((/) The tempei'atiire is usually normal, although slight elevations may occur (100°-101° F.— 37.7°-38.3° C). {e) G- astro-hepatic Symptoms. — Dyspeptic symptoms — viz. anorexia, a sense of fulness after eating Avith flatulence, acid eructations, nausea and vomiting, accompanied by a dull, heavy pain over the hepatic area, with some tenderness on pressure — are present. These often develop in- sidiously ; more rarely they occur suddenly with a severe rigor or chill, violent headache, and vomiting — e. g. at the onset in the epidemic form. (/) Cutaneous Phenomena. — Pruritus or itching often becomes a troublesome symptom, being more common, however, in the chronic forms. Lichen, urticaria, furuncles, and sweatings (diffused and local- ized) may develop, the latter being often limited to the skin covering the abdomen and the palms of the hands. A peculiar disease of the skin called xanthelasma or bita higoidea may also occur. It consists of bright-yellow spots, slightly elevated, appearing on the eyelids, and rarely on other parts of the body. In the more severe forms spots of ecchymosis, and in some instances profuse hemorrhages, may occur into the skin and mucous membranes. These are usually associated with other symptoms of a grave type. (g) Nervous Symptoms. — Headache and vertigo are common; irri- tability of temper, despondency, and wakefulness or mental dulness almost equally so. With the oncoming of darkness vision may grow indistinct (hemeralopia) or it may attain unnatural clearness {nyc- talopia). Rarely, objects look yellow (xanthopsia). The nervous phe- nomena observed in catarrhal jaundice are attributable to the effects of the bile-acids. In certain cases, however, associated with destruc- tion of the hepatic substance, as in acute yellow atrophy, carcinoma, cirrhosis, and f\itty degeneration, grave cerebral symptoms (acute delirium, convulsions, and coma) may develop suddenly and prove fatal. This class of symptoms has been named acholia., cholemia, or cholesteremia (the latter owing to the mistaken supposition that cho- lesterin is the poisonous product). The true nature of the toxic agent 1 Tests for Bile. — Omelin's test, or the play of colors, consists in bringing a few drops of urine in contact with the same quantity of commercial nitric acid on a plain white slab, whereupon various shades of yellow, green, red, and violet are produced. RosenbacKs test is made by filtering the suspected urine and touching the filter-paper with a drop of nitric acid. If bile be present, a green circle will form at the point of contact. (See also Choluria, p. 948.) CATARRHAL JAUNDICE. 851 in the blood is unknown. In some fatal terminations of this character death Avas due directly to a renal complication. The physical signs in a case of simple catarrhal jaundice show on palpation and percussion an increase in the hepatic area, the lower bor- der of the liver projecting in some instances several fingers' breadths below the ribs. Rarely, the distended gall-bladder projects below the lower lobe of the liver, as when there is complete obstruction near or at the duodenum, and then it can be distinctly palpated. Diagnosis. — The etiology (errors in hygiene and diet), a history of previously existing gastro-intestinal catarrh, the age of the patient (young adult life), and the appearance of the jaundice unaccompanied by pain or general emaciation, together with an absence of symptoms pointing to cirrhosis, carcinoma, or acute yelloiv atrophy, form a char- acteristic grouping of clinical indications. Duration and Progfnosis. — The duration of catarrhal jaundice varies from two to eight weeks. If the symptoms continue longer than two months, grave doubts may be entertained as to the case being one of simple jaundice. The prognosis is guardedly favorable. A rise of tem- perature usually indicates mischief (Pepper), while hemorrhages of the skin and mucous membranes always influence the issue unfavorably. Treatment. — The diet and hygiene are the first considerations in the treatment. Rich, highly seasoned foods, rich pastries, fats, and sweets, are to be interdicted ; starchy foods, lean meats, bread, soups (contain- ing no fat), and green vegetables may, however, be used in moderation. Skimmed milk, butter-milk, and alkaline drinks (Vichy and Saratoga mineral waters) may be used freely, while sour wines, lemonades, and tamarind-water are allowable. Systematic bathing (Turkish or Russian baths, under supervision), regulated hours of sleep, and moderate exer- cise in the open air, all exert a beneficial effect. The free use of pure water often does good by increasing the flow of bile and by dislodging plugs of mucus that may obstruct the duodenum and the common duct. Gerhardt and Kraus have recommended the faradic current, applied over the region of the gall-bladder ; manipulation has also been tried with a view to removing the obstruction in the common duct. Neither of these methods has met with success. The first therajyeutic indication is to keep the bowels freely soluble by the use of saline aperients, as Hunyadi water or Carlsbad salts (^ to 1 teaspoonful in hot water before meals). The latter remedies tend to lessen the catarrhal inflammation by depleting the mucous membranes. In obstinate constipation calomel, rhubarb, the extract of colocynth, or castor oil may be employed. Prevost and Binet believe that calomel is in part converted in the economy into mercuric chlorid, which stimu- lates the biliary secretion. Conspicuous among other remedies may be mentioned the alkalies, sodium bicai'bonate, salicylate, and phosphate, which tend to increase the flow of bile and render it less thick ; hydrochloric acid (which, accord- ing to Ewald, by aiding digestion prevents the formation and consequent absorption of toxic substances), in combination with the bitter tonics — gentian, quassia, and nux vomica; ammonium chlorid, which sometimes proves beneficial ; and silver nitrate (gr. -|--l — 0.008-0.016, three times daily). 852 DISEASES OF THE DIGESTIVE SYSTEM Injections of cold water (60°-70° F.— 15.5°-21.1° C), daily, in quantities of 1 or 2 quarts (1-2 liters), are highly recommended as promoting the secretion of bile ; while lavage, practised daily and over a protracted period of time (one to two months), has proved highly bene- ficial, especially when gastro-duodenal catarrh has existed. This treat- ment was advocated by Krull, but has given negative results in the hands of Osier and Burney Yeo. Itchinfj. — This troublesome symptom may often be relieved by the ex- ternal application of a solution of borax or sodium bicarbonate (5ss-0j — 16.0-512.0), or of menthol and alcohol (gr. x-sj— 0.648-32.0). Inter- nally, large doses of the bromids (gr. xx-xxx — 1.29-1.94, at bedtime) or the continued use of pilocarpin (gr. -jL. to -| — 0.005 to 0.008, two or three times a day), as recommended by Witkowski, are worthy of a trial. Flatulence. — To this end it is important to regulate the diet, avoid- ing starches and sugars. Ox-gall and sodium chlorate (gr. v — 0.324 — of the latter three times a day). Charcoal tablets, bismuth subnitrate or salicylate, and beta-naphtol are all useful in checking fermentation. Irrigation of the colon with some efficient antiseptic in solution is often a factor of service. Diarrhea. — Occasionally attacks of diarrhea alternate with constipa- tion in catarrhal jaundice, and when present demand treatment. As they are usually due to fermentation, salol and creasote (ITiss — 0.033), combined with the bismuth salts (subgallate, subnitrate, subcarbonate, or salicylate), are usually efficacious ; they are administered before meals. Headache is caused by the circulation in the blood of some toxic prin- ciple, due to the absorption of bile ; it is often persistent and annoying, although rarely acute in character. Temporary relief may sometimes be obtained as the result of free sweating induced by means of the hot bath or hot pack. Of drugs, caffein citrate, camphor monobromate. and phenacetin, either singly or in combination, may be recommended. In the other forms of hepatogenous jaundice permanent relief can only be afforded by removing the obstruction in the biliary channels, and thus permitting the normal outflow of bile. When the obstruction is due to mechanical causes (biliary calculi, tumors pressing on the duct) the treatment is chiefly surgical, and con- sists in their removal {vide Cholelithiasis). OTHER FORMS OF JAUNDICE. Modern experiments, as I have said {vide p. 848), tend to show that the so-called hematogenous jaundice is always hepatogenous — /. e. the blood-dyscrasia probably exerts a toxic influence on the liver-cells and intra-hepatic gall-ducts ; and there may at the same time be a more rapid blood-destruction in the liver (Neumeyer, Stadelmann, et al.). There are instances of jaundice in which active hemolysis is an ele- ment of importance (Stengel) : (a) Severe infections, as septico-pyemia, yellow fever, acute yellow atrophy of the liver, and the jaundice of the new-born, {b) Grave forms of anemia, as pernicious anemia and chlor- osis, (c) Certain poisons, as the venom of snakes, chloroform- and ether-poisoning; also in poisoning by phosphorus, arsenic, mercury, and other minerals. BILIARY CALCULI. 853 Experiments conducted by Miinzer, Starling, Hopkins, and others, tend to show that the liver-function if not suppressed by many of the conditions and affections mentioned above ; but, on the other hand, that increased secretion {polycholia) and increased formation of bile-pigments {polychromia) may prevail. Again, the poisons or toxins may cause swelling of the cells and compression of the biliary capillaries ; this would cause obstruction of the outflow of bile and the subsequent ab- sorption. Lastly, circulatory disturbances (emotional jaundice) may lead to overproduction, or obstructive retention, of bile. A consideration of the diagnosis, prognosis, and treatment of this variety of jaundice is embraced in the description of the various causative disorders. BILIARY CALCULI. {Gall-stones; Cholelithiasis^ Definition. — Concretions formed in the gall-bladder, due to an altered physiologic function or pathologic change ; they vary in their composition and consist for the most part of bile-elements, and often set up characteristic disturbances {cholelithiasis). !^tiology. — As a result of biliary retention increased consistency and a concentration of bile occurs, and certain constituents that were before held in solution are thrown down. Among the most common predisposing causes may be mentioned the folloAving : {a) Female sex, especially between the ages of forty and sixty. Senac's statistics, out of a total of 311 individuals, give 227 women (Dujardin-Beaumetz). (6) Irregular meals and an excessive diet of starches and of fats, com- bined with a sedentary life, are strong predisposing factors, (c) Accord- ing to Harley, gall-stones and biliary concretions of all kinds are fre- quently hereditary. Among other, and perhaps minor, causes are con- stipation, tight-lacing, pregyiancy, chronic obstruction to the flow of bile (as from tumors, catarrh of the ducts, or heart-disease, as mitral stenosis), and, more rarely, the rachitic and lithic-acid diathesis, {d) It may oc- cur during childhood, (e) Incidence. Brockbank found among 13,047 completed post-mortem records, 7.4 per cent, were gall-stones. Composition and Appearance. — Water comprises from 2 to 5 per cent, of the composition of gall-stones, the chief solid constituent being cholesterin, and the remainder being composed of bile-pigment and salts (lime, potash, soda, and perhaps traces of iron and copper). Pigment-lime may be, though rarely, the main constituent. In size they vary from the smallest particle of sand to that of a goose-egg. Harley records a case in which a pyriform cholesterin-calculus was discovered in the feces; in a dry state it weighed 400 grains (26.0) and measured 2^ inches (5.6 cm.) in length and l^^^^- inches (2.7 cm.) in diameter. Fagge reports a calculus Aveighing, in a dry state, 462 grains (30.0). The color varies from Avhite or light-yellow to that of a dark- green (as in pigment-lime calculi), and may present any variation 854 DISEASES OF THE DIGESTIVE SYSTEM. between these two extremes. The nucleus often consists of cholesterin, the outer layer being usually the harder, and made up, for the most part, of lime-salts. The center of the nucleus generally consists of desquamated epithelium or dried mucus, and on cross-section concentric laminje are usually developed. The cholesterin gall-stones cut like wax, are white, and the cut section presents a crystalline appearance. Other forms are apt to be brittle. The surfaces may be smooth, stri- ated, or hollowed out, solitary calculi being usually round or ovoid, while multiple stones often present smooth facets, due to the massing together of the calculi (Dujardin-Beaumetz). They are usually olive- shaped, but may be pyramidal, cylindric, lenticular, pisiform, cubic, finger-shaped, or olivary. Their seat is usually the gall-bladder, but they may be found anywhere along the biliary passages. Symptoms. — There may be no subjective symptoms of biliary cal- culi unless the stone becomes impacted in the hepatic, cystic, or com- mon duct. Thus, Naunyn states that '• the gall-bladder will tolerate large numbers for an indefinite period of time, postmortem examinations showing that they are present in 25 per cent, of all women over sixty years of age;" and I quite agree with him in his estimate. The passage of a calculus through the duct will give rise to hepatic colic, whereas a permanent blocking of the duct will cause symptoms of chronic obstruc- tion, followed in many cases by those of ulceration and perforation, with the establishment of a biliary fistula. Hepatic Colic. — When a gall-stone becomes impacted in a bile-duct the patient experiences agonizing pain (tearing, cutting, or lancinating in character) in the right hypochondriac region, radiating to the right shoulder, and accompanied often by profuse stveating, vomiting, and a feeble, running pulse. The most common seat of the pain is two to three inches to the right of the median line and about an equal distance below the ensiform cartilage. Less frequently it is in the region of the gall-bladder. This happens in cases in which the gall-stone is impacted in the cystic duct, and may be due to distention of the gall-bladder, or to associated cholecystitis. The pain is sometimes so severe as to pro- duce syncope. Hepatic colic, however, may occur independently of the passage of biliary calculi, as from inflammation of the gall-bladder. On the other hand, large calculi have been found in the dejecta Avithout having excited hepatic colic. I recently saw an instance of this kind in which the gall-stone Avas of the size of an English Avalnut. A rigor or chill often precedes the attack, Avhich is usually accompanied by mod- erate fever, the temperature reaching 101°-102° F. (38.3°-38.8° C). If the stone passes through the duct without becoming impacted, jaun- dice and pain may either be only slight or entirely absent. When, hoAv- ever, occlusion of the common duct occurs, the jaui^dice becomes intense. This symptom, hoAvever, may be present, though less marked, before the gall-stones reach the ductus communis. Jaundice occurs in about 50 per cent, of the cases (Fitz), and it sets in from eight to tAventy-four hours after the onset of the attack of pain. Physical examination reveals on inspection a slight prominence in the hepatic area, and on palpation the edge of the liA'er can often be distinctly felt beloAv the costal margin — at times as Ioav as the umbilical level. The enlarged liver is sensitive on pressure, and particularly the gall-bladder, Avhich can be often pal- BILIARY CALCULI 855 pated. If the latter viscus contains many calculi, crepitation may be noticeable to the palpating fingers (rarely), and a friction-sound may be distinguished on auscultation. The s^vollen organ, after the cessation of the colic, quickly subsides. Recurrences of the painful attacks after varying intervals of time are common. Finally, the gall-stone is ex- pelled and the colic ceases to return. Multiple stones, however, may be passed. Rupture of the duct, followed by fatal peritonitis, has been known to occur. Attacks of biliary colic are of variable duratio7i, lasting from a few hours to a few days, and in some instances one or more weeks. Sudden cessation of the pain is usually followed by rapid disappearance of the jaundice (when present) and the discovery of the stone in the feces. Examination of the urine after the paroxysm reveals bile and an abundance of uric acid and urates. The j:»w?se often becomes slowed. Exner has demonstrated the presence of about 0.4 per cent, of sugar in the urine in 39 out of 40 cases of gall-stones. On the other hand, Kausch has found glycosuria in only one of 85 cases of cholelithiasis. The prognosis of biliary calculi as regards life is good, but as re- gards recovery only guardedly favorable. Cardiac distress with palpi- tation may occur during hepatic colic and form a serious complication. Fatal syncope has also been known to occur, and fatal intussusception has followed the impaction of gall-stones in the region of the ileo-cecal valve. If evidences of an infectious inflammation arise, the outlook is then more serious. Diagnosis. — The diagnosis of gall-stones is sometimes extremely difiicult on account of the obscure clinical symptoms and the entire ab- sence of physical signs. When, however, the calculus becomes impacted in the duct, symptoms of biliary colic — intense pain in the epigastrium and right hypochondriac region, radiating to the back and right shoulder — usually appear. There are also fever, vomiting, and in one-half the instances jaundice and the finding of the stone in the dejecta. Differential Diagnosis. — G-astralgia usually occurs in individuals with neurotic tendencies, and is characterized by severe paroxysmal pains in the epigastrium, extending to the back and base of the chest. It occurs often when the stomach is empty and is relieved by eating. Fii'm press- ure over the epigastrium often alleviates the pain temporarilv, and the absence of fever, jaundice, stones in the dejecta, and the negative urinal- ysis, together with the history of former attacks, would tend to differenti- ate it from hepatic colic. Renal Colic. — The pain in this condition, which is often as acute as that of biliary colic, starts in the flank of the affected side and is trans- mitted down the ureter. The testicle and inner side of the thigh are very painful, the former being often retracted. Micturition is frequent and sometimes painful, and the urine is scanty in amount and often mixed with blood. Intense pain may also be felt in the back and abdomen, although it is usually localized in the aflfected side. This grouping of symptoms is wholly unlike that characterizing biliary colic. Intestinal Colic. — In this variety the pain is of a boring or twistino- character, usually centering about the umbilicus. It is relieved by firm pressure. Abdominal distention is often present, and relief comes with the passing of flatus. Usually there is a history of an indiscretion in 856 DISEASES OF THE DIGESTIVE SYSTEM diet. When due to lead-poisoning, the history, the blue line on the gums, and the presence of wrist-drop would tend to confirm the diagnosis. Beflex colic, due to uterine or ovarian disease, may also occur. The recurrence of the attacks, together with other symptoms pointing to dis- ease of these organs and the exclusion of all other causes, would tend to establish the identity of the condition. In all forms of colic, if the pain be very severe symptoms of shock may develop, indicated by vomiting, cold, clammy skin, pale and pinched features, and a rapid running pulse. CHRONIC OBSTRUCTION OF THE DUCTS BY GALL-STONES. The obstruction may exist in the ductus choledochus. in the cystic duct, or in both. 1. Obstruction of the Common Duct. — Pathology. — The result of the irritation produced by the presence of the stone is a catarrhal pro- cess {cholangitis) that may either remain chronic or terminate in suppu- ration (sujjjmrative cholangitis). In a case of simple obstruction the gall- bladder is often moderately enlarged, though rarely extending below the loAver border of the liver. The common duct is greatly distended, the stone being usually located near its termination; it is distinctly felt just beneath the mucous membrane of the descending duodenum. Occasion- ally two or more calculi are present, completely obliterating the canal. The hepatic duct and its branches are greatly dilated, and often contain thin, colorless mucus, the membrane lining the ducts being smooth and clear. The liver in these cases is firmer in consistency than normal, showing some increase in the connective-tissue elements (biliary cirrhosis). Following moderate enlargement of the organ progressive atrophy may rarelv occur. When suppuration has occurred the mucous membrane is greatlv swollen and reddened, and in some instances shows erosions or ulceration. The process often extends through the hepatic and cystic ducts into the liver and gall-bladder, giving rise to localized abscesses in the former and to empyema of the latter. In some instances the gall-bladder has been perforated and abscesses have formed between the liver and stomach. Diverticula are sometimes found post-mortem, containing biliary calculi. Symptoms. — Chronic obstruction by gall-stones, with coexisting ca- tarrhal inflammation, is characterized by a distinctive group of symp- toms, among the most prominent of Avhich are — Jaundice. — This may be constant and very intense, or intermittent and slight, depending upon the amount of obstruction present. In some cases it disappears entirely for several months, and then recui's with vary- ing intensity (ball-valve action of the stone). Itching is, as a rule, a most distressing feature. Pain., occurring in paroxysmal attacks and referred to the region of the liver. This is accompanied by fever that may reach a high degree (102°-103° F.— 38.8°-39.4° C), also by chills and sweating, resem- bling somewhat the paroxysms of malaria. Painful points in the right side posteriorly may be annoying ; these are either constant or par- oxysmal. The chills are often intense, and may present a quotidian, tertian, or CHRONIC OBSTRUCTION OF THE DUCTS BY GALL-STONES. 857 quartan form. The temperature of the intervals is normal. The peculiar exacerbations of temperature were first described by Charcot, and to them has been given the name of Charcot's intermittent fever. Many theories have been advanced as to its cause, and Murchison writes : " These paroxysms may be more or less periodic, and may extend over several months, without necessarily indicating pyemic hepatitis, the pa- tient ultimately recovering." He further states that they are probably due to simple irritation by a stone, and are analogous to febrile paroxysms produced in passing a catheter along the urethra. Charcot believes the etiologic factor to be a septic poison, bacterial in origin and the result of chemical changes in the bile. Various micro-organisms have been de- tected in the bile in such cases (bacterium coli commune, streptococcus pyogenes, et al). Gastric Disturbances. — These may be so severe during the paroxysm as to excite alarm. Intense pain is complained of in the epigastrium, accompanied often by persistent nausea and vomiting, which, however, usually subsides at the close of the paroxysm, while the jaundice at this time deepens. The attack may persist for years without progressive fail- ure of health. When, however, suppurative cholangitis occurs the prognosis becomes grave and recovery is unknown. The paroxysms occur more frequently, the fever merging into a remittent rather than an intermittent type. Grave constitutional symptoms, indicating septico-pyemia, are present, the duration is shorter, and the case rapidly tends to a fatal issue. The attacks of colicky pain occur and the jaundice, but the latter symptom is less intense than in the catarrhal form. Hepatic enlargement, on the other hand, is more marked than in the latter variety. 2. Obstruction of the Cystic Duct. — This almost invariably causes distention of the gall-bladder (dropsy of the gall-bladder), which may be felt distinctly below the lower edge of the liver as a pyriform, fluctuating tumor. If obstruction of the cystic duct alone occurs, jaun- dice may be entirely absent, the bile in the distended tissues being re- placed by a thin, mucoid fluid. This is more apt to exist as the obstruc- tion becomes more chronic. In some instances the distention is so great as to reach below the umbilicus, and the dilated viscus has even been mistaken for an ovarian tumor. Osier records a case in which 18 oz. (556.0) of fluid were removed from the gall-bladder. The contents are neutral or alkaline in reaction, albumin being often present in abun- dance. Catarrhal inflammation of the gall-bladder is often associated, causing pain and sensitiveness in the region of the organ. The pain may be severe and simulate biliary colic or appendicitis. The examiner can/eeZ an elastic, gourd-shaped tumor closely connected with the liver, movable in respiration in the vertical, and also, under the influence of the palpating fingers, in the lateral, direction. I have observed a tongue- like projection of the anterior margin of the right lobe, to which Riedel first called attention. Given a gall-bladder well filled with stones and a relaxed abdominal wall, gall-stone crepitus may be detectable ; it was felt in two cases under my immediate observation. If the obstruction persist for a length of time, calcification or atrophy of the bladder are common sequelae. Complete obliteration of the cavity of the gall-bladder may ensue. 858 DISEASES OF THE DIGESTIVE SYSTEM. Among rarer sequelae of chronic obstruction may be mentioned — (a) Empyema of the Gall-bladder. — When this takes place the organ be- comes greatly distended, and has been known to contain as much as a pint of purulent material. The symptoms of suppurative cholecystitis simulate those of purulent cholangitis, and are often preceded by those of catarrh of the gall-bladder and ducts. Perforation may occur, giving rise to circumscribed periportal abscesses or to generalized peritonitis. (6) Phlegmonous Cholecystitis. — This is of very rare occurrence, cha- racterized clinically by pain and tenderness in the hepatic region, rigors and high fever, and intense prostration. It often proves fatal as the result of peritonitis from perforation. More Remote Effects of Gall-stones. — These will be spoken of under three headings : 1. Stricture of the duct, resulting from ulceration and cicatrization produced by the passage of a stone. 2. Intestinal obstruction, due to impaction of gall-stones. 3. Biliary fistuhie resulting from perforations. 1. Stricture of the Duct. — Obliteration of the common duct may re- sult from the passage of a gall-stone, giving rise to ulceration and cica- trization, or the stone may become impacted and lead to adhesions and permanent closure of the duct below it (Murchison). When due to ulceration the seat of the stricture is usually low down in the common duct.^ Symptoms. — The symptoms are those of chronic obstructive jaundice (Osier). In many cases there will be an antecedent history of the passage of gall-stones. In all cases in which the symptoms of gall-stones are followed by permanent jaundice without pain it may be suspected either that the calculus has become firmly impacted or that it has produced organic stricture or closure of the duct. 2. Intestinal Obstruction from Impaction of Gall-stones. — The ileum is commonly the seat of obstruction by gall-stones, that may give rise to intussusception or cause ulceration and gangrene of the bowel with per- foration and fatal peritonitis. The latter event, however, occurs more frequently when the biliary concretions are situated in the cecum. Earely they are found in the appendix, causing, as other foreign bodies, inflam- matory changes, followed by ulceration and in many cases by perforation and death. Cases of impaction in the rectum of several biliary calculi have been recorded. I have recently seen a case with Dr. R. Bruce Burns. Symptoms. — If the impaction occurs in the small intestine, the abdo- men becomes tympanitic and tender on pressure. The contents of the stomach are first vomited, followed by bile and stercoraceous matter. Obstinate constipation persists, and symptoms of peritonitis develop and continue until either the impaction disappears or death ensues. Ileus, the result of biliary concretions, is common in females of advanced age. The history of previous acute attacks would tend to confirm the diagnosis. The pain is intense and vomiting severe and persistent. The duration of the last attack is often short, terminating fatally in a few hours. ^ In vol. ix. pp. 22 and 130, Pathologic Transactions, two cases are recorded in which the strictures were exactly similar to those of the urethra, one being situated in the hepatic duct of the left lobe and the other in the common duct. TREATMENT IN CHOLELITHIASIS. 859 3. Perforation may occur with the establishment of fistulous coin- munications between the gall-bladder and stomach, intestinal canal, blad- der, vagina, lungs, abdominal parietes, or portal vein. Fistulje between the gall-bladder and stomach are rare, though cases are recorded by Oppolzer, Frerichs, Cruveilhier, Murchison, and others. Cruveilhier states that vomited gall-stones necessarily reach the stomach through fistulous tracts, as the passage from the duodenum through the pyloric orifice would be impossible. Fistula into the duodenum are of much more common occurrence, ulceration taking place usually in the fundus of the gall-bladder and in the descending or third portion of the duodenum : 39 cases are recorded of fistulous communication with the colon (Osier). I have reported a fortieth case,^ which prior to reaching a fatal issue had developed wide- spread septico-pyemic lesions. In 6 of 9 cases reported by Murchison carcinoma of the gall-bladder was present. Fistulge into the urinary passages may occur, 2 authenticated cases being reported. The distended gall-bladder may come in contact with the urinary viscus, or the stone may perforate into the pelvis of the kidney and pass through the ureter into the bladder. Fistulous openings through the abdominal parietes are the most com- mon of all fistul^e, the place of exit of the biliary concretions being usually in the region of the gall-bladder or at the umbilicus, to which (according to Murchison) it may be directed by the suspensory ligament of the liver. As many as 600 stones have been removed from the gall- bladder in this manner. They vary greatly in size, being often as large as a goose-egg. Advanced life and female sex are said to be predis- posing causes. Murchison records 5, and Courvoisier's statistics show 184 cases, in 78 of which recovery took place. Fistulje into the pleura, bronchi, and vagina have been recorded, but are extremely rare. Courvoisier records 24 cases of fistul^e into the lungs, only 7 of which terminated in recovery, Fauconneau, Dufoesne, Frerichs, Bristowe, and Murchison mention cases of fistulse into the portal vein, with the presence of biliary concretions in the latter. Diagnosis. — I would strongly urge an exploratory celiotomy as an accurate means of diagnosis in obscure cases. Treatment of Foregoing Conditions. — The indications for treatment in cholelithiasis are {a) to remove the cause ; (h) to relieve the paroxysms of hepatic colic ; and (c) to adopt palliative or radical measures for the removal of the stones. Preventive Treatment. — In this, as in the treatment of jaundice, diet and hygiene play an important part. The former should be as simple as possible, consisting largely of skimmed-milk, lean meat, eggs, fruit, and green vegetables. Fatty foods, sugars, starches, and pastries are to be strongly interdicted. All foods should be thoroughly masticated, so as to digest easily, and meals should be taken at regular intervals. Syste- matic exercise in the open air is of signal value, as it stimulates the flow of bile. Punkhauer strongly recommends horseback-riding, believing this to be efficient in removing obstructions in the common duct. Among the drugs mostly used in the treatment of this condition I would advise the following : Sodium sulphate, combined with the extract of taraxacum (Harley) ; ox-gall (Dubney), in 5- to 10-gr. (0.324-0.648) ^ Clinical Lecture, International Clinics, vol. ii. third series, p. 27. »6u DISEASES OF THE DIGESTIVE SYSTEM. doses, three times daily (to relieve flatulency and stimulate the biliary secretion) ; sodium salicylate (gr. x to xv — 0.648 to 0.972, three times daily) ; and sodium chlorate (gr. iv to vj — 0.259 to 0.388) three times a day'(Schiff). The bowels should be kept freely soluble, constipation being carefully avoided. In my own experience a dram (4.0) of sodium phosphate or of Rochelle salts in concentrated solution in the morning on rising has yielded excellent results. Other laxatives whose use is to be advised and encouraged are cascara sagrada, podophyllin, and rhubarb. Treatment of the Paroxysm of Biliary Colic. — At the very onset of an attack of hepatic colic the prompt exhibition of morphin or of codein may greatly mitigate an attack. The former may be given hypodermi- cally in \- to ■j-gi'- (0.008-0.016) doses every hour until relief follows ; the latter is exhibited by the mouth in doses of 1 gr. (0.0648) every hour. Inhalations of chloroform, with morphin hypodermically, the former being continued until the latter has taken effect, may be regarded as the typical treatment during an attack. Hot baths and hot applications (with counter-irritation) over the liver are valuable aids in the treatment of hepatic colic, being given at a tem- perature of 98° to 100° F. (36.6° to 37.7° C), and continued for twenty minutes if endurable, so as to effect relaxation. If cardiac depression results and the pulse becomes weak, the baths should be discontinued. Hot flaxseed-poultices, cloths wrung out of hot water, hot hop-bags, or turpentine stupes may be applied over the hepatic region until the attack subsides. Ice-poultices have been advised by Buchetan. If shock or syncope should develop, the body-temperature must be maintained by hot bottles or bricks placed in contact with the surface of the body, together with strychnin (gr. -^ — 0.0021), atropin (gr. y^-g- — 0.00042), and brandy (1 dram — 4.0) hypodermically. Nausea and vomiting may be reduced by 15-drop doses of spirits of chloroform every half hour ; also by brandy and soda-water or cham- pagne. In mild cases sodium salicylate (gr. viij-xv — 0.518-0.972 in twenty- four hours), recommended by Prevost and Binet, or codein (gr. j), with phenacetin (gr. x), every few hours gives relief. The free use of olive oil or glycerin in hepatic colic has been followed by a beneficial effect (Rosenberg, Goodhart). The former is given in quantities of 4 to 6 oz. (128.0—192.0) by the mouth every three or four hours, nausea being pre- vented by concealing the taste with lemon-juice ; the latter, recommended by Ferrand, is given in doses ranging from 1 to 2 tablespoonfuls, repeated in the same length of time. Both remedies are supposed to do good by increasing the flow of bile, thus forcing the stone outward toward the bowel. Treatment for Removal of Gall-stones. — The palliative treatment consists in the administration of agents that tend to increase the flow of bile. The free use of pure water by the mouth, together with copious rectal injections daily of cold water, has been found effective. It may be rendered alkaline by sodium bicarbonate or borate in a 3 per cent, solution. A course of alkaline treatment at some of the more noted mineral springs (Bedford, Vichy, Carlsbad) is often attended with good re- CARCINOMA OF THE BILE-DUCTS. 861 suits. Perhaps the three best cholagogues that may be mentioned are sodium phosphate, sodium chelate, and ox-gall. Olive oil and glycerin also increase the secretion of bile. Willoughby reports a case in which prompt recovery ensued from the use of toluylenediamine after three years of unsuccessful treatment ; he began with 1 grain daily, and increased to 2 grains. Agents to dissolve the stone have been tried at various times, among them being Durandes method (turpentine and ether), but, so far, all such methods of treatment have been unsuccessful. Of the various surgical measures for the removal of gall-stones the fol- lowing are the chief: (a) Removal of the stone from the common duct (choledochotomy) ; (^) Removal of the stone from the cystic duct (cho- lecystotomy) ; (c) Establishing a fistulous opening between the gall-blad- der and the bowel (cholecystenterostomy) ; (c?) Extirpation of the gall- bladder (cholecystectomy), the latter operation giving a mortality of 17 per cent., according to Murphy's statistics. And operative procedure is indicated in infectious (suppurative) cholecystitis as Avell as in infec- tious (suppurative) cholangitis. CARCINOMA OP THE BILE-DUCTS. The biliary passages may be the seat of carcinoma, which may occur primarily and exist over a long period of time without being recognized. Pathology. — The gall-bladder, as the result of obstruction of the duct, is often greatly distended, measuring as much as 7 inches (17.7 cm.) in length (in a case reported by Harley) from the entrance of the duct to the fundus, and being filled with a cloudy liquid, somewhat resembling barley-water, that contains flakes of epithelium, giranular matter, and particles of inspissated bile. If the growth be near the duodenal orifice, the common and cystic ducts are often greatly dis- tended, and the dilatation may extend into the hepatic ducts and their branches. The liver may be enlarged, and in some instances presents the secondary nodules that are characteristic of the disease. Micro- scopically, carcinoma of the gall-bladder exhibits marked variations in different cases; "it maybe either columnar or spheroidal-celled" (Rolleston). !^tiology. — The causes of carcinoma of the bile-ducts are the same here as elsewhere, and among these the mechanical or inflammatory theory of VirchoAV must be accepted. Tight-lacing and mechanical irritation by gall-stones are followed in many instances by cancerous degeneration ; Osier states that " biliary calculi are present in at least seven-eighths of all cases." Among other factors, heredity and age (after forty) play an important part. Although carcinoma of the liver undoubtedly occurs more frequently in males, Musser found that out of 100 cases of carci- noma of the ducts, 75 were female ; and Ames found the ratio to be 4 to 1 in favor of females. 862 DISEASES OF THE DIGESTIVE SYSTEM. Symptoms. — The signs and symptoms, according to Harley, present nothing characteristic to distinguish them from other causes of obstruction in the ducts. On palpation in the early stages the gall-bladder is found moderately enlarged, hxxi later it rapidly undergoes diminution in size. Jaundice becomes very intense, and remains permanent. Throughout the course of the disease all the symptoms referable to chronic obstruction of the duct by gall-stones (paroxysmal pain, gastric disturbance, rise of temperature, Charcot's fever) may develop. Examination of the urine and feces reveals the presence of bile-pigment in the former and its absence in the latter. The urine often shows the presence of bile-stained casts (vide Fig. 63). Ascites not rarely occurs during the later stages, with the involvement of surrounding organs by contiguity, as well as with the appearance of secondary nodules in the liver and the development of cachexia. Diagnosis. — Carcinoma of the biliary ducts cannot always be detected by physical examination. Distinct evidence of chronic obstruction of the duct, as persistent and intense jaundice (which occurs in three-fourths of the cases), the development of cachexia and the absence of cancerous in- volvement of other organs, however, will tend to characterize it. Often a hard tumor-mass is present in the region of the gall-bladder, project- ing in the direction of the umbilicus. It should be recollected that the bile-ducts are oftener the seat of the primary affection than the liver. An assured diagnosis, however, is often impossible. Prognosis. — The prognosis of carcinoma of the bile-ducts is, like that of other organs, absolutely fatal, though the course of the disease is not so rapid as that of carcinoma elsewhere until secondary involvement of the liver occurs. Treatment. — The treatment is merely palliative. Operative meas- ures are rarely justifiable, since the disease is rarely recognized before the liver becomes involved. As seven-eighths of the cases follow obstruc- tion of the duct by gall-stones, the preventive treatment of the latter should be carefully observed whenever symptoms of disordered liver-func- tion manifest themselves. The treatment of the pain, anemia, and emaciation will be described in the discussion of Carcinoma of the Liver (vide p. 899). STENOSIS OF THE BILE-DUCTS. Stenosis may result from any of the following causes : (a) JRound- ivorms in the duct (rarely) ; (h) Foreign bodies, as seeds ; (c) Ulceration and cicatrization following the passage of gall-stones (most commonly) ; (d) Pressure from Avithout, as from tumors (carcinoma chiefly) of the head of the pancreas and pylorus (rare) ; (e) Abdominal tumors ; (/) Aneurysm of the abdominal aorta or of the celiac axis (rare); (g) Secondary enlargement of the lymphatics of the liver (common) ; (h) More rarely in man than in the lower animals distoma hepaticum of liver-flukes and echinococci ; (i) Adhesions due to chronic peritonitis. Pathology. — If the stenosis is of recent origin, the liver is enlarged STENOSIS OF THE BILE-DUCTS. 863 and shows more or less congestion, with some increase of the connective- tissue elements. The substance is firmer than normal, the color varying from an olive-green to a deep bronze. If, however, the obstruction be of long standing, the presence of the dilated intra-hepatic ducts and the increase of connective tissue cause secondary atrophy of the hepatic cells, with a diminution in the size of the organ. Symptoms. — The symptoms vary greatly according to the cause of the stenosis, but in the main they are those of chronic obstruction of the duct — viz. paroxysmal pain in the region of the liver, referred to the right shoulder ; jaundice of varying intensity, but gradually deepening after each attack ; and gastric disturbance, with ague-like paroxysms (fever and sweating), the latter being most frequently met with in occlu- sion from gall-stones. Diagnosis. — The pathognomonic symptoms determining the nature of the stenosis are very often wanting, and the diagnosis is rendered cor- respondingly difficult. On the other hand, stenosis or complete occlusion of the bile-passages calls for diagnosis principally on account of the special cause or causes of the given case. When the condition is due to lumhricoid worms reflex symptoms usually appear, as pruritus of the nose and anus, grinding of the teeth during sleep, and convulsions. In carcinoma of the head of the jjancreas or the pylorus pressing on the ducts the growth may be detected by palpation, together with a rec- ognition of other more or less characteristic features {vide infra, p. 911), and the rapid course of the disease. Abdominal aneurysm may give rise to obstruction of the duct without being evidenced by physical signs. Usually, however, when the saccula- tion presses against the bile-duct, the throbbing in the epigastrium, the tumor (which can often be grasped), and the expansile pulsation on pal- pation will tend to establish the cause of the obstruction. When due to cancerous nodules iri the liver there is usually a history of primary carcinoma of the stomach, mammary gland, rectum, or of one of the pelvic viscera. Osier records a case in which jaundice (thought to hare been catarrhal in origin) developed seven weeks previously. On careful examination " a small nodule was detected at the umbilicus, which on removal proved to be scirrhus." When the stenosis is due to ulceration following the passage of gall- stones, the history of biliary colic and of the presence of calculi in the dejecta, and the paroxysmal pain with jaundice and intermittent fever, will serve to establish the cause. If the fever be of the continued type and the liver uniformly enlarged, with the development of jaundice, the case is probably one of hypertro- phic cirrhosis ; whereas if the enlargement be progressive and nodules can be detected on palpation in addition to the appearance of cachexia and jaundice, carcinoma is undoubtedly present. Physical signs aid but little in the diagnosis, as obstruction of the common duct is usually unattended by any great enlargement of the gall-bladder. In many cases only by remembering the various causes and elim- inating them carefully, one by one, can the diagnosis be positively made. 864 DISEASES OF THE DIGESTIVE SYSTEM. Progrnosis. — It may be said of the prognosis, as of the symp- toms, that both vary accordino; to the cause of the stenosis. Gen- erally speaking, the outlook is rather grave, since many of the causa- tive conditions are fatal. If the obstruction is due to cicatricial contraction, the prognosis is guardedly favorable as to life, but hope- less as to recovery. If the obstruction is permanent, the case ends fatally. Treatment.— The treatment of occlusion of the bile-ducts varies according as it is due to cicatricial contraction following ulceration or to foreign bodies (seeds or lumbricoid worms), or to gall-stones or tumors pressing upon or involving the ducts or adjacent organs (pancreas, pylorus). If the stenosis follows ulceration in the duct, and is sufficient to cause almost complete occlusion with biliary retention, the operation of cholecystenterostomy may become necessary in order to prevent dila- tation of the gall-bladder with resorption of bile. Foreign bodies in the duct may be removed by free purging, aided by the liberal use of alkaline mineral Avaters. In critical cases the operation of cholecystotomy has been practised. Gall-stones form the most frequent cause of stenosis, and the treat- ment, both for the prevention and removal of calculi, has already been described in the discussion of Biliary Calculi {vide p. 859). ICTERUS NEONATORUM. Definition. — Jaundice occurring in the new-born. This may be either pathologic or physiologic — a slight tinting of the skin occurring quite commonly in the new-born. Pathology. — The morbid anatomy of the pathologic form varies with the cause of the jaundice. The secretion of bile, like the secretion of urine, begins long before birth, and Zweifel has found bile-picrment and bile-acids in the contents of the intestines of a three-months' fetus. Hence children may be born laboring under an attack of well-marked jaundice. In well-marked cases of pathologic jaundice the skin presents a deep greenish-yellow hue. The internal tissues are also stained. Knop- fermacher has studied the condition of the blood, and found that the r6d cells presented no signs of destruction, but rather of active new- formation. Ktiology. — Of the physiologic forms, the following are the main causes : 1. The ductus voiosus may remain patulous, allowing some of the portal blood, containing bile, to flow into the systemic circulation (Quincke). 2. Diminished pressure in the portal vessels from ligation of the umbilical vein causes increased tension in the hepatic capillaries and absorption of bile. Pathologic Icterus. — The causes are the following : (a) Congenital stricture or absence of the duct ; (b) Syphilitic disease of the liver ; (c) Septic processes set up by infection through the umbilical vein. Symptoms. — In physiologic jaundice the skin is tinted greenish- VASCULAR {CIRCULATORY) AFFECTIONS OF THE LIVER. 865 yellow, resembling somewhat that of chlorosis. The mucous membranes are pale and the conjunctivae pearly-white. The pulse is feeble and some- times rapid. Auscultation over the base of the heart often reveals a soft systolic murmur transmitted to the vessels of the neck and associated with a venous hum. According to Murchison, false or physiologic jaundice differs from the true or pathologic form in that — 1. The conjunctivse are of a natural color ; 2. The urine is free from bile-pigment ; 3. The yel- low color gradually fades from the skin after a few days ; 4. The child is quite well and the bowels are*acting properly. In j?a^AoZo^^c jaundice the skin and conjunctivae are more or less in- tensely icteroid, the urine is loaded with bile-pigment, while the feces are of the pipe-clay variety. Hemorrhage from the cord may occur and de- struction of life may be rapidly accomplished, or the condition may la^t for some weeks without serious impairment of the general health, with final recovery. Treatment. — In the milder cases calomel in minute doses, combined with lactopeptin and sodium bicarbonate, can be recommended. In ma- lignant cases treatment is of no avail. VASCULAR (CIRCULATORY) AFFECTIONS OF THE LIVER. ANEMIA. The physical symptoms of this condition are absolutely nil, and its existence only discoverable postmortem. Its most common causes are those of general anemia, fatty and amyloid degeneration. HYPEREMIA. Definition. — An excess of blood in the liver. This may be of two varieties : (a), active and {h) passive, the latter being the more common. ACUTE HYPEREMIA. (Active Congestion.) Definition. — An excess of arterial blood in the liver. Ktiology. — Among the common causes are rich living, sedentary habits, alcoholism, traumatism, acute infectious diseases (typhus, typhoid), and pernicious malaria. The condition may also be vicarious, due to a sudden cessation of menstruation or of hemorrhage in other parts of the body. A physiologic condition is the temporary hyperemia that occurs during the ingestion of a full meal. Symptoms. — There are no symptoms characteristic of this condition ; those present in the different cases are varied and referable to disturb- ances of other viscera, as in coexisting cardiac hypertrophy or gastro- intestinal catarrh. Often, however, there is a sense of fulness and dis- tress in the right hypochondrium after eating, with tenderness on palpa- tion over the lower margin of the organ. • Prognosis and Course. — It is impossible to make any definite state- ment as to the course and prognosis of active hyperemia, these depending 55 866 DISEASES OF THE DIGESTIVE SYSTEM. wholly upon the cause of the affection. When due to errors of diet and hygiene the condition is easily remedied ; the prognosis of hyperemia accompanying hepatic cirrhosis, however, is decidedly grave. PASSIVE HYPEREMIA. {Passive Congestion.) Definition. — An increase of venous blood in the liver. Pathology. — The organ is enlarged ill size and changed to a deep- red color, its substance being firmer than normal. The center of the lobule (the area of the hepatic vein) becomes deeply pigmented, the pe- riphery (occupied by the portal vein) being lighter in color, sometimes owing to fatty infiltration. Because of its mottled appearance this has received the name of the "nutmeg liver." In long-standing passive congestion there is an increase of connective tissue, due to a proliferation of round-cells, causing atrophy of the parenchyma. The blood in the central capillaries becomes altered, the capillaries themselves are distended, and brown pigment is deposited about the center of the lobules. The organ becomes very much darker in color, and to this condition the name "cyanotic induration" or "cardiac liver" has been given. Later, contraction of the connective tissue occurs, causing a diminution in the size of the organ, and forming the so-called "atrophic nutmeg liver." Ktiology. — The causes that lead to passive hyperemia are both local and general. Among loceil causes may be mentioned the following : 1. Pressure over the portal area from without, as from a tumor or cyst. 2. Disease of the walls of the veins, as in syphilitic phlebitis. 3. Coagulation of the blood in the veins (thrombosis). Among the general causes are — 1. Chronic valvular disease affecting the right side. Passive hyper- emia is .also common in mitral disease. 2. Pulmonary emphysema and cirrhosis of the lung. 3. Intrathoracic tumors, which by their mechanical action cause an increased pressure in the efferent branches of the hepatic veins. Symptoms. — Often the patient experiences a sensation of fulness and tveight in the region of the liver that amounts in some instances to actual pain. Jaundice is usually present, but varies in intensity, and is due to obstruction of the smaller ducts by the distention of the hepatic venules. Hematemesis is not rare, and symptoms of gastro-intestinal disturbance are usually present. In marked cases the stools are clay- colored, showing the absence of bile ; the urine is loaded with bile-pig- ment ; and jaundice deepens with the development of ascites or anasarca from portal obstruction. On palpation the organ is tender and increased in size, extending in some instances fully a hand's breadth below the costal margin. In marked cases the whole organ pulsates, owing to the regurgitation of blood into the hepatic veins. This symptom is best elicited by placing one hand on the ensiform cartilage, while the other presses against the liver below the right lower border of the ribs. Diagnosis. — The diagnosis of passive congestion, per se, is often very difficult, but when secondary to heart- and lung-diseases it is ren- dered more plain. DISEASES OF THE PORTAL VEIN. 867 The prognosis and treatment depend wholly upon the causal factors. DISEASES OF THE PORTAL VEIN. THROMBOSIS AND EMBOLISM. Pathology. — In the early stages the clot presents a grayish-red or yellowish appearance, and on loosening it is found to adhere more or less closely to the inner coat of the vein. Later it becomes a mass of small white fibrin tightly adherent to the sides of the blood-vessel, which itself undergoes fibroid change, giving, rise to the so-called adhesive pylephle- bitis. Organized thrombi are rarely found, except in the smaller branches of the portal area. If the throinbus obstruct the vessel, collateral circu- lation may be established for years, as in a case recorded by Osier. Septic softening, however, is a very common result, and most frequent of all is pylephlebitis. If a parietal or channelled thrombus be formed, partial or complete circulation may be re-established and recovery take place. Hem- orrhagic infarction may take place, but is very rare. Ktiology. — Thrombi are rare occurrences in the portal vein. Among the causes that lead to their occurrence, however, may be mentioned — (a) Traumatism ; (h) cirrhosis ; (c) carcinoma of the liver, involving the portal area ; (c?) pressure from without, as in proliferative peritonitis involving the gastro-hepatic omentum, abscesses, enlarged glands, or impacted calculi pressing on the veins ; (e) it may be occasioned by ulcerative affections of the bowels and appendicitis, and pylephlebitis may precede its occurrence; (/) slowing of the circulation due to splenic diseases, such as marasmus. Symptoms. — Symptoms may be almost lacking in portal obstruction, or the condition may simulate cirrhosis of the liver. In ordinary cases the symptoms are very slight, the hepatic circulation, as shown by Cohn- heim and Litton, being " sufiicient for the nourishment of the liver and secretion of the bile" (Henry). If the occlusion be complete., edema followed by the rapid development of ascites may occur. In such cases loss of strength is persistent and progressive, and death may result from exhaustion. Hemorrhages due to venous stasis may occur from the nose, stomach, and intestines. Jaundice and diarrhea occur frequently, the former being the result of obstruction to the biliary passages from the same causes that produce the thrombosis or the diminished pressure in the portal area. On palpation the liver is found slightly enlarged and tender on pressure, and projecting below the lower margin of the ribs ; the spleen is also enlarged. Percussion also reveals enlargement over the splenic area. If ascites is present, percus- sion will reveal dulness in the flanks, changing with the position of the patient ; and on gently tapping one side of the belly-wall, with the hand on the opposite side, a wave of fluctuation will be felt. Diagnosis. — The diagnosis of portal thrombosis is often extremely difiicult. "A suggestive symptom, however, is sudden onset of the most intense engorgement of the branches of the portal system " (Osier). Sequelce. — If the emboli are septic in origin, an abscess, with all its accompanying symptoms, will be the result. Hemorrhagic infarction 868 DISEASES OF THE DIGESTIVE SYSTEM. may occur, but is very rare, since a free anastomosis exists between the lobular plexuses and the hepatic artery. " Pylethrombosis may be regarded as probable if no other possible cause of the portal obstruction seems likely, and if we are able to discover a cause for thrombosis, like a former attack of circumscribed peritonitis " (Strlimpell). The progriiosis is always unfavorable, although certain cases have been demonstrated by autopsy to have improved temporarily. Course and Duration. — Nothing definite can be stated in regard to the course and duration of this affection, since these depend entirely upon the cause. Treatment. — The symptoms resulting from portal congestion, due to thrombi in the portal vein, are those described under Cirrhosis of the Liver, and the treatment is identical with that of interstitial hepatitis. In rare instances septic emboli give rise to abscesses that are usually multiple; when these occur the treatment is purely symptomatic. SUPPURATIVE PYLEPHLEBITIS. Definition. — A purulent inflammation of the portal vein or its branches. Pathology. — If noted in the early stages, the coats of the portal vein are distended and thickened, and the connective tissue surrounding the portal area is infiltrated and the seat of minute ecchymoses. The inflammation usually originates in the smaller veins of the portal system or in the hepatic branches of the vein itself; the main trunk is attacked least often. Numerous thrombi are found obstructing the vein and its branches, which finally undergo suppuration. From these, emboli enter the circulation and are carried to all parts of the liver, forming meta- static abscesses. In advanced cases the whole organ (especially the pe- ripheral parts) becomes infiltrated with pockets of pus, that communicate with the portal vein or its branches, and extend in some instances into the mesenteric or gastric veins. A single large abscess may be present, but multiple abscesses are the rule. The contents may be very fetid and bile-stained, or, as in many instances, they may be composed of thick, creamy laudable pus. From this focus of suppuration embolic abscesses may extend to the lungs, brain, kidneys, and joints. The macroscopic appearance, with the organ in situ, is sometimes practically normal. The liver may present a uniform enlargement, the surface being of normal color and the capsule non-adherent. More com- monly, however, the cortex presents a mottled appearance, and numerous yellowish-white spots are seen beneath the capsule. Htiology. — The most frequent source of purulent pylephlebitis is appendicitis with abscess. Rarely the disease arises idiopathically. Among other causes are the following : (a) A secondary (becoming a general) pyemia, (b) Ulceration of the intestines, occurring in dysentery and, more rarely, in typhoid fever, (e) Gastric ulcer, (d) Pelvic ab- scess ; abscess of the spleen, (e) Specific infection through the umbili- cus, occurring in the new-born. Symptoms. — The symptoms vary according as to whether the case remains one of suppurative pylephlebitis or terminates in hepatic ab- SUPPURATIVE PYLEPHLEBITIS. 869 scess. If the condition is part of a general j!??/e7nza, the symptoms refer- able to the liver may be almost negative. The Uve7- is usually enlarged, and tender on pressure, the enlargement being most marked when an he- patic abscess exists. Though paiii is present, in many cases it is not a marked feature ; it is frequently referred to the epigastrium, and may radiate laterally or downward. Percussion in the left axillary line shows splenic enlargement, and the organ can in some instances be felt below the costal margin, constituting the ^^ acute splenic tumor" of septico- pyemia. The fever is of an irregular septic type, the elevation in temperature is accompanied by rigors or chills and followed by profuse sweating. Other febrile symptoms, as headache, anorexia, and scanty, high-colored urine, are present. Jaundice of varying intensity is present, although usually it is not pronounced, the complexion being merely doughy or muddy. Diarrhea is not an infrequent symptom of this condition, and the dejecta sometimes contain blood as a result of the venous engorge- ment. Xausea and vomiting are often marked. As the case advances the pulse becomes rapid and small, and a low form of delirium develops ; this is followed by stupor, coma, and death. Duration and Prognosis. — The duration of suppurative pylephle- bitis is usually from one to three or four weeks or longer. The prognosis is absolutely fatal. Diagnosis. — The diagnosis of suppurative pylephlebitis is sometimes extremely difficult, unless the case is complicated by hepatic abscess, as enlargement of the liver is not constant in the former condition. The etiology, septic temperature, enlargement of the spleen, jaundice, and pain in the region of the liver would all, however, point to this affection. The differential diagnosis of hepatic abscess will be spoken of later. Treatment. — Unfortunately, the treatment of suppurative pylephle- bitis can only be palliative. Sm^gical measures are rarely curative, unless the abscess is single and localized and shows signs of pointing. Free stimulation should be begun early, and should be persisted in throughout the course of the disease. Nausea and vomiting may often be relieved or controlled by pellets of cracked ice, brandy, and soda-water or champagne. One-drop doses of wine of ipecac every half hour until relieved, or the antiemetics, as cre- asote (m^ — 0.033 — every half hour combined with bismuth subnitrate gr. V — 0.324) or cerium oxalate (gr. \ — 0.016 — every two hours), often check the gastric irritability. The pain in suppurative pylephlebitis may be acute, and demand the free use of morphin, either hypodermically or by the mouth. If much nausea exists, suppositories containing the extract of opium may be given at intervals. As the disease is almost invariably fatal, opium or its alka- loids may be given liberally. Fever may be controlled by repeated cold spongings or by the cold pack (68° F. — 20° C), aided by large doses of quinin and salol. As the pyrexia is pyemic in character, however, drugs have little or no effect in reducing the temperature. Delirium, which, with the rise of temperature, usually becomes aggra- vated toward evening, can best be subdued by applying an ice-cap to the head ; this may also be reinforced by motor and sensory depressants, 870 DISEASES OF THE DIGESTIVE SYSTEM. as chloral hydrate and the bromids. In well-marked cases hypodermic injections of hyoscin hydrobromate (gr. y^-g — 0.0006 — every two hours until relieved) may be necessary. STENOSIS. Obstruction of the portal vein may be due, as before mentioned, to {a) thrombosis ; {b) cicatricial contraction from cirrhosis or syphilis of the liver ; and {c) tumors pressing on the portal area. The first cause is the more common, chiefly because mechanical obstruction, by causing a stasis of the blood-current, induces the formation of a thrombus. The symptoms of portal stenosis may be nil ; if the stenosis occurs slowly, the hepatic artery furnishes sufllcient blood to carry on the func- tions of the liver, the compensatory circulation being established by means of the systemic vessels. If due to thrombosis, the symptoms of portal engorgement appear suddenly with the development of edema and ascites. The liver is rarely enlarged in this condition. Prognosis. — This depends wholly upon the cause of the aifection. Thrombi in the portal vein often give rise to a suppurative pylephlebitis, terminating in hepatic abscess ; tumors are rarely accessible ; whereas fibroid conditions of the liver causing cicatricial contraction are incurable. As a rule, the prognosis may be said to be guardedly unfavorable. AFFECTIONS OF THE HEPATIC BLOOD-VESSELS. OsLER records a case of stenosis of the hepatic veins that Avas asso- ciated with fibroid obliteration of the inferior vena cava, with a greatly enlarged and cirrhotic liver. Among other affections of the hepatic veins are (a) Emboli, orig- inating from a thrombus in the right auricle, and (b) Dilatation, from stasis of the blood-current flowing to the right heart, due to enlarge- ment of the latter. Affections of the hepatic arteries are exceedingly rare, but ma}'^ occur in one of the folloAving forms: («) Ayieurysm. — Only 10 or 12 cases of aneurysm have been reported. (6) Hypertrophy and Dilatation. — These may occur in connection with general hepatic cirrhosis, the cicatricial bands obstructing the lumen of the artery, and causing thickening in some places, and ampullae, or sac-like dilatations, in others, (e) Sclerosis. — This may form a part of a general arterio-sclerosis, though it occurs oftener in connection with cirrhosis or syphilitic hepatitis. ATROPHY AND HYPERTROPHY OF THE LIVER. (a) Atrophy. — Simple atrophy of the liver may result from pressure (corset-liver), syphilis, advanced cirrhosis, senility, and from the toxic HEPATIC INFILTRATIONS AND DEGENERATIONS. 871 action of phosphorus, arsenic, or chloroform — all factors that induce rapid fatty degeneration with cell-destruction. ih) Hypertrophy is of two kinds — (1) true and (2) false. (1) True hypertrophy may be subdivided into simple and numerical (hyperplasia), the latter referring to an increase in the number of the parenchymatous cells, and not, necessarily, implying an increase in the size of the organ. The tAvo causes of simple hypertrophy are active and passive conges- tion. Among the causes of numerical hypertrophy may be mentioned the following : Leukemia, hypertrophic cirrhosis, atrophic cirrhosis (hyper- plasia), syphilis, diabetes, and malaria. (2) Pseudo- or false hypertrophy occurs in amyloid and fatty infiltra- tion, carcinoma, and abscess, and consists in an increase in the tissues least concerned in the function of the organ. HEPATIC INF.ILTRATIONS AND DEGENERATIONS. AMYLOID INFILTRATION. {Waxy, Lmrlaceous, Bacony. or Albuminoid Infiltration ; Amyloid Disease.) Definition. — A deposit in the hepatic connective tissues of a peculiar substance having some of the reactions of, and resembling, starch. A physiologic example of amyloid infiltration may be found in the corpora amylacece of the prostate gland, in which there is a concentric arrange- ment somewhat resembling a starch-granule. Pathology. — The organ is larger than normally and of firmer con- sistence. The edges are rounded and not well defined, and the surface is of a light color, presenting in some instances a mottled appearance. On section the surface presents a grayish-brown, glistening appearance, which when scraped fails to exude oil-droplets, as in the fatty liver. On microscopic examination the connective-tissue trabeculse and the intima and media of the capillary walls (the starting-points) are chiefly affected, the lumen of the latter being lessened ; this decreases the blood- supply to the liver, and often directly induces fatty degeneration. The hepatic cells may be atrophied and show evidences of fatty change. Amyloid material is structureless, and appears in small cloudy masses under the microscope. Chemically, it contains small amounts of potassium and phosphorus and an excess of sodium and chlorin. Ktiology. — Amyloid infiltration may occur primarily in the liver, but it is often a part of a general infiltration, affecting especially the spleen {sago spleen) and kidneys. It is also found in some syphilitic scars and in certain tumors and old thrombi. Dickinson believes that the deposition of amyloid material is due to a decrease in the alkalinity of the fluid of the body, the pus (in cases of long suppuration) having removed a large quantity of the natural potas- sium salts. In malarial cachexia, however, such losses could not have occurred. It is a frequent sequel to long-standing and exhausting suppurating and cachectic affections, as necrosis of the bones, hip-joint disease, and 872 DISEASES OF THE DIGESTIVE SYSTEM. pyelitis ; "especially is this the case Avhen they occur in an hereditary tuberculous or syphilitic constitution " (Harley). Amyloid disease may also complicate chronic malaria. In children tuberculosis and rachitis not uncommonly contribute to amyloid infiltration. Tests and Characteristics of Amyloid Material. — Although of animal origin, amyloid matter is closely related to a vegetable albuminoid starch. It is, however, slow to decompose, and is not acted on by weak acids and alkalies, whereas strong alkalies dissolve it. lodin gives a blue color upon the addition of sulphuric acid. Lugol's solution (the aqueous solu- tion of iodin and potassium iodid) gives a brown tint to amyloid liver- substance and stains ordinary hepatic tissues a yellow color. Gentian- violet gives a I'eddish or pinkish hue to amyloid substance, while normal tissue is stained blue. The following is taken from Harley's Comparative Table of Amyloid Tests : Starch. A-Myloid. Cholesterin. Water. Ether. Heat. Sulphuric acid. Iodin. Dissolves on boil- Dissolves on boil- Unchanged. ing. Insoluble. Dries up. Chars. Becomes blue. Dissolves. Melts. Becomes green, blue, etc. Remains un- changed. Sulphate of indigo. ing. Insoluble, Dries up. Swells up, reddish- brown. Blue color with 11.^- SO4, which is de- stroyed by excess. . Amyloid tissue soaked in it be- comes a brilliant blue, while with ordinary liver-tis- sues the blue fades to a pale green. Symptoms. — When amyloid disease occurs in children the subjects are poorly developed and puny, the complexion is, as a rule, muddy or sallow, and the abdomen usually prominent. Occasionally the skin is exceedingly transparent. At any age gastro-intestinal symptoyns occur, prominent among which are marked constipation and a capricious appe- tite. Mental phenomena, as impairment of memory and inability to con- centrate, are not unusual in this disease. Pain about the hepatic region is a rare symptom. The spleen is usually enlarged from coexistent amyloid infiltration. The urine often contains albumin (globulin is nearly always present) and Avaxy tube-casts ; it is of high specific gravity, and is usually scanty and dark colored. The physical signs show an increase in the area of hepatic dulness ; the edges of the organ extend below the costal margin and have a rounded outline. Sometimes, however, the edge, even in a very great enlargement, is sharp and large. Wilks speaks of an amyloid liver weighing 14 lbs. — 6.35 kgms. (Osier). In rare instances the liver is reduced in size. Diag"nosis. — The foregoing symptoms and physical signs, in con- junction with an ordinarily clear etiology, are sufficient to establish the diagnosis. Treatment. — As amyloid disease is almost invariably a secondary FATTY INFILTRATION OF THE LIVER. 873 condition, the treatment must be directed to the removal of the primary cause, whether syphilis, tuberculosis, or rickets. The diet should consist of nitrogenous or animal substances, with a minimum amount of fatty or farinaceous foods. French rolls and bran- or gluten-bread are allowable, together with lean meat and green vegetables. Stimulants are to be strictly avoided. Moderate exercise, with the judicious use of Turkish (hot-air) and Russian (hot-vapor) baths, is also of great value. Many drugs are mentioned in the treatment of this disease, among the more important being the ammonium salts (the chlorid, gr. v to x — 0.324 to 0.648 — three or four times a day), and other alkalies, together with tonics and laxatives. When syphilis has been clearly established as an etiologic factor of the disease, the tincture of iodin in 10- to 15-minim (0.666-0.999) doses, well diluted, has been recommended to be given three or four times daily. Cod-liver oil as a nutritive has been tried with good effect. Of tonics, the dilute mineral acids, given in moderate doses over a long period of time, have probably achieved the best results. FATTY INFILTRATION. Definition. — A deposit of fat in the hepatic tissues due to the in- gestion of fats and albuminates. Pathology. — The infiltration occurs often in localized areas, and may be so intense that the organ when cut presents a shiny, oily ap- pearance. The liver is often evenly enlarged, and may weigh twelve to fifteen pounds. The edges are rounded and the substance less firm than normally. Portions of the liver-substance float in water, being of low specific gravity. The color is light-yellow or grayish. On micro- scopic examination the protoplasm of the cell is seen to be pushed to one side by the fat-droplets, which tend to coalesce. When the fat is removed the cells resume their normal outline and appearance. Htiology. — (a) Fatty infiltration may form part of a general obesity or it may folloAv excessive over-eating or sedentary habits, {h) It often occurs in wasting diseases, as carcinoma, syphilis, chronic malaria, and tuberculosis, and often accompanies fatty degeneration. Symptoms. — The subjective symptoms of fatty infiltration may be entirely wanting, since the function of the liver is not impaireji to any extent. "When they are present progressive anemia and debility are noted, and are accompanied by nervous irritahility and insomnia. In marked cases the cardiac rhythm is disturbed, causing a feeble and irregular impulse. The physical signs are usually well defined, and the area of hepatic dulness is uniformly increased, extending in some instances as low as the umbilicus. The enlargement, however, is not so great as in amyloid disease. Differential Diagnosis. — Fatty infiltration of the liver is not apt to be mistaken for any other affection of this organ. The occurrence of general obesity, together with an entire absence of symptoms of obstruction to the portal vessels or bile-ducts or of other evidences of fatty degeneration (particularly feeble heart-sounds), will help to distin- guish it from this latter condition. The etiologic factors above men- tioned will also aid in the differentiation. 874 DISEASES OF THE DIGESTIVE SYSTE3L Prognosis. — This is decidedly favorable, as the function of the liver in many instances is not impaired in the slightest degree. Treatment. — As the disease is of gradual development and long duration, a modification of the diet constitutes the first essential of the treatment. That prescribed under the Treatment of Amyloid Liver is admirably suited to this affection. Saccharine and farinaceous articles of food (potatoes, oatmeal, and sweetmeats) must be eschewed. Wheat- bread must be partaken of sparingly, and in its place gluten- and bran-bread or crusts of French rolls should be used. Fish, lean meats, fresh vegetables, and fruits are also allowable. Alcoholic beverages must be interdicted. Graduated daily exercise and Turkish or Russian baths, judiciously used, are important factors in the treatment. Medicinally, the salts of the alkalies are highly recommended: sodium sulphate (in dram — 4.0 — doses, taken on an empty stomach) and ammonium carbonate (gr. xv to XXX — 1.0 to 2.0 — in twenty-four hours). FATTY DEGENERATION OF THE LIVER. Definition. — A conversion of the albuminates of the cells into fat ; it is characterized anatomically by a destruction of the liver-substance, with atrophy of the organ, and clinically by biliary, gastro-intestinal, cardiac, and renal symptoms. Pathology. — On examining a liver that is the seat of marked fatty degeneration the organ is found smaller than normally, and the sub- stance is light yellow in color, soft, pliable, and easily torn. On section the relation between the interlobular connective tissue and the acini is lost, the latter being replaced by fat-cells and oil-droplets. Scattered areas of pigmentation may be observed throughout the organ. 3Iicroscopically, the cells lose their shape and become globular ; the nuclei tend to coalesce, and finally disappear, together with the cell-wall, giving rise to compound globule-cells, which do not tend to coalesce and are staiped black by osmic acid. Crystals, granular debris, Lener's spheres, cholesterin, tyrosin, and phosphatic crystals are also found in this form of granular change. Htiology. — The following are among the recognized causes of the aflfection : (a) The excessive use of beer or alcoholic liquors, (h) It may be a sequence of amyloid disease, and hence result from any of the causes of the latter, (c) Diminution of the oxygen-supply to the tissues, occurring in phosphorus-, chloroform-, or arsenic-poisoning and in certain "wasting diseases (carcinoma, phthisis, and chronic dysentery), (d) It may occur as a complication in the grave anemias, especially pernicious anemia, and in acute infectious diseases and the intoxications ; also as a part of the pathology of acute yellow atrophy of the liver. Symptoms. — I feel convinced that partial or mild cases of fatty de- generation of the liver present no morbid symptoms of diagnostic import. Pain, jaundice, and ascites may occur separately or conjointly, but form the exception rather than the rule. The severe forms are characterized PERIHEPATITIS. 875 by the symptoms seen in phosphorus-poisoning and acute yellow atrophy, to the discussion of which the reader is referred. Complications. — The disease may be complicated with fatty change in the kidneys. Under these circumstances the urine is diminished in amount, of low specific gravity, and contains an abundance of albumin, fatty or oily casts, and crystals of cholesterin, leiicin, and tyrosin. In marked cases there is a yev^ feeble and irregular cardiac impulse, accom- panied by attacks oi vertigo and syncope, the latter symptoms indicating beginning degeneration of the cardiac muscle. Edema of the lower ex- tremities and anasarca may occur as complications of this condition. The physical signs elicited by palpation and percussion show increas- ing diminution in the size of the liver as the disease advances. Diagnosis. — The chief diagnostic points of fatty degeneration may be summated thus : (a) A history of alcoholism, of poisoning by drugs (arsenic, phosphorus, or chloroform), or of an acute infectious disease (acute yellow atrophy) ; (6) Grave general symptoms, as albuminuria, edema, ascites, cardiac failure, terminating often in acholia or cholemia ; {c) Progressive diminution in the size of the organ. When these occur conjointly the diagnosis is established beyond a doubt. Prognosis. — The prognosis is entirely dependent upon the cause. If due to an excessive use of stimulants, the process, if recognized early, may be arrested ; if associated with acute yellow atrophy or other infec- tious disease, the outlook is unpromising. Treatment. — The indications for treatment may be divided into the dietetic, hygienic, and medicinal. The same precautions regarding diet should be observed as in fatty infiltration. An open-air existence, short of injurious exposure, aided by hot salt-water, Turkish, or Russian baths, under restriction, is sure to improve the general condition of the patient. The medicinal treatment varies according to the cause of the disease. If due to grave anemia, iron (tinct. ferri chlorid. or syrup, ferri. iodid.) may be given in ascending doses. Poisoning by drugs that produce fatty degeneration of the liver is to be combated by their respective antidotes. Gastro-intestinal disturbances, if coexistent, demand appropriate treat- ment. For the latter Frerichs recommends highly the salts of the alka- lies (sodium sulphate in dram — 4.0 — doses taken on an empty stomach and ammonium carbonate). Ascites and cardiac asthenia, when occurring as complications, must be met by suitable measures. PERIHEPATITIS. ACUTE PERIHEPATITIS. [Pyo-pneumothorax Subphrenictts.) Definition. — An inflammation, either suppurative or fibrinous, of the peritoneal covering of the liver and the corresponding portion of the diaphragm. Pathology. — The morbid changes may consist in a purely plastic inflammation, the serous layers being thickened, opaque, and covered with a fibrinous exudate leading to adhesion. In the majority of cases. 876 DISEASES OF THE DIGESTIVE SYSTEM however, the inflammatory product is chiefly purulent, and is ribboned by fibrous bands so as to form circumscribed areas, filled Avith pus, lying between the liver and the diaphragm ; this constitutes the suhplirenic abscess. The latter is found more commonly to the right than to the left of the suspensory ligament. It may contain much pus (1 quart — 1 liter — or even more), which in most cases is mixed with air or gas de- rived from the gastro-intestinal canal. Rarely, bilirubin-crystals are found, betraying the presence of bile. If the latter be present in large amount, the pus assumes an ocher-yellow hue. !]^tiology. — The fibrinous variety may result from the direct exten- sion of one or other of the acute forms of inflammation of the liver (ab- scess, hydatid cyst), from a pleurisy spreading along the lymphatics in the diaphragm, or from traumatism — particularly a blow. The suppura- tive form {pyo-pneumotJiorax subphrenieiis, Leyden) may be caused in the same manner as the former, but far oftener — in more than one-half of the instances — it follows perforation of a gastric ulcer, and far less commonly perforation of a duodenal or colonic ulcer. Appendicitis and penetrating wounds are not infrequent causes. Perihepatitis is a grave complicating event in carcinoma (of the stomach, esophagus, and intes- tines), in lobar pneumonia, and purulent pleuritis. Symptoms. — Those of the acute fibrinous variety are either alto- gether missing or too vague to admit of correct interpretation. The coappearance, however, of severe pain, increased on deep breathing, and tenderness over a circumscribed area either in the right hypochondrium or the epigastrium, after the action of some known cause or the occur- rence of one of the causative affections, is strongly suggestive of this form of the complaint. A friction-sound may at times be heard below the seventh rib in the mammillary and the ninth rib in the axillary line, or over the epigastrium, as in two cases in my practice. It is of short duration, and is limited usually to the end of inspiration. It must be recollected that plastic pleurisy may be an associated condition. In suppurative perihepatitis the symptoms are sometimes screened by those characterizing the special causative complaint ; but in my experi- ence, in cases due to perforation — the most common cause — the onset is rapid and severe, and is marked by acute pain referred to a circumscribed spot in the hepatic region, great tenderness, rapid, embarrassed, and painful respiration (owing to implication of the diaphragm), by vomiting (often bilious, though at times hemorrhagic) or nausea, and by faint jaundice in some cases. Shortly the general features of circumscribed peritoneal abscess also appear — rigors, irregular fever, sweats, and pro- gressive prostration and emaciation. Physical Signs. — Inspection discloses bulging of the right hypo- chondrium and often of the epigastrium. The same regions are immo- bile, but this is best appreciated by palpation. The anterior edge of the liver is felt even as low as the umbilical level. Percussion reveals a variable increase of hepatic dulness upward, sometimes touching the fourth rib. The upper level of the fluid is movable on changing the po- sition of the patient, and this is particularly striking if air or gas is con- tained in the abscess ; the presence of the latter also causes a zone of tympanitic resonance above the dull area, while overlying the latter CHRONIC PERIHEPATITIS. 877 there is the semi-tympanitic area of the retracted lung. Auscultation reveals an absence of breath-sounds and of the vocal resonance over the dull and tympanitic areas, while the respiratory sounds over the dis- placed lung are broncho-vesicular. Diflferential Diagnosis. — Acute perihepatitis often remains unrec- ognized during life. It may be confounded Avith empyema of the right side, but the tAYO conditions have different modes of development. Perihepatitis is preceded and accompanied by abdominal symptoms ; empyema mani- fests thoracic symptoms — e. y. cough and pleuritic pain. At a later stage the exaggerated respiratory murmur above the dull area, the slighter cardiac displacement toward the left, and the greater hepatic displacement downward in suppurative perihepatitis aid in the differen- tiation. The introduction of the trocar in the seventh or eighth inter- costal space in the mid-axillary line may also be helpful, especially if the exudate be found to contain bile-pigment. PfuliVs sign — the more ready escape of the fluid during inspiration on aspiration of abscesses below the diaphragm — may not be without value. The points narrated above may likewise serve to separate pyo-pnqumothorax from suppurative perihepatitis (see also Pneumothorax, p. bQS). Course and Prognosis. — In the milder or fibrinous variety the outlook is favorable and the course is brief. On the other hand, the suppurative type due to perforation, if not early brought under proper surgical treatment, often terminates unfavorably by gradual asthenia. Rarely the pus is resorbed, or it may find an outlet through the lungs, abdominal walls, or other avenue, folloAved by slow recovery. The treatment is the same as for localized peritonitis. The first evidence of the presence of pus is the signal for appropriate surgical interference — evacuation and drainage. CHRONIC PERIHEPATITIS. {Zuckergussleber.) This affection is a chronic inflammation of the perihepatic fibrous membrane, which becomes opaque and thickened. Contraction of this capsule ensues, with compression of the liver and atrophy to even one-half the size of the normal organ (as in a case reported by Rumpf ^), and par- tial or total occlusion of the vessel and bile-ducts. Perhaps these changes are most marked in cases that follow acute suppurative perihepatitis. Genuine instances show no hyperplasia of the interstitial connective tis- sue ; hence the condition is closely related pathologically to " Glissonian cirrhosis " (vide p. 886). The main causes of chronic perihepatitis are great and protracted local pressure, as from a corset, and certain occupations. It may rep- resent a portion of a more general chronic inflammation of the serosie. Finally, I am of the belief that syphilis is the leading single cause, and could discover no other factor present in tAvo cases that yielded to anti- syjDhilitic treatment. The diagnosis is generally problematic. Of especial clinical worth are the etiology, pain in the right hypochondriac region — particularly in cases due to syphilis — absence of the signs of stasis of the gastro- intestinal tract, and the very protracted course. ^ Beutsch. Arch.f. klin. Med., March 13, 1895. 878 DISEASES OF THE DIGESTIVE SYSTE3I. The treatment is purely palliative, apart from the effort to remove the special cause, whether this be syphilis, occupation, or other influ- ential factor. ABSCESS OF THE LIVER. {Hepatic Abscess; Suppurative Hepatitis.) Definition. — A circumscribed collection of pus in the hepatic parenchyma. Pathology. — If examined in situ, a liver that is the seat of ab- scess-formation is usually found to be symmetrically enlarged, and on careful palpation one or more areas of fluctuation (either deep or super- ficial, according to the location of the abscess) may be detected. If single, its position is usually in the right lobe near the convexity of the organ (TO per cent, of cases). The tissue surrounding the abscess-wall is usually deeply injected, Jhe wall itself in acute cases being poorly defined, but grayish in color, irregular and shreddy, and composed of necrotic liver-cells, pus-corpuscles, and often amebfe. In chronic cases it becomes greatly thickened and often cartilaginous in appearance. Microscopically, the hepatic cells are altered in shape and devoid of nuclei ; they undergo rapid degeneration. A round-celled infiltration occurs about the blood-vessels, their walls being filled with small emboli containing innumerable staphylococci and streptococci. As the sup- purative process continues liquefaction-necrosis occurs, resulting in complete destruction of the hepatic parenchyma. The amount of fluid contained in a liver-abscess may exceed 2 or 3 quarts (2-3 liters), and its color varies from grayish-white to a creamy, reddish-brown. The collection in some instances resembles healthy pus. I have spoken of the methods of infection and of some of the different varieties of hepatic abscess in the discussion of Dysentery (see p. 96). Various odors are described, depending largely on the extent of bac- terial invasion and the degree of necrosis. In this connection it may be said that in amebic dysentery, with abscess of the liver as a compli- cation, the abscess is often single (involving more often the right lobe), whereas other forms due to septic infection give rise to multiple abscesses. In the latter instances the surface of the organ presents many small yellow areas beneath the capsule, varying from 5 to 15 mm. (i— f inches) in diameter. Usually, in such cases infection has taken place through the portal circulation, and on section the appearances of a suppurative pyle- phlebitis present themselves. If thrombi have formed in the portal tributaries, localized necrotic areas are the result, but more often the invasion affects the whole portal system, the liver being riddled with abscesses. If the abscess is secondary to obstruction by gall-stones or inspissated bile, the ducts are greatly distended and the gall-bladder is filled Avith pus mixed with bile. Ktiology. — Idiopathic abscess of the liver is rare even in tropical climates. The affection, even when excited by mechanical causes, as traumatism or obstruction by gall-stones, is invariably septic in cha- ABSCESS OF THE LIVER. 879 racter, and the infecting material reaches the interior through the hepatic vessels or the biliary passages. Septic emboli enter the liver by means of the vascular system through the hepatic artery or portal vein, the latter being the more common channel of transmission. Gastric ulcers, or the ulceration occurring in dysentery, typhoid fever, typhilitis (?), or appendicitis, may be followed by a purulent portal pylephlebitis, resulting in abscess-formation. In gen- eral pyemic processes or in bone-suppurations of long standing the germs enter the venous circulation, traverse the intralobular pulmonary plex- uses, and enter the liver through the hepatic artery. Suppurating wounds of the head are not uncommonly followed by abscess of the liver. Because of obstruction of the common duct by gall-stones, either from pressure-necrosis or owing to the decomposition of accumulated bile, pathogenic organisms may enter the liver and cause abscess-forma- tion through the medium of the bile-ducts. The most common method of infection, however, is through the portal vein. Among other causes may be mentioned foreign bodies travelling up the ducts, as parasites, round-worms, liver-flukes ; also, more rarely, suppuro-perforation by mechanical irritants (needles, pins, fish-bones, and the like), and sup- puration occurring in the course of an hydatid cyst. Leick has tabu- lated 19 cases of hepatic abscess caused by the ascaris lumbricoides. Symptoms. — In a typical case of hepatic abscess the most promi- nent symptoms are — hectic temperature, jmin, tenderness, and enlarge- ment of the organ, and often slight jaundice, although it must not be forgotten that any or all of these may be absent during the development of an abscess. The multiple abscesses occurring in pyemic conditions, which are frequently diagnosed Avhen in view upon the postmortem table, form an instance of this. To facilitate the subject I shall consider the more important symp- toms seriatim : Pain is circumscribed to the hepatic region, and radi- ates to the right shoulder in conjunction with the other symptoms and physical signs ; it is very characteristic, although not pathognomonic of hepatic abscess. In the earlier stages this symptom is not pronounced unless the abscess or abscesses lie superficially. It is usually of a dull, boring character, difiering in severity Avith the patient's position ; it is usually aggravated by pressure over the costal margin and by lying on the left side, this tending to drag the liver by its own weight from its normal position. Luschka explains the radiation of pain to the right shoulder by stating that filaments of the phrenic nerves that distribute themselves in the suspensory ligament and Glisson's capsule are irri- tated. The phrenic arises from the third, fourth, and fifth cervical nerves, and, as the fourth supplies sensation to the right shoulder, the impression is thus transmitted through the central nervous system. In acute cases accompanied by rapid destruction of the hepatic tis- sues the temperature usually rises rapidly, reaching 103° or 104° F. (39.4°— 40° C.) in the course of from twenty-four to thirty-six hours. Its course, however, is irregular and intermittent, and it may be hectic in character; just as often it resembles a tertian or quartan intermittent or a remittent temperature. Rigors or decided chills frequently accompany the rise of temperature, and during the decline profuse sweatings may take place, thus simulating to a certain extent the symptoms of malarial 880 DISEASES OF THE DIGESTIVE SYSTEM. fever. In chronic abscess of the liver pyrexia may be entirely absent. Less commonly the temperature may remain continuously high, with slight morning and evening exacerbations and remissions. The jpulse is usually rapid in proportion to the temperature. The physical signs in a case of hepatic abscess are always present to a greater or less degree, and are often pathognomonic. Inspection may reveal nothing during the entire course of the dis- ease, although in cases accompanied by intense congestion in which the abscess involves the anterior surface of the right lobe, bulging of the ribs on that side will occur, with a marked prominence in the hypo- chondriac region extendino- three or more finorer-breadths below the costal margin. Palpation confirms inspection and reveals tenderness on pressure below the costal margin in the mammary line. The liver, if projecting below the edge of the ribs, is usually enlarged uniformly, unless the abscess involves the surface of the margin. As the upper right lobe is more often involved, especially in a large single abscess, the increase in size is in an upward direction, thus rendering palpation negative. In rare instances the abscess gives rise to fluctuation on palpation, and if the peritoneum be inflamed a friction fremitus may be detected. Percussion. — The area of hepatic dulness may be increased uni- formly, but it is usually most marked upward and to the right, in some instances reaching at the anterior axillary line to the fifth rib, and pos- teriorly to the level of the angle of the scapula. This high position of the upper boundary of dulness which starts about the nipple-line serves to diff"erentiate abscess from other aff'ections of the liver, in which the enlargement extends in a downward direction. Other Symptoms. — The skin is pale and shows slight icterus, the conjunctivae being often bile-stained; intense jaundice, however, is rare. Progressive loss of flesh and strength, Avith gastro-intestinal disturbance (fulness in the epigastrium, flatulence, water-brash, nausea, and occasional vomiting), are common symptoms at the onset. The bowels are variable, and constipation usually alternates with diarrhea, the stools in some cases containing the ameba coli. Ascites may develop from pressure on the inferior vena cavse, but these cases are rare. The spleen may undergo active hyperplasia in acute abscess-fornlation. Puhnonart/ Si/ mptoms [severe cough, characteristic reddish-brown sputum, resembling anchovv sauce, broncho-vesicular breathing, rales) are commonly present ; they are due to compression of the base of the lung by the abscess press- ing upon the diaphragm. In fatal cases certain nervous symptoms (mut- tering delirium, cephalalgia, subsultus tendinum, stupor, coma) make their appearance. Complications and Sequelae. — The abscess may perforate into the pleural cavity (pyothoraxj, bronchi, lungs, intestinal tract, stomach, pericardium, peritoneal cavity, or externally through the abdominal wall, giving rise to various symptoms. If rupture occurs into the intestinal tract, sudden diarrhea, with the discharge of large quantities of pus, takes place ; there is then an amelioration of the pain, fever, and other .symptoms. If the rupture is into the lung, the physical signs will reveal the sudden development of weak, tubular breathing over the base, with increased tactile fremitus and percussion-dulness, together ABSCESS OF THE LIVER. 881 with the occurrence of profuse and typical expectoration. Reese and Latieur found the ameba coli in the bronchial discharge. S. Flexner has reported two cases of amebic abscess of the liver in Avhich perfora- tion into the vena cava occurred. Rupture into the abdominal cavity gives rise to the rapid development of a purulent peritonitis that is often fatal. Rarely, the abscess is emptied into the pericardium, giving rise to fatal acute pericarditis. Septic emboli have been known to lodge in the circle of 'Willis, producing fatal brain-abscess. Diagnosis. — The clinical symptoms of hepatic abscess are of diag- nostic importance only when taken in the aggregate, since the pain, fever, enlargement, and even hectic symptoms occur singly in other conditions unaccompanied by suppuration. The principal points in the establishment of the diagnosis of the affection may be summed up as follows: Residence in tropical countries, the previous existence of typhoid or dysenteric ulceration (or other gastro-intestinal inflamma- tion), the characteristic expectoration, enlargement of the liver, with pain and tenderness on pressure, and in some instances fluctuation on palpation. Lastly, aspiration may reveal pus-corpuscles, hepatic cells, staphylococci and streptococci, the ameba, and bile-pigment, which when found are pathognomonic : if the abscess be secondary to an echinococ- cus cyst, the presence of booklets will be detected. Differential Diagnosis. — Hepatic abscess may be misdiagnosed for empyema, malarial fever, and hepatie calculi. Empyema. — The mode of onset and the physical signs peculiar to this condition, if studied carefully, are entirely diiferent from those of abscess. In empyema there may be the history of a perforating wound of the chest, the rupture of a bronchiectatic or tuberculous cavity, or the pre-existence of a sero-fibrinous pleurisy ; whereas hepatic abscess may be preceded by an attack of amebic dysentery or intestinal ulcera- tion, or it may follow the impaction of biliary calculi. In both there may be the occurrence of a hectic temperature, with chills and sweating; but in empyema cough and dyspnea are prominent, and, if the pleural cavity communicates with a bronchus, profuse muco-purulent expectora- tion containing pus-cells, staphylococci, streptococci, and in many cases elastic tissue and tubercle bacilli. Rarely, an abscess of the liver pene- trates the diaphragm, and, entering the bronchi, is expectorated. The recognition of hepatic abscess under these circumstances is to be based mainly upon clear evidence of the affection prior to the occurrence of perforation, and copious, blood-tinted, purulent expectoration. The detection of the ameba coli in the sputum alone would set the diagnosis at rest. The contents of hepatic abscess obtained by aspiration consist of the micro-organisms of suppuration, and in addition broken-down liver-cells, bile-pigment, and in some cases the ameba coli. Inspection in empyema reveals bulging of the intercostal spaces on that side, while percussion gives absolute flatness over the base of the chest, rising pos- teriorly and changing with the change from a dorsal to a sitting position. Above the area of flatness Ave find either a normal pulmonary note or hyper-resonance. In abscess of the liver the lung is slightly displaced upward, being often bound to the diaphragm by adhesions ; and the upper boundary of dulness is lower, particularly in front, and is not changed with the decubitus of the patient. 56 882 DISEASES OF THE DIGESTIVE SYSTEM. Hepatic Abscess. Malaria. History of traumatism, dysentery, intes- History of previous attacks. Residence tinal ulceration, or residence in tropi- in warm, damp climates among the cal countries. lowlands. Hectic character of the temperature — Regularly recurrent rise of the tempera- high every evening and low every ture (intermittent or remittent, quotid- morning; irregular chills, followed by ian, tertian, quartan, or septinarian), fevers and sweatings. and the rise occurring during the chill, followed by profuse sweating ; chills more often in morning. An irregular, fluctuating tumor or multi- The spleen is enlarged : also there is a pie nodules in the liver : no splenic en- yellow-brown coloration of the skin, largement : rapid emaciation, with or more or less marked ; and. in long- without jaundice, but no cachexia. standing cases, the occurrence of ca- chexia. Blood shows simple anemia and leuko- The presence of the hematozoa of Laveran cytosis, and in marked cases disinte- and free pigment in the blood, gration of red blood-cells. Abscess-contents show the staphylococci. Absent, streptococci, amebae, or bacillus coli communis, and pus. Impacted Calculi. — In this condition attacks of hepatic colic are often first noticed, followed by jaundice, and. if impaction be not absolute, by the occurrence of stones in the feces. In abscess the pain is not parox- ysmal, but dull and boring in character, increasing in severity as the disease progresses. In chronic impaction jaundice, dull pain over the hepatic area, distention of the gall-bladder (which in some instances may be palpated), and clay-colored feces, constitute the principal symp- toms. There occurs also an intermittent fever as in hepatic abscess, but it is occasional — i. e. the febrile paroxysms recur at longer intervals. Again, the course of intermittent hepatic fever associated with biliary calculi is much more chronic than the fever-stage of suppurative hepa- titis. On the other hand, in abscess of the liver jaundice is compara- tively rare, and, unless the abscess rupture into the gastro-intestinal tract', the stools show nothing abnormal. In some instances biliary ab- scesses may follow impacted calculi, and it is always a secondary affection. Among other liver-conditions that are liable to be mistaken for hepatic abscess may be mentioned carcinoma, hypertrophic cirrhosis, and hydatid cyst, the differential diagnosis of which will be spoken of under these diseases. Prognosis. — The prognosis of hepatic abscess is unfavorable, the disease generally progressing to a rapidly fatal termination. Prompt evacuation of the abscess when its location can be detected, however, may be successfully performed. The mortality ranges from 50 to 60 per cent. In rare cases the walls of the abscess become calcified and the disease remains latent. The single large abscess that most often follows dysentery offers the best opportunity for surgical measures. Treatment.^^ — Barring operation, the treatment of abscess of the liver is purelv svmptomatic, being in many instances identical with that of septico-pyemia. The temperature often responds to repeated spong- ings with cool water (65° F — 18.3° C). For the pain mustard-poul- tices, the turpentine stupe, or hot fomentations over the hepatic area, in conjunction Avith full internal doses of opium, prove beneficial. Full and free stimulation and the free exhibition of quinin as soon as the ACUTE YELLOW ATROPHY. 883 condition is detected both support the system and control, in a measure, the pyemic process. If the abscess be single and localized, prompt evacuation should be resorted to. ACUTE YELLOW ATROPHY. {Malignant Jaundice: Icterus Gravis.) Definition. — An acute and probably infectious disease, character- ized by a rapid destruction of the parenchyma of the liver and by a diminution in the size of the organ : also bv iaundice, hemorrhacre. and grave cerebral phenomena. Patliology. — Macroscopically, in a case of acute yellow atrophy the liver is seen to be much reduced in size, weighing but 15 or 20 ounces (480.0-640.0). instead of its normal weight (50 oz. — 1.6 kgms.). The capsule is shrivelled and the organ is of a pulpy consistence, and changed in appearance from a mahogany-brown to a grayish-yellow hue. Some- times the liver is primarily enlarged. The cut section often presents areas of red and yellow discoloration, the so-called '' red atrophy " and "yellow: atrophy," the former being a later stage of the latter. The red appearance is due to an excess of blood in the capillaries, with free pig- ment that has been liberated by destruction of the red blood-cells. Microscopic examination reveals destruction or necrosis of the hepatic cells. The nuclei have disappeared, and the cell-wall contains a num- ber of fat-globules of various sizes containing free pigment. In ad- vanced cases, accompanied by total disintegration of the cells, fat-drop- lets, granular debris, cholesterin-plates, leucin-spheres, tyrosin-needles (first discovered by Frerichs, both in the cells and in the lolood-vessels), and crystals of bilirubin may be found. The common duct is patulous, and the gall-bladder is usually empty. In well-marked cases both the heart and 'kidneys show evidences of fatty degeneration, the kidneys often showing ecchymotic areas. The spleen is greatly enlarged from active congestion, giving rise to the so- called " acute splenic tumor." The splenic substance is soft and easily- torn, and on section the organ often drips blood. The skin and mucous membranes may be the seat of numerous ecchymoses, and dropsy of the pericardial and other serous cavities is frequently noted. The hlood is dark and fluid, and under the microscope is seen to contain disintegrated red corpuscles, with crystals of leucin and ty rosin. !^tiolo§fy. — The causes of acute yelloAv atrophy are both primary and secondary. Primarji or idiopathic acute yellow atrophv is rare and its coui'se as yet unsettled. Among the secondary predisposing causes may be mentioned age (fifteen to thirty-five years), female sex, parturi- tion, syphilis, and certain acute fevers (puerperal fever, typhoid, septic- emia, malaria). Acute phosphorus-poisoning sometimes presents changes resembling those of acute yellow atrophy. The disease rarely accompanies cirrhosis of the liver, and may follow a debauch. Rarely, an endemic form is assumed, but the exciting cause is thus far unknown. The disease is probably microcirganismal or toxic in nature, and 884 DISEASES OF THE DIGESTIVE SYSTEM. although various germs have been discovered, their claim to specificity has not been established. Symptoms. — The clinical histoi*y of acute yellow atrophy varies considerably in the early stages of the disease, the graver symptoms of the later stage alone being pathognomonic. The attack is usually ushered in by headache, malaise, anorexia, nausea, and iwmiting, mod- erate fever, and after a few days jaundice appears. Physical examina- tion at this time shows the area of hepatic dulness to be normal or only slightly increased. After a period varying from a few days to two or three weeks (during which the typical features of catarrhal jaundice have been present), grave nervous and cerebral symptoms present them- selves, as restlessness and violent headache, followed by delirium, which often becomes maniacal. Co7ivulsions then appear, and are succeeded by stupor and coma, the latter occurring usually within forty-eight hours from the onset of the period of cerebral excitement. Often coarse tremors are noticed in the voluntary muscles, and with the onset of the second stage the jaundice usually deepens. The temperature often remains normal until just before death, when it may rise one or two degrees. The pulse is much diminished both in volume and tension, and is rapid in proportion to the temperature. The tongue at the onset is covered with a light coating, most marked on the dorsum and tip. Later, it changes to a thick yellow color and becomes dry and fissured, with the development of a typhoid state. Vomiting appears usually during the premonitory stage and often becomes in- tense ; the vo77nt consists at first simply of the gastric contents, which later in the disease becomes mixed with blood (hematemesis). Hemor- rliages also frequently occur into the skin (ecchymoses) and from the mucous membranes, giving rise to epistaxis, hematuria, melena, he- moptysis, and menorrhagia. Constipation with clay- colored stools is common. The urine in acute yellow atrophy is often scanty in amount, high col- ored, and shows an increase in specific gravity (1028-1032). The urea is greatly diminished, but bile-pigments and albumin, tube-casts, leucin and tgrosin are found both on chemical and microscopic examination. The latter can be easily demonstrated by allowing a drop of the urine to evaporate on a cover-glass and examining under the microscope. Tyrosin- crystals are deposited in the form of sheaves and rosettes, leucin as globular masses. These bodies are not constantly present. Thus, out of 34 cases collected by Thierfelder, in which the urine was ex- amined in this relation, "in 7 the result was negative; in 17 both were found; in 3 tyrosin only; in 7 leucin only." Among other products found in the urine Avorthy of mention are creatinin, lactic and sarco- lactic acids, and other bodies belonging to the fatty acid series. Acute yellow atrophy of the liver is a striking example of acid-intoxi- cation due to rapid and Avidespread destruction of proteids as the source of the fatty acids — sarcolactic, lactic, diacetic, and /3-oxy butyric. It is probable that the rare nervous phenomena of the disease are, in part at least, due to the diminished alkalinity of the blood arising from the ab- normal metabolism. The physical signs reveal tenderness over the hepatic region, often amounting to actual pain. During the second stage, in extreme cases, the THE LIVER IN PHOSPHORUS-POISONING. 885 edges of the organ cannot be palpated under the costal margin. Per- cussion, moreover, shows a great diminution in the size of the liver, the area of dulness in a case recorded by Harley extending over but 1 inch (2.5 cm.) in the mammary line and IJ inches (3.1 cm.), measured per- pendicularly, in the mid-axillary line. The left lobe is often the first to show physical signs of atrophy, per- cussion giving tympany instead of flatness in the upper epigastric region. As the atrophy continues the tympany exends below the seventh rib from above and advances upward from the costal margin, leaving but a small circumscribed area of hepatic dulness. The atrophy is usually progres- sive until death occurs, although favorable cases have been recorded in which the liver increased in size perceptibly during recovery (Harley, p. 260). Diagnosis. — The symptoms occurring during the second stage of the disease are usually so characteristic as to leave little doubt concern- ing the diagnosis. The occurrence of gradually increasing jaundice with vomiting, grave delirium, hemorrhages, the presence of an immense amount of bile, with leucin and tyrosin, in the urine, and greatly dimin- ished size of the liver, all combine to form a typical clinical picture. Unfortunately, leucin and tyrosin are also found in the urine in acute phosphorus-poisoning and rarely in severe acute infective diseases. Differential Diagnosis. — In hyjjertroijhic cirrhosis the onset is more gradual. There is generally a negative previous history ; and examina- tion of the urine fails to reveal leucin and tyrosin ; fever is rarely present in cirrhosis, and the physical signs often show a considerable increase in the area of hepatic dulness. The differential diagnosis between this disease and phosphorus- poisoning is given under the latter condition {vide infra). The prognosis is almost invariably fatal, since every case of true yellow atrophy is associated with a destruction of liver-cell^ that is accompanied by acute toxemia. Treatment.^As yet no specific treatment has been discovered, all remedies used being directed to the relief of symptomatic indications. The gastro-intestinal system should be relieved at the onset by divided doses of calomel. For the vomiting cracked ice, with 1-minim (0.066) doses of the wine of ipecac repeated every half hour or divided doses of opium, may be given. Marked nervous phenomena with delirium I have seen controlled by cool baths and the ice-cap, together with cam- phor, chloral, or other antispasmodics used internally. Free stimulation should be begun early and persisted in throughout the course of the disease. THE LIVER IN PHOSPHORUS-POISONING. FoLLOWiXG the ingestion of a dose of phosphorus varying from gr. \ to gr. 1 (0.008-0.0648) symptoms of poisoning manifest themselves (Taylor, Wormley) as folloAvs : After a period of time varying from three to tAvelve hours a sense of wretchedness, nausea, abdominal pain (not intense), and often vomiting, 886 DISEASES OF THE DIGESTIVE SYSTEM. occur. The vomitus consists of the gastric contents, with bile, and dur- ing the first few hours it may contain phosphorus, which gives it a luminous appearance in the dark. After the second or third day the vomiting usually ceases with the appearance of jaundice, which may become intense as the process con- tinues. Later in the course of the case emesis recommences, the vomita consisting of altered blood, giving rise to the so-called " black vomit." At this stage nervous symjjtoms usually manifest themselves (headache, insomnia, vertigo, and delirium, with convulsions and coma in fatal cases), death closing the scene usually in from thirty-six to forty- eight hours. The hoiveh are constipated, although attacks of diarrhea may super- vene, the evacuations being in some instances phosphorescent. Fever is irregular and usually is not marked, the temperature swing- ing from 99° to 101° F. (37.2°-38.3° C). In fatal cases the temper- ature may become subnormal just before death. The urine is scanty, of high specific gravity, and contains bile, bile- acids, albumin, sarcolactic acid, and in rare cases leucin and tyrosin (Wood). Renal epithelium and free fat-globules have also been found. When occurring in pregnant women, abortion or miscarriage invariably follows. Physical examination reveals a liver uniformly enlarged and tender on pressure. In protracted cases atrophy of the organ may rarely occur. Htiology. — The most common causes are — («) Occupation, workers in match-factories being the most frequent sufferers ; (6) The accidental swallowing of phosphorus {e. g. rat-poison, friction-match heads). Pathology. — On opening the abdominal cavity in a case of phos- phorus-poisoning the liver is seen to extend below the costal margin, its surface being lighter in color than normal and mottled in appearance, and its substance softer in consistence and friable. The cut section presents marked evidences of fatty degeneration, the acini being lighter in color than the interlobular tissue. Portions of the hepatic parenchyma are deeply bile-stained, and on scraping the cut surface bile- and fat-globules will be found on the edge of the knife. The gall-bladder may be either full or empty. Microscopically, disin- tegrated liver-cells, fat-globules, granular debris, biliary coloring-matter, leucin-spheres, cholesterin-plates, and tyrosin-needles are noted. The gastric mucosa is found thickened, opaque, and yellow-white in appearance, due, as pointed out by Virchow, to a universal gastro-adeni- tis, and not to the local action of the poison. Ulcerative or erosive gastritis is very rare in phosphorus-poisoning. The kidneys may show beginning atrophy, the epithelium in the cortices undergoing granular and fatty degeneration, with final destruc- tion of the cells. The blood is dark, fluid, and not easily coagulable. Concato found that during life the white corpuscles are increased in number, and that the red are changed in shape and smaller than normal (Wood). Pete- chipe and ecchymoses frequently appear in all parts of the body. Diagnosis. — The diagnosis of acute phosphorus-poisoning is always extremely difl^cult and often impossible. The disease with which it is CIRRHOSIS OF THE LIVER. ' 887 most apt to become confounded is acute yellow atrophy of the liver. The differential points may be summated as follows: Acute Phosphor rs-poisoxixG. Acute Yellow Atrophy. There is a history of accidental ingestion There may be an endemic history. of poison (friction-match heads, rat- poison) or occupation. The onset is sudden ; violent nausea, A slow onset — malaise, slight fever, with vomiting, and pain over the region of nausea and vomiting : jaundice is a be- the liver. Jaundice appears on the ginning symptom. second or third day. K^ervous symptoms appear late in the Xervous symptoms may appear early, disease — always preceded by jaundice. even before the occurrence of jaundice. The vomit and stools are phosphorescent. Black vomit occurs early and persists Black vomit precedes death. throughout. Temporary arrest of symptoms between Progressive march of symptoms with no the occurrence of jaundice and black remission. vomit. Sarcolactic acid is present in the urine, Leucin and tyrosin are common in the and rarely leucin and tyrosin. urine. Prognosis and Duration. — The prognosis in phosphorus-poison- ing is bad, as small a dose as gr. i (0.008) of white phosphorus having caused death (Wormley). The duration is usually from one to six days, although the symptoms have been known to persist for tAvelve days be- fore death. In violent cases the end may come within twenty-four hours. Treatment. — The initial plan of treatment is by causing emesis to free the system of the poison that still remains undigested. For this purpose copper sulphate (gr. x — 0.648) in divided doses (gr. ij or iij — 0.129 or 0.194 — everv five minutes) should be oriven until free vomitino- occurs. As copper sulphate is a chemical antidote, forming with phos- phorus black copper phosphid. it should be continued in less frequently repeated doses (gr. ij — 0.129 — every half hour) and guarded by morphin to prevent vomiting. If emetics by the mouth fail to afford relief, apo- morphin muriate (gr. 1 — 0.0129), hypodermically. may be resorted to. The free evacuation of the stomach should be folloAved by the adminis- tration of the French oil of turpentine. Wood recommends that 1 part be given to every 100th part of the poison ingested. Ordinary turpen- tine is useless, but combined with mucilage of acacia 2 fluidrams (8.0) of French oil of turpentine may be given every fifteen minutes until 1 ounce (32.0) has been taken. Alkalies (magnesia) have been given, but are practically valueless. Free purgation should be effected if possible by Rochelle salts or mag- nesium citrate. Demulcent oils are never allowable, as they dissolve the phosphorus and hold it in solution. After absorption of the poison and degeneration of the tissues have taken place all known remedies are futile. CIRRHOSIS OF THE LIVER. {Sclerosis of the Liver ; Nutmeg Liver ; Gin-drinker^ s Liver ; Interstitial Hepatitis.) Definition. — A chronic disease of the liver, characterized, patho- logically, by an excess of connective tissue. It presents various biliary, gastro-intestinal. circulatory, and cerebral symptoms. 888 DISEASES OF THE DIGESTIVE SYSTEM. Pathology. — There are three pathologic varieties : (a) atrophic cir- rhosis, or '• giu-drinker's liver"; (h) hypertrophic cirrhosis; and (c) biliary cirrhosis. (a) Atrophic Cirrhosis {Laennee s^ or alcoholic cirrhosis) is the most common form, at least in the earliest stages, as Foxwell's studies teach ; the alcoholic (indurative) liver is more commonly enlarged than decreased in size. Morse ^ examined the records of 37 cases of cirrhosis, and found that among these there Avere 13 instances of enlarged liver, 11 of nor- mal size, and 12 smaller than normal. In typical examples the capsule is thickened, the organ greatly reduced in size, hard, granular, and much altered in shape. On section (which resists the cutting-knife) the surface presents grayish-Avhite bands of connective tissue surround- ing yellowish areas (acini) that project above the surface from com- pression (hob-nails); hence the term '* hob-nailed liver." 3Iicroscopicalh/., the process is seen to commence as an increase in the connective-tissue element surrounding the terminal branches of the portal vein. Compression of the liver-cells and of the portal veins, with consequent obstruction of the circulation, coustantl}' increases with the progress of the proliferation of the connective tissue and its secondary contraction. Atrophic changes in the hepatic cells, however, are often comparatively slight. The biliary canaliculi may be increased in number. Weigert and his disciples contend that atrophy or degenera- tion of the acini is often the primary change, and the connective-tissue production the secondary — filling the gap, so to speak. In alcoholic cirrhosis the liver is sometimes large, smooth, or slightly granular, soft rather than hard, as ordinarily the case, and presents a light yellow color {fatty cirrhosis). Histologically, this is a form of true cirrhosis, as shown by the presence of an increase in the connective tissue, with which, however, fatty infiltration of the acini is associated. (b) Hypertrophic Cirrhosis (Hanot). — On examining the liver in situ during hypertrophic cirrhosis the organ is found enlarged (sometimes enormously), the lower border projecting several fingers' breadths below the ribs. The margin of the organ is well defined, the substance firmer than normal, and it cuts with difficulty. The organ is lighter in color than in health, and presents a yellow or mottled-green appearance. On treating a section with compound iodin solution (Lugol's) the color changes to that of a deep mahogany-red. The acini are darker in hue than the interstitial tissue. 3IicroscopicaUij . the peripheral zones of the acini are first seen to be the seat of a round-cell infiltration, with the formation of embryonal tis- sue ; later, the interlobular connective tissue undergoes hyperplasia, caus- ing obstruction of the biliary ducts with retention of bile, and subsequent atrophy of the liver-cells. New-formed bile-ducts are proliferated. {c) Biliary Cirrhosis. — French writers have described "biliary cirrho- sis " as opposed to a "portal cirrhosis" or atrophic. It results from obstruction of the bile-ducts ; this causes retention of bile with swell- ing of the organ as a consequence. The irritant substances that are the result of stagnation of the bile start a cirrhotic process around the small bile-ducts (reactive inflammation). The microscopic appearances of the organ simulate those of hypertrophic cirrhosis; but the hepatic ' Boston Mfd. and Surrj. .Journ., Marcli 10, 1898. CIRRHOSIS OF THE LIVER. 889 cells are more deeply bile-stained. Microscopically., the first discover- able changes are spots of insular necrosis in the peripheral zones of the acini (Stengel). These are shortly replaced by proliferation of the interlobular connective tissues. The formation of new-ducts and liver- cells is common. There is also a so-called Glissonian cirrhosis (perihepatitis) in which the capsule of the organ is surrounded by a dense white fibrinous mem- brane, which contracts, reducing the size of the liver and altering its shape. This I have described elsewhere {vide Chronic Hepatitis, p. 877). Syphilitic cirrhosis of the organ receives special consideration in the section devoted to Syphilis {vide p. 334). etiology. — (a) Atrophic Cirrhosis. — 1. Alcoholism. — Freyhan, Osier, and I myself have found this causal factor operative in nearly all cases. Clinical history tends to prove that the stronger the alcoholic beverage (e. g. raw spirits) and the larger the amount consumed the sooner cir- rhosis develops, although the quantity necessary to produce the disease varies greatly in different individuals. Doubtless by the side of alcohol- ism all other causes combined are comparatively insignificant. 2. Spicy foods are, according to some, classed as predisposing agents. Tiraboschi records a case that had long been induced by the use of spicy foods and by over-eating. In many cases ptomains, the products of mal- assimilation through faulty digestion, are supposed to be the exciting cause. 3. Male Sex and Middle Life. — The cases produced by alcohol occur chiefly in males. According to my experience, females who misuse potable alcohols, particularly the more concentrated liquors, are less susceptible to the poison than males. Two-thirds of the fatal cases occur between the ages of 35 and 50 (Hawkins), although cases have been known to occur at both extremes of life. In children the disease is mostly caused by inherited syphilis, in which the organ is the seat of a general fibroid process. It may follow the acute infectious diseases, notably scarlet fever, in the young. 4. Certain chronic diseases (syphilis, rickets, diabetes, gout, malaria, carcinoma, tuberculosis) that favor the formation of connective tissue are apt to be complicated by cirrhosis, usually partial. 5. Passive congestion, secondary to chronic cardiac lesions or to obstructive lung-disease, not infrequently gives rise to hepatic cirrhosis. 6. Fatty cirrhosis results from the abuse of malt liquors in some cases, and is often associated with more or less obesity. {h) Hypertrophic Cirrhosis (Hanot). — -In most cases there is an absence of recognizable causes. Sex is a strongly predisposing cause, males being the most frequent victims, in the proportion of 6 to 1. It is not uncommon in young adults. In catarrhal jaundice the morbid processes may rarely extend to the liver and there persist, giving rise to hyper- trophic cirrhosis. Cases are met with in children, in whom it may follow the acute infectious diseases. Alcohol plays an unimportant role in the causation of Hanot's cirrhosis. The disease is most common among the inhabitants of warm climates. {c) Biliary Cirrhosis. — This form is produced by chronic obstruction of the bile-ducts (see .also Obstruction of'the Common Duct, p. 856). Symptoms. — Atrophic Cirrhosis. — The symptoms of this variety of cirrhosis may present nothing characteristic as long as the sclerotic 890 DISEASES OF THE DIGESTIVE SYSTEM. process does not interfere with the portal circulation. In some cases the collateral (compensatory) circulation is maintained throughout the long course and symptoms fail to arise. Among the prodromal symptoms, a gradual loss of flesh, anorexia, constipation, a coated tongue, slight jaundice, dyspepsia, and occasionally hematemesis are to be mentioned. As the obstruction of the portal circulation becomes more marked the mucosa of the gastro-intestinal tract becomes more and more swollen and congested, and gives rise to augmenting nausea and vomiting (most mai-ked in the morning), and hemorrhages from the stomach (hemateme- sis) and intestines (melena), which may be frequent and profuse, but are rarely fatal. Severe hemorrhages may also occur from enlarged, vari- cose esophageal veins. The tongue is coated. Owing to the establishment of a compensatory circulation the super- ficial epigastric and internal mammary veins enlarge, forming about the umbilicus the so-called "caput Medusa." Hemorrhoids also are not uncommon, and are due to passive conges- tion of the inferior hemorrhoidal veins. As the disease progresses the general emaciation becomes more marked. The face assumes a pinched expression, the tip of the nose has a purple tinge from distended veins ; the eyes are sunken, the cheeks hollow, and the skin presents a sallow tint {hepatic fades). The failure of the compensatory circulation gives rise to ascites., and the latter causes in many instances hydroperitoneum, leading to enormous distention of the abdomen. The spleen becomes enlarged. At any stage, although generally in advanced cases, toxemic symptoms may develop, due to some poisonous product in the blood, the exact nature of which is unknown : these are violent headache, followed by wild, noisy delirium, convulsions, stupor, and coma. They not un- commonly occur without jaundice, and have been mistaken for uremia. Fever may be absent throughout the course of the disease, but is often present, and'may reach 100°-102° F. (37.7°-38.8° C). Examination of the urine shows it to be of increased specific gravity, loaded with urates, and containing bile. In a small proportion of cases it is slightly albuminous, and contains casts, though out of 28 urinalyses in cases of cirrhosis Henry discovered the presence of albumin in but one. The amount of urea is constantly diminished, owing to the dis- turbance of the urea-forming function of the liver. An excess of indoxyl sulphate in the urine is a frequent occurrence. The physical, examination in a typical case of atrophic cirrhosis reveals a distention of the abdomen ; there may be also an extreme enlargement of the superficial veins over the surface of the body. An icteroid tint of the skin is present in about 25 per cent, of the cases. Palpation of the liver and spleen may be greatly interfered with by the large amount of peritoneal fluid present. On withdrawal of the latter, however, the spleen is found greatly enlarged and extending in some instances to the epigastric region. The liver may show slight enlargement in the beginning of the dis- ease; but it soon atrophies, and in emaciated subjects with lax abdominal walls its finely granular or nodular edge can be felt above the margin of the ribs. Percussion shows its vertical diameter, which normally extends from the sixth interspace to the costal margin, and averages about 4 inches (10 cm.), diminished, especially toward the median line. CIRRHOSIS OF THE LIVER. 891 Posterior dulness begrins lower than normallT. It must be recollected that the liver is often enlarged in otherwise typical cases. Fatty cirrhosis, in which the organ is sometimes enlarged, may be latent and remain unrecognized or be discovered on the post-mortem table. In five of the six cases that have fallen under my observation. however, the symptoms closely resembled those of the ordinary form of atrophic cirrhosis, apart from the alteration in the size of the liver. {h) Hypertrophic Cirrhosis. — In this variety of the disease there is usually an absence of any alcoholic history, and it is apt to be met in young adults and even children {vide Etiology). Moderate enlargement of the liver may be present before any subjective symptoms are observed. The latter may be absent, except the presence of slight jaundice and an occasional disturbance of digestion, until late in the course of the dis- ease. Intense jaundice, fever, and hepatic enlargement may then appear, ■with the rapid development of a grave general condition. The urine con- tains bile-pigment, but the stools are not typical (pale drab or slate col- ored). Paroxysms oi pain resembling hepatic colic, though less severe, may occur at irregular intervals. Hemorrhages into the skin from the mucous surfaces (due to passive congestion) are also common. In long- standing cases albumin and tube-casts may be present in the urine. Leucin and tyrosin have also been found, but are not constant. These svmptoms are probably due to recent inflammatory infiltration arising in the course of an old cirrhosis. Splenic enlargement occurs, but ascites is exceedingly rare. The cases run an extremely chronic course, and in an instance under my care in a lad of 14 years, the grave svmptoms mentioned above suddenly developed and carried off the patient after four years of slight, though decisive jaundice, and moderate hepatic enlargement. The stools were dark and bilious look- ing, and hemorrhages from the mucous surfaces frequently occurred ; petechise, with urticaria and lichen, marked the skin, while pruritus was exceedingly distressing. There was a leucocytosis. Sicard and Remlinger speak of a deformity — a lowering of the shoulder, arm. and side of the chest and pelvis on the right side — but this has not been observed in any of my cases. Physical examination shows a decided, and. in some cases, a uniform enlarsrement of the organ ; the lower border is felt distinctlv outlined below the costal margin, its edges being rounded and in some instances finely granular. On making deep pressure tenderness may be elicited. Percussion shows an increased area of hepatic dulness. most marked anteriorly toward the median line, extending below the costal margin. Late in the disease, in addition to the grave symptoms described above — icterus gravis, higrh fever, hemorrhages, and the like — serious nervous symptoms, as delirium, convulsions, stupor, and coma, may supervene. The temperature now usually ranges from 102° to 104° F. — 38.8°-40° C, {febrile jaundice) — although fever may sometimes be absent throughout the course of the disease. Death is sometimes threatened, also, by the development of an intercurrent disease or progressive asthenia. (c) Biliary Cirrhosis. — Symptoms and Diagnosis. — The clinical in- terest of this form centers principally around the symptoms of the causative condition — chronic obstruction of the bile-ducts — which have 892 DISEASES OF THE DIGESTIVE SYSTEM. been given in detail elsewhere {vide p. 856). With the latter may be associated the features,- both local and general, of either catarrhal or suppurative cholangitis. Jaundice is usually more intense than in the hypertrophic form, particularly during the earlier stages. Intermittent hepatic fever is commonly observed. The physical signs are similar to those of Hanot's cirrhosis. The diagnosis of biliary cirrhosis rests on the presence of the char- acteristic features of prolonged obstruction of the bile-ducts, from im- paction by gall-stones, a tumor or stricture of the duct, and the like, ■with slow and gradual, smooth, or slightly granular, hepatic enlarge- ment. It is to be recollected that when obstruction of the gall-ducts becomes complete, or "■ acute fermentative changes " are set up in the retained bile, the cases may terminate acutely (('. g. in acute atrophy or acute fatty degeneration). General Diagnosis. — {a) Of AtropMc Cirrhosis. — An assured diag- nosis may be based on the following points : 1. A clear history of th« most common causes (inebriety, male sex and middle life, rickets, dia- betes, gout, malaria). 2. The combined presence of ascites, with hyper- trophic facies. and diminution in the size of the liver, as shown by the physical signs. 3. Absence of the characteristic features of acute dis- ease, and the negative character of results from an examination of the heart, lungs, and kidneys. It is to be recollected that the volume of the liver is not invariably decreased in this variety, and even may be slightly increased. With the atrophic form of cirrhosis, chronic peritonitis with effusion is most liable to be confounded. In the latter disease there are charac- teristic abdominal tenderness, fever, and usually associated tuberculous lesions of other organs (lungs, kidneys, intestines) ; but the hepatic facies and clearly indicative history of atrophic cirrhosis are absent. A large peritoneal effusion is in favor of cirrhosis (h) Of Hypertrophic Cirrhosis. — The principal diagnostic points are an absence of the usual alcoholic history, slight icterus, extending over a variable and oftentimes long period, paroxysms of pain, mucous and cutaneous hemorrhages, with moderate enlargement of the liver, and the rapid development of grave symptoms at any stage, as intense jaundice, fever, and sometimes marked nervous phenomena. Differential Diagnosis of Hypertrophic Cirrhosis. — This may be con- founded with carcinoma of the liver, hydatid cyst, hepatic abscess, and the biliary form of cirrhosis. Hypertrophic Oirrhosi5. Carcinoma of the Liver. Absence of recosnizable causes. Hereditary history. Occurs in young adults and even in child- Usually occurs after forty years of age. hood. Usually a primary aflPection. Often occurs as a secondary growth. Jaundice is slight unless grave symp- Anemia is present, and also the develop- toms suddenly develop : there is no ment of a typical cachexia, cachexia. Paroxysms of pain. The case runs a Pain more constant with rapid emacia- slow course, usually lasting many tion. The case terminates usually years. " within one year. Enlargement is uniform. The liver is irregularly enlarged, and contains umbilicated nodules. (See Fig. 60.) CIEBEOSIS OF THE LIVER. 893 Hypertrophic Cirrhosis. History negative as to alcohol. More common in warm .climates. Occurs idiopathically. Fever, jaundice, and ascites may be pres- ent singly or together. Anemia and emaciation slowly progres- sive. There is a leucocytosis. Regular enlargement of the liver. No fluctuation nor thrill. Aspiration is negative. MULTILOCULAR HYDATID CyST. History of ingestion of the embryo of taenia echinococcus with improper food. Simultaneous occurrence in colonies or in others in the vicinity. No fever, pain, jaundice, or ascites. Emaciation not marked ; no leukocytosis. On palpation an irregular, fluctuating tumor is felt over the hepatic area, giving an " hydatid thrill." Aspiration gives a clear, serous fluid, rich in chlorids, and containing hook- lets. Fig. 60.— Showing approximate enlargement of the liver corresponding to the different dis- eases described in the text (after Rindfleisch) : I, position of the diaphragm to the maximum enlargement (carcinoma) ; II. II, normal situation of the diaphragm ; II, III, relative dulness ; IV, border of the liver in cirrhosis ; V, border in health ; VI, lower border of the fatty liver ; VII, of the amyloid liver; VIII, of carcinoma, leukemia, and adenoma. Hypertrophic Cirrhosis. Etiology usually negative. May rarely follow acute infectious diseases. There are tenderness on deep pressure and paroxysmal pain. Hectic symptoms absent although a con- tinued fever may develop usually late. Runs a slow course, lasting months or years. Abscess op the Liver. History of dysentery, traumatism, or pyemia. Severe and constant pain ; marked ten- derness. Hectic symptoms appear early (fever, chills, and sweating). Runs an acute course, lasting a few weeks. 894 DISEASES OF THE DIGESTIVE SYSTEM. Hypertrophic Cirrhosis {continued). Abscess of the Liver {continued). Slow enlargement, regular, or slightly Rapid development of a fluctuating nodulated. No fluctuation. tumor in the hepatic area. Aspiration gives negative results. The aspirating-needle reveals the pres- ence of pus. So-called fcdty cirrhosis may be distinguished from abscess, hydatid cvst, and carcinoma of the liver in a manner similar to hypertrophic cirrhosis, if one makes due allowance for its etiology, particularly the Avrong use of alcohol. (e) Biliary cirrhosis causes enlargement of the liver, but to a much more moderate extent than hypertrophic cirrhosis. In the former the symptoms of chronic obstruction of the bile-ducts are in evidence, so th^t jaundice is usually marked. The duration of biliary cirrhosis is, on the whole, shorter than that of hypertrophic, and the organ is more likely to undergo terminal diminution in size (atroph}^). Prognosis. — The prognosis of the atrophic form of cirrhosis is decidedly unfavorable, the function of the liver-cells having been impaired, although the principal source of danger is probably the ascites ; and death usually takes place Avithin a few months or a year after symptoms of portal obstruction appear. In rare cases the symp- toms abate, owing to the establishment of a compensatory circulation, and may remain in abeyance for months or years. The prospect of life is much enhanced by an early recognition and removal of the overshadowing cause — alcoholism. I have seen a few cures made in this manner. Even after the occurrence of jaundice, hematemesis, and toxic symptoms, under appropriate treatment patients have been known to enjoy comparative health for years. Treatment. — Th.e prophylactic treatment consists in improving the general health of the patient and in removing, if possible, the cause of the affection. Rest, graduated exercise, systematic bathing, and regular hours for eating and sleeping should be inaugurated and strictly adhered to. Alcohol, strong coffee, spices, and gastro-intestinal irritants of every nature must be interdicted. H. C Wood states that tavern-keepers and bartenders who are unable or will not cease using alcohol may greatly prolong life by substituting hard cider for all other drinks. The diet should be simple and easily digestible. An exclusive milk-diet has been highly recommended (Semmola). The medicinal treatment is largely symptomatic, no remedy having been discovered to prevent the formation of, or remove, the new-formed connective tissue. The chief object is to deplete the portal system and prevent, if possible, the occurrence of ascites. The bowels should be kept freely open by the use of saline purgatives (concentrated solution of Epsom salts), elateriuin, or compound jalap powder. The skin is to be kept active by means of Turkish or Russian baths (under supervision), and in extreme cases by the steam bath or hot pack, employed just short of the point of exhaustion. The kidneys should also be kept active by the hydragogue diuretics, as potassium acetate, squills, calomel, digitalis in the form of the infusion, or Niemeyer's pill. Klemperer and others have also recently recommended urea as an efficient diuretic, and from 20 to 30 grains (1.29-1.1I4) may be given in solution. Urea acts best after paracentesis. CARCINOMA OF THE LIVER. 895 If the case be syphilitic in origin, potassium iodid should be exhibited in ascending doses. Ascites, when it appears, calls for free and thorough diuresis, diapho- resis, and catharsis ; and if not relieved in the course of a few days, tap- ping should be resorted to. The operation of jyaraceiitesis abdominis, if performed under strict antiseptic precautions, is free from danger. The bladder having been emp- tied, a spot over the linea alba about 3 inches (7.5 cm.) above the sym- physis pubis is anesthetized (preferably Avith a compress of cracked ice and salt), and a trocar is quickly thrust through the abdominal -wall for a distance of about 1 inch (2.5 cm.). The distance is determined by the fore-finger, Avhich is placed at the desired distance from the point of the cannula before its insertion. The patient must be in a sitting or semi-reclining position, so as to allow the ascitic fluid to collect by grav- ity in the lower part of the abdominal cavity. A tube having been attached to the cannula to convey the liquid to a receptacle, the trocar is Avithdrawn, the fluid alloAved to run out, the cannula removed, and the Avound closed by antiseptic gauze or a pledget of cotton. Turlington's balsam is then smeared over the "site of puncture, and the abdominal binder, which has been previously applied, is tightened (vide Ascites, p. 927). Complications, as cardiac hypertrophy, tuberculous peritonitis, or chronic meningitis, demand appropriate treatment ; this is described in full in' the discussion of the respective diseases. CARCINOMA OF THE LIVER. Definition. — A malignant groAvth of the liver, occurring usually after the age of forty, and characterized by pain, progressive emaciation, cachexia, and the appearance of a nodular mass in the hepatic paren- chyma. It may be primary or secondary, though the former variety is very rare as compared Avith the latter. Pathology. — Histologically, the cells are not distinctive, being iden- tical Avith those of carcinoma elscAvhere ; they are epithelial in charac- ter, having a small vesicular nucleus and much protoplasm. They are altered greatly by pressure, and vary in shape, being hexagonal, poly- hedral, or amorphous. Large giant-cells and spots of pigment known as " brownish granules " are not uncommonly found in tlie cancerous mass. The so-called colloid cancers are nearly ahvays mucoid, and the cells have undergone a mucoid change; the stroma of connective tis- sue surrounding the cancer-nests in some instances undergoes hyaline or myxomatous degeneration. In other instances the interstitial tra- becule completely surround the epithelial nests, Avhich are separated by a basement membrane ; to this variety the name of adeno-carcinoma has been given. When examined microscopically, medullary cancer, either in a laro-e mass (primary) or in secondary nodules scattered throughout the oro-an, is the most common variety found in the liver. On examining a liver that is the seat of carcinoma, one of tAvo conditions usually presents itself: First, the organ may be apparently normal with the exception of one lobe (usually the right), AA^hich contains a dense Avhitish groAvth of firm 896 DISEASES OF THE DIGESTIVE SYSTEM. consistence, being distinct and sharply defined from the surrounding liver-tissue. On section the tumor is often of uniform density, bluish- white in appearance, and exudes a milk-white fluid known as " cancer- juice," which, when examined microscopically, is found to contain large, nucleated, and irregularly-shaped cells containing free granular matter. The center of the tumor may have undergone liquefaction-necrosis, with the formation of a cyst, or it may be the seat of an abscess. Various smaller nodules may be scattered throughout the organ by metastasis from the primary growth. The second and most common condition is secondary carcinoma of the liver, the primary lesion being situated in the mammary glands, pylorus, or the cervix uteri. The organ is greatly en- larged, as a rule. Numerous nodules are scattered throughout, and can usually be seen projecting beneath the capsule, those superficially situ- ated having received the name of " Farre's tubercles." In the center of these nodules characteristic pits or umbilications are often present, caused sometimes by contraction of the interstitial trabeculae and some- times by a central softening. On section they are usually grayish-white in color and of firm consistence, although cysts, hemorrhages, pus-cav- ities, or areas of hyaline and fatty degeneration are often found. The cells are identical with those of the primary growth, and are composed for the most part of cylindric epithelium. In rare instances carcinoma occurs simultaneously with cirrhosis in the same liver, the organ presenting an uneven, nodular appearance, and being slightly increased in size and of firmer consistence than normal. When examined in situ the external appearance does not diff'er materi- ally from that of cirrhotic liver, but on section the whole organ is found to be infiltrated with various-sized cancer-nodules surrounded by bands of cicatricial tissue. In some cases the excess of connective tissue and the amount of contraction are extreme, and the size and weight are reduced below the normal. Ktiology. — Among the more important predisposing factors may be mentioned — (a) Age. — The disease seldom occurs before thirty-five or forty years of age, although cases have been known to occur in children. Descroi- zilles reports the case of a child eleven years old who died with a tumor in the right hypochondriac and iliac region, the autopsy revealing a liver studded with cancerous nodules, the nature of which was demonstrated microscopically. (b) Sex. — Men are more often the victims of carcinoma of the liver than women. When occurring in the latter it is often secondary to car- cinoma of the uterus or mammary gland. (c) Heredity is said to be the cause of hepatic carcinoma in at least 20 per cent, of all cases, and is one of the strongest arguments in sup- port of the diathetic theory of the disease. {d) Traumatism may contribute, (e) Mechanical Obstruction. — Primary carcinoma of the gall-bladder and bile-ducts not infrequently follows chronic obstruction by gall- stones. Symptoms. — There may either be almost no symptoms of carci- noma involving the liver, or its manifestations may be intense and varied according to the extent and location of the growth or growths. Associ- CARCJXOMA OF THE LIVER. 897 ated gastric symptoms, T\liich increase as the disease advances, usually attend. A more or less marked cachexia may be the first noticeable feature. The chief symptoms may be considered in detail, as follows : (a) Jaundice. — Discoloration of the skin and tissues is often by no means intense, and maybe entirely absent. Harley states that true icterus was present in only 6 out of 100 cases seen by him, though few obseryers agree with him in his extreme yiew as to the rarity of this symptom. The reason given for its lack of intensity is that in the great majority of cases the growth is situated in the right lobe of the liver, and neither compresses the bile-ducts nor destroys the secretory cells of the liver. (b) Pain is usually present to a marked degree, though it also may be entirely wanting. It is dull and boring in character, and localized generally in the right hypochondriac region. In some instances (as in the case of impacted biliary calculi) it may radiate to the right shoulder and the scapular region. It usually appears as the hepatic enlargement progresses, although cases of enormous-sized cancerous tumors of the •liver have been known to occur without pain. The character and loca- tion of the pain are of diagnostic importance, and will be spoken of under the differential diagnosis. (c) Ascites. — When the cancerous growth compresses the portal ves- sels, and also in cases of cirrhosis with carcinoma, obstruction to the portal circulation occurs, and results in the development of ascites. This may cause distention of the abdominal cavity to such an extent as to occlude the physical signs of hepatic enlargement. The cancerous growth may invade the peritoneum and cause an effusion. This symp- tom, however, is not frequent, at least two-thirds of all cases terminating without the appearance of ascites. {d) Fever is usually absent until the later stages of the disease. It may then appear and rise to hyperpyrexia (105° F. — 40.5° C), but it is usually moderate in degree, irregular, and intermittent in type. {e) Cachexia. — In every case of carcinoma, at some stage of the dis- ease, cachexia develops ; when pronounced, it is almost pathognomonic. (/) Cerebral Symptoms. — These may be absent throughout. In the advanced stages, however, the deleterious products in the blood, due to the perverted functions of the liver and the toxemic condition of the patient, often produce such striking symptoms as violent headache, mental hebetube, or delirium (less frefjuently) which may be maniacal in character. These symptoms resemble those of cholemia'^(r/(:Ze Hepatic Cirrhosis, p. 887). The patient may die in sudden coma. Physical Signs. — Inspection often reveals enlargement of the super- ficial veins over the abdomen, and a prominence in the upper epigastric and hepatic regions, varying wath the degree of enlargement, may also be seen. In the nodular form and late in the disease, when emaciation has become extreme, elevations that are movable with respiration can be noticed beneath the skin. On palpation the organ can be distinctly felt projecting below the costal margin and extending in some instances to a point below the level of the umbilicus. During deep inspiration the liver can be felt to move downward, and during expiration upward, the organ being under the influence of the diaphragmatic excursions. In emaciated subjects 57 898 DISEASES OF THE DIGESTIVE SYSTEM. the cancer-nodules are readily appreciable, and in some instances the central pits or depressions are palpable, forming a pathognomonic sign. Cancerous infiltration of the anterior margin is most easily felt, and in any enormous enlargement of the organ I have frequently detected them on the posterior surface as well. Rarely the liver is found to be uniformly large. Palpation may also show splenic enlargement, due to passive congestion. Percussion shows flatness, extending in many cases in both an up- ward and a downward direction. In primary carcinoma (usually found in the right lobe) the area of hepatic dulness is increased irregularly downward and generally to the right. On the other hand, in second- ary growths (usually massive) the nodules are oftener distributed equally throughout the liver. In such cases the area of dulness may extend across the epigastrium to the left hypochondriac region, the heart and other viscera being now displaced. Posteriorly, dulness may extend upward on a level with the fourth rib, and anteriorly downward to the iliac fossa. The organ may now weigh from 15 to 20 lbs. (6.5-9 kgms.), Avhile the weight of cancerous livers in ordinary cases varies between 3' and 6 lbs. (1.8-2.6 kgms.). Diagnosis. — In forming a positive diagnosis the family tendency, the history of primary carcinoma elsewhere in the body, the age of the patient, the localization of the pain in the right hypochondrium, the cachexia, and the progressive enlargement of the liver, with the charac- teristic umbilicated nodules, are the most reliable points. The appear- ance of jaundice or ascites, or both, is confirmatory. Differential Diagnosis. — Among affections of other organs that are likely to be mistaken for carcinoma of the liver may be mentioned — (1) carcinoma of the pylorus ; and (2) carcinoma of the colon and omen- tum. The chief diseases of the liver itself apt to be diagnosed as car- cinoma are — {a) abscess, {b) syphilis, {c) benign groivths {adenomata, angiomata), (d) hydatid cysts, and (e) liypertrophic cirrhosis. (1) Carcinoma of the Pylorus. — In carcinoma of the pylorus the phys- ical examination frequently shows a hard nodular tumor that is most plainly outlined in the epigastric region. In a typical case, on deep inspi- ration, the tumor is pressed downward by the liver, but is not pulled up- ward by forced expiration, as in hepatic carcinoma. In many instances, however, adhesions bind the stomach firmly to the under surface of the liver, which may be the seat of secondary involvement. The absence of early nausea and vomiting and the presence of jaundice, as well as the negative results from an examination of the gastric contents, would tend to eliminate pyloric carcinoma. (2) Carcinoma of the Colon and Omentum. — Secondary carcinoma of the intestine aflFects most frequently the sigmoid flexure. The symptoms of intestinal obstruction arise, constipation being followed by attacks of serous diarrhea due to irritation, and later by the presence of blood in the stools. In carcinoma of the liver, on the other hand, the bile-ducts may be obstructed, causing clay-colored stools, but otherwise the dejecta are normal ; the seat of the nodular enlargement and pain is located in the right hypochondrium. Jaundice and ascites are absent in carcinoma of the colon. The tumor, if palpable, in the latter condition is more movable and is less under the influence of the diaphragm. It does not CARCINOMA OF THE LIVER. 899 give an absolutely flat percussion-note, as does hepatic carcinoma. Car- cinoma of the omentum is usually secondary. The absence of small mov- able tumors in the umbilical, lumbar, or hypogastric regions, ranging in size from that of a pea to a walnut, aids in the elimination of carcinoma of the omentum. As the latter affection advances the abdomen be- comes distended and painful to the touch, the bowels are obstinately constipated, and the physical signs reveal the presence of an effusion which, w^hen aspirated, is generally serous, but sometimes bloody. Mi- croscopic examination may possibly reveal the presence of- cancer-cells, though their recognition is difficult. The liver, unless primarily in- volved, is not enlarged, and cachexia does not usually appear until late in the course of the disease. From hepatic abscess the points of differentiation are — Carcinoma of the Liver. Hepatic Abscess. Is often hereditary. There is a history of There is a history of traumatism or of in- a primary growth or chronic irritation. testinal ulceration, as in dysentei^. Occurs usually after the age of forty. Occurs at any age. Jaundice is rare. Jaundice is sometimes present. Fever is absent or slight. Hectic temperature, chills, and sweating. Cachexia' is present and almost pathog- Anemia may be present, but newer ca- nomonic. chexia. Pain is dull and boring in character, and Pain is sharp, lancinating, and paroxys- more constant. mal. A nodular, umbilicated tumor or tumors A fluctuating tumor may sometimes be may be detected. detected below the costal margin. The enlargement is downward. The enlargement usually upward. The duration is a few months to one year. The duration is usually a few weeks. Microscopic examination reveals disinte- The microscope reveals pus, liver-cells, grated liver-cells, cancer-nests, and in staphylococci and streptococci, the some cases the micro-organisms of sup- bacillus coli communis or the amoeba puration. coli. Benign Groivths {Adenomata, Angiomata). — Occasionally growths are detected in the liver, and may occur at any age ; when these are present at or about the age of forty, they may be mistaken for carci- noma. The absence, however, of a primary growth in some one of the other viscera, together with the duration of the growth and the absence of cancerous cachexia, would tend to differentiate them from cancerous involvement. An examination of the blood may be of service, leuko- cytes being more common in carcinoma. The prognosis is invariably fatal, the disease terminating rapidly in from a few months to a year. The most rapid course is run by sec- ondary carcinoma of the organ. Treatment. — The treatment is purely symptomatic. An easily digested, nutritious diet should be given, together with active stimulation to support the system. The pain may be relieved by the free use of morphin, given by the mouth, rectum, or hypodermically. For the nausea and vomiting that are apt to supervene the carbonated waters, cracked ice with champagne, or repeated doses of creasote (beechwood), dilute hydrocyanic acid, or wine of ipecac (2 minims — 0.133 — eveiy hour until relieved) may be given. If violent delirium should occur during the later stages of the disease, cold compresses to the forehead or vertex, and bromids and chloral hydrate given in rectal enemata, may prove efficient. 900 DISEASES OF THE DIGESTIVE SYSTEM OTHER NEW GROWTHS IN THE LIVER. (a) Angioma, Adenoma, and Cyst. Occasionally, benign growths occur in the liver, and often -with an absence of symptoms unless their increase in size gives rise to mechan- ical obstruction. One of the most common of these is angioma, which is often found in the livers of old people. Angiomata consist of tortu- ous and dilated capillaries in the hepatic connective tissue ; they rarely attain to a size larger than a crab-apple, and usually cause no symp- toms. Although most common in adults, they have been known to occur in children. Adenomata and cystomata may also occur in the liver. They are both benign growths. The former is of the tubular variety, consisting of connective-tissue nests lined with cylindric epithelial cells. Von Berg- man removed a portion of a tuberous adenoma of the liver with perfect recovery and non-recurrence of the growth. {h) Sarcoma. Of the many varieties of sarcomata, those occurring most commonly in the liver are the small and large round-celled and the melanotic vari- ety, the latter often being secondary to sarcoma of the choroid coat of the eye. These grow rapidly, causing a widespread destruction of the liver-structure, with a change in the size and shape of the organ that is often demonstrable by palpation. E. R. Axtell reports a case in which at the postmortem the upper two-thirds of the liver revealed an entire absence of hepatic structure, and consisted of three tumor-masses which, on microscopic examination, were found to be small round-celled sar- comata. On section the tumor is seen to be of firmer consistence than the surrounding liver-tissue, and presents a dark, grayish-white, striated . appearance. If the growth be of the pigmented variety, patches of a deep black or of different shades of pigment may be scattered through- out the mass. Metastasis is rapid and widespread (lungs, kidneys, heart, skin), as is shown by the fact that other organs are invariably found involved at the time of the growth and development of the sar- coma in the liver. The symptoms are those of mechanical obstruction, and consist of gastro-intestinal disturbances due to passive congestion, edema, and ascites. Anemia and emaciation may become marked late in the disease, but cachexia does not develop. The passage of an intensely dark-col- ored urine (melanuria) has been noted in some cases. Secondary nod- ules may appear on the skin-surface. The diagnosis can often be made from the primary growth (melano- sarcoma of the choroid or sarcomata of the lymphatic glands) and from the rapid development of the tumor. From carcinoma of the liver melanosarcoma may be distinguished by the presence of ocular symp- toms, particularly blindness of one eye, by the rapid widespread meta- stasis, the melanuria, perhaps, and by the absence of a true cancerous cachexia. The prognosis is, of course, absolutely fatal, and the treatment merely palliative. DISEASES OF THE SPLEEN. 901 X. DISEASES OF THE SPLEEN. Diseases of the spleen are mostly secondary to other diseases, the consideration of which embraces an appropriate description of the as- sociated splenic disorders. The intimate relation between the spleen and blood accounts for the frequency with which this organ is involved in many of the blood-diseases. DISLOCATION OF THE SPLEEN. {Floating Spleen.) Ktiology. — This may be due to the increased Aveight of an enlarged spleen, to tight-lacing, to relaxation of the ligaments, or to traumatism, and is met in splanchnoptosis. Carcinomatous enlargement of the left lobe of the liver caused it in a case I saw recently. Symptoms. — The symptoms are vague, and are the result of pressure. By physical examination we discover with the touch the spleen as a mo- bile tumor pendant from the left hypochondrium ; the tumor is super- ficial, blunt-edged, and notched on its anterior border, and may be re- placed by the hand nearly in its normal position. On percussion over the splenic area the normal dulness is found to be absent. In the diagnosis it is important to distinguish between floating spleen and simple enlargement, as well as between the former and mov- able kidney . The prognosis is guarded as to cure, though favorable as to life. The treatment must be mechanically supportive, consisting of pads and bands. Splenectomy has given excellent results. SPLENIC HYPEREMIA. Acute or active hyperemia may be found as the result of the acute infectious diseases, giving rise to the acute splenic tumor, or as the result of amenorrhea, or of injuries and inflammation {circumscrihed liyper- emia). The organ is uniformly enlarged (except in the last-named cases), and is darker in color and softer in consistence ; the capsule also is tense. This condition merges insensibly into acute splenitis. Chronic or passive hyperemia is due to some mechanical obstruction of the portal circulation caused by tumors, cardiac, hepatic, and pulmo- nary disease, and pylephlebitis. The spleen is enlarged, firm, dark-red in color, and the capsule is somewhat thickened. The symptoms are vague, and may consist of simply a sense of weight, fulness, and pressure, and some tenderness in the left hypochondrium. In cases of extravasation of blood and rupture of the spleen the symp- toms of intestinal perforation, hemorrhage, and collapse may supervene. On physical examination the edge of the spleen may be palpated be- low the margin of the ribs. The percussion-dulness is increased in area, especially downward and forward, and may encroach upon the slightly-curved umbilico-axillary "resonant line." 902 DISEASES OF THE DIGESTIVE SYSTEM. The detection of acute or chronic splenic hyperemia, as manifested in enlargement of the organ, is often of invaluable aid in the diagnosis of the causative disease. The prognosis and treatment are embraced in those of the disease causing the conorestion. SPLENITIS. Definition. — This term comprises acute and chronic (hypertrophic) proliferative splenitis and suppurative inflammation. Pathology. — Next to the kidneys, the spleen is the favorite seat of metastatic inflammation and embolic infarction. Splenitis, due to a benign embolus originating in the left side of the heart or from the aorta above the splenic arteries, is usually circumscribed to a zone of sero-hemorrhagic infiltration about the resultant infarct. The latter is hemorrhagic at first, and later becomes particolored or mixed, and is of a yellow color, owing to partial fatty degeneration ; still later it may become Avhitish and remain as a wedge-shaped (the base being periph- eral), cheesy (necrotic softening), or even calcareous mass or as a fibrous cicatrix. Infection of the infarcts by pus-micrococci leads to the devel- opment of synall abscesses, and the trabecule surrounding the latter may give Avay until several abscesses or one large pus-sac may be formed. Perisplenitis generally follows, and sometimes with adhesions attached to adjacent hollow organs, as the stomach and colon, through which the perforating abscess may discharge its purulent contents. An unfor- tunate termination is the bursting of the abscess into the peritoneal cavity ; a more fortunate ending results in an external opening. In acute splenic tumor there is an active congestion, with round-cell infil- tration and some proliferation of the splenic cells. The spleen is mod- erately enlarged, dark, soft, pulpy, and friable. In cases of intense vascular engorgement, as in the acute splenic tumor of severe typhoid fever, intermittent fever, and epilepsy (during the paroxysm), liemorrliagic extravasation may occur, and there may finally be even a rupture of the capsule and a passage of the blood into the peritoneal cavity. In chronic splenic tumor there is a persistent hyperplasia of the splenic cells, and frequently also of the trabecular cells, minus the acute engorgement. Cirrlwsis of the spleen (chronic interstitial splenitis) diflfers characteristically from that of other organs (as the liver and kidneys) in that there is enlargement instead of con- traction. Added to the increase in the size of the spleen, there are in both forms of chronic splenitis thickening of the capsule, patches often of old perisplenitis, and a slaty color of the tissues, with more or less pigmentation. !^tiology. — The disease probably never starts primarily in the spleen itself. Acute proliferative or liyperplastic splenitis {acute splenic tumor) is seen as the result of the acute infectious diseases (typhoid, typhus, relapsing, malarial fevers). CJironic proliferative splenitis {chronic splenic tumor) occurs in connection with chronic malarial in- fection, splenic anemia, chronic passive congestion of the spleen, and SPLENITIS. 903 leukocythemia. The leukemic spleen represents a somewhat different form of chronic proliferative splenitis from the ordinary forms. Acute suppurative splenitis (abscess), either diffuse or circumscribed, is usually secondary to infectious (pyogenic) emboli, as in ulcerative endocarditis and pyemia. Again, as the result of simple valvulitis or aortic throm- bosis, embolic infarction of the spleen may be found, which may soften and break down in abscess-formation from subsequent infection. Abscess of the spleen may also follow traumatism or the perforation of a gastric ulcer and the extension of adjacent suppurative processes. Symptoms. — These are indefinite or absent in most cases. Usually there is no pain or tenderness unless perisplenitis exists. Considerable enlargement of the spleen may be attended with a sense of weight, ten- sion, or distress in the left hypochondrium, and perhaps by slight dys- pnea. Any suppurative fever present will most probably be disassociated from the idea of abscess of the spleen, provided the local signs of pus be absent. /Sudden paiii appearing in the gastric region, followed by the vomiting of j^us and blood, in the course of an infectious disease, with splenic enlargement, may be due to the rupture of an abscess of the spleen. Ascites may also be present. The physical examination may reveal some bulging on inspection, and a fluctuating tumor may be palpated. The enlargement may be sufficient to enable the examiner to feel the notch in the spleen, and also the anterior and low^er borders reaching even to the umbilicus and to a level with the pelvic brim. The percussion-dulness is correspond- ingly increased. Diagnosis. — This may be made from a consideration of the physi- cal signs in conjunction with a study of the primary disease. In cases in which pus is suspected an exploratory puncture may clear the diag- nosis. The splenic inflammation is rather an aid to diagnosis than a condition essentially needful of recognition in itself, by reason of its almost invariably secondary nature. Differential Diagnosis. — Acute suppurative splenitis might be mis- taken for gastric or pancreatic disease ; but the previous history in the former, as contrasted with that of the latter affection, conjoined with the local symptoms that are more or less characteristic of the organ involved, will generally furnish an accurate means of differentiation. The huge enlargements of chronic splenitis may be confounded with hepatic, renal, omental, or ovarian growths. Here a careful, discriminat- ing observation of the constitutional state and of the physical signs is requisite for a diagnosis ; even then it is often puzzling and difficult to attain. Care must be taken that splenic enlargement be not assumed when a large pleural effusion on the left side is causing the depressed lower border of the organ to be felt. Finally, fecal accumulation in the splenic flexure of the colon may be mistaken for moderate enlarge- ment of the spleen. The former gives an irregular, doughy tumor, tympanites, vomiting, and a history of constipation alternating some- times wdth diarrhea ; there is no increase in the splenic area of dulness. Prognosis. — This will depend upon the primary systemic condition in most cases. Abscess of the spleen is always a very grave complica- tion, the main danger consisting of rupture and fatal peritonitis. Eren in acute splenic tumor of a violent type there may be a hemorrhagic ex- 904 DISEASES OF THE DIGESTIVE SrSTE:^! travasation so severe as to burst the capsule. Chronic splenitides are not in themselves orrave disorders. Treatment. — This is to be directed mainly at the causative condi- tion. Quinin and arsenic are often useful in the malarial form, and the chalybeates, iodids. and ergot have been recommended for the various chronic splenic enlargements- Abscess must be treated by splenotomy and drainage. Splenectomy may be useful in certain cases of simple hypertrophy, but records show only about 20 per cent, of recoveries from the operation. The state of the patient must be well considered. Splenectomy is probably never justifiable in leukemic enlargement. AMYLOID DEGENERATION OF THE SPLEEN. {Sago Spleen.) This occurs as a part of the cachectic condition attending amyloid or waxy degeneration of other organs (liver and kidneys). The con- dition develops in the course of cases of prolonged and wasting dis- charges (phthisis, empyema, suppurative ostitis, syphilis, chronic peri- tonitis, chronic entero-colitis). The spleen is, as a rule, greatly enlarged, putty-like, and rotund. The capsule is tense and glistening. There are two forms of waxy degeneration — namely, the so-called ''sago' spleen and the diffuse waxi/ or lardaeeous spleen. In the former the Mal- pighiau bodies are chiefly affected and appear on section like sago- granules ; in the latter the whole splenic pulp, and even the trabeculae, are more or less degenerated, and on section the spleen appears pale, smooth, and homogeneous (boiled-ham appearance). This may be but a late stage of the '^ sago " spleen. The symptoms are those of general cachexia, and -the diagnosis rests upon the detection of an enlargement of the organ associated with evi- dences of amvloid disease in other orgrans. The progyiosis is unfavorable, and the treatment does not differ from that indicated for the underlying and causative disease. MORBID GROWTHS OF THE SPLEEN. The principal new-growths are the granulomata, as tubercles and syphilitic gummata ; also secondary carcinoma, melanotic sarcoma, and hydatid and other cysts. Lymphadenoma {e. g. in leukemia) may be included among tumors of the spleen (Stengel). These affections of the spleen are all of rare occurrence, and are not readily, if at all. discoverable during life. They are of no clinical or therapeutic interest apart from the general or primary disease. It may be stated that carcinoma of the spleen is always secondary ; it may be diagnosticated by a physical examination, showing the organ to be en- larged, with the unmistakable signs of the primary carcinoma, as of the stomach. Secondary sarcoma is more common, and is recognized by an irregular enlargement and the presence of a primary tumor. Sgphilitie gummata of the spleen are often associated with amyloid degeneration and enlargement. BISEASES OF THE PANCREAS. 905 RUPTURE OF THE SPLEEN. This may occur as the result of an intense hyperemic engorgement, both in splenitis from the rupture of an abscess and from traumatism. In the acute splenic tumor of typhoid fever, in malaria, and during an epileptic paroxysm, rupture of the capsule has been known to occur on account of the extravasation of blood. The symptoms are usually mis- taken for those of intestinal perforation Avith internal hemorrhage. The treatment is palliative. XI. DISEASES OF THE PANCREAS. ACUTE PANCREATITIS. Investigations of late years have rendered it probable that this disease is not so rare an occurrence as was formerly presumed, when it was not so readily recognized, owing partly to insufficient clinical and pathologic data, and partly to an indifference as to its existence. HEMORRHAGIC PANCREATITIS. Pathology. — The pancreas is enlarged, usually firm, and somewhat chocolate-colored. Irregular areas show the circumscribed as well as the diffused form of hemorrhagic infiltration of the interstitial fat-tissue, with thrombosis of the pancreatic veins in some cases (Day). There is also an infiltration with round-cells of the interlobular tissues. Some cases are examples of degeneration (non-inflammatory). The adjacent tisslies may also be found to be hemorrhagic, as the mesentery, meso- colon, omentum, and perinephric tissues. The gastro-intestinal mucosa may be hyperemic, ecchymotic, or in a slightly catarrhal state. Evi- dences of a localized peritonitis (peripancreatitis) are not frequent, though they should be looked for. Disseminated fat-necrosis is quite commonly associated with hemor- rhagic pancreatitis. Small areas of a peculiar (tallow-like) substance, ranging from the size of a miliary tubercle to that of a pea or even larger, are found scattered in the fatty interlobular pancreatic tissue in the omentum, mesentery, and sometimes in the abdominal panniculus or fat. H. U. Williams, from experimental researches, concludes that some sub- stance in the pancreas, probably the fat-splitting ferment, is capable of causing changes similar to fat-necrosis. Flexner's experiments render it probable that the escape of pancreatic secretions into the peri- and para-pancreatic tissues is the origin of the fat-necrosis. Mention should be made here of the fact that as the result of the in- fectious fevers we find the pancreas showing diffuse, parenchymatous, and granular degenerative changes. Chiari has also recently pointed out the fact that postmortem digestion is very frequent in the pancreas. Ktiology. — Most of the cases reported have occurred in men, and in persons past fifty years of age. An especial vredisposition to the disease seems to be the result of cases of severe and obstinate dyspepsia (gastro-duodenal), alcoholism, glycosuria, gall-stones (Fitz), and trau- 906 DISEASES OF THE DIGESTIVE SYSTEM. matism. Hemorrhage into the pancrea.s may lead to subsequent pan- creatic inflammation. A prolonged course of mercury has seemed to have a causal influence. It is seen occasionally postmorteni in cases of acute tuberculosis, of the specific fevers, and of septico-pyemia. The direct cause is probably an infection through the ducts of the gland. Symptoms. — The onset is sudden and violent. It is character- ized by enruriating, deep-seated pain, usually in the epigastrium or between the xiphoid and umbilicus. There are also nausea and severe retching and vomiting, constipation, and speedy collapse, ending fatally within a few days (second to the fourth — Fitz). The vomitus mav con- sist at last of slimy mucus or dark blood. Fever is generally slight at first, though it may touch 103° or 104° F. later. Dyspnea and a rapid, ieehle puhe, with jactitation and marked anxioiisness or an afebrile de- lirium, may perhaps be present. In some cases there may be diarrhea, with thin and watery stools containing free fat. Instances may he re- peated in which, owing to the coincident presence of gall-stones, there may he Jaundice and colicky pains over the right hypochondrium. The jaundice, hoAvever, may sometimes be due to a considerable swelling of the head of the pancreas, which presses upon the common bile-duct. Tympanites occurs in a majority of the cases. Hiccough and cdhumin- uria have also been noted. The pain in this disease, as well as the pro- found collapse, may be due either to a circumscribed peritonitis or to pressure upon the solar plexus. Diagnosis. — This is at all times difficult, since many or all of the symptoms enumerated may be present in other affections. A careful inquiry into the previous history is important. The sudden develop- ment of an intense, deep-seated pain in the epigastrium, followed by vomiting, collapse, abdominal distention, with circumscribed resista'nce in the epigastrium, and the presence of constipation and slight fever, should point strongly to hemorrhagic pancreatitis. The detection of free fat in the dejections, and the discovery of scattered points of tenderness, when they occur, are also of corroborative significance. Differential Diagnosis. — The temperature is apt to be higher and the pain and tenderness less localized and more constant in pjeritonitis. Fecal vomiting would indicate obstruction of the boicel. Here also we may determine the patency of the bowel by injection or inflation. Intestinal obstruction is of comparatively rare occurrence in the epigastrium, where the pain and distention of acute pancreatitis are localized ; there are likely to be present more marked and general tympany, including the flanks, and a circumscribed distention of the intestinal coils. In ])erforating gastric or duodenal ulcer there is a histoiy of pain after eating, hemorrhages from the digestive tract, and of anemia or chlorosis occurring more commonly in the young female. Corrosive poisons may be excluded by the history of the case and by an examination of the mouth and vomitus. Hepatic colic may also be excluded ; the pain in this condition is intermittent, and referred more to the right side than in pancreatitis. There are also an early collapse and an absence of jaundice in the pancreatitis, as a rule. Acute gastro-duodenitis is characterized by fever, by a history of injudicious eating, followed by mild inflammatory symptoms within a few SUPPURATIVE PANCREATITIS. 90T hours, and by an absence of the sudden prostration and collapse so com- mon to hemorrhagic inflammation of the pancreas. Prognosis. — Acute hemorrhagic pancreatitis in most cases ends in death. It is but fair to state, however, that in view of the ease with which the disease may be overlooked it is quite possible that certain cases of a less severe type may often recover ; in these the recovery has been said to follow an entirely diiFerent affection. Osier reports a case diag- nosticated as one of intestinal obstruction in which abdominal section was performed and recovery followed. Thayer and Krirte have also reported cases of cure in which a celiotomy decided the diagnosis. Treatment. — This must needs be merely palliative and symptomatic. The treatment as for shock by the use of external heat and of warm saline solutions (by injection), hypodermics of morphin, atropin, strych- nin, and of diffusible stimulants may probably be of some avail. SUPPURATIVE PANCREATITIS. Pathology. — The suppuration may be diffuse, with numerous small abscesses, or a single abscess may exist in the head or body of the pan- creas, which may be considerably enlarged and the glandular structure extensively destroyed. The abscess may communicate with peripancreatic areas of suppuration, or it may evacuate either into various organs (stom- ach, duodenum, peritoneal cavity) or externally. Pylephlebitis and hepatic abscess or pyemia may follow. A disseminated fat-necrosis is not found so frequently as in hemorrhagic pancreatitis. etiology. — Most of the cases collected have occurred in adult males prior to fifty years of age. Intemperance, debauchery, gluttony, and various dietetic errors are among the p^'edisposing causes. Infection takes place through the ducts, or from extension of neighboring septic foci. Symptoms. — These may be acitte, subacute, or chronic. Acute cases occur less frequently than the latter, there being a marked tendency of the disease to chronicity. Acute suppurative pancreatitis usually begins suddenly, with severe epigastric pain, vomiting, hiccough, chills, and an irregidar p)yemic temperature, progressive tympanites (at times limited to the left half of the abdomen), and perhaps acute splenic enlargement. Constipation may be followed later by diarrhea, and slight jaundice may appear. Prostration is generally great, and death may set in within one week from the onset. Not seldom, however, the course is prolonged to three or four weeks, the symptoms persisting with progressive emaciation and final exhaustion. Hupture of the circumscribed peritoneal abscess, evidenced by copious dejections in which the sloughing pancreas has been found, and rapid diminution in the size of the abdomen, may take place. Again, the onset may be less severe, and yet the case progresses steadily downward with little pain, slight suppurative fever, anorexia, anemia, and gradually increasing debility, lasting for months or even a year, and ending in anasarca and death. A pancreatic swelling is rarely palpable. Diagnosis. — A limitation of the pain and tympany to the epigas- trium, irregular fever, and the constitutional indications of suppuration are probably all that can be relied upon in arriving at a diagnosis. In fact, the diagnosis is hardly made antemortem. The differentiation from circumscribed peritonitis, perforative gastric 908 DISEASES OF THE DIGESTIVE SYSTEM. or duodenal ulcer, and acute obstruction of the bowel is the same as in the case of hemorrhagic pancreatitis {vide ante). The prognosis is fatal and the treatment surgical- GANGRENOUS PANCREATITIS. Pathologfy. — The pancreas may be found in various stages of necro- sis, depending upon the duration of the disease. It may be a dark-brown, flabby, soft, friable, shreddy, and putrid mass, with areas of hemorrhagic infiltration and yellow softening, and surrounded by a dirt3'-greenish, thin, purulent, and ichorous fluid. In cases lasting for from three to seven weeks the gland may be found completely sequestrated, lying in the omental cavity as a small, thin, brownish-black, shreddy, and foul-smell- ino- detritus, soaked in a dark-colored, ichorous, and purulent fluid. The peri- and para-pancreatic tissues are usually involved with acute peritonitis. Splenic thi'ombo-phlebitis is commonly associated, and, as in the hemor- rhagic, so in the gangrenous pancreatitis, disseminated fat-necrosis is fre- quently seen. The sloughed pancreas may be discharged into the intestine. Btiology. — Males and females seem to be equally liable to this variety of pancreatitis, and persons past thirty years of age are most commonlv afi'ected. Hemorrhagic pancreatitis is the most frequent ante- cedent of the gangrenous form. The disease may result also from perfor- ative inflammation of the gastro-intestinal or biliary tract, or from the simple extension of a catarrhal inflammation of those tracts into the pancreatic duct (Fitz). Symptoms. — These are essentially the same as those of hemorrhagic pancreatitis. The course may last longer, however, so that death may not occur until the second or fourth week, preceded by symptoms of collapse. CHRONIC PANCREATITIS. Pathology. — The pancreas is indurated from an increased develop- ment of interstitial fibrous tissue. The secreting glandular substance may be nearly obliterated, or at least considerably changed, and, owing to occluding pressure upon the duct of Wirsung. small pancreatic cysts may be formed. Interstitial hemorrhages and peripancreatic adhesions may be present. In chronic suppurative piancreatitis there may either be several small circumscribed abscesses or one large pyogenic cyst. The pus is often found to have undergone cheesy changes or calcareous infil- tration. Btiology. — Chronic pancreatitis may be due either to one or to sev- eral attacks of the acute disease. Chronic inflammation of the pancreatic duct — often secondary to gastro-duodenal catarrh — is the most frequent cause. Persistent inflammations of contiguous structures, frequent irri- tation from biliary calculi, and the causes of cirrhotic changes in other organs (chronic alcoholism, syphilis) probably also lead to this disease. The condition may be limited to a part of the organ. PANCREATIC HEMORBHAOE. 909 Symptoms and Diagnosis. — The symptoms are hardly indicative of the disease. For a long time the symptoms of chronic gastric catarrh, frequently attended by diarrhea, may compose the clinical picture. Later there may be paroxysms of deep epigastric pain, and slight /ever, with great anxiety and faintness, occurring at irregular intervals. Some ascites and oGca.siona\ jaundice, due to pressure, may be observed. The detection of free fat in the dejections (without jaundice), and the occur- rence of glycosuria and lipuria, would be of distinct diagnostic value. The presence of glycosuria in this variety of pancreatitis probably indi- cates an extreme degree of destruction of this gland (Fitz). A cachectic, emaciated appearance liiay be associated. Circumscribed resistance on palpation in the pancreatic area has been noted. Evidences of hepatic cirrhosis or of chronic renal and arterial disease may be present, and are likely to overshadow the pancreatic lesions. The prognosis is grave. It is to be recollected, however, that the greater portion of the gland may become functionless, as the result of progressive fibrous change, without much impairment of the general health or the production of permanent (fatal) glycosuria. Treatment. — The major treatment is dietetic. Fats and starches, since they demand the pancreatic ferment for their conversion, are to be interdicted, or, if permitted, are to be, so far as may be, artificially di- gested by the administration of tablets of pancreatin and soda (gr. v-x — 0.324—0.648) fifteen or twenty minutes after meals. Malt diastase, com- bined with alkalies, should also be tried. Becher has found that car- bonated waters stimulate pancreatic secretion in dogs, and hence their use may be advised. According to the result of Abelmann's experiments, minced pancreas promotes the digestion of fats. PANCREATIC HEMORRHAGE. {Pancreatic Apoplexy.) It is only in recent years that this fatal affection has been clearly iso- lated and defined, and mainly through the observations of Zenker, Draper, and especially Fitz. Pathology. — The pancreas may or may not be enlarged ; it may also be soft and friable. The hemorrhage is apt to occur into circumscribed areas of the gland, particularly its head, the interstitial and subperi- toneal tissues both usually being the seat of hemorrhagic infiltration of a dark-purple color. Extensive hemorrhage may be found in the omen- tum, transverse mesocolon, in the retroperitoneal fat-tissue, and sur- rounding the kidney even. Hemorrhages into the adjacent mucous surfaces have been detected in some cases. Secondary reactive inflam- mations and necrosis are commonly noted. Htiology. — Slight hemorrhages into the pancreas may be found that are secondary to excessive chronic passive congestion or to hemophilic or purpuric cases, and they may be met with in acute infective diseases. These have, however, no clinical import. The precise cause or causes of marked hemorrhage into the pancreas are not known. Most cases have occurred in adults past forty years of age in whom the previous health yiO DISEASES OF THE DIGESTIVE SYSTEM. was unusually good. Traumatism may be a direct cause. Again, some local vascular weakness or lesion [e. g. necrosis), superinduced by alco- holic habits or a rich diet in an atheromatous person ; or. some corrosive action of the pancreatic secretion, may operate as causes. Symptoms. — The patient may have been in apparently robust health when the attacic comes on with sudden and startling gravity. The most prominent earh'^ symptom is intense pain located in the epigastric region or in the lower chest, together with a sense of constriction. Nausea and vomiting may be associated, and the latter is usually obstinate and gives only temporary relief. Tympanites may also occur. There are early and constant general evidences of internal bleeding — an anxious countenance, restlessness, depression, yawning, pallor, cold sweat, a lowered surface- temperature, and a small, rapid, and weak pulse. Prostration and syn- cope follow, and death ends the case in from half an hour to twenty-four hours. Death is caused by reflex paralysis of the heart, due either to some coincident vascular affection, or to pressure, perhaps upon the solar plexus and semilunar ganglion (Zenker). I have collected 24 cases of pancreatic apoplexy exclusive of the 16 cases previously reported by Fitz, in which the condition led to speedy death from shock or possibly from compression of the solar plexus. Owing to its apparently "' idiopathic " character, its sudden development, and quick destruction of life, pancreatic hemorrhage assumes intense medico-legal interest and importance. Diagnosis. — Given the sudden-developed signs of a concealed in- ternal hemorrhage, with pain referred distinctly to the epigastrium, and vomiting and rapid collapse, a probable diagnosis may be made. Treatm.eiit. — This consists in relieving the pain by opiates and in overcoming the collapsed condition by free stimulation. CARCINOMA OF THE PANCREAS. Pathology. — Primary carcinoma is the more frequent variety. It is of the scirrhous form in most cases, and usuallj^ involves the head of the gland. Avhich may attain to the size of a child's head. Not rarely the adjacent organs are found affected, either by direct or metastatic exten- sion of the disease, or by the pressure of the growth ; the liver, perito- neum, stomach, portal vessels, bile-ducts, ureters, and aorta may thus be involved. The pancreatic duct may be occluded, so as to form retention- cysts. Mechanically, carcinoma of the pancreas causes jaundice and other symjitoras {vide infra). Htiology. — Jlen past forty years of age are most liable to carci- noma of the pancreas, though it has been met with even in the new-born. Mirallie has collected 113 cases of primary carcinoma of this viscus (Fitz). Symptoms. — These are scarcely ever sufficient to indicate the dis- ease with any certainty. There are usually a stubborn dyspepsia, a progressive loss of flesh and strength, anemia, and a dull, or sometimes neuralgic, epigastric pain. Xoeturnal paroxysms of pain are common, and are often accompanied by signs of collapse. In some cases vomiting and diarrhea are present. The stools may be light in color and greasy, and may contain blood. There may also be found an abundance of undigested CARCINOMA OF THE PANCREAS. 911 muscular fibers in the stools in the absence of diarrhea ; this is an incon- testable proof of faulty pancreatic digestion. Among the j^ressure-effects due to carcinomatous enlargement of the head of the pancreas there may, not rarely, he jaundice (due to pressure upon the common duct), Avhich persists and " is associated with an enlargement of the liver and gall- bladder." Ascites may appear, from pressure on the portal vein. Chyl- ous ascites, from pressure upon the thoracic duct, has been observed in 2 cases. The inferior vena cava may be compressed, causing dropsy of the lower half of the body ; also the duodenum, followed hj gastrectasis or by signs of intestinal obstruction. Fitz points out that carcinoma of the tail of the pancreas may be a cause of hydronephrosis of the left kidney, from pressure upon the ureter. Marasmus and the cachexia grow from bad to worse, and emaciation may become so extreme as to permit of a satisfac- tory ])alpation of the tumor., which occupies a position near the median line above the umbilicus. Very often, however, the growth is too deep- seated to be felt, being palpable in about one-third of the cases only. Gilycosuria may be associated. Diagnosis. — Carcinoma of the pancreas is probably present in a given case in which there are rapid and progressive emaciation, deep- seated epigastric pain, muscular fibers in the stools without diarrhea, late jaundice and enlargement of the gall-bladder, and the detection of a deeply-situated, fixed, and firm tumor in the region of the gland. The quantity of indican in the urine is diminished. Aortic abdominal aneurysm may be mistaken for carcinoma of the pancreas because of the transmission of the aortic pulsation to the tumor. But in aneurysm the impulse is expansile instead of to and fro, and the contact is neither so sharp nor so sudden ; moreover, the cancerous cachexia is absent in aneurysm, and the history of the case may be clearly indicative. It is sometimes difficult to diiferentiate a malignant tumor of the pan- creas from carcinoma of the pylorus., of the stomach, or of the transverse colon or omeyitum ; the following points will help in the differentiation of the former two : Carcinoma of the Pancreas. Carcinoma of the Pylorus. The tumor is deep-seated and fixed ; later The tumor is more freely movable, and it becomes slightly movable. It is not is usually associated with dilatation of associated with gastric dilatation. the stomach. Symptoms of chronic dyspepsia manifest There are more marked gastric symptoms, themselves. The vomitus is bilious : rarely contains There is " coffee-ground " vomitus ; it is blood ; often is that of gastrectasis. seldom bilious. HCl is present, while there is an absence HCl is absent from the gastric contents ; of lactic acid. lactic acid is present. The stools contain undigested muscle- Usually the bowels are constipated, with fibers. There is an absence of pan- occasional diarrhea. The stools are creatic secretions. The urine may con- black after a hemorrhage. The urine tain sugar. does not contain sugar. There is usually jaundice; sometimes Usually there is no jaundice or ascites, ascites is present. Inflation of the stomach shows the absence Inflation shows the presence of a pyloric of a pyloric growth. tumor. The course is more acute. Death may The course is more chronic, and second- occur within a few weeks or months. ary growths appear in the liver. 912 DISEASES OF THE DIGESTIVE SYSTEM. Neoplastic growths of the transverse colon are also more often super- ficial, and are movable and definable with the palpating fingers. There are symptoms of intestinal obstruction here, and inflation of the colon will show the relation of the tumor to the gut. In carcinoma of the colon the urine generally contains an increased amount of indican. Obstructive jaundice due to gall-stones may be mistaken for pancre- atic carcinoma; but in the latter affection the jaundice develops more gradually, may be less marked, and is permanent, while that of chole- lithiasis is transient. In hepatic colic the onset is sudden and the pain is severe and colicky, or is reflected to the right and posteriorly, with equally sudden relief. A discussion of the prognosis and treatment of carcinoma of the pancreas is obviously unnecessary. PANCREATIC CYST. Pathology. — Pancreatic cysts may be single or multiple, and large or small. When large they develop chiefly to the left of the median line. Sometimes a cystic pancreas may have the appearance of a bunch of grapes. Single cysts may grow to an enormous size, containing as much as several gallons of fluid. The contents may at first consist simply of retained pancreatic juice, and usually the liquid is dark gray or dark brown, alkaline, and hemorrhagic or albuminous. A hematoma may be converted into a serous cyst. The specific gravity is from 1010 to 1024. Atrophy of the pancreas may ensue. Examined 7nicrosco])ically, the contents reveal leukocytes, red blood-corpuscles, oil-drops, fatty degen- eration of the epithelium, and crystals of fatty acids and cholesterin. Ktiology. — Cysts of the pancreas may be due to occlusion of the pancreatic duct or its branches by compression from within or without the gland. They may also be due to tumors, to impaction of biliary or pancreatic calculi, to cirrhosis or angular displacements of the gland, or to the obstructive swelling from extension of catarrh of the bowel (Krecke). Many cases have been traced distinctly to traumatism. Lloyd suggests that the cysts that follow local injury are in reality instances of encysted peritonitis involving the lesser omentum or that portion of the latter covering the pancreas. Cysts of the pancreas usually occur in adults ; Railton, however, met a case at six months of age. Symptoms. — The symptoms are those of 'pressure., and in part are the result of an absence of the pancreatic secretion. Pain may be absent, or it may occur as colicky paroxysms, referred either to the epi- gastrium, the left hypochondrium, or even the left shoulder. Jaundice and ascites are present in large tumors. Vomiting, constipation, or fatty diarrhea, with undigested muscular fibers in the dejecta, or clay-colored, pasty, and offensive stools, may be present. Albumin and sugar may be found in the urine. Emaciatioii is not infrequent. Intestinal hemor- rhage may occur and recur. A late and constant symptom is a feeling of 'pressure in the epigastrium. On physical examination a smooth, elastic, lobulated tumor is discov- ered in the region of the pancreas if the growth is moderate in size. Sometimes a very large cyst develops in a remarkably short s])ace of PANCBEATIC CALCULI. 913 time — i. e. in a few weeks. When very large in size fluctuation is easily elicited. It may be slightly movable in the grasp and during inspiration. It usually presents between the stomach and transverse colon an area of dulness, and unless the tumor be of large size it is surrounded by tym- panitic resonance of deeper timber above than below. Auscultation may reveal a murmur caused by compression of the aorta. When the cyst attains enormous dimensions the usual mechanical pressure-effects are produced. Diagnosis. — The diagnosis rests on the typical physical signs — the discovery on palpation of a smooth, elastic, lobulated, or rounded tumor that is slightly movable, and on percussion of a dull area that is not con- tinuous above with the spleen- and liver-dulness. Resort has been had to filling the stomach with air and the colon with water (after purging), and thus proving by palpation the deep-seated situation (behind the stomach and omentum) of the tumor. If pancreatic fluid be obtained from the supposed cysts, it will digest albumins and emulsify fats. This test is not wholly reliable, however. A pancreatic cyst may be mistaken for an ovarian cyst., for renal tumors {cysts), dropsy of tlie gall-bladder, and retroperitoneal sarcoma (Lohstein s cancer). The diiferentiation is extremely difiicult, and must be made by a comprehensive and careful study of all the points in the case. The prognosis is good under proper treatment — incision and drain- age. Of 31 reported cases thus treated, only 2 proved fatal. PANCREATIC CALCULI. Pathology. — These, are grayish-white, rounded concretions, consist- ing of calcium carbonate or phosphate. The calculi may be as fine as dust or as large as an almond. Among their remote pathologic efi"ects are fistulous communications with the colon, peritoneal cavity, and stomach ; also cystic dilatations of the duct and abscess-formation. Atrophy of the organ is frequently, and carcinoma rarely, associated. Ktiology. — Pancreatic calculi presuppose a catarrhal condition of the pancreatic duct, with retention of secretion, anomalies of the pancre- atic secretion, or the presence of cysts or some other form of obstruction of the pancreatic duct. The symptoms are developed when, during the passage of the stones along the duct to the duodenum, the latter excite inflammation. In con- sequence, paroxysms of p>ain occur [pancreatic colic) that are usually attributed to gall-stones, and we are often unable to diff"erentiate the two conditions. The radiation of pain along the lower left costal border to the back rather than to the right side, and possibly the detection of free fat in the stools or glyeoswia, may aid markedly in the diagnosis. Jaundice is usually absent in pancreatic colic. Moreover, the finding of characteristic calculi in the stools is entirely confirmatory. Emaci- ation may become marked in calculi of the pancreas. The prognosis is mainly dependent upon the associated lesions and upon certain sequelae — pancreatic cysts and chronic pancreatitis. The indications for treatment do not difi'er materially from those of hepatic colic. Surgical intervention should be considered. 58 914 DISEASES OF THE DIGESTIVE SYSTEM. XII. DISEASES OF THE PERITONEUM. ACUTE PERITONITIS. Definition. — An acute inflammation of the peritoneum. The con- dition may be primary or secondary. Clinically, two varieties — general and circumscribed — are recognized, -while, pathologically, the disease is classified according to the nature of the exudate. Anatomic and Physiologic Pec\diarities. — The surface area of the peritoneum is quite extensive, being almost equal to that of the skin. Fluids of all sorts are rapidl}' absorbed by the peritoneum, and thus, if they be poisonous, constitutional infection is speedily propagated. Pathology — Upon opening the abdomen in acute generalized peri- tonitis vascular injection both of the serous covering of the intestine and of the parietal layer is observed. Even in the most recent cases the coils of intestine may be feebly glued together by lymph, while in those of longer duration the adhesions are quite firm. As in the analo- gous inflammation of the pleurae or pericardium, we distinguish the fol- lowing forms pathologically : (a) A jylastic or fibrinous, in which there may be also a small amount of serum present, (b) Sei'o-fihrinous (inflam- matory ascites), chiefly characterized by considerable sero-fibrinous fluid; additionally, the coagulated fibrin forms a covering for the parietal and visceral layers of the peritoneum, {c) Purulent (most frequent). The amount of inflammatory exudate varies greatly, and is frequently enor- mous, exceeding 30 liters (quarts). Putrefactive decomposition of the pus may occur, especially in cases due to gangrene of the gut or to puerperal peritonitis (violent forms), giving rise to a thin fluid that is grayish-green in color, is sometimes distinctly sanious. and ill-smelling. Off"ensive gases are present with relative frequency. These mav come from the intestinal canal, following the track of perforations ; or they may be due to decomposition of the purulent exudate, (t/) Hemorrhagic. This form is common in cases that are of a cancerous or tuberculous nature, and in subjects whose vitality has been lowered by various other affections. It may also be of traumatic origin. Changes in the Intestines. — The effect of acute peritonitis is to thicken the coats by inflammatory edema : soon the musculature is paralyzed. An associated catarrh of the mucosa of the intestine is sometimes observed. The different pathologic varieties above described may be limited to definite portions of the peritoneal sac, when they are termed " encapsu- lated " or localized acute peritonitis (vide supra). In localized purulent peritonitis further extension of the process is arrested by the rapid for- mation of circumscribed adhesions due to the exudation of lymph ; there are also undoubted instances of circumscribed, aplastic peritoneal ab- scesses. The milder forms of limited plastic and sero-fibrinous perito- nitis pursue a slower course than the pui'ulent variety, and commonly lead to the development of firm adhesions (adhesive j^o'itonitis). Since the histologic changes in acute peritonitis do not differ from those ob- served in other inflammations of serous membranes, the reader is referred to the section on Pleurisy (p. ,541) for their consideration. Ktiolog3^. — The irritants causing acute peritonitis may be — (a) Or- ACUTE PERITONITIS. 915 ganized inflammatory agents (organic irritants). These may be sjyeeijic or non-specific. Among the non-specific agents are the pyogenic bac- teria. GraAvitz has shown that the latter can only cause peritonitis under certain conditions : they excite the disease when injected into the perito- neal cavity or Avhen poured out from the diseased or injured membrane more rapidly than the peritoneal tissue can dispose of them ; also Avhen the epithelial layer has from any cause been removed. Absorption may be interfered Avith, Avhile the pyogenic micrococci continue to enter from the boAvel or other viscera in great numbers. Unfortunately, the clinical practitioner often meets Avith cases of peritonitis in Avhich these pyogenic organisms are the only positive agents. These essential conditions obtain Avhen the membrane is Avounded by the perforation of gastric and intesti- nal ulcers, and also in perforation of the gall-bladder, in rupture of the liver, kidneys, and spleen, AA^hen the latter are the seat of abscesses, and, with uncommon frequency, in appendicitides, in purulent inflammation of the ovaries and of the Fallopian tubes. " There are instances in AA'hich peritonitis has folloAved rupture of an apparently normal Graafian follicle " (Osier). These perforative forms of peritonitis are at the same time the most serious and the most important. "Death may result from the in- jection into the peritoneal sac of putrid liquid if the dose be large enough ; but it is practically the same whether the fluid is injected into the blood-stream at once or allowed to find its Avay into the peritoneal cavity, and the result folloAA'S nearly as quickly in the one case as in the other" (Moullin). The rapid absorption of liquid substances gives full opportunity for the phagocytic action of the AA'hite blood-corpuscles. Among specific organic irritants the tubercle bacillus deserves especial mention, though, as before intimated, a discussion of its characteristics is not in place here. The streptococcus pyogenes is probably responsible for the most violent forms of peritonitis (e. g. those occurring in puerperal sepsis and post-operative varieties). The staphylococcus pyogenes aureus (or alius) has also been found in such instances. The bacterium coli commune (ahvays present in the intestinal tract) is frequently the leading factor in peritonitis of intestinal origin, and, I believe, also in that form following operations upon the appendix. Occasionally other organisms, as the pneumococcus, the bacillus of Fried- lander, or the bacillus pyocyaneus, typhosus and proteus, the gonococcus, and the anthrax bacillus, have been found. Multi-infection is quite common. Some contend that all forms of peritonitis are due to bacteria or their toxins. (5) Chemical Irritants. — These are rather numerous and varied, though all produce their efi'ects in one of tAvo ways. First and most frequently, the irritant acts upon the membrane, exciting an exudation of lymph. In this instance constitutional intoxication is secondary. Secondly, the chemical irritant may be quickly absorbed and produce systemic intoxi- cation immediately. {c) Mechanical irritants, as, for example, a hernia. Avhich may produce a localized peritonitis. (fZ) Peritonitis may be due to a direct extension of infective processes from the intestinal tract or other adjacent organs. Doubtless the bac- teria often penetrate the intestinal wall and gain the peritoneum by way of the lymph-channels. In the majority of instances this variety \q pro- 916 DISEASES OF THE DIGESTIVE SYSTEM. tective in character and results in local adhesions. I have seen a few undoubted instances of peritonitis secondary to pleurisy in which the irritants penetrated the diaphragm along the course of the lymphatics. (e) The disease very rarely occurs idiopatldcally : It has been attrib- uted to exposure to cold or Avet (rheumatic peritonitis). These so-called idiopathic cases are probably instances of cryptogenetic infection. As in other inflammations of serous membranes, so peritonitis may be second- ary to chi-onic Bright's disease. In such cases the special irritants reach the membrane either from the intestinal canal or through the general circulation. Clinical History. — The symptoms are both of a local and a general nature. In sthenic cases of perforative peritonitis they occur simul- taneously with great severity and suddenness. On the other hand, in asthenic cases, such as occur frequently in those already afllicted with some serious disease that is apt to result in perforation (for example, typhoid fever), both the local and constitutional symptoms are more or less overshadowed by the disturbances due to the primary affection. Again, circumscribed abscesses of the peritoneum often lead to diffuse suppura- tive peritonitis, and the change may take place so insidiously as to defy detection. These anomalies from the typical onset and course of the disease are by no means exceptional, and should ever be distinctly borne in mind by the physician. Local Symptoms. — Among these, pain is the chief. At the commence- ment its seat of greatest intensity corresponds, in most instances, with the seat of origin. Hence the character of the causal disease is often betrayed by the location of the chief pain. For instance, if this ap- pears in the region of the stomach and is referred to the back or shoul- ders, we would think of gastric ulcer ; if in the ileo-cecal region, of ap- pendicular disease ; and so on. It follows that quite commonly the severest pain is in the lower half of the abdomen. It is almost constant, increases in severity, and finally becomes general and excruciating ; it is also much increased by deep respirations, by pressure, and by bodily movements. It remits, but does not intermit, though it may be slight in asthenic cases. Here the patient is excessively weak, while his sen- sibilities are greatly blunted. Gastro-intestinal symptoms are prominent, more particularly vomiting, which occurs early and is apt to recur with comparative freijuency. It may follow the taking of food, though, in my own experience, it has more frequently taken place spontaneously ; the vomitw'i then consists of a watery liquid greenish in color and contains mucus. In rare instances the matter vomited is a dark-brown liquid. Vomiting may sometimes be absent, however, owing to the presence of marked asthenia or coma. Eructations are common, and constipation is usually present and may become exceedingly obstinate. On the other hand, there may either be diarrhea throughout the disease, or this symp- tom may precede the constipation. Constipation is due chiefly to paral- ysis of the musculature of the intestine. It is to be ascribed to an in- creased peristalsis due to intestinal catarrh. The apex of the heart is elevated ; the tongue at first is furred and moist, and later it is dry, brown, and often fissured. Constitutional Symptoms. — At the onset the patient in sthenic cases is seized with a rigor that may be repeated. The shock sustained by ACUTE PERITONITIS. 917 the nervous system in acute peritonitis is most intense ; the temper- ature rises immediately, though it does not, as a rule, attain to a high level, and it frequently presents a curve more or less characteristic of suppuration. The rectal temperature is often relatively high ; the respirations are shallow and much accelerated, ranging from thirty to forty per minute. We have, as factors to account for this increased frequency, (a) a crowding upward of the diaphragm, [b) the greatly en- feebled heart, and {c) the pain occasioned by throAving the diaphragm into action. The heart early becomes excessively weak, and, as would be expected, the pulse is rapid, small, and soft. The pulse toward the close becomes exceedingly frequent (130 to 150 beats per minute) and is almost imperceptible ; during the early stages the pulse ranges from 100 to 130. Other evidences of more or less marked circulatory col- lapse soon manifest themselves. The patient wears an anxious facial expression, the eyes are sunken, the features pinched and cool, the lips cyanotic, and the extremities are likewise cold and somcAvhat livid. The patient invariably assumes the supine position, Avith the lower extrem- ities draAvn up, so as to lessen the tension of the abdominal muscles, and thus to secure the greatest possible comfort. The urine is scanty and high-colored, and contains indican. There may be a retention of urine ; though oftener, perhaps, micturition is more frequent than in health. Marked nervous symptoms do not appear ; indeed, the mind usually remains quite clear to the close. Moderate delirium, however, which sometimes gives way to mild stupor, is met Avith occasionally. In con- nection with these facts it should be pointed out that in the asthenic form of acute peritonitis the constitutional features differ from those above described. The temperature is usually subnormal (except in the rectum), the pulse is exceedingly feeble and running, and the signs of collapse are well marked from the onset. Physical Signs. — Inspection reveals the gradually increasing abdom- inal distention, that frequently becomes excessive if the intestinal walls are more or less completely paralyzed. Often the amount of effusion soon becomes large, when the abdomen appears Avidened. The degree of distention bears a definite relation to the severity of the inflammatory process, and is in inverse ratio to the development of the abdominal muscles. Thus, ivhen the latter are poorly developed or greatly relaxed the expansion is enormous. On the other hand, when they are strong the muscles are apt to be quite tense, permitting of a relatively slight enlargement ; the abdomen may even show a small concavity, in which case the Avails are of a board-like hardness. The cardiac apex-beat is displaced upward and outward, occupying the fourth interspace. Palpation elicits extreme tenderness, more particularly in the vicinity of the umbilicus. In not a few instances of acute peritonitis have I been able to detect a distinct friction-rub. Percussion gives at first an exaggerated tympanitic note. There is often an absence of liver-dulness in the mammary line, and rarely also it is absent in the mid-axillary line. In pneumo-peritoneum, resulting from perforation of the gut or stomach, we often meet Avith an absence of liver-dulness, especially when a large purulent effusion coexists. Again, a great diminution in, or even the total effacement of, the dull area may be caused by coils of in- testine forcing their way up betAveen the anterior surface of the organ 918 DISEASES OF THE DIGESTIVE SYSTEM. and the inner surface of the abdominal wall. Owing to the fact that the diaphragm is pushed up, both the upper and lower lines of hepatic dulness are correspondingly higher than normal. When air is present within the abdominal cavity and the patient lies upon his right side, splenic dulness disappears from displacement by the air. The loAver level of cardiac dulness is as high as the fifth rib. By means of percussion, sooner or later, fluid effusions are usually detectable in sthenic cases. On the other hand, there may be in mark- edly asthenic cases an amount of li(}uid exudation present that is often too small to admit of detection. When the effusion is considerable in quantity there is dulness on percussion over the most dependent parts ; when tympanitic distention is excessive, however, even a copious effusion may be so effectually hidden as to elude discovery in this way. I have elswhere reported one such instance.^ On account of the painful character of the illness the patient's position cannot, in the majority of instances, be changed. When, however, the decubitus can be altered the line of dulness will be found to be movable, but the degree of mo- bility varies exceedingly, depending upon the extent of the peritoneal adhesions present. The effused material is partly contained in pouches, giving rise to areas of circumscribed dulness, and these must not be mistaken for the lesions of a localized peritonitis. Course and Prognosis. — Asthenic forms of diffused peritonitis are perhaps invariably fatal. Though the local symptoms and signs are not marked, the characteristic evidences of collapse or of general septicemia appear and grow in intensity to the end. The duration in sthenic cases rarely exceeds one or two days ; in asthenic cases it is longer, lasting from four or five to six or eight days. Death sometimes occurs quite suddenly, owing to cardiac exhaustion or primary shock. Although most instances are dynamic in the early stages, acute diffuse peritonitis assumes a markedly adynamic form in the later stages. The clinical peculiarities and the course of an individual case are greatly influenced by the etiology. Acute generalized peritonitis arising from perforative appendicitis, from perforation of a gastric ulcer, puerperal sepsis, or from external injuries, is usually of a violent form and ends fatally. Prompt operative intervention, however, is powerful in saving life in a small percentage of the latter class. When the disease is traceable to rheumatism or exposure recovery may take place. A case occurred in my own practice in which acute sero-fibrinous peritonitis with consider- able effusion was associated with acute articular rheumatism and organic lesions of the aortic segments ; the patient recovered. Acute generalized peritonitis may not infrequently merge into a chronic condition ; this, however, will receive separate consideration in its proper place. LOCALIZED OR PARTIAL PERITONITIS. {Circumscribed Periionitis ; Visceral Peritonitis.) This is a localized form of inflammation of the peritoneum that is coextensive only with the serous covering of single organs, and involves a limited portion of the membrane. Hence, to the various forms of cir- ' International Medical Clinics, vol. iii.. second series, p. 82. LOCALIZED OR PARTIAL PERITONITIS. 919 cumscribed peritonitis such terms as perihepatitis, perisplenitis, peri- nephritis are applied. The condition is found in its most important form in appendicitis, but the points that are characteristic of localiza- tion in this disease have been mentioned elsewhere {vide Appendicitis, p. 819). Localized peritonitis may also be caused by a carcinomatous growth. PyO'jjneumothorax subjphrenicus is the term applied to a circum- scribed peritoneal abscess containing air, situated between the liver and diaphragm. The condition is described under the heading Acute Peri- hepatitis (p. 875). Local pelvic peritonitis (perimetritis) is the most frequent variety, and is secondary, as a rule, to inflammation about the uterus, Fallopian tubes, and ovaries. Its consideration, however, must be left to special works on gynecology. Sj^tnptoms. — The local clinical features do not differ from those described under the diffuse form, but their area of distribution is more or less strictly limited to definite regions. By e\\c'\tmg\he physical signs with care fluid collections are sometimes demonstrable. The constitutional symptoms are likewise similar in character, though less marked than those belonging to the diffuse variety. There may be rigors, and pyemic symptoms appear, together with the temperature- curve peculiar to this condition. The danger of involvement of the general peritoneal cavity as the result either of rupture or of an exten- sion of septic inflammation is a constant menace. When the peritonitis remains localized these cases may pursue a subacute or even a chronic course, though in most instances the constitutional disturbance becomes grave at last. Diagnosis. — In attempting to diagnosticate acute generalized peri- tonitis it is of great importance for the clinician to keep in remembrance the sthenic and asthenic forms of the affection. The character and gravity of the symptoms, both general and local, are such as to render the diagnosis of the sthenic form entirely easy. Especially valuable features are the constant pain, the marked tympany, the excessive ten- derness under pressure, and the vomiting at intervals of a greenish fluid material. Of equal importance are the serious general disturbance previously depicted, and in particular the cool, sharpened features and the ever-increasing weakness and rapidity of the pulse. These clinical manifestations clearly foreshadow cardiac exhaustion or fatal collapse. When the cases are not seen until the advanced stage has arrived, how- ever, the diagnosis presents many difficulties. Nothing is now more important than the consideration of the history from the time of onset, also of the previous history, with a vicAV to determining the point of origin and the probable cause of the disease (usually some such primary disease as appendicitis or gastric ulcer). The smaller number of cases belonging to the adynamic type are from the start extremely difficult of diagnosis. Here a history that is clearly indicative, the presence of moderate tenderness, and augmented tension of the abdomen, with profound collapse, would point to this con- dition. It. must, however, be confessed that a positive opinion is often unwarranted, owing to the absence of the more characteristic clinical indications. 920 DISEASES OF THE DIGESTIVE SYSTE3I General Differential Diagnosis. — ffysteric peritonitis (so-called) simu- lates in every leading particular the genuine form so closely as to make the distinction an insurmountable difficulty, unless there be present other hysteric manifestations. In my experience the tenderness has been out of proportion to the gravity of the constitutional disturbance. The patient often complains bitterly before the abdomen has been touched ; on the other hand, when his attention has been otherwise engaged firm and prolonged pressure can be made. Acute generalized peritonitis occasionally supervenes on typhoid fever. In such cases it is caused either by perforation of the intestine or by a direct extension of inflammation from a deep typhoid ulcer. If con- sciousness be retained, sudden severe pain, tenderness followed by ex- cessive tympany, and signs of collapse will establish the diagnosis. Peritonitis, however, develops more often in those grave cases of typhoid that are attended w ith coma, marked meteorism, and profound adynamia, and under such conditions it often remains unrecognized {vide Typhoid Fever, p. 35). In acute etiteric catarrh the meteorism and sensitiveness under press- ure are usually less pronounced ; the disease also lacks the marked con- stitutional symptoms of acute peritonitis. The pain is colicky, is cha- racterized by exacerbations, and even intermits in entero-colitis, while it is constant in peritonitis. The pain in acute enteric catarrh is often followed by diarrheal stools. Intestinal colic is distinguished from peritonitis by the flatulence, the borborygmi, and the wandering pain in the absence of all other phe- nomena. Rheumatism of the abdominal muscles excites pain, which, however, is superficially located (the disease being an aff"ection of the muscular layer), and is frequently associated with rheumatism in other parts of the body. There may also be a clear history of previous rheumatic attacks. Tubal i^regnancy {after rupture) has also been confounded with acute peritonitis, but its difi"erential diagnosis is fully discussed and must be looked for in special works on gynecology and obstetrics. Rupture of an abdominal aneurysm and embolism of the superior mesenteric artery are also conditions that give rise to peritonitic symp- toms — meteorism, recurrent vomiting, and collapse — all appearing with explosive violence. Acute generalized peritonitis in its symptomatology bears a close resemblance to acute intestinal obstruction, and the discriminating points have already been tabulated {vide p. 831). Prognosis. — This is less grave than in the difl"used form, and re- covery may often be expected. Timely surgical intervention, particu- larly if a tendency to spreading be shown, may render the outlook en- couraging or even lead to prompt recovery. Sequela'. — If recovery should take place, the inevitable result is the formation of adhesions and fibrous bands, the contraction of which may cause constriction of the bowels, bile-ducts, and other structures. Treatment. — Hygienic and Dietetic. — The patient should be placed in the position that will give him most comfort, and should be kept ab- solutely undisturbed. The sick-room should be of good size and well ventilated ; the temperature should be kept at from 65° to 70° F. LOCALIZED OR PARTIAL PERITONITIS. 921 (18.3°-21.1° C). The diet demands careful attention. Pancreatized milk in accurate dosage (liv-vj — 128.0-192.0 — every two hours) should be administered, and if the stomach will not bear the introduction of nourishment, recourse should be had to rectal alimentation. Other liquid food-stuffs, as meat-juices and egg-white (diluted), may also be allowed. In asthenic cases alimentation must be generous, although solid articles of food are to be avoided. Medicinal. — Formerly the opium method of treatment, first insti- tuted by the late Alonzo Clarke, was the one followed by the bulk of the profession. His plan was to administer ^ gr. (0.0824) of mor- phin or its equivalent (gr. ij — 0.129) of opium, and repeat the dose every two hours until the respirations were lowered to ten or twelve per minute. The pupils were then observed to be contracted, the pulse from 76 to 80, the pain relieved, and peristalsis arrested. This latter effect was obtained, even though in the case of some patients larger doses of opium than here indicated were necessary ; in others smaller doses sufficed. The bowels w^ere absolutely let alone. It is explained that in favorable cases the bowels moved spontaneously at the end of one week, and that the patient then entered upon convalescence. This method of treatment is at present adhered to only by the ultra-conserv- ative element of the profession. Among those authors who recommend opium as the most efficient measure in the treatment of this disease many still advise against the immoderate dosage previously so generally administered, but employ just enough to keep the patient well under the influence of the drug. The leading mode of treatment to-day consists in the use of saline purgatives, exhibited in divided doses in concentrated solution (3J-ij — 4.0-8.0 — every two or three hours) until the irritating intestinal contents, should any be present, are removed, and additionally several copious serous discharges occur daily. Purgatives do good when given in this manner principally by causing a rapid exosmosis of serum from the blood- vessels of the intestines, by removing the collateral edema, and by indi- rectly relieving the congestion of the peritoneum, thus promoting a rapid absorption through the latter membrane. By increasing the peri- staltic movement they also diminish the danger of peritoneal adhesions. The remedies to be selected will depend upon two primary considera- tions : first, the etiology of the individual case (whether a communica- tion has or has not been established between the peritoneal cavity and the bowel), or an intra-peritoneal abscess or abscess-cavity in one of the abdominal viscera ; and secondly, the type of the case, whether sthenic or asthenic. If perforation is known to have taken place or the occur- rence of this accident is strongly suspected, a prompt laparotomy, fol- lowed by the free use of salines, is the proper treatment. After the prirace vice have been looked after by the surgeon, salines, for the reasons before stated, are to be used with a free hand. For a like reason they are most serviceable in peritonitis due to extension of the inflammation, and also in the puerperal form. If the patient be robust, with a full, tense pulse, we may begin the treatment by the use of mercury, the best preparation being calomel, exhibited in fractional doses (gr. ss — 0.0324 — every hour) until its purgative action is obtained ; this is to be followed by the salines. The object of the calomel treatment is to de- 922 DISEASES OF THE DIGESTIVE SYSTEM. fibrinate the exudations as Avell as the blood of the patient. Certain observers advocate the use of small doses of calomel, and seek to avoid any purgative action of the remedy. Indications demanding the opium treatment do not often present themselves. When, however, the vital forces are profoundly depressed, as shown by the symptoms of collapse, and there is not even a reasonable suspicion of perforation, then opium should be tried, but not in the heroic doses formerly advocated. Enough only should be given to obtain the physiologic effect of the drug in a moderate degree. Again, if the evidences of perforation into the gen- eral peritoneal cavity are complete and competent surgical skill is not at hand, large doses of morphin are imperative, with a view to relieving pain, keeping the patient at absolute rest, and sustaining the heart against the exhausting eff"ect of shock. The bowels should now be relieved by simple large enemata. The value of serum-therapy in this disease is as yet uncertain (Fowler). Local Treatment. — At the onset, if the patient be strong, from twenty to thirty leeches are to be applied to the abdomen. The ice-bag or ice- poultices are often of distinct service in the earlier stages. Later, in localized peritonitis, blisters may be useful, although objectionable in the event of surgical intervention becoming necessary. In cases in which meteoric distention is not great I have also made repeated trial of an ointment containing ung. ichthyol (5] — 32.0); ung. belladonnas (.^ss — 16.0); ung. hydrarg. (sij — 64.0); this is applied to the entire abdomen thrice daily. In order to relieve the tympany turpentine stupes are serviceable. I have also had f\ivorable results from the insertion of the long rectal tube (soft esophageal) well up in the colon. Large high enemata should be used ; and turpentine combined as follows may prove efficacious : ^. Turpentine, 3ij(8.0); Ox-gall, 3ij(8.0); Milk of asafetida, l\y (128.0) ; Warm water, §vj (192.0). Puncturing the abdomen Avith a hypodermic needle in order to re- lieve tympany, as recommended by Loomis, may also be resorted to, though I have had no personal experience with this measure. Pain. — No matter what general plan of treatment is pursued, the pain must be relieved by opium in some form. Thirst is to be relieved by chipped ice, over which a little brandy may be sprinkled. The vomiting is best treated by carbonated water exhibited in small quan- tities, or by iced champagne similarly administered. One-drop doses of creosote are also of value. For the systemic collapse, as Avell as for combating thirst and vomiting, I can warmly recommend saline infu- sion, to be repeated if needful. CHRONIC PERITONITIS. 923 CHRONIC PERITONITIS. Definition. — Chronic inflammation of the peritoneum. Pathology and Htiology. — The anatomic characters presented by different cases are greatly varied, though for convenience of study they may be considered under two divisions (as in the acute form) : 1. Local ; 2. G-eneral. The latter may be («) Adhesive, when the peritoneal layers are inseparable and indistinguishable, with an obvious thicken- ing, and the intestinal coils are everywhere seen to be grown together. The cause is usually a previous acute attack, and, doubtless with great relative frequency, the condition is produced by the acute progressive form (Mikulicz), which is localized at the start. Rheumatism is also an occasional factor, and a mild variety of adhesive peritonitis, confined, as a rule, to small circumscribed areas, may be engendered by the trocar used for tapping in ascites. (h) Proliferative Peritonitis. — " The essential anatomic feature is great thickening of the peritoneal layers, usually without much adhesion" (Osier). It has been found to be associated with cirrhosis of the stom- ach, liver, and other abdominal organs. The amount of liquid effusion, varying in composition from serum to pus, is usually moderate, and it may, owing to adhesions, be loculated. The omentum is sometimes rolled up in the form of a massive cord, with its long axis in the trans- verse direction. In an autopsied case of chronic peritonitis apparently secondary to hepatic cirrhosis I observed in the thickened membrane numerous small hard nodules that were at the time regarded as being tuberculous in nature. It is to be pointed out, however, that a number of cases of pseudo-tuberculosis have been recently reported. In several of these an operative incision was followed by recovery, and this was put down as a cure of tuberculous peritonitis till the microscope showed the nodules to be fibrous. Among etiologic factors chronic alcoholism stands first. In one case that I saw, acute folloAved by chronic rheumatism seemed to be the only assignable cause. The condition is sometimes secondary to chronic nephritis, to syphilis, or a general fibroid process. (c) Cancerous Peritonitis. — Quite often in connection with cancerous growth* in the peritoneum a well-marked peritonitis is evident. There may be a liquid exudation, which is apt to be bloody and chylous. (d) Chronic Tuberculous Peritonitis. — This is the most important vari- ety. The inflammatory lesions are quite pronounced, as a rule, and lead to marked thickening of the layers — changes that are to the naked eye identical in appearance with those noted under the preceding forms, but which on histologic examination show the presence of tubercles and caseous degeneration. The amount of liquid effusion varies within Avide limits, and is usually blood-stained. The frequent association of hepatic cirrhosis with tuberculous peritonitis should be remarked. From tuber- culous peritonitis, tuberculosis of the peritoneum is also to be distin- guished clinically ; the latter may be acute or chronic, and the lesions consist in the deposit of various sized tubercles without much collateral inflammation. Acute and chronic tuberculosis of the peritoneum have received due consideration in their appropriate place (p. 309). (e) " Chronic Hemorrhagic Peritonitis." — This term should be limited in its application to that form first described by Virchow, in Avhich the 924 DISEASES OF THE DIGESTIVE SYSTEM. peritoneum is at intervals partly covered by a membrane of new con- nective tissue that alternates, as it were, with layers of hemorrhagic extravasation. A similar condition results from the frequent use of the trocar for ascites. Chronic Localized Peritonitis. — This is of frequent occurrence, and is confined most commonly to the serous covering of the spleen, liver, and certain portions of the bowel, particularly of the appendix. The condi- tion results in the formation of firm adhesions, with matting of the in- testinal coils and fibrous bands. It is usually the sequel of localized acute peritonitis occurring in connection Avith inflammatory diseases of the different abdominal organs. Symptoms of the General Forms. — Whether chronic peritonitis follows the acute form or not, it always develops insidiously. Most cases remain quite obscure, and not a few are totally devoid of clinical mani- festations. The patient may complain of disorders of the alimentary tract, and especially of constipation. On the other hand, diarrhea is observed in tuberculous peritonitis from associated intestinal ulceration. Rarely pressure, from the traction force of the adhesions, on the common duct or portal vein gives rise to ohiivuci\\e jaundice, or ascites, as the case may be. I saw an instance recently in which compression of the veins leading to the lower extremities caused unilateral edema. Suhjective abdominal sensations, as uneasiness, oppression, heat, and pain (often colicky in character), are experienced. Sometimes pain is entirely absent. General symjjtoms appear, though they are quite vague as a rule. An irregular fever, hectic in type, is occasionally observed. Later, in- creasing general weakness, emaciation, and general nervous disturbance become rather prominent clinical features. Some of these phenomena, however, may be due to associated affections. When the peritonitis is tuberculous we frequently see clinical evidence of the causal disease in other parts of the economy (vide Tuberculous Peritonitis, p. 309). Physical Signs. — Inspection usually shows the belly to be slightly, though unefjually, enlarged. As in acute peritonitis, so here, we find the belly flat, or even concave occasionally, with great tension of its walls. Fluctuation is sometimes obtainable over limited area^ only» since the fluid is not free, but encapsulated. The coiled-up and shrunken omentum may be palpable as a sausage-shaped mass, and thick bands of adhesion may also not rarely be felt, in different places, as hard, un- even masses simulating neoplasmata. The pe?'cussion-dulness varies con- siderably with the amount of effusion, its arrangement, the degree of peritoneal thickening, as well as with the character and locality of the fibrous bands. It follows that in some cases irregular areas of tym- panitic percussion-resonance and of dulness are to be found side by side scattered over the abdomen. Obviously, too, changing the patient's posture Avould not give movable dulness, owing to sacculation of the fluid. A marked sense of resistance is experienced on percussion over the dull area. Friction-freynitiis can sometimes be elicited, and less fre- quently friction-soimds also during forced breathing. Symptoms of Chronic I/Ocal Peritonitis. — This condition is often entirely latent. When not so, the most characteristic indication is constant pain, distinctly colicky in nature and often quite intense. CHRONIC PERITONITIS. 925 The physical signs are negative, as a rule. Very rarely a resistant, ill- defined mass, corresponding with the seat of greatest pain, can be felt. A fibrous band may be so arranged as to form a snare through -which a knuckle of bowel may pass, with resulting strangulation. Fitz's analy- sis of 295 cases showed 63 to be caused in this Avay. Diagfnosis. — That form of chronic peritonitis (serous or granular) most frequently seen in females at the commencement of puberty is hard to discriminate from tuberculous peritonitis, since the latter may be more or less latent. Tuberculous peritonitis is attended with fever, more pain and tenderness, and there is a more rapid accumulation of the exudate. Again, the general features, debility and loss of flesh, progress more rapidly than in granular peritonitis. The detection of conclusive evidence of the disease in persons closely related, or on phys- ical examination of associated pulmonary or pleural lesions, would ren- der the diagnosis of tuberculous peritonitis almost certain. In obscure cases the guinea-pig should be inoculated with the exudate (see Pleu- risy, p. 541). Course and Prognosis. — The milder varieties of simple chronic peritonitis may, though rarely, reach a favorable issue. In cases belong- ing to this category the disease takes a chronic course, and leads gradually to a condition of extreme debility, even if it does not, as is usually the case, materially shorten life. Tuberculous peritonitis has, until recently, been regarded as being almost uniformly fatal at the end of several months. Cures that must be attributed to the surgeon's work, however, are at present by no means uncommon. Rarely spontaneous cures also occur, particularly among children, in whom the disease is less serious than in adults. Treatment. — The patient should be enabled to enjoy the benefits of good sanitary surroundings. Close attention is to be paid to the diet, the coarser vegetables and sweets being prohibited, since they increase the pain by exciting the production of gas. A change of air has im- proved the condition in several instances occurring in my own practice. The usual constipation may be relieved by simple enemata or by the use internally of the fluid extract of cascara sagrada. Tonics and alter- atives, the latter with a view to promoting the absorption of the exudate, may also be employed, and I would recommend especially for this pur- pose the double iodids, as in the formula given in the discussion of Pleurisy {vide p. 556). In the early stages some degree of relief, or even a curative eff"ect, may be secured by local means, as the application of equal parts of belladonna and iodin ointments until mild counter- irritation is produced. Ichthyol ointment is also serviceable. After all, however, little is to be gained from therapeutic measures, and it is to surgery that we must look for fresh triumphs in the treatment of this truly distressing complaint. Cases of chronic localized peritonitis with adhesions have been operated upon successfully by W. E. Ashton, H. A. Kelly, and others. Instances of chronic generalized peritonitis, whether tuberculous or not. in which the fluid effiision reaccumulates rapidly after repeated tappings, also furnish adequate indications for operative procedures. 926 DISEASES OF THE DIGESTIVE SYSTEM. ASCITES. {Hi/drops Peritoncei ; Dropsy of the Peritoneum.) Definition. — An accumulation of serum in the peritoneal cavity, resulting from stasis (obstruction) in the branches of the portal vein. Pathology. — The quantity of liquid contained in the peritoneal cavity is quite variable, though it often amounts to several gallons. It is clear and transparent, or slightly opalescent, especially on standing, and the specific gravity ranges from 1010 to 1014. In color it often has a faint lemon-yello\v tint; it may, however, be either distinctly yellow, brownish (in cirrhosis), bile-stained (as when jaundice is present), or slightly blood-stained. In reaction it is usually alkaline ; very rarely it is either acid or neutral. The ascitic fluid usually contains much albumin, resembling in this respect blood-serum, as would be expected from its source. The per- centage of albumin may be approximately ascertained by noting the specific gravity of the fluid by the urinometer. Thus, in true ascites the specific gravity ranges from 1010 to 1014. and the variation in the percentage of albumin is from 1 to 2. In eflusions due to pe7'ithritis ; Chronic Diffuse Nephritis irith Exudation : Chronic Tubal and Chronic Desquamative Nephri- tis: Chronic Glomerulo-nephritis : Large White Kidney: Secondary or Fatty and Contraxited Kidney.) Definition. — A chronic diffuse inflammation of the kidneys, at- tended with epithelial degeneration, exudation from the blood-vessels, and permanent connective-tissue changes in the stroma. According to Delafield. this is the chronic productive {or diffuse) nephritis with exu- dation — one of two varieties of chronic Bright"s disease. Patiiology. — Although there are several types of pathologic kidney in this disease, and many individual cases in which anatomic differences are noted, the changes of structure are essentially the same, and the variations depend upon the causation and duration of the nephritis. The first type of kidney to be mentioned is the large white Mdney (without waxy degeneration). It is either enlarged or normal in size, and pale or yellowish in color. The surface is smooth, and the capsule is easily stripped off. On section the cortex is broader than normally, yellowish-white throughout, or it may present opaque yellowish or whit- ish areas with mottlings of red. The pyramids are congested in some 982 DISEASES OF THE UEiyARY SYSTEM. cases. Microscopically, the following changes are commonly observed : the renal epithelium is swollen, hyaline, granular, or fattv, and more or less disintegrated or flattened ; the glomeruli are enlarged from the growth of the capsule-cells and of the cells covering the capillaries, and in some cases, owing to the connective-tissue thickening of the capsule, the tuft of capillaries is found to be atrophied. The interstitial tissue shows some thickening of the arterial walls and a moderate growth of connective tissue in patches around the glomeruli and tubules ; the latter contain hyaline and granular casts. The small white kidney, or secondary contracted kidney, in most in- stances is probably a later stage of the preceding, in which the degen- eration of epithelium is more advanced and the growth of connective tissue and resultant cicatricial contraction are prominent features. The kidneys are about normal in size (shrinkage of the large white kidney), the surface is slightly granulated, and the capsule is proportionately ad- herent. "While this kidney is usually grayish or yellowish -in color {pale, granular kidney), there may be some mottling due to red spots. The consistence is firmer than that of the large white kidney. The cut- surface shows yellowish-white foci of the fatty degenerated epithelium in the somewhat narrowed cortex, and hence the term that is sometimes used of "small, granular, fatty kidney." Under the microscope we find extensive degeneration and disintegration of the epithelium of the glomeruli and convoluted tubules, with atrophy of the parenchyma, and a corresponding increase of the interstitial connective tissue. "Waxy degeneration may be associated. Another variety is the large red or variegated kidney of chronic hem- orrhagic nephritis. The organs are usually enlarged, swollen, red, and congested-looking or mottled, and frequently "bumpy" or slightly bossellated. The capsule is slightly adherent to the depressions between the bosses. Red spots, due to small hemorrhages, may be noticed on both the outer and cut-surfaces of the kidney. The section shows also congested portions and gray or yellow spots corresponding to the anemic and fatty degenerated portions. Small cortical hemorrhagic areas or striations, brownish-red in color, are distinctive of the kidney. The microscopic appearances are those of the large white kidney plus those of acute nephritis. Or, there may be inflammatory edema and cellular infiltration of the intertubular tissue, and dilated tufts of capillaries with surrounding cellular hyperplasia. This variety of chronic nephritis is frequently found in inebriates. Ktiology. — The disease may follow either the acute diflFuse nephri- tis, as of scarlet fever or pregnancy, or simple chronic congestion and chronic degeneration of the kidneys. More often it arises insidiously, in a subacute manner and without any previous acute manifestation. Males are more frequently subject to this form of chronic Brights disease than females. Children aff"ected with the disease have usually had scarlatinal nephritis. Young adults are more commonly afl"ected, however, with the usual variety, developing subacutelv. Drinkers of beer and other malt and alcoholic intoxicants seem to be liable to the disease. It is not improbable that some toxic or infectious agency, acting sloAvly and persistently, may in the insidious cases be the cause of the nephritis, although manifestations elsewhere may be absent. I have observed it CHRONIC NEPHRITIS. 983 in certain individuals living in malarial regions. Persons working under exposure to cold and wet, or those living in humid and low, marshy localities, are more liable to this renal malady than those who are better protected from climatic vicissitudes. Tuberculosis, syphilis, and chronic suppuration may give rise to this so-called " parenchymatous " form of chronic Bright's disease, and it is usually combined Avith amyloid disease (waxy degeneration). Symptoms. — There may be a persistence, in a lesser degree, of the symptoms of an acute parenchymatous nephritis, particularly the anemia, dropsy, and the albuminuria, until the affection becomes chronic. In most cases, however, the disease develops slowly and gradually, in a subacute manner, though the earlier symptoms seldom indicate any renal derangement. There may be simply a general impairment of health and strength, loss of appetite, nausea, and attacks of indigestion, headache, dulness, and perhaps some pallor. Soon there is puffiness of the eyelids or swelling of the feet or ankles, or both, and the com- plexion takes on a blanched appearance. The edema gradually extends up the legs, and is often worse as the day grows, while on rising in the morning it may be found to have disappeared during the night's rest and recumbency. The quantity of urine is diminished in the majority of cases, though in the later stages it may be nearly or quite normal, and even slightly increased in long-standing instances of pale contracted kidney or when absorption of the dropsy is taking place. Superadded acute nephritis may cause a very scanty or a suppressed secretion of urine. The specific gravity is, of course, increased in scanty urine, and vice versa. Albuminuria is often quite marked. The amount of albumin may be from one-fourth to three-fourths of the volume of the urine, or from 1 to 3 per cent, by weight, so that the daily loss of albumin may be considerable. The urea is much diminished. The color of the urine is turbid, sometimes smoky-yellow, and urates, casts, red and white blood-cells, epithelial cells, granular debris, and fatty granular cells are found in the usually abundant sediment. The tube-casts are of different varieties, but narrow or broad hyaline, fatty granular (Fig. 65), and epithelial casts are commonly observed. The edema is prominent and persistent. It gradually extends all over the body, so that pitting can be obtained on the limbs, chest, abdo- men, and back. The loose subcutaneous tissues, as of the penis, scrotum, and eyelids, are particularly distended. In chronic hemorrhagic nephri- tis, only, the edema may be absent or very slight. The pasty, pallid complexion and anasarca are most characteristic of chronic exudative nephritis, especially Avith large white kidney. The dropsy may be mod- erate and about stationary for several months ; then, despite all treat- ment, it becomes insidiously worse, death ensuing in a month or two. Dropsy of the serous sacs, with its attendant distressing symptoms, may be present in serious cases, and edema of the larynx and lungs may come on suddenly and cause death. Dyspnea may be toxic and nervous, as well as mechanical or cardiac in origin. Cardiac dyspjiea, due to failure of the heart's action, as seen in many cases, is usually worse on lying down. It may be provoked by vaso-constriction, and is then a danger-signal of uremia. Catarrhal bronchitis may be associated with cough and expectoration. 984 DISEASES OF THE URINARY SYSTE31. The heart is often affected with moderate hypertrophy' of the left ventricle, and later by dilatation and weakness of both ventricles. The aortic second sound is accentuated and the pulse-tension increased. Uremic symptoms are frequently manifested, except the convulsions which are common to chronic nephritis without exudation. Headache, vertigo, sleeplessness, nausea and vomiting, diarrhea, and stupor, coma, or delirium, may develop and precede a fatal termination. Albuminuric neuro-retinitis, as evidenced by dimness of vision and field-defects, occurs in quite a number of cases. The skin of the legs becomes subject to a red eczematous eruption in some cases of great dropsical distention. In the absence of complicating inflammations, such as pericarditis, endocarditis, pneumonitis, and ulcerative colitis, which are rare, the temperature is practically normal. The course of chronic exudative nephritis may either continue from bad to worse, until death ends all in a year or two, or anemia, dropsy, and albuminuria may attack one who for years previous has had apparent good health, after a first attack the second proving fatal within a few months. Again, some patients, having a little pallor, slightly diminished urine of high specific gravity, with albumin, may complain of nothing for years, until decided attacks, lasting for several months, may occur, Avith intervals during which the dropsy, dyspnea, etc. may be absent, although some albuminuria persists. The average duration of the disease varies from one and a half to three years. The duration of chronic hemorrhagic nephritis may be somewhat longer (eight months to two years) than that of the large white kidney (six to eighteen months), but it is shorter than the second- ary, contracted kidney, which lasts from one and a half to three or even five years. Diagnosis. — The diagnosis of the disease itself is not difficult, but of the stage or the variety of kidney it is almost impossible to tell cor- rectly in some instances. The urinary examination, coupled with the symptoms of dropsy and anemia, is sufficiently diagnostic of chronic diff'use nephritis (with exudation). In cases of large white kidney the urine passed is less in quantity and of higher specific gravity than in the small, pale, and contracted kidney. Edema is usually greater in the former also, while in the latter cardio-vascular changes are more marked, as shoAvn by the physical signs and the hard pulse. The transition of the disease from the earlier to the later stage may be thus noted. The casts in the latter may also be narrower and more darkly granular than in the large white kidney. The existence of hemorrhagic kidney may be inferred from the history of alcoholism and the persistent presence of red blood-corpuscles and blood-casts in the urine. Chronic parenchymatous is distinguished from chronic interstitial nephritis by the following points of difference : Chronic Parenchymatous Nephritis. Chronic Interstitial Nephritis. Occurs in early or middle life. Occurs later in life. There is a previous history of an acute A previous history of gout, chronic lead- attack of scarlet fever, or perhaps of poisoning, syphilis, excessive eating acute alcoholism. and drinking (spirits), nerve-strain; otherwise often negative. CHRONIC NEPHRITIS. 985 Chronic Parenchymatous Nephritis. Chronic Interstitial Nephritis. The onset is gradual or markedly mani- The onset is very slow, insidious, and in- fest. " definite. Dropsy is a constant symptom. Dropsy is rare. Vascular changes and cerebral symptoms Arterio-sclerosis, cardiac hypertrophy, are comparatively uncommon. and cerebral symptoms are common. Marked albuminuria, with tube-casts. Very slight albuminuria and few_ casts. Urine but little increased in quantity, Urine of very low specific gravity, and often diminished; specific gravity is excessive in quantity. increased or slightly diminished. Anemia occurs earlier and is more dis- Anemia slowly progressive and less tinct. marked. Uremic symptoms are generally less se- Uremic symptoms are, generally severe vere — amaurosis, vomiting, diarrhea, — coma and convulsions, great dyspnea. headache. Kuns a shorter course — from two to six Has a more chronic course — seven to or seven years. thirty years. Prognosis. — This is invariably bad as to cure, though life may be prolonged in certain cases. In severe cases death may take place in from three months to a year, either from uremia, dropsy, cardiac dilatation, or complications. Cases of a year's duration almost never recover, and, afortioi'i, those in which advanced secondary contraction of the kidney may be inferred are incurable, and may soon terminate fatally. Com- plete recoveries from the disease, particularly in children that have had scarlet fever, may occur but rarely. The prognosis depends greatly on the quantity of urine passed in the twenty-four hours, the excretion of urea and total solids, and upon the amount and persistency of the albu- min, as well as upon the degree of cardio-vascular and retinal changes. Treatment. — The indications for treatment are similar to those in acute nephritis. The dropsy and uremia must be treated symptomatically, and the diet is of importance. Skimmed milk and buttermilk, with dried bread, crackers, and zwieback, perhaps, should be depended on as much as possible when dropsy is pronounced. When dropsy is slight, more solid food, white meat, vegetables, rice, and other light cereals, and fruits, and an out-of-door life should be recommended. Residence in a warm, dry climate may aid in prolonging life. Wool- lens should be worn next to the skin, and prolonged, sudden, and severe exercise should be forbidden. The infusion of digitalis, strophanthus, spartein, or convallaria, may be needed in cardiac weakness, or nitroglycerin for contracted and tense arteries with a tendency to uremic twitchings. Unirritating diuretics and Basham's mixture for the anemia are useful. Strontium lactate in doses of from 15 to 20 grains (0.972-1.29), three times daily, I have found useful in some cases. Diuretin has lately been tried, also, with favorable results. 986 DISEASES OF THE URINARY SYSTEM. CHRONIC NEPHRITIS (NON-EXUDATIVE j. {Chronic Interstitial Nephritis: Chronic Bright' s Disease; Primary, or Genuine, Contracted Kidney; Cirrhotic Kidney: Red Granular Kidney; Renal Arterio- sclerosis : Chronic Productive (Diffuse) Nephritis without Exudation (Delajield) ; Gouty Kidney.) Definition. — A chronic diflFuse inflammation of the kidneys, attended with a growth of connective tissue in the stroma, degeneration and atrophy of the renal parenchyma, and marked change in the cardio- vascular system. Pathology. — In genuine primary contraction of the kidneys there is a reduction in size and weight about equal in both organs. They may be only one-half or one-third the size of normal kidneys, and the two kidneys together may not weigh over two ounces. They are often found imbedded in thick adipose tissue, the capsule being thick, opaque, and very adherent, so that on stripping it ofl" it brings away portions of the renal cortex. The outer surface of the kidney is red, irregularly granular, or finely nodular, and occasional small cysts are sometimes present. The consistence is firm, dense, and resistant to the knife. Ex- amination of the cut-surface shows a thin atrophied cortex, and dark, reddish streaks alternating with pale portions. The pyramids are also diminished, and darker than the cortex. In the gouty contracted kidney the pyramids show fine striations of sodium urate or of uric acid, or crys- tals representing uric-acid infarctions. Microscopically, the essential changes are an increased production of connective tissue, especially in the cortical substance, and a more or less proportionate degeneration and atrophy of the renal parenchyma, the destruction of which is due to the circulation of noxious agents, but which is replaced by cicatricial fibrous tissue (Weigert). The new tissue is not uniformly distributed in the cortex, but occurs in irregular masses around the shrunken glomeruli or between the tubules. The distribution of connective tissue in the pyramids is more diffuse. Many of the glomeruli are quite small and fibrous in advanced cases, while in the earlier cases the cells of the tufts and capsules are swollen and multiplied, and a small-celled infiltration is seen around the glom- eruli and tubules. Later this infiltration of cells becomes fibrillated and ends in thickening. Glomerular atrophy is due partly to the changes in and crrowth of the capillary and intra-capillary cells, as well as of those around the tufts ; partly also to capsular thickening and hyaline or waxy degeneration ; and partly to the thickening and occlusion of arterioles. The tubules show marked changes. Some are included in masses of connective tissue, so that there is compression-atrophy and even total oblit- eration of the lumen. In other instances the intertubular connective tissue constricts the tubules in certain places, so that the lumen is else- where increased. This dilatation is especially prominent in the granules seen on the outer surface of the kidney, and, owing to the damming back of urine in some of the tubules thus obstructed, little cysts are visible to the naked eye here and there. The epithelium lining these tubules shows granular, fatty, or waxy degeneration, and may be either flattened, CHRONIC NEPHRITIS. 987 cuboid, or swollen. The tubes may contain granular or fatty debris and tube-casts. An important change in most cases is the gro-wth of fibrous tissue in the wails of the arteries, causing sclerosis. This aifects the intima (end- arteritis), the media, and adventitia, all of which are thickened by the hyperplasia of connective-tissue elements. The arteries and capillaries are thus mostly occluded by the obliterating endarteritis or by their con- version into masses of connective tissue. Waxy or hyaline degeneration is seen also {vide Arterio-sclerosis). These arterio-capillary changes may in some cases be the primary condition that leads to granular and con- tracted kidneys, and may represent the renal effects of a general arterio- sclerosis or fibrosis. An almost constant accompaniment of chronic, non-exudative, produc- tive nephritis is cardiac hypertrophy. The degree of the latter depends upon the extent of the renal, and also of the general arterial, degener- ation and sclerosis. The whole heart may become so large that the term cor hovinum has been fittingly applied to it. In moderate enlarge- ments the left ventricle only is hypertrophied. Complicating lesions of chronic Bright's disease that may be men- tioned are cerebral hemorrhage, cirrhosis of the liver, pulmonary em- physema, chronic endocarditis, chronic endarteritis, pericarditis, bron- chitis, and gastric catarrh. Ktiology. — The cause of the very slow primary, diffuse degenera- tion, atrophy, and fibroid contraction of the kidneys is sometimes quite obscure, (a) In some cases it would seem to be " only an anticipation of the gradual changes which take place in the organ in extreme old age" (Osier) — the "senile kidney." (h) Heredity undoubtedly plays a part in the causation of certain cases, even to the third or fourth gene- ration, (c) Age mid Sex. — The disease is more common in males than in females, and it usually begins near middle life ; it is seldom manifested symptomatically until about fifty or sixty years of age, and is therefore an affection of advanced life, (d) Individuals having a special tendency to sclerotic degeneration of the arteries, from whatever injurious influ- ence, are more liable to chronic interstitial nephritis, although the pro- longed irritation of deleterious (especially chemico-toxic) agents may give rise to the disease in those whose cellular nutrition is usually not defective. Thus, the disease has been attributed to the following causes : alcoholism, uric acid, and lead, giving rise to chronic poisoning. Chronic syphilis and chronic malaria probably are also causative factors, {e) Habitual overeating and drinking, owing to the imperfect metabolism of the substances ingested, cause a constant excretion of irritating prod- ucts by the kidney, and no doubt frequently cause granular atrophy and sclerosis of th'e organ. The continuous and even moderate use of alcohol for many years, especially of spirituous liquors, is a widespread cause of the disease. It is equally likely that the excessive use of red meats in the diet leads to the production of the uric acid that induces the renal disorder {tiricemia ; litliemia). by deranging the function of the liver (Murchison). (/) Allied to the above is gout, which causes chronic Bright's disease — in England perhaps more than in this country, lithemia and nervous dyspepsia being more common there. [g) According to Strlimpell, severe acute articular rheumatism is some- 988 DISEASES OF THE URINARY SYSTEM times followed by contracted kidney, {h) Chronic Bright's disease with renal sclerosis is favored in origin and development by the anxieties, worries, and high nervous tension connected with modern business ac- tivity and "social functions," the latter particularly acting their part among elderly ladies. Associated with these are usually over-indul- gence in rich foods and Avines, and sedentary habits, {i) The cold, moist climate of New England and the Middle States would seem, ac- cording to Purdy, to predispose to contracted kidney. A chronic pro- ductive nephritis without exudation, though not the true " contracted and red granular " kidney, may be caused by hydronephrosis, chronic pyelitis, and chronic congestion of the kidney, as from heart-disease. Sjrmptoms. — These may be latent for years, while the morbid pro- ductive changes in the kidneys are slowly eifected. The first symptoms may not appear until late in life, although the kidneys may be in an advanced stage of degeneration. Or some complicating or intercurrent aflfection may set in, as pneumonia or pericarditis, and cause the de- velopment of grave or fatal renal symptoms. More commonly, how- ever, there is an attack of uremia, with headache, stupor, or convulsions, dyspnea, nausea and vomiting, and a tense pulse. This attack may be recovered from. Then there is an interval of variable duration, during which the health is more or less impaired, and lassitude, drowsiness, disordered digestion, headache, failing vision, dyspnea, and frequent micturition are complained of. This is followed by another uremic attack, severer than the first, or perhaps fatal ; if not fatal, the general health is still more reduced, and confinement to the house or bed is necessary, until the vital forces can no longer compensate for the destruc- tion of the renal parenchyma. Spasmodic dyspnea (uremic ; cardiac) is sometimes the first manifes- tation of contracted kidney. The gradual onset of periods of uncon- trollable drowsiness during the day is often marked. An attack of hemiplegia may also be the first indication of renal disease. Sometimes progressive loss of flesh and strength, with a dry, harsh, wrinkled skin, may be from the beginning the only clinical features of the affection until death results from sheer feebleness and emaciation. The complex- ity and variability of the symptoms make it best to describe them under the heads of the various systems : Urinary System. — The daily quantity of urine is usually increased so much that patients are troubled wnth a desire to urinate frequently, not only during the day, but two or three times during the night. This complaint may be aggravated by the hyperacidity of the urine and the irritability of the prostate (especially in advanced age) that are so often associated with cases of renal cirrhosis. The urine voided during the twenty-four hours may measure several quarts (2 to 4 liters) in well- marked cases of the disease. Early in the attack, when the incipient degeneration and destruction of the parenchymatous cells is taking place, the quantity of urine may be slightly decreased ; but as the "blood-flow to the parts that remain must, cceteris paribus, be as great as it would have been to the w^hole of the organs if they had been in- tact," excessive pressure is brought to bear within the capillaries by the compensating hypertrophy of the heart, and the secretion of the urine, especially of the watery elements, becomes more active. The polyuria CHRONIC NEPHRITIS. 989 may give rise to a suspicion of diabetes. The urine is clear and pale- yellow in color, the specific gravity being seldom above 1010 or 1012, and it may be as low as 1002 or 1005. Albumin is found only in traces or it may be absent altogether {glomerular atrophy)., especially in urine voided in the early morning. The urea is diminished, as in all forms of Bright's disease, and there is little or no sediment. A very careful microscopic examination may reveal a feto, usually narroiv., hya- line or granular casts, perhaps some leukocytes, and rarely a few ery- throcytes. In the later stages of the disease or upon the supervention of an uremic exacerbation or of a complicating inflammation the urine may be decreased, the albumin increased, and numerous casts be discovered in a more apparent urinary sediment. Hematuria is rare. Circulatory System. — The physical signs of cardiac hypertrophy are present. Symptoms referable to the heart are absent, unless dilatation and feebleness, sudden arterial contraction, cardiac complications, or endocarditis occur. Inspection and palpation of the hypertrophied heart show an apex-beat displaced downward and to the left, and an increased, heaving, and rather circumscribed apical impulse. These signs may be less evident both in cases of coexisting emphysema and later when dila- tation may eclipse the hypertrophy. The left border of the deep cardiac dulness extends outside the nipple-line in the fifth or sixth interspace. The first sound of the heart is loud and may be duplicated. A dis- tinctive auscultatory sign is the accentuation of the aortic second sound, indicating increased vascular tension ; it may have a metallic quality. In quite a majority of the cases I observe, sooner or later, a mitral sys- tolic murmur ; it is due to relative insufficiency. The pulse is increased in tension, and is hard, incompressible, and persistent, the duration of each pulse-wave being increased ( pulsus tar- dus). The radial artery itself — and this is true of most of the palpable arteries — feels hard, thickened, and often tortuous, on account of the arterio-sclerosis. As soon as compensation of the heart fails, symptoms of breathlessness (especially on exertion), palpitation, and the like, ap- near, and sometimes in paroxysmal attacks (" cardiac asthma "). The resultant stasis gives rise to transudation into the lungs (bronchorrhea ; pulmonary edema), and later to edema of the extremities. Respiratory System. — Epistaxis may be a serious symptom. Sudden edema of the larynx may also occur, and is always grave. Transuda- tions into the pleural sac (hydrothorax), as well as into the lungs {vide supra), may precede death. Dyspnea, which is either cardiac or uremic, is usually worse at night, and a true orthopnea, together with Cheyne-Stokes breathing, may be observed toward the end of the pa- tient's life and in association with uremic stupor and coma. Nervous System. — Symptoms referable to the nervous system are very important, since they are usually indicative of grave uremia. Cephal- algia is frequent, and neuralgic pains throughout the body, and insom- nia, may be complained of. Later great droivsiness is often a premo- nition of uremic coma. Convulsions may be preceded by muscular twitchings, which should attract attention to the imminent danger of the former. Cerebral apoplexy with hemiplegia may be the first symptom of contracted kidney. It is especially apt to occur in cases of marked hardening and weakening of the arteries. There may be 990 DISEASES OF THE URINARY SYSTEM. an hemorrhagic pachymeningitis, as well as a hemorrhage into the brain-substance. The hemiplegia may persist until death ; or it may disappear in a short time, and be followed by subsequent attacks at in- tervals. Formication^ numbness^ and pallor of one or more fingers (the so-called "dead finger") I believe with Dieulafoy to be sometimes the earliest symptoms of chronic Bright's disease. Of the special senses, nephritic retinitis is often the earliest evidence of chronic Bright's disease. The patient may or may not have had slight dimness of vision (mistiness) prior to the ophthalmoscopic exami- nation. The loss of vision affects both eyes, and is usually partial {(tni- hlyopia). Sudden and complete blindness may come on in grave cases — uremic amaurosis — the condition being due to neuro-retinitis. The optic papilla is swollen, and surrounded by retinal hemorrhages or by white dots and streaks ('' feather-splashes "). Tinnitus aurium, deafness, and vertigo are not uncommon. Digestive System. — Anorexia, nausea, and annoying dyspepsia are often complained of. Severe vomiting may usher in an uremic attack. Catarrhal gastritis may exist for some time, the tongue being coated and the breath heavy and urinous. Uremic diarrhea may also occur. The Skin. — Edema is usually absent in renal sclerosis ; when it does occur, however (as in the ankles and limbs), it is due to dilatation and failure of the heart. The skin is dry, and minute lustrous scales of urea may be seen around some of the pores. A certain degree of pallor is noticed, and often the skin has a cyanotic tinge. Pruritus and trouble- some eczema are frequently present, and muscular cramps, occurring especially in the calves of the legs and at night, may also be associated. The general nutrition gradually fails, so that in advanced cases the debility and emaciation are extreme. It is important to bear in mind the fact that urei/iia may come on at any time during the course of the disease, and that it may be the first symptomatic manifestation ; also that it may either be sudden and severe in its onset (acute uremia) or mild, insidious, and gradual (chronic uremia). Moderate fever may attend an uremic attack, or the tempera- ture may be normal ; in chronic uremia, with prostration, coma, delir- ium, and feeble pulse, it may be even subnormal. Among the complications that may occur in the red, granular, and contracted kidney are the following : pneumonia, either lobar or lobu- lar ; pleuritis, pericarditis, laryngitis, bronchitis, gastritis, enteritis, peritonitis, meningitis, endocarditis, emphysema, phthisis, and hepatic cirrhosis. Diagnosis. — This depends in great part upon the physical, chemi- cal, and histologic examination of the urine. Both the morning and evening urine should be examined repeatedly for albumin and casts, since one examination — and especially that of the morning urine — may give negative results, owing both to the scarcity of these two pathologic elements and to the fact that albumin may be altogether absent in some instances. The mere discovery of a trace of albumin or of a few casts is not always positive evidence of chronic Brights disease, as both may exist in other conditions. But the age, habits, and symp- toms of the patient must be studied in connection with frequent urinary examinations ; and a persistent slight albuminuria, with casts, and the CHRONIC NEPHRITIS. 991 passage daily of large quantities of clear, pale urine of low specific gravity, afford sufficient grounds for making the diagnosis. Contracted kidney should be suspected in all cases in which, during middle life, either one or more of the following symptoms and signs may be noticed : frequent headache, congestive disorders, repeated epistaxis, vertigo, dimness of vision, intractable conjunctival irritation (Alle- man), impaired strength, dyspneic attacks, gastro-intestinal dyspep- sia, noises in the ear, itching of the skin, cramps in the calves, mus- cular twitchings, growing mental dulness, increasing pulse-tension, and rigidity and tortuosity of the temporal and radial arteries. Sud- den coma, convulsions, amaurosis, apoplexy, vomiting, or dyspnea in persons in the middle period of life, Avith or Avithout a history of poly- uria, should create the suspicion of chronic Bright's disease. It will be found in such cases that there has been a diminution in the urinary flow before the attack. Persons of lithemic, gouty, rheumatic, or alcoholic habits, or in whom lead-toxemia is discoverable, with evidences of car- diac hypertrophy, an accentuated aortic second sound, and a hard pulse, are often readily diagnosed as subjects of contracted kidney when a fur- ther examination of the urine is made. The diagnosis may be very difficult, however, in cases in which the first examination of the patient is made during a sudden uremic or apo- plectic attack. Catheterization should be done if necessary, and the detection of albuminuria will then clear the diagnosis. In order to differentiate between primary renal affection with second- ary cardiac hypertrophy and primary heart-disease with a secondary con- gested liidney occurring late in the case, the general features, course, symptoms, and signs must be carefully and judiciously balanced. Prom- inent cardio-vascular changes Avould indicate an arterio-sclerotic kidney, rather than the primary granular and contracted kidney of toxic origin, though even here the diagnosis is often quite difficult. The symptoms of ordinary non-inflammatory senile kidney may not be unlike those of chronic interstitial nephritis, though not so severe; and yet, from excessive eating and drinking at times, uremic attacks may supervene to cloud the diagnosis. Prognosis. — The duration of chronic interstitial nephritis varies. In uncomplicated cases it may last for five, ten, twenty, or possibly thirty years. Complications or intercurrent affections may, however, shorten the duration very much, or the existence of the condition may be unknown, as frequently happens, when the postmortem examination shows the char- acteristic kidneys in one who during life had no symptoms indicating renal disease, and whose death was caused by some intercurrent disease. The gradual destruction of the renal parenchyma and its replacement by scar-tissue cause irreparable damage to the organs. On the other hand, the fact that the process is usually a slow one and its duration long is compatible with the preservation of life for many years, and with comparative comfort, even, in many instances. The prognosis in a given case depends very much upon the general constitutional condition, the cardio-vascular state, and the presence or absence of uremia and inflam- matory complications. Cardiac dilatation and insufficiency indicate a not far distant end. Convulsive and apoplectic seizures are often fatal, and hemorrhages, persistent vomiting, and diarrhea, retinitis ncpliritica. 992 DISEASES OF THE URINARY SYSTEM. coma, and delirium render the prognosis as to further systemic toler- ance of the degenerated kidneys exceedingly grave. Treatment. — An early recognition of the disease and the steadfast practice of careful hygienic measures will prevent, to a considerable degree, the advance of the cirrhotic changes. Noxious substances enter- ing into the etiology of the affection must be avoided and removed as far as possible. The formation of uric acid must be reduced by dietetic management, alcoholics must be interdicted, and lead — Avhen the cause of the condition — must be kept from further poisoning the system by a change of occupation. By diminishing these irritants the heart and blood-vessels are also conserved — a point of vital importance. The hygienic treatment must embrace a regulation of all the habits of body and modes of life. The patient must be treated, and not his malady, since that is incurable. A dietary that is suitable for each in- dividual case must be made out, and on general principles. Saundby's rule is a good guide : " Eat very sparingly of butcher's meat ; avoid malt liquors, spirits, and strong wines." An exclusive milk diet may be necessary for short periods when gastric irritation is present, but in such a chronic disease undue weakness would result from a restriction to milk alone. I would therefore recommend a light nourishing diet, including lean meat once daily in favorable cases. Vege- tables, greens, fruits, and light, well-cooked farinaceous articles may also be partaken of, and tea, Coffee, and cocoa may be drunk. The use of natural mineral waters aids in the renal circulation and keeps the kidneys flushed. In general a mixed diet will be of advantage ; the nitrogenous and carbohydrate elements (sugars and starches) are used in limited amounts, Avhile pure fats and fruits (raw or cooked) are to be recommended. Stout persons and those leading sedentary lives should have less food than those taking exercise, and gastric disorder requires the elimination of all but soft, bland foods, or a liquid diet until diges- tion is restored. Extremes of bodily, mental, and emotional activity should be avoided, and physical exercise should be moderate, regular, and taken in the open air, provided the latter be warm and dry. Men- tal labor should never be excessive, nor should the patient be subjected to the vicissitudes of worry, anxiety, or competitive tension. A enereal excitement and indulgence of any kind tending to unbalance the self- control or disturb the equanimity, cheerfulness, and contentment should be strictly forbidden and guarded against. A change of residence to a warm, mild, and dry climate is often of service in prolonging life. The variability and humidity of temperate climates, particularly during the winter months, aggravate this disease, Avhile a sea-voyage or a sojourn at some southern European resort may be very beneficial to one who can afford it. The indications for medicinal treatment are principally as follows : The bowels should be kept free by the aid of laxatives or laxative alka- line mineral waters. Papoid, peptenzyme, and other digestants, with bitter tonics, are useful in some cases in which a furred tongue and indi- gestion are troublesome. Acids or alkalies, according to special indica- tions, may also be used simultaneously. An increased vascular tension (vaso-constriction), such as to place a serious strain upon the heart ; the other extreme, of a very low tension that induces dropsy ; and compli- PYELITIS. 993 cations, usually uremic (convulsions, dyspnea, headache), also call for therapeutic assistance. High tension is to be met by the cautious use of nitroglycerin in gradually ascending doses, beginning Avith 1 minim (0.066) three or four times daily, until all danger of rupture of the ves- sels seems to be past. Headache, vertigo, and the so-called renal asth- ma (dyspnea) are also often relieved by this drug. Low tension, with signs of cardiac dilatation, scanty albuminous urine, and edema, requires heart-tonics and stimulants, in conjunction with purgatives. Digitalis (preferably in infusion) has good effects, especially when combined with strj^chnin nitrate or with caffein citrate. Calomel and the salines should be given for the dropsy. Uremic symptoms should be treated as in acute Bright's disease by causing profuse sweating and free catharsis, and in some cases by phle- botomy. Inhalation of amyl nitrite or chloroform, or, what is often a useful and necessary measure, the hypodermic injection of morphin (gr. ^0.0108), may be tried in convulsions, severe headache, or dyspnea. Contracted kidney of a probable malarial or syphilitic origin may be benefited somewhat by the use of arsenic and the iodids respectively ; but no drugs can possibly restore the destroyed renal parenchyma or transform connective-tissue cells into secreting kidney-cells. PYELITIS. {Pyelonephritis ; Pi/onephrosis.) Definition. — Inflammation of the pelvis of the kidney. The com- pound terms above (in italics) represent an inflammation of the kidney- structure as a result of, and combined with, pyelitis. Pathology. — In the mildest varieties of pyelitis (the catarrhal) the morbid changes consist simply of a reddened, swollen, and turbid mucous membrane, covered with an exudation of viscid muco-pus and desqua- mated epithelium. Ecchymoses are sometimes seen. The urine in the pelvis of the kidney is also turbid from the admixed pus-corpuscles and pelvic epithelium. In calculous pyelitis, owing to prolonged and severe irritation, purulent inflammation and ulceration prevail, and the kidney- structure is also involved by extension (pyelonephritis). Renal ab- scesses are thus formed, and small dark calculi are frequently found mingled with the pus in quite a number of small abscess-cavities ; or perhaps, as noted before (vide Nephrolithiasis), one large abscess-cavity may replace the destroyed renal parenchyma {ijyonephrosis). A diphtheritic inflammation, with the formation of a false membrane and sloughing of the pelvis, sometimes follows the severe infections of the specific fevers. Marked hemorrhagic areas may be seen also. In tuberculous pyelitis there is usualty an association of nephritis with areas of tuberculous softening and ulceration, and later pyonephrosis. In very chronic and sluggish cases the pyelitis may be followed bv an infiltration of the kidney-structure with cheesy or putty-like masses that may become the seat of calcification. Persistent obstruction leading to pyelitis is associated with dilatation 6.3 994 DISEASES OF THE URINARY SYSTEM. of the pelvis from retention of urine or of pus (pyonephrosis). This in turn, from prolonged pressure, causes the marked atrophy of the secret- ing structure of the kidney that is seen in such cases. There is also an increase in the interstitial tissue and secondary contraction. The so-called surgical kidney/ is found ■when an acute bilateral pye- litis, folloAving a severe cystitis, has excited an acute suppurative in- flammation of the kidney. Acute suppurative or interstitial inflamma- tion of the kidney due to metastatic or miliary abscesses is considered under the heading Pyemia (vide p. 199). l^tiology. — Pyelitis rarely is primary or independent in origin, as after exposure to cold and wet. The secondary causes of pyelitis are as follows : (1) renal calculi (the most frequent) ; (2) extension upward of urethritis, cystitis, or ureteritis, particularly when gonorrheal in origin ; (3) retention of decomposed urine in the pelvis of the kidney ; (4) renal aff"ections, as tubercle, carcinoma, and acute nephritis ; (5) specific fevers ; (6) foreign bodies, other than stone in the pel- vis ; (7) irritating diuretics. To point out briefly certain additional facts bearing upon the causation of pyelitis in the order named, it should be mentioned that calculous pyelitis may result from the irrita- tion of the constant presence and passage of small stones ("gravel "), or even of uric-acid "sand," as well as from the large dendritic concre- tions that send off"shoots into the calyces. Extensions of inflammation to the pelvis from lower portions of the urinary tract may occur in pro- tracted cases of such aff'ections as gonorrheal urethritis aud puerperal and calculous cystitis. Obstructive pyelitis sometimes follows the im- paction of renal calculi or of other foreign bodies in the ureter when there is pre-existing inflammation of the tract, or when, as usually hap- pens, there is chemical irritation from the decomposition of the accumu- lated urine. There may be obstruction in the bladder aud urethra, as from enlarged prostatic tumors, stricture, phimosis, and paralysis of the sphincter vesicae, or as in paraplegia. Under the consideration of tuber- culosis and carcinoma of the kidney is included the involvement of the pelvis by these conditions. Infectious pyelitis may also result from small-pox, diphtheria, typhus and typhoid fevers, and scarlatina, and it depends upon the irritating effect of certain substances eliminated by the kidneys. It is usually associated with more or less nephritis (pyelo- nephritis). Parasites, such as the echinococcus (hydatids), distoma, strongylus, and filaria, may give rise to pyelitis. Cantharides, cubebs, copaiba, turpentine, and diabetic urine even, may in rare instances also excite a pyelitis. Symptoms. — These are frequently overshadowed by those of the primary condition that causes the pyelitis : they are varied also for the same reason. The clinical manifestations of a simple catarrhal pyelitis are slight pain and tenderness in the region of the aff"ected kidney or kidneys, mild fever, with a turbid urine of acid reaction, showing a few pus-cells, a little mucus, rarely some red blood-corpuscles, and a trace of albumin. In the severer varieties, as in calculous pyelitis, especially when there are attacks of renal colic, the urine frequently shows to the naked eye the presence of blood and a marked amount of pus, some mucus, and the transitional caudate epithelial cells from the middle layers PYELITIS. 995 of the mucosa. The presence of the latter, however, is not constant, hence its absence does not exclude the existence of a pyelitis, since some of the most destructive forms of the aifection, as the acute or chronic suppurative or the pyelonephritic, may be unaccompanied by the presence of the pelvic epithelium in the urine. This holds still more true in the case of true pyonephrosis, in which the kidney usually be- comes one large abscess. In severe pyelitis the pain is often acute, coursing down the ureters. The fever is moderate, and there are present the common symptoms de- scribed under Nephrolithiasis (vide p. 970). The fever in purulent pyelitis (pyonephrosis) and pyelonephritis takes on a hectic or typhoid type. Paroxysms of rigors or chills, fol- lowed by a rapid rise in temperature and ending in perspiration, may be observed ; or there may be marked prostration and feebleness of circulation, delirium, and stupor. The temperature-curve runs an irregular course, with marked remissions, in cases having a pyemic nature. In obstructive pyelitis the urine sometimes flows freely and nor- mally for a while, until the developing pain over the inflamed kidney ends in relief by the expulsion of the obstacle and the passage of puru- lent urine. This alternation of normal with pyoid urine is indicative of a unilateral pyelitis. Ammoniacal urine is met with in cysto-pyelitis. Albuminuria is de- cidedly shown according to the degree of pyuria. In chronic suppurative pyelitis or pyelonephritis the pyuria is vari- able both in quantity and constancy. Intermitteyit pyuria may be due to the temporary blocking of the ureter by a stone {vide Obstructive Pyelitis). The pus is seldom mixed with epithelium in chronic purulent pyelitis. The associated intermittent fever may be like that of tubercu- lous pyelitis, and marked prostration, anemia, and emaciation are con- comitants. Evidences of amyloid change may be revealed in long-stand- ing, chronic cases. The term ammoniemia has been applied to that complexus of nervous symptoms that is supposed to arise from the decomposition and absorption of urinary substances. These symptoms may be similar to the manifesta- tions of diabetic coma. Distinct enlargement and fluctuation of the diseased kidney may be determined in some cases of pyonephrosis. This may also be inter- mittent, being detectable while there is obstruction to the flow of pus, and vice versd. According to A. H. Smith, at the menstrual periods pyelitis may be subject to marked exacerbations, simulating renal colic. In chronic pyelitis with atrophy of the kidney the onset of uremia may terminate the case. Granular kidney alone may have been simulated by the passage of an increased quantity of urine of proportionately low specific gravity. Diagnosis. — This embraces the discrimination from other afiections, and the possible detection of the variety — etiologically considered — of the pyelitis. It is most important to pay attention to the clinical history of any case with a view to the discovery of the cause ; also the urinary con- dition must be carefully studied. In the very nature of this affection it 996 DISEASES OF THE UEINAEY SYSTEM. is often impossible to exclude other affections of the urinary tract, as nephritis, cystitis, and urethritis. Epithelium from the pelvis of the kidney cannot be distinguished from transitional bladder-cells ; but, given the indications of a pyelitis, its cal- culous cause is at once made clear upon the passage of the characteristic uratic or oxalatic concretions. It may happen that the urine from one kidney is prevented from flowing by the impaction of a stone in the ureter. The urine may now flow clear from the other and vicariously acting kidney until, -the stone having given way, it suddenly increases in quantity and changes in character, owing to the return of the m.or- phologic elements of the pyelitis (corpuscles, desquamated epithelium, crystals, and debris). In women catheterization of the ureters and renal pelves, as described and practised by Pawlik and Kelly, is a most certain method of deter- mining in doubtful cases from which side the purulent urine arises. Pal- pation of the ureters through the lateral and anterior foi'nix of the vagina will sometimes reveal thickening and tenderness in cysto-pyelitis, and ureteral distention sometimes may be felt in pyelitis calculosa. Vierordt mentions having seen in some cases of pyelo-nephritis pecu- liar hyaline casts ''split like a pair of trousers." Casts and albumin are usually present when the kidney-structure is involved by extension of the pyelitis, while marked pain in the region of the kidney indicates predom- inant pyelitis, though it does not exclude the possibility of coexisting nephritis. Marked vesical irritability points to associated cystitis, but in intense p3^elitis with much pus and an acid urine vesical tenesmus may also be troublesome. Tuberculous can be discriminated from calculous pyelitis by finding tubercle bacilli in the pus. The presence of a fluc- tuating tumor in the lumbar region is significant enough of pus ; but it may be difiicult to determine whether it is due to pyonephrosis or peri- nephric abscess, although pyuria and the previous history of pyelitis, as w ell as the more circumscribed and less edematous character of the swell- ing of the former, are important distinguishing points. Differential Diagnosis. — The hemorrhagic pi/elitis of Senator, Dela- field, and others, described as occurring in milder forms, and particu- larlv in girls of neurotic types, may be distinguished by the intermit- tent hematuria and the occasional lumbar pain, lasting but a few days or a week, and followed uniformly by recovery. Digestive disturbances may be prominent in these cases. Difiiculty is sometimes experienced in diagnosticating pyelitis Avhen coexistent Avith cystitis — 2:)yelo-ciistitis. These aff"ections will not be con- founded, however, when it is recollected that their histories diS"er. There is pain in one lumbar region in the former, and in the bladder in the latter. According to Rosenfeld, (1) an alkaline reaction is not found in uncomplicated pyelitis ; (2) the limit of albumin in the urine, even with severest cystitis, is 0.1 per cent, (maximum, 0.15) ; (3) if the pus- corpuscles are crenated, and, in the absence of vesical tumor, if the red corpuscles of a microscopic hemorrhage are chemically or morphologically decomposed, pyelitis exists, and especially if non-imbricated, small epi- thelial cells are practically absent. Stress is laid upon the relation of the albumin-content, which is from two to three times greater with pye- litis than Avith cystitis. HYDRONEPHROSIS. 997 Progfnosis. — Renal complications always make the pyelitis a serious affection. Catarrhal cases recover. Calculous pyelitis tends toward chronicity. Pyelo-nephritis and pyonephrosis are apt to end fatally from exhaustion or uremia. Perforation and the discharge of pus into the peri- toneal cavity, pleural sac, intestine, and bronchi even, may precede death. The gravity of all cases of pyelitis depends upon the causes and upon the tendency to consecutive suppuration. Treatment. — This varies according to the cause : the latter needs to be removed, its effects counteracted, and its return avoided. The treatment of calculous pyelitis is essentially the treatment of nephro- lithiasis. Primary inflammation of the lower portions of the urinary tract must be combated ; causes of retention of decomposed urine, as an urethral stricture or enlarged prostate, must be diminished ; infectious fevers must be judiciously handled and irritating diuretics withheld. Local measures are of value in all forms of pyelitis. Hot-water bags, fomentations, poultices, and dry cupping are often of great service. Internally, the use of diluents is to be recommended, especially the alkaline mineral waters, flaxseed tea, barley-water, skimmed and butter- milk, and lemonade. Potassium citrate, uva ursi, buchu, and pareira brava are some- times selected for their soothing properties. But, practically, none of the remedies named nor any other drug is of any avail when suppu- ration is once established. Irrigation by means of Kelly's ureteral catheter may be practised with good results in females. Hypodermo- clysis of normal salt-solution may be of sustaining value at critical times in cases of infectious pyelonephritis. In chronic pyelitis salol and the oils of turpentine, sandalwood, juniper, copaiba, and erigeron have been used for their stimulating and alterative effects upon the mucous membrane. Surgical intervention is necessary in severe puru- lent pyelitis, pyelonephritis, and pyonephrosis. HYDRONEPHROSIS. Definition. — An obstructive accumulation of urinary fluid in the pelvis and calyces of the kidney ; it may cause dilatation, pyelitis, or inflammation and atrophy of the renal structure. Pathology. — Hydronephrosis is usually unilateral. The pathologic changes consist of a dilatation of the pelvis of the kidney, associated with a degree of atrophy of the renal tissue depending upon the degree and persistence of the pressure. The accumulated fluid causes flatten- ing and atrophy of the papillae, and gradually of the tubules and glom- eruli, as the dilatation and distention increase, until in extreme cases remnants only of the renal structure remain in the walls of the hydro- nephrotic cyst. The mucous membrane lining the pelvis and calyces first becomes thinned, and later thickened, by the growth of connective tissue, thus forming the dense sac-wall. There is also a growth of con- nective tissue in the renal parenchyma, medullary and cortical, a chronic nephritis with degeneration and atrophy of the renal cells being set up. A nephrydrotic cyst ma}^ be very large, containing as much as several 998 DISEASES OE THE URINARY SYSTEM. gallons of liquid. Sometimes in medium-sized sacs the external appear- ance of the walls may be lobulated ; the interior, however, usually shows only partial septa projecting from the wall into the cavity of the sac. The smaller sacs partially enclosed by the membranous septa probably represent the dilated calyces. According to the seat of obstruction one or both ureters may also be dilated. If one kidney is affected, its fellow is often hypertrophied. The fluid contained in the sac varies in composition, but usually is a clear, thin, yellowish, watery urine. The specific gravity is low, and the reaction is often slightly alkaline. Traces of albumin, urea, uric acid, and salts are found. Turbidity may be present, owing to admix- ture with pus, blood, or epithelium, but only in instances in which pre- vious inflammatory conditions, as a calculous pyelitis, or subsequent complications of like nature have existed. Ktiology. — Hydronephrosis — or, better, nephrydrods — is in most instances secondarily produced by diseases — congenital or acquired — that cause occlusion of the ureter. Probably from 20 to 35 per cent, of cases are congenital (Roberts). In these cases the causal condition is one of stricture, due to obstruction caused by a defective development or malformation in the urinary passage of one or both sides, usually the latter. Thus, there may be a valve-like formation or a very acute in- sertion of the ureter into the kidney. The dilatation has occasionally become so great in the fetus as to cause considerable mechanical diffi- culty during labor. Among adults, women are more often subject to hydronephrosis than men, and especially women who have borne children. The condition may be bilateral, as from a stricture low down and due to gonorrheal urethritis, but more often it is unilateral. The causes of these acquired cases are as follows : (1) Impacted calculi in the ureter or renal pelvis. (2) Disease of the ureteral walls, as inflammatory thickening and cica- tricial stenosis from ulcers. (3) Flexion and twisting of the ureter, as from movable kidney. (4) Pressure upon the ureter from without, as by tumors and constricting bands (pelvic adhesions). The gravid and retrodisplaced uterus, uterine and ovarian neoplasms, enlarged and pro- lapsed spleen, and similar conditions causing compression or traction and obliteration of the lumen of the ureter, are found in this class. (5) Diseases and tumors of the bladder that involve the ureteral orifices, particularly carcinoma, or that cause retention, as prostatic enlargement. (6) Urethral stricture. Symptoms. — These depend somewhat upon the cause and extent of the hydronephrosis. Marked bilateral disease, when congenital, may render the fetus inviable. The unilateral variety may be overlooked for years, and no symptoms may point to the trouble until a tumor can be made out by inspection and palpation, or until the ureter of the re- maining kidney may become obstructed and symptoms of uremia super- vene. The latter are more apt to come on, and earlier too, in double hydronephrosis. Locally, the patient may complain of frequent and severe fains that shoot about the aff"ected loin and downward toward the thigh. Sensa- tions of weight and a dragging discomfort are common. Anorexia, nausea and vomiting, eructations, and irregularity of bowel-action are HYDRONEPHROSIS. 999 associated sometimes. In large hydronephrotic cysts a continuous dull, aching pain only may be felt, or, as is not infrequently the case, the tumor may be absolutely painless. Obstinate constipation may result from compression of the colon, or in moderate enlargements diarrhea may occur from the pressure-irritation. Usually a swelling is detected in the region of the affected kidney. It gradually increases in size, and in marked enlargements distinct bulging may be visible in the hypochondriac and lumbar regions. Pal- pation reveals a rounded, firm, yet somewhat elastic and sometimes fluc- tuating tumor. There may be slight tenderness. Dulness on percussion is found over the mass, except where the colon overlies it, when tym- pany is elicited ; this is a characteristic sign of kidney-tumors. Mod- erate enlargements generally do not descend during inspiration. There may, however, be exceptions to this rule. The intermittent form of hydronephrosis (Landau) is interesting from the variations that occur in the size of the tumors. A marked diminu- tio7i is coincident ivith a more or less sudden increase in the quayitity of urine passed ; and, on the other hand, as the tumor gradually enlarges the flow' of urine decreases. These cases are in most instances due to movable kidney. Colicky pains often usher in the periods of greatest distention preceding the sudden increase in the flow of clear urine. This variety of the affection occurs most frequently in women that have borne children. The general symptoms scarcely amount to more than a certain loss of flesh incident to the associated worry and anxiety. The filling of the nephrydrotic cyst, the distention, and the pain and discharge, with subsidence of the tumor, recur with variable frequency. According to Osier : " Among the circumstances liable to cause them are sudden and violent exercise, the jarring and jolting of riding and driving, any fatigue, mental emotions, and errors in diet." The tumor may continue to develop in size for several days after the pain has dis- appeared. The latter may last from several hours to a day. During the intervals, and after the urine has increased in quantity, gradually or quickly, the patient feels tolerably comfortable, and this sometimes for weeks or months. For obvious reasons the tumor is rather mobile in intermittent hydronephrosis. The occurrence of chills, fever, and sweats, nausea and vomiting, abdominal distention, and rapid pulse usually indicates suppuration, and pyonephrosis may be the consequence. The urine will then be cloudy and reveal pus, following both discharge and aspiration. A lowered specific gravity and the presence of albumin will be noted when a chronic nephritis has been set up. Increased arterial tension and symp- toms of acute febrile or chronic afebrile uremia may be added. Hydronephrosis paraplegica is a form of the disease in which para- plegia develops as a complication. The course of nephrydrosis is usually chronic, with variations and exacerbations depending upon the cause of the aff"ection. Diagnosis. — This is obviously very difficult in cases in which the accumulation of liquid is small. Characteristic signs are the gradual development of a tumor in either flank, as described above, with dimi- nution in the urinary flow, followed by a more or less sudden free dis- charge and the subsidence of the tumor, with recurrences (as in the in- 1000 DISEASES OF THE URINARY SYSTEM. termittent variety). When these do not occur and the tumor continu- ously enlarges, aspiration may be practised to determine whether the mass is solid or liquid ; the nature of the latter may also thus be ascer- tained, whether urinary or not. Ureteral catheterization will determine which is the dry side. The history of the case and the detection of some causative occlusion will point to the diagnosis. Differential Diagnosis. — The nephrydrotic sac must be distinguished by exclusion from an ovarian cyst, cystic kidney, and tumors of the spleen, liver, and gall-bladder. Very large cysts may be mistaken for ascites. Assurance of the presence of the colon over the tumor is diagnostic, and a chemical examination of the fluid obtained by the use of the ex- ploring needle will suffice in most cases. It should be remembered, however, that a slight amount of urea is sometimes found in ovarian cystic fluid. The presence of pus-cells in abundance in the aspirated fluid, with symptoms of suppuration, is significant of pyonephrosis. Prognosis. — This is generally unfavorable, though in unilateral hydronephrosis evidences of compensation on the part of the unafl"ected kidney should render the case guardedly favorable, particularly if the cause be a movable kidney. The bilateral afi"ection is always grave, owing to the danger of uremia. Infection of the cyst with pus-organ- isms is usually a fatal complication. Recovery may ensue in rare in- stances in which a spontaneous discharge of the liquid takes place. Eup- ture of the sac is unlikely. Treatment. — Tlie removal of the cause is seldom feasible. Symp- tomatic treatment only is required in mild cases, though sometimes gen- tle massage over the sac, properly directed and cautiously applied (to avoid rupture), may cause a reduction in the size of the tumor. Most often surgical measures only are of use. These embrace puncture and aspiration, incision (nephrotomy) and drainage, nephrorrhaphy, ne- phrectomy, and the formation of a renal fistula. These procedures, how- ever, are undertaken only when successive reaccumulations of the fluid follow those measures first mentioned. PERINEPHRIC ABSCESS. ( Perinephritis.) Definition. — Suppurative inflammation of the connective tissue surrounding the kidney. Pathology. — The suppuration attacks the lax adipose tissue or the fatty capsule in which the kidney is imbedded and the adjacent retroperitoneal tissue. The starting-point of suppuration is usually be- hind the kidney. There may be several small abscesses at first, but more often a single large abscess is found. The walls may be soft and shreddy, or in more chronic cases thickened and fibrous. A bulging externally over the aff'ected lumbar region is not infrequent, particularly in larore and extensive accumulations of pus. The latter has a tendency PERINEPHRIC ABSCESS. 1001 at a given point to burrow into the surrounding tissues, and especially downward toward the iliac fossa, pointing in the groin near Poupart's ligament. It may extend backward and open upon the skin-surface. Sometimes the pus perforates the diaphragm and discharges through the pleural cavity and lungs, or the colon, vagina, bladder, or peritoneum may be perforated. The pus is occasionally quite offensive, and may be ichorous from an admixture of infiltrated urine. Perirenal abscess due to calculous pyonephrosis may contain calculi that have ulcerated through pelvic or renal walls. Thickening of the adjacent peri- toneum is often found. In certain cases of perinephritis, which usually gave no symptoms during life, the 'postmortem, examination has revealed fibrous adhesions and a firm and thickened and fatty capsule, stripped with difficulty from the true capsule of the kidney. Ktiology. — Perirenal abscesses, when not traumatic in origin, de- velop most frequently as a result of purulent pyelo-nephritis or pyo- nephrosis. Hence they are usually secondary. Other primary condi- tions that may cause perirenal suppuration are the following : extension of inflammation from the ureter or pelvis of the kidney; from a pelvic abscess ; from appendiceal or hepatic abscesses ; and from spinal caries (psoas abscess) and empyema. Sometimes tuberculous processes in the kidney and suppurating new growths, as carcinoma and cysts (includ- ing the echinococcus), are complicated by perirenal abscess. More rarely such severe infectious diseases as typhus fever, small-pox, and pyemia lead to purulent perinephritis. Finally, there are cases for which no cause is discoverable. Symptoms. — Subjectively, there is noted a duU, tlirohhing -pain over the affected region that is increased by motion ; sometimes, when the abscess is large and presses on the large nerve-trunks, the pains may become shooting in character and be felt in the leg on the same side. Numbness may also be felt. Pain and tenderness on palpation are com- mon. The patient is prostrated, weak, and often quite emaciated, and flexure of the thigh on the affected side is frequent. The characteristic fever of suppuration is present in the deeply remitting or intermitting type, with alternating chills and debilitating sweats. Pus is found in the urine only when the kidney is involved. Sooner or later evidences of a tumor are seen ; the areas can be palpated, and a gradual bulging in the lumbar area, increasing slowly, with smoothness and glistening of the skin and pitting (edema), may be observed. Fluctuation is fre- quently apparent in advanced cases, and in favorable cases signs of ''pointing" appear. Diagfnosis. — Should the abscess tend to burrow downward, the condition may be somewhat obscure on account of the absence of dis- tinct local symptoms. Indeed, involvement of the psoas may give rise to symptoms of coxitis, as pain referred to the knee-joint. The diag- nosis is usually easy, and when in doubt as to whether the tumor is an abscess or an hydronephrosis or solid mass, the exploring needle should be used. Differential Diagnosis. — An important point in differentiating peri- nephric abscess from suppurative pyelitis or pyelo-nephritis alone is the fact that in the latter the quantity of urine is usually diminished, whilst in the former there is less apt to be any interference with t^e 1002 DISEASES OF THE URINARY SYSTEM. renal secretion. Again, Avliilst in the latter the urine usually contains blood and pus, in the former the urine is free from blood, though not necessarily from pus, and casts are also absent here. Prognosis. — This is guardedly favorable if the abscess points ex- ternally in the lumbar area. Of course rupture into the peritoneal cavity, bladder, bowel, and groin is ahvays a serious occurrence. The treatment is essentially surgical, and consists in free incision and drainage. CYSTIC KIDNEY. {Renal Cj/st.) Pathology. — Congenital cystic kidneys are in reality collections of cysts, varying in size from a pea to a marble, and separated from each other by septa of compressed renal or fibrous tissue. Either one, or fre- quently both, kidneys may be affected with what is sometimes termed congenital cjiHtic degeneration of the kidnegs. There is considerable en- largement of the organs, and during intra-uterine life they may attain a size so enormous as to render parturition extremely difficult and danger- ous. The fetus is usually non-viable, though in mild cases the affection may be tolerated for some years after birth. The cystic fluid may be either clear or turbid, a reddish-yellow or a dark-brown in color, acid in reaction, and holds in solution urinary salts, blood, cholesterin, and sometimes uric acid and urea. A single layer of flattened epithelial cells lines the cyst-walls. The cysts themselves seem to be dilatations of the renal tubules and of Bowman's capsules, due, in some instances, to an obliteration of the tubules of the papill;^ or to stenosis of some portion of the urinary tract. The cystic kidneys usually met with in adult life (acquired) are of several varieties : (1) One or perhaps a few cysts may be present, larger usually than those in the congenital c^^stic kidney, which seem to cause no interference with the normal renal functions. Sometimes a reddish- broAvn colloid material is contained in these cysts. (2) Small and often quite minute cysts frequently accompany the chronic nephritic kidney that is small, contracted, and cirrhotic. These result from dilated tubules and capsules when the former are narrowed by the hyperplasia of fibrous tissue. (3) Cystic kidneys in adults may have the pathologic characteristics of the congenital variety — a mere conglomeration of cysts containing a clear or colored serum or a cloudy, dark, thick, and colloid liquid. This condition is sometimes associated with similar cystic disease of the liver and spleen. It may be a late manifestation of mild congenital disease. The kidneys have been found converted into cysts in cases in which the presence of calculi (uric acid) in the tubules has probably started the the cystic degeneration. (4) Solitary cystic adenoma occurs rarely. It is in the form of a globular tumor projecting from the surface (usually the anterior) of the kidney. It may be as laroje as an orange, and may be enclosed in a dis- NEW GROWTHS OF THE KIDNEY. 1003 tinct capsule. On section the mass is found to be composed of various- sized cysts separated by septa of fibrous tissue lined with cuboid or columnar epithelium. The remainder of the kidney appears to be quite healthy. Htiology. — Cystic disease of the kidneys is either congenital or acquired. The former is probably commoner than the latter condition, and may persist for a while in extra-uterine life, Avhile the acquired variety may be of unknown origin or secondary to chronic interstitial nephritis or to urinary calculi in the renal tubules. The direct cause of intra-uterine renal cysts is not definitely known, but they are probably developmental rather than pathologic, since other defects of embryonic growth are frequently associated with the disease. Symptoms. — These may be absent in adults until the sudden de- velopment of uremia. Ordinarily, the clinical picture is similar to that of chronic interstitial nephritis. There is an increase in the quantity of urine,, which is of low specific gravity. Slight albuminuria may be present. On palpation a large, rounded, and sponge-like mass may be felt in either hypochondrium or on both sides. Cardiac hypertrophy and increased arterial tension, as in chronic cirrhosis, are also fre- quently met with in cystic degeneration of the kidneys. The diagnosis can only be made upon the presence of the above symptoms and the discovery of the clear physical signs of the tumor. It should be pointed out that a possible complication of perinephric abscess, due to rupture of one or more of the cysts (as has occurred — Osier), would of course render a diagnosis wellnigh impossible. Prognosis. — Bilateral cystic disease of the kidney must eventually prove fatal, owing to the sudden onset of uremia or cardiac failure. Solitary cysts give a tolerably favorable outlook under proper surgical interference. Treatment. — The unilocular cysts just referred to above may be removed, capsule and all, and the kidney sutured. Bilateral disease cannot be operated upon for obvious reasons ; unilateral cystic degen- eration may be treated by nephrectomy, with narrow chances of success. NEW GROWTHS OP THE KIDNEY. The most common tumors of the kidney are those belonging to the class of adenomata (benign) and those that are either sarcomatous or car- cinomatous (malignant). Adenomata may be congenital or acquired. They grow in the cortex of the kidney in the form of small nodular masses, which in some cases may increase to a considerable size before any symptoms are pro- duced. A cystic growth may be combined with adenoma {cystic ade- noma), and lympliadenoma is also occasionally seen as a secondary growth. Other benign tumors that may aff'ect the kidney are angioma, jihrojiia, and lipoma. Very large vascular adenomata may become malignant. Grawitz, Lubarsch, Kelly, and others have described a variety of tumor {Jiy'pernephromd) derived from aberrant adrenal tissue misplaced in the kidney. 1004 DISEASES OF THE URINARY SYSTEM. Sarcoma and carcinoma may be either primary or secondary. Sarcoma is frequently congenital in origin, and may have an admixture of striped muscular tissue. The presence of the latter in the kidney points to developmental disturbances during embryonic life as the cause of a variety of tumor knoAvn as rhabdomyoma. Alveolar sarcoma is also met with. Renal carcinoma is probably of less frequent occurrence than sar- coma ; it may, however, be found in children as well as in aged persons, the two extremes of life. Carcinoma of the kidney is usually of the soft medullary or encephaloid variety. As a primary affection it probably originates in the renal tubules. Both sexes are subject to the disease. Secondary carcinoma of the kidney, although probably more frequent than the primary form, is seldom of clinical importance. Renal carci- noma may occur as a diffuse infiltration or in nodular masses, one kid- ney usually being affected in primary carcinoma. The tumor sometimes reaches an enormous size, and instances are recorded in which nearly the whole abdomen has been filled, and in which the growth weighed as much as 31 lbs. (14 kgms., Roberts). Rhabdomyomata do not, as a rule, attain a very large size, though sarcomata may grow quite large. Softening and hemorrhage within these malignant growths may occur. The pelvis of the kidney may be invaded, and metastatic areas may form in the liver or the lungs, though this occurs in tlie case of primary renal carcinoma less readily than from carcinoma in other organs. Me- tastatic growths arise most likely through involvement of the renal vein. The renal parenchyma is either partially or wholly destroyed, the pyr- amids being attacked later than the cortex. Symptoms. — Lumbar pain on the affected side is often an early symptom, and may persist throughout the course of the disease. It may be paroxysmal, and be felt extending down the thigh, or it may be dull, dracrffing, and limited in character. Pain is not, however, a con- stant symptom in a certain proportion of the cases. Hematuria may occur early or late, and often appears before any tumor is palpable. The blood may be in a fluid state or in clots, the latter not seldom taking the form of pelvic or urethral casts, the passage of which may give rise to colicky pains. Casts of the ureter sometimes resemble lumbricoid worms. The hemorrhage may be excessive and cause marked weakness and a symptomatic anemia, superadded to the cancerous anemia that is usually present ; on the other hand, it may be so slight as to be discoverable only microscopically. It recurs at irreg- ular intervals of days or weeks. Large clots may accumulate in the bladder and cause vesical irritability. The urine from the healthy kid- ney may be quite normal, and may be secured for observation by ureteral catheterization. Cancer-cells or tissue-fragments of the neoplasm very rarely appear in the urine, at least so as to be distinctly recognizable as such. Anorexia, nausea and vomiting, progressive loss of flesh and strength, increasing pallor, and the concomitant symptoms of the can- cerous cachexia are seen to develop. Physical Signs. — These may not be sufficient to reveal the presence of the tumor for some time after the above symptoms have been observed. The appearance of a palpable tumor in either flank is a definite aid to diagnosis. It is felt between the ribs and pelvis latero-anteriorly, and at first, when small and on the right side, it may be movable. Both NEW GROWTHS OF THE KIDNEY. 1005 sarcoma and carcinoma of the kidney may assume enormous sizes. The tumor feels dense and hard (except rapidly-growing tumors, as encepha- loid), either smooth or lobulated, and, when not too large, may retain the natural position and form of the kidney. The growth extends downward and inward, and in the very large malignant renal tumors of childhood the abdomen shows considerable enlargement, along with an abnormal pulsation and a prominence of the veins. Usually the tumor does not move with respiration. Percussion gives dulness over the mass, although in small and moderately large tumors the overlying colon may cause a tympanitic note to be heard. Neighboring organs, as the liver and spleen, may be found by palpation and percussion to be displaced by the renal tumor. Diagnosis. — The presence of a tumor, when not too large and dis- tinctly occupying the lumbar and lower lateral abdominal region, to- gether with hematuria, pain of a local nature, and progressive failure of nutrition, may be looked upon as diagnostic of a malignant type of renal tumor. The relation of the colon to the tumor and immovability of the latter during respiration are also diagnostic. When the tumor is very large and adhesions have formed, as in cancerous kidney, it may be mistaken for other conditions. Differential Diagnosis. — Affections such as hydronephrosis, pyone- phrosis, cystic kidney, hydatids, ovarian, splenic, and hepatic tumors, and (particularly in children) retroperitoneal sarcoma must be differentiated from renal growths. Careful bimanual palpation will aid in the diagno- sis, but the exclusion of other lumbar enlargements must be made by close attention to the history and to the development and course of the symptoms. Hematuria alone, in aged persons, is suggestive of carcinoma when no tangible cause for the presence of the blood is at hand. . Hepatic and splenic tumors are usually movable during deep breathing, whilst renal tumors are not so. In cases of hepatic growths also the area of dulness extends higher, whilst in renal growths on the right side a tym- panitic area generally lies between the liver and the tumor. The cha- racteristic notch and edge of the spleen, and the absence of the overlying colon-tympany, are points that distinguish splenic enlargements from those of the left kidney. Pelvic growths (ovarian and uterine) enlarge from below upAvard, and are readily detected by vaginal examination. In children Lobstein's cancer (retroperitoneal sarcoma), if very large, is easily mistaken for a renal tumor, except that it is usually more cen- trally situated and more firmly fixed. Prognosis and Treatment. — The termination in cases of renal carci- noma is inevitably fatal, and children succumb more quickly than adults. The disease may last from a few months to sometimes a year or two. If the kidney be removed while the groAvth is" still small, the prog- nosis is fairly good ; but if large or if metastatic tumors have formed, the prognosis is always bad. Bloch warmly advocates in some cases the removal of small sections of kidney-substance, to avert the necessity of a nephrectomy by proving the non-malignancy of the growth. The treat- ment^ aside from early surgical measures, is entirely symptomatic and supportive, and obviously it is unsuccessful. Renal colic, excessive hematuria, and a gradually lowered vitality may be met by the use of palliatives, tonics, and by nutritious and easily digestible diet. Nuclein may be tried hypodermically or by the mouth. 1006 DISEASES OF THE URINARY SYSTEM. II. DISEASES OF THE BLADDER. CYSTITIS. Definition. — Inflammation of the mucous membrane of the bladder. It may be either acute or ehro7iic, the latter being clinically the much more frequent condition. ACUTE CYSTITIS. Pathology. — Cystoscopic examination performed according to Paw- lik's or Kelly's method, hereafter to be described, reveals an intensely hyperemic condition of the vesical mucosa, which is puffy, edematous, and of a bright-red color ; this may be more intense at points, especi- ally in the vicinity of the trigone. The membrane is bathed in a thick, tenacious muco-pus, and here and there may be noted denuded areas, and the exfoliated epithelium often hanging in shreds from the bladder- wall ; overlying these denuded patches hemorrhagic effusions may be observed. In the severer grades of the disease the intense general hy- peremia causes a disappearance of the blood-vessels that are to be seen in the normal condition. Occasionally small patches of ulceration, due to abscess-formation {phlegmonous cystitis), may be observed, and in rare and fatal instances the entire bladder-wall is involved in a necrotic process. Ktiology. — Cases of acute cystitis may be grouped according to their origin into four main classes, as follows : (1) Catarrhal. — Like other mucosae, the vesical epithelium is very re- sponsive to systemic circulatory disturbances. Thus, sudden exposure to extremes of cold or heat or violent atmospheric changes, thereby abruptly suppressing the action of the skin, may be potent influences in the etiology of the disease. An intense acute catarrhal inflammation may follow retention of the urine in the bladder, with or without its subsequent decomposition ; it may also be the result of pressure from an enlarged prostate or other tumor, and may follow cystocele, urethral stricture, or paresis of the bladder-wall. In simple over-distention of the bladder, with the accumulation of a gallon (4 liters) or more of urine, the so-called acute exfoliative cystitis may result, in which the entire mucous membrane of the bladder may be shed, and the patient shortly manifest all the symptoms of grave uremic intoxication. The prolonged retention of urine is folloAved by decomposition of the fluid, and this by its irritant action always excites a cystitis that soon assumes the chronic type. (2) Septic. — This may result either from the direct introduction of pus-producing germs into the bladder or from the systemic transmission of these micro-organisms to the organ. This is known as the bac- terial origin of cystitis. Under the first class may be mentioned the passage of a dirty catheter or sound ; this is a cause of cystitis in puerperal women, and in men who are the subjects of minor grades of urethral stricture, and who have been subjected to gradual dilatation by means of bougies. Gonorrheal cystitis is also to be included under this heading. There is a condition known as febrile cystitis, which consti- tutes the second class of septic cases. This comprises the vesical in- ACUTE CYSTITIS. 1007 flammation that is present in the various febrile conditions, and which is probably a direct result of the presence in the urine of the causal bacilli or their toxins (Fitz). Thus, in all of the infectious diseases and fevers (typhoid and the other exanthemata, rheumatism, diphtheria, tuberculosis) there is noted a cystitis of varying degrees of severity that can be accounted for only by the local irritant action of the spe- cific germ of the associated disease, or its eliminating toxins. The so- called gouty cystitis, which is often present in lithemic individuals, and which is due to the irritating and concentrated urine, may also be here included. (3) Toxic. — Certain drugs when introduced into the system manifest an irritant action upon the vesical mucosa, and promptly excite a severe grade of acute cystitis. Prominent among these may be mentioned cantharides and other irritants of the urinary tract- — cubebs, copaiba, and sinapis. Workers in coal-tar dye-stuffs are sometimes affected with acute cystitis. (4) Traumatic. — -Traumatic inflammation of the bladder follows the improper and careless use of the catheter, sound, or other instrument ; the presence in the bladder of calculi or other foreign bodies ; and the pressure of the fetus in parturition, or of large masses of impacted feces. (5) From Adjacent Inflammation. — Irritation with consecutive inflamma- tion may result from the extension of an inflammatory process from sur- rounding structures either by continuity or contiguity of tissue. Thus, a cystitis may follow a urethritis — gonorrheal or otherwise ; it may re- sult from an extension downAvard of a ureteritis, or it may be conse- quent upon a vaginitis, a malignant neoplasm of an adjacent viscus, a salpingitis, pelvic peritonitis, or pelvic abscess in the immediate vicinity of the bladder, as in the vesico-uterine pouch, the inflammation extend- incf bv an involvement of contiguous tissue. Symptoms. — The symptoms of acute cystitis are very marked. Pain., vesical irritability, vesical and rectal tenesmus, frequency of mic^ turition, fever, and urinary changes are all pronounced. Prominent among these is pain, which may be most intense and is the earliest and most persistent manifestation of the disease. Its seat is the suprapubic region, whence it may radiate to the sacral region, the perineum, the end of the penis, or the upper portion of the thighs ; it is most con- stant, but is worst just before micturition, by which it may be alleviated. It is considerably relieved by the recumbent posture, and is aggravated by pressure over the bladder. As the inflammatory process diminishes the pain gradually disappears, and the entire attack may subside in a few days or a week. With the pain, and probably ranking second in severity, is the rec- tal and vesical tenesmus, or strangury. There is an almost constant de- sire to urinate, the patient sitting upon the urinal, it may be, for hours. The urine may be opaque or highly-colored. It is often bloody (in very acute cases the vesical contents may consist of a small quantity of pure blood only), is of a specific gravity varying from 1005 to 1030 (in the febrile cases), and contains pus-corpuscles in abundance, mucous flakes in large quantities, shreds of disintegrated and exfoliated epithelium (blad- der) ; also numerous micro-organisms (streptococci, staphylococci, gono- 1008 DISEASES OF THE URINARY SYSTEM. cocci, proteus vulgaris, bacilli of tuberculosis, and very corumonly the bacillus coli communis) ; fungous mycelial threads and yeast-cells have even been found in certain cases (^mycotic cystitis). Its reaction may be either acid or alkaline ; if alkaline, it contains ammonium urate, amorphous phosphates, and triple phosphates (crystalline) as a rule. More or less albumin will be noted, and on standing a dense sediment forms in the bottom of the flask, composed of all the foregoing substances, as shown by chemical and microscopic examination. The total quantity of urine voided in the twenty- four hours may be normal in amount or even slightly in excess of the normal. On the other hand, if exfoliation of the mucous membrane takes place, there may occur partial or even total suppression of the urine. Fever, Avith or without an initial rigor, persists through- out the attack, but is not of a severe type, save in the septic and ma- lignant (diphtheritic) forms of the disease, when it may reach 103°-105° F. (39.4°-40.5° C). Abscesses may form, and betray themselves by localized pain, ten- derness, and, in some cases, by a circumscribed induration. These may rupture into the bladder, followed by the free escape of pus from the urethra and by relief (temporary as a rule) from urgent symptoms, or they may spread to the peritoneum and induce peritonitis, which, if not promptly treated by surgical measures, may prove fatal by gradual asthenia. In the variety associated with extreme exfoliation of the vesical mucosa grave uremic manifestations follow. These include all the features of the typhoid state (dry, brown tongue, mild delirium, ner- vous and muscular twitching ; headache ; gastric disturbances ; and coma). There is also some degree of malaise and anorexia. It must not be forgotten that acute cystitis may represent an acute exacerbation in the chronic form, and at times may assume a severe type of the disease. Diagnosis. — Cystitis should be readily recognized from the history of the case and the frequency of the two almost pathognomonic symp- toms — suprapubic pain and vesical tenesmus. An examination of the urine will reveal the characteristic clinical features. Cystitis may be confounded with acute nephritis or pi/elo-nephritis, but a careful study of the clinical manifestations and, if need be, the catheterization of the ureters after vesical irrigation, will reveal the true condition. The presence of tube-casts in the urine would indicate renal involvement. The percentage of albumin is usually much larger in nephritis than in irritability of the bladder. The differentiation between cystitis and vesical irritability will be noted under the latter condition. The prognosis of the milder grades of cystitis is good ; the septic and malignant (diphtheritic) cases offer a much graver outlook. Exten- sion of the process upward toward the kidneys is always serious. Treatment. — The treatment of acute cystitis includes prophylactic, hygienic, and medicinal measures. Prophylactic. — Most important is the prevention of the disease, and this includes, in addition to the usual care of the body, the observance of thorough asepsis whenever it becomes obligatory to introduce an instrument (catheter, sound) into the bladder. CHBONIG CYSTITIS. 1009 Hygienic. — The cause of the disease, if evident (calculus, external pressure), should be sought and removed. The patient should at once be placed absolutely at rest in the recumbent posture. The value of this injunction will be most clearly understood when it is stated that in the erect position the intra-vesical pressure is three times that in the dorsal position. The simple observance of this law will do much toward relieving the sufferings of the patient. The diet must be regulated, and all irritating, highly seasoned articles of food must be interdicted. Alcohol in any form is prohibited. If it can be enforced, during the early stages of the disease an absolute milk diet will be most bene- ficial. The patient should be instructed to drink freely of water and other diluent drinks, whereby an internal irrigation of the bladder may be secured and much of the irritating substance removed. The free action of the skin may be secured by friction and warm bathing. Medicinal. — The drugs to be employed are the saline laxatives and the various mild diuretics and urinary alterants. The reaction of the urine will indicate the variety of alterant to be employed. If it be acid, alkaline waters are serviceable, as the soda-preparations, Vichy, or the potassium salts. In alkaline conditions of the urine probably the most valuable drugs are benzoic and boracic acid and salol. Benzoic acid is best administered in the form of ammonium benzoate, which may be given in 10-grain (0.648) doses thrice daily in the compound infusion of buchu, or in uva ursi. Hot applications and hot local bathing (sitz- baths) will do much to relieve the pain and tenesmus ; if these be severe, a rectal suppository of opium and belladonna or an enema of chloral hydrate Avill generally give prompt relief. Tincture of cannabis indica, administered internally, may answer if opium be contraindicated. Under such a course as the preceding a cure may be expected within eight or ten days. It is prudent to advise the patients to wear flannel or silk binders over the abdomen, to avoid chilling of the surface and subse- quent acute attacks. CHRONIC CYSTITIS. Patholo^. — The vesical mucosa is not so hyperemic as in the acute variety, but is of a peculiar muddy or grayish-blue (slate) color, dotted here and there with patches of erosion or of actual ulceration. The muco-pus that bathes its surface is not so apt to be hemorrhagic as in the acute form of the disease, although slight hemorrhages may and do occur. Owing to the slow course and long duration of the disease there follows an immense thickening of the bladder-wall from hyperplasia of its constituents, conjoined with more or less edema of the tissues. The result is a contraction of the wall with a proportionate diminution in the vesical capacity. The mucosa may become, as it were, polypoid in spots, and there may follow obliteration or partial obstruction of the ureteral orifices, with consequent dilatation of the ureters and renal pelves from a damming back of the secretion. The urinary changes are about as in the acute form, save that the reaction is always alkaline and the amount of mucus and pus is proportionately greater. Btiologfy. — Chronic inflammation of the bladder may be the result of a neglected or oft-repeated acute attack. It may occur from the persistent action of an exciting cause, as the presence of some irritating 64 1010 DISEASES OF THE URINARY SYSTEM. substance (calculus) in the bladder, or of some excitant external to that viscus, as a localized inflammation or a displaced uterus. Again, the inflammation of the bladder may be of a chronic nature from the begin- ning ; especially is this true of the tuberculous variety and of that due to neoplasraata of the organ. The symptoms and diagnosis diff"er but slightly from those of acute cystitis. It may, however, be pointed out that the pain and tenes- mus are less intense. Oppositely, the amount of albumin in the urine is comparatively large. The same remark applies to t4ie quantity of mucus and pus {vide Pathology) ; indeed, the last-named ingredient often forms a thick gelatinous mass in the standing urine that tends to adhere to the receptacle. Chronic cystitis is accompanied by debility and emaciation. Avhich. however, are of slow development. The prognosis is always serious, and the course of the disease is at the best protracted. Treatment. — Very generally, the treatment set down for the acute disease will not answer in the chronic form. Undoubtedly, there will follow more or less amelioration of the symptoms, but the tendency is toward a prolonged chronicity. In such cases, after the removal of the ascertainable causes so far as practicable, we ai'e compelled to resort to local treatment of the bladder. This includes — (1) Vesical irrigation ; (2) Topical applications ; (3) Permanent drainage of the bladder. Vesical irrigation is secured by means of an aseptic soft-rubber catheter which is connected with a graduated glass funnel : a siphonage is produced by the alternate elevation and depression of the funnel, which contains the irrigating fluid. The latter may consist of plain sterilized (boiled) water, sterile normal salt-solution (40-60 gr. to the pint — 2.59-4.0 per ^ liter), or a weak solution of mercuric chlorid (1 : 50,000—100,000). The irrigation should be done slowly, and not more than twice or thrice daily in severe cases, and much less frequently in ordinary cases, according to the exigencies of the condition. Vesical medication may be secured by means of the funnel after irri- gation, the medicating substances being dissolved in a pint of water and allowed to flow slowly in and out of the bladder. The drugs that may be used in this manner are silver nitrate or zinc sulphate (1-5 gr. to the ounce — 0.0648—0.324 to 32.0) or a saturated solution of boric acid. If the salts of zinc or silver are used, not more than an ounce of the solu- tion should be allowed to enter the bladder, and much less than this amount will generally suffice. In cases in which there exist patches of ulceration the application must be made directly to these areas through the endoscope or cystoscope (Pawlik, Kelly). In women this may be readily done by placing the patient in the exaggerated lithotomy or knee-chest posture, dilating the urethra, and introducing the cystoscope, through which a reflected light is thrown upon the distended bladder- wall. Stronger solutions may now be employed, as silver nitrate, 20- 30 gr. (1.29-1.94) to the ounce. This application should be folio Aved bv a slight irrigation of the bladder. When this local medication fails to efl'ect a cure, permanent drainage of the bladder must be secured — in the male by a suprapubic or perineal incision, and in the female bv the establishment of a vesico-vaginal fis- VESICAL HEMORRHAGE. 1011 tula. This places the bladder absolutely at rest, and gives the inflamed mucosa a chance to heal under proper medication. As to internal remedies, various agents that possess a local stimulating effect upon the genito-urinary tract are advised by most authors, but I think little is to be gained from their employment as compared with the results achievable from topical treatment. Most efficacious among inter- nal remedies are — oil of sandalwood, terebene, pichi, buchu (fluid ex- tract), and the oil of copaiba. If disinfection of the bladder in loco is not practicable, antiseptics should be given internally, combined with those stated above. Salol and potassium chlorate are excellent for this purpose. NEOPLASMS OP THE BLADDER. Primary new-growths of the bladder are exceedingly rare, occur- ring, however, with greater frequency in males in about the proportion of 3 to 1 ; they may be either benign or malignant. On the other hand, secondary neoplasmata, particularly carcinomata, are relatively common. The most frequent variety of new-growth encountered is carcinoma, par- ticularly the so-called villous or papillomatous carcinoma, Williams ^ find- ing in 20 women affected with bladder-tumor, carcinoma in 16. Other growths are sarcomatous, fibromatous, cystic, and papillomatous in nature. The symptoms are the same for all varieties, and include, first and most commonly, hemorrhage (which is both persistent and free), together with pain, frequency of micturition, and occasionally the discharge of detached fragments of the groAvth. In carcinomatous cases of advanced standing cachexia will be marked. Examination by means of the cysto- scope will reveal the nature of the complaint. In the case of secondary growths the primary tumor may often be detected. The prognosis, of course, will depend upon the nature of the growth. The treatment is purely surgical, and comprises enucleation of the tumor either by means of the snare, or after a vesical section. VESICAL HEMORRHAGE. ( Vesical Hemorrhoids.) Hemorrhage of the bladder has been mentioned as a symptom of various affections, both general and local, among the former being leu- kemia and malarial hematuria, and among the latter nephrolithiasis and tuberculosis and carcinoma of the bladder. It is also a prominent mani- festation in stone in the bladder, and not infrequently appears in preg- nancy (late). Independently of the operation of all of the above-men- tioned etiologic factors, hemorrhage has been known to occur from the bladder, and recent precise methods of exploring the viscus (endoscopic 1 Brit. Med. Joiirn., 1889. 1012 DISEASES OF THE URINARY SYSTEM. examination) have shown it to be due to a hemorrhoidal state of the ves- sels. The hemorrhage may be profuse, and. rarely, even fatal in its effects. The diagnosis is based in part upon the absence of the more obvi- ous causes of hematuria and the presence of free bleedings, but chiefly upon the result of a careful cystoscopic exploration of the bladder. The prognosis, so far as my experience extends, is eminently favor- able, though a few fatal cases have been reported. Treatment. — This is mainly local. The bladder may be irrigated with an astringent solution (1 per cent, tannic acid, ^ per cent, alum), and this may be alternated with an antiseptic solution (3 per cent, boric acid, 1 per cent, salicylic acid). I have recently observed a case in which recovery followed the internal admission of the extract, hamamelis fluid. (3J-4.0), t. i. d. NEUROSES OF THE BLADDER. IRRITABILITY OF THE BLADDER. Definition. — By this term is meant a condition of the bladder in which there exists an hyperesthesia of the organ, especially of the neck — that portion surrounding the urethral and ureteral orifices {vesical trigone) — without the presence of any tangible cause therefor. This must be dis- tinguished from the irritability that is associated with true organic dis- ease of the bladder itself, as in the presence of calculi, tumors, or fissure of the neck, or with disease of the surrounding structures. Pathology. — There are no pathologic features to be noted. A cysto- scopic examination of the bladder may reveal a slight increase in the vas- cularity of the mucous membrane, but the condition, in most instances at least, must be regarded as a true neurosis. The condition of irritable bladder in women, which has previously been held to be a purely func- tional derangement, is now regarded by Dacheux and Zuckerkandl as a localized hyperemia, especially at the has fond, and less often at the beginnino; of the urethra.^ Ktiology. — While in many instances no well-defined causal relations can be determined, it is very generally true that the patients who are the subjects of vesical irritability are individuals of a neurotic temperament, very often manifesting strong hysteric tendencies. They present the cha- racteristic features of this unfortunate group. They are generally illy- nourished, fretful, irritable, peevish, suffering almost constantly from vague neuralgic attacks in different portions of the body (cephalalgia, tic douloureux, lumbo-sacral pain), and in a chronic condition of physical prostration. Frequently they eventually develop a true hypochondriasis or melancholia. In others there may be found a history of extreme men- tal and physical tire, overwork, business anxiety, over-indulgence in ven- ery, menstrual irregularity, dysmenorrhea, ovarian or uterine disorders, long-continued gastro-intestinal disturbance (dyspepsia), improper hy- ' Tke American Year-Book of Medicine and Surgery, 1897, p. 576. NEUROSES OF THE BLADDER. 1013 gienic surroundings, improper regimen, indulgence in late hours, and a general lack of will-power. It must, however, be remembered that sub- jects of chronic malarial intoxication very often manifest all the symp- toms of vesical irritability, marked, it may be, by a feature of more or less periodicity. This has been termed by some malarial fever of the urethra and bladder. Lithemic individuals also are very prone to develop a pro- nounced vesical irritability, the affection in them probably resulting from the local action of the highly concentrated and irritating urine. The con- dition must commonly, however, be regarded as belonging essentially to the large group of neuroses. In a certain percentage of cases the bladder-trouble is a reflex mani- festation of some disease of an adjacent organ, as the urethra, ureter, va- gina, rectum, anus, or the internal organs of generation. These are not, however, to be looked upon as cases of true neurotic vesical irritability. Symptoms. — The symptoms of irritable bladder are mainly extreme painfulness 2ind frequetiei/ of micturition, associated with marked vesical and rectal tenesmus. The dysuria is not always or altogether relieved by micturition; indeed, the pain may be just as severe, or even worse after, than before, the voiding of the urine. Especially is this true when there coexists a more or less spasmodic muscular action of the bladder-walls, the hypersensitive mucosa then being squeezed, and the patient suffering at times to such an extent as to be throAvn almost into a state of collapse. There is usually a sense of weight or pressure in the pubic region, which is largely relieved when the patient assumes the recumbent posture. Uri- nation is often performed spasmodically, or there may be a spasm of the urethra and neck of the bladder resulting in an utter inability to perform the act. The urine may be normal in appearance and amount. Very often it is increased in quantity [hysteric polyuria), and at times the op- posite may be true and more or less suppression be noted. In lithemic cases the urinary characteristics already mentioned under that condition will be present (vide p. 401). Diagnosis. — Very frequently will simple vesical irritability be con- founded with true cystitis. The points of differentiation, however, are as follows : Irritable Bladder. Cystitis. The patient is of a neurotic tempera- May occur in any individual, irrespective ment, and generally gives no history of temperament. It frequently follows of organic bladder-disease nor of ope- catherization, sounding, or other trau- rations upon the bladder. matism. Pain is severe, and often ^vorse after mic- The pain is usually much relieved by turition. micturition. The constitutional symptoms are those of The constitutional symptoms are not nervous depression. marked, save in grave cases. Never results fatally. May result fatally. The urine does not present any marked There are always present marked and alteration in its physical or chemical characteristic alterations in the physi- qualities. It may show hyperacidity, cal and chemical qualities of the urine. or extreme concentration, or dilution. The appearance of the mucosa is negative Cystoscopic exploration reveals the angry in true neurosis. and diseased mucosa, and may show the cause (calculus, tumor). The duration is always protracted. The duration of acute attacks may be short. 1014 DISEASES OF THE URINARY SYSTEM. Prognosis. — Good as regards life ; doubtful as regards the ultimate cure of the patient. Treatment. — Since the condition is largely one of neurotic origin, the attention of the physician must be directed mainly toward a bet- terment of the state of the nervous system. Absolute rest, physical and mental, must be insisted upon, and the patient must be subjected to a course of strict moral suasion whenever this may be deemed necessary. Any cause of reflex irritation must be removed, and a careful search should be instituted for some such condition as cervical stenosis, uterine displacements, anal fissure, hemorrhoids, stricture of the rectum, vaginitis, urethritis, tuberculous infection of Skene's glands of the urethra, chronic gastro-intestinal catarrh, and the like. The habits of the patient must be inquired into, and late hours, the eating of improper and unwholesome articles of food, masturbation, or the reading of sensational and trashy literature corrected. In many instances the pronounced neurasthenic condition demands a course, more or less protracted, of the Weir-Mitchell rest-treatment {vide Neurasthenia, p. 1177). The urine should be care- fully examined for lithemic and other pathologic features, and by an ap- propriate course of treatment it should be rendered as bland and unirri- tating as possible. Large draughts of diluent drinks may be of benefit, and if these be combined with the prolonged administration of nerve- sedatives and antispasmodics, a marked amelioration of the patient's con- dition may be secured. In cases associated with spasmodic muscular con- traction it may become necessary to employ an occasional suppository of opium and belladonna, or an enema of chloral hydrate. Change of air and scene, regulation of the diet, the institution of a proper course of gymnastics, mental and physical, and the observance of a happy and cheerful atmosphere will generally do much to improve the patient's con- dition. The administration of tonics (strychnin, iron) and the prevention of constipation are very essential. Especially must it be remembered that in all these cases of simple vesical irritability physical exploration of the bladder is absolutely contraindicated. The patient's mind must be directed away from the bladder in order to secure good results. NEUROSES OF MICTURITION, 1. Incontinence of Urine {Enuresis). — An inability to retain the urine. This may arise from a number of causes. Frequently it is the result of some lesion of the spinal cord involving the sphincteric cen- ter of the bladder ; this is known as paralytic incontinence, and is to be recognized by a constant dribbling, alternating with spurts of urine when voluntary or involuntary muscular action is brought into play, as in the act of coughing, sneezing, or bending forward of the body. It may be the result of a general bodily weakness or after prostrating diseases (typhoid, late stages of pulmonary tuberculosis). Again, it may result from some local condition in the bladder or urethra. Here may be mentioned paralysis of the urethra from over-dilatation or from traumatism, or that due to pressure of the fetal head in a prolonged labor ; imperfect vesical innervation ; over-distention of the bladder, producing a paresis of its walls ; or from some temporary obstruction at the urethra or base of the bladder, such as a tumor or a sharply retroflexed uterus. NEUBOSES OF MICTURITION. 1015 It may be a result of over-distention of the bladder, with partial paral- ysis of the sphincter, the bladder remaining overfilled, while there is a constant escape of a few drops of urine {incontinence of retention). It may follow some local causes of irritation, as the presence of vesical cal- culi, pressure from an anteflexed uterus upon the fundus of the bladder, cystitis, and parasites. The condition known as spasmodic incotitinence is that due to an over-action of the compressor muscle of the bladder, as a consequence of which there is a diminution of the vesical capacity, the urine being forcibly and involuntarily ejected at irregular intervals. Finally, nocturnal enuresis is that variety which is so common in young, delicate, and often neurotic children : this is usually noticed in the early hours of sleep, and is often the result of some local irritation acting upon a hypersensitive organism, such as the presence of ascarides, an elongated prepuce, contraction of the urethral meatus, or masturbation. Nocturnal incontinence may be a manifestation of nocturnal epilepsy or of incipient cerebral or spinal disease (Fitz). The constant escape of urine in the paretic cases is apt to result in extensive excoriation of the parts. The treatment varies according to the cause. The enuresis of chil- dren, if left alone, will eventually cure itself as the age and strength of the patient increases, though obvious exciting causes, if present, should be removed if not impracticable. Good hygiene, systematic evacuation of the bladder, elevation of the hips on a pillow in bed, plenty of out- of-door exercise, a change to the seashore or mountains, an abundance of suitable and strengthening food with a minimum of water, and the administration of tonics (iron, cod-liver oil, and strychnin), will gener- ally efi"ect a cure. The iluid extract of rhus aromatica in 5 to 15 drop doses, thrice daily, has been very beneficial in children- Excellent re- sults often follow the administi'ation of minute doses of atropin or tinct- ure of belladonna. A favorite formula of my own in cases possessing a hypersensitive nervous organization has long been as follows : :^. Tr. belladoun^e, 3ss-j ( 2.0-4.0); Sodii brom., gij ( 8.0); Ac. hydrobrom. dil., sijss ( 10.0); Ext. ergotse fl., ^ij ( 8.0); Glycerini, 3j ( 4.0); Elix. simplicis, q. s. ad |iv (128.0). M. et Sig. 3J (4.0) three or four times a day for a child of five years. In very delicate or feeble children suffering from enuresis I substitute a motor tonic and stimulant (tr. nucis vom.) for the bromids or nerve- sedatives. Spasmodic action of the vesical compressor may be relieved by the cautious use of the motor depressants, while its converse, paresis, de- mands the exhibition of full doses of strychnin or tincture of nux vomica. The judicious and careful use of the catheter, followed by the adminis- tration of strychnin, will promptly effect a cure in the incontinence of retention. Any local cause of vesical irritation must be removed. Gal- vanism in the paretic cases, applied both to the bladder and to the urethra, may be of service, and in the female Sanger suggests massage 1016 DISEASES OF THE URINARY SYSTEM. of the urethra. Should excoriation occur, bland ointments, as of zinc oxid and lanolin, should be used. 2. Retention. — Nervous retention of the urine is occasionally encountered in hysteric and highly neurotic individuals. Its most common manifesta- tion is an inability to urinate in the presence of others. It is also occa- sionally noted after childbirth, when it may be due to nervous reaction, to edema and tortuosity of the urethra, or to a temporary inability of the bladder-walls to contract upon their contents, thereby permitting a longer retention of the vesical contents, and even favoring over-disten- tion of the organ. If the urine be allowed to remain for too long a period in the bladder, fermentative changes follow and a secondary cys- titis will result. Under these circumstances an exfoliation of a portion or even of the entire bladder-epithelium may be noted. The treatment consists in the administration of strychnin and other nerve-tonics, in building up the general constitution, and in affording a change of air and recreation. In that variety following childbirth the patient should be urged to make voluntary efforts at micturition, and these may be seconded by the firm application of an abdominal binder and compress, or of hot, moist flannel cloths, kept up for twenty minutes or a half hour. The sound of running water, as when pouring water from a pitcher into the basin, often causes a contraction of the bladder and excites the flow of urine. It may become necessary, the foregoing methods failing, to resort to catheterization, the usual antiseptic precau- tions being observed. PART VIII. DISEASES OF THE NERVOUS SYSTEM. The central nervous system is generally divided into two parts — the brain and the cord. The hrain consists of the cerebral hemispheres, the basal ganglia, the pons, the cerebellum, and the medulla. The cerebral hemispheres are joined together by the corpus callosum and the anterior and posterior commissures. They are united to the pons by the crura cere- bri, and the pons is continuous with the medulla, which in turn is con- tinuous with the spinal cord. The surface of the cerebral hemispheres is divided by sulci or fissures into various regions, known as the frontal, parietal, temporo-sphenoidal, and occipital lobes. The superior longi- tudinal fissure separates the two convolutions ; the fissure of Sylvius is be- tween the frontal and parietal lobes above and the temporo-sphenoidal lobe below. The fissure of Rolando divides the frontal from the parietal lobe, and the parieto-occipital fissure the latter from the occipital lobe. The continuation of the last-named fissure upon the median surface forms the upper boundary of the cuneus, the lower boundary of which is the cal- carine fissure. The hippocampal fissure separates the fascia dentata from the hippocampal gyrus, and by its extension inward produces an elevation in the lateral ventricle known as the hippocampus major. Each lobe is subdivided by secondary fissures into a number of lobules. The topography of the hemispheres is important because it is now pos- sible to map out with considerable accuracy the regions in which vari- ous motor impulses originate, and with less accuracy the regions in which various sensory phenomena are perceived. The accompanying diagrams illustrate, more satisfactorily than could any description, the regions that have been hitherto determined. There is some dis- cussion in regard to the degree of individuality of these centers, but the weight of evidence inclines to the belief that they are not sharply delimited. Ordinarily speaking, one side of the brain innervates the opposite side of the body ; but certain parts, as the muscles of the trunk, appear to receive impulses simultaneously from both hemispheres, and other functions seem to be accomplished exclusively upon one side ; thus motor speech is ordinarily disturbed only when the lesion is in the left hemisphere. The central nervous system is composed practically of two ele- ments — the neuroglia, or supporting substance, and the neurons. The neuroglia consists of round cells with radiating processes, lying in the 1017 1018 DISEASES OF THE NERVOUS SYSTEM. midst of a tangled network of fibers. Its function appears to be ex- actly similar to that of connective tissue. Tlie neuron, or nerve-unit, consists of a ganglion-cell, the protoplasmic processes springing from it, and the neuraxon, or axis-cylinder. The cell-body consists of pro- toplasm and nucleus. The latter contains a nucleolus and a small amount of chromatin ; the former is composed of a reticulum of fibril- lar ground-mass, in which are found, in certain cells, peculiar bodies, that take the basic stain, are irregularly spindle-shaped, and are often arranged concentrically to the nucleus ; they also extend a short dis- tance into the protoplasmic processes. The protoplasmic processes branch irregularly, and along the sides of the finer ramifications are placed short lateral offshoots, the buds or gemmules. The axis-cylinder is a single process, of uniform thickness, usually single, but sometimes w\ T KiG. 67.— Diagram of the cortical centers and areas of representation on the lateral aspect of the hemicerebrum (Mills). branched, and giving off at regular intervals fine, long branches, the collaterals ; it terminates either as a tuft of fine fibers surrounding a ganglion-cell, or in a motor plate in the muscles, or in a special sense- corpuscle in the skin. It cannot be too frequently reiterated that each neuron constitutes an individual unit that is entirely independent of all other neurons and has no anatomical connection with them whatever.^ A physiological communication must, of course, exist, that perhaps is analogous to electric induction ; and it has been suggested, by Dercum among others, that during life the protoplasmic processes move about and make contact with the surrounding nervous structures. The func- tions of the various elements of the neuron are as yet imperfectly un- derstood. The cell-body appears to exercise a trophic action over the 1 Apathy, and more recently Bethe, have claimed that delicate neuro-fibrils pass from one neuron to another. This has not yet been confirmed. DISEASES OF THE NERVOUS SYSTEM. 1019 other parts, especially the axis-cylinder. It probably also generates the nervous impulses. The protoplasmic processes may have nutritive func- tions, or serve to conduct impulses to the cells (cellipetal). The axis- cylinder conducts impulses from the cell (cellifugal), except in the case of the peripheral process of the cells of the spinal ganglion.^ A short distance from the cell the axis-cylinder is enveloped by the myelin- sheath, giving rise to the nerve-fiber, and when aggregated together these fibers form the white matter of the nervous system. It has been possible to trace more or less accurately the course of many of the groups or systems of fibers. These exist because cells Fig. 68.— Zones and centers of the mesial aspect of the human cerebrum (Mills). having the same functions are usually grouped together, forming cen- ters or ganglia, and the fibers from these, taking the same course, form a bundle. Three classes are recognized : (1) fibers wholly within one hemisphere, fibriae proprise, uniting adjacent convolutions, and long as- sociation-fibers, uniting different lobes ; (2) fibers passing from one hemisphere to the other, commissural fibers ; (3) fibers passing from the cerebrum to the other parts of the central nervous system, the pro- jection-fibers, forming the corona radiata. The columns or tracts that have been mapped out in the cord may be seen in the accompanying diagram (Fig. 69). In the antero-lateral por- tion are found the anterior or uncrossed pyramidal column, the antero- lateral column of Gowers, the cerebellar column, and the crossed pyram- idal column. In the posterior region are the columns of Goll and Bur- dach. The rest of the white matter forms the so-called ground-bundles. In the area comprising the anterior and lateral columns both ascend- ing and descending fibers are found. ^ Lenhossek has suggested that this is a modified protoplasmic process. 1020 DISEASES OF THE NERVOUS SYSTEM. The columns fhat transmit ascending impulses are — 1. The direct lateral cerebellar column. 2. The antero-lateral ascending column of Gowers. 3. The antero-lateral ground-bundle or fundamental column. 4. The columns of Goll and Burdach. Desceyiding impulses are trans- mitted chiefly by the direct and crossed pyramidal tracts and the antero- lateral descending tract. The direct lateral cerebellar tract of Flechsig takes origin in the cells of the column of Clarke, and first appears in the lower dorsal region, and passes through the restiform body to the cere- bellum. Gowers' tract, or the antero-lateral ascending column, is first seen in the lumbar cord, and arises from some of the cells of the pos- terior horn. It then crosses to the other side of the cord through the posterior commissure and terminates in the region of the lateral nucleus. Fig. 69.— Section of spinal cord (after Dana), sliowing complete subdivision of white columns r DPy, direct pyramidal Anterior J tract, columns. 1 AFC, anterior funda- l^ mental column. Lateral columns. f LFC, lateral fundamental column. I LL, lateral limiting layer. CPijT, crossed pyramidal tract. CT, direct cerebellar tract. ALT, antero-lateral ascending tract. C Column of Goll. T>„„*^-,- «^i,-,.v,.^o J Column of Burdach. Posterior columns. \ j^^ rim.zone, or Lissauer's \ column. ARZ, anterior root-zone. MKZ, middle root-zone. OZ, oval zone. PRZ, posterior root-zone. The direct and crossed pyramidal columns constitute the great motor path by which fibers descend from the cortex and end in the motor nuclei of the cranial and spinal nerves — in the latter case in the multipolar gan- glion-cells of the anterior horns. Their origin is in the motor region of the cerebral cortex — i. e. the ascending frontal and pai'ietal regions, the paracentral lobule, and the posterior part of the inferior frontal convolu- tion ; they then approach one another, as do fibers from all parts of the cerebral cortex (known collectively as the corona radiata), to enter the internal capsule. This may be described as a wedge, bounded in front and to the inner side by the caudate nucleus and the optic thalamus, and on the outer side by the lenticular nucleus. All of the fibers of the corona radiata do not pass through the internal capsule, some being lost in the gray matter of the basal ganglia, while Fig. 71. Fig. 70. — X, Peripheral sensory tract ; b, b^, h-, V-, cells in the short fibers, through the intercalation of which sensory impulses are conducted to the brain ; c, continuation of the paths for sensory impulses leading to the cortex. Fig. 71.— 1, Motor centers for the lower extremities ; li, motor centers for the upper extremities ; 2, motor centers for the nerves of the face ; 8, 4, 5, lateral pyramidal tract (red) ; 6, 7, 8, anterior pyramidal tract (green) ; py, pyramids (red) ; col (red and green), collateral fibers leading to gray substance. The Roman numerals dll, IV, etc.) indicate the nuclei, and correspond with ihc numbers of the cerebral nerves ; the letters ((/, h, etc.) represent the points of decussation and liie names of the individual nerves. DISEASES OF THE NERVOUS SYSTEM. 1021 others take origin in the ganglia. The angle of the internal capsule is known as the genu or knee, the part anterior to it as the anterior limb, and the posterior portion as the posterior limb. Through the anterior limb pass the fibers from the frontal region ; in the region of the genu are the fibers for the muscles of the face and tongue ; and in the pos- terior limb, the motor fibers to the extremities, also the sensory or teg- mental fibers, and at its posterior end the fibers of the optic radiation. The crusta consists of fibers that pass through the pons and enter the medulla, constituting its pyramidal tracts. The tegmental fibers are continuous through the longitudinal fibers of the pons with those derived from the formatio reticularis of the medulla. This is formed by fibers from the superior cerebellar peduncles, the olivary body, and the posterior and lateral columns of the cord, which are rein- forced in their upward course by fibers derived from the quadrigeminal and geniculate bodies. Tracing the pyramidal fibers through the medulla, they will be found to divide into two unequal portions at its lower part. The larger decussates at this point (the region of the first and second cervical nerves), constitut- ing the decussation of the pyramids ; it then crosses to the posterior part of the lateral column of the opposite side, in which it runs as the crossed pyramidal tract. In their course these fibers give oif collaterals at right angles to them- selves. These pass into the gray matter, and terminate in arborizations about the root-cells of the anterior horn of the same side. The main axes end in the same manner. As these main fibers with their collaterals pass into the gray matter at various levels of the cord, the tract becomes more and more attenuated, and terminates finally in the lumbar enlargement of the cord in the neighborhood of the third or fourth sacral nerve. The smaller division of the medullary pyramids passes directly into the anterior region of the cord without decussating, and is known as the direct pyramidal tract, or the column of Tiirck. In its course it gives off collaterals at right angles. These pass through the anterior commissure at different levels of the cord, and end in relation with cells of the anterior horn of the oppo- site side. The main fibers terminate precisely in the same manner. Thus it will be observed that the fibers of the column of Tiirck de- cussate in the anterior commissure of the cord ; like the tract previously described, it becomes gradually smaller from above downward, and ends in the lower part of the dorsal cord. The axis-cylinders of the multi- polar ganglion-cells of the anterior horns pass out through the anterior roots of the same side and terminate in end-plates of muscles. Dejerine, Oppenheim, Monakow, and other neurologists believe that each motor cortex sends fibers to both sides of the body, and that the decussation of the pyramids is not a complete one, a small number of the fibers running in the lateral pyramidal tract on the same side as the lesion. This is borne out clinically by the slight paresis and the plus knee-jerk on the same side, neither of which, however, approaches in degree the palsy and increased knee-jerk on the side opposite to the lesion. Pathologic confirmation of this view has been obtained by several observers, who have found degeneration in both latero-pyramidal col- umns in cases of a unilateral lesion in the motor cortex. Motor-fibers from the nuclei of cranial nerves after decussating 1022 DISEASES OF THE NERVOUS SYSTEM. join with motor fibers of the internal capsule. The exact course of these fibers, however, has not been demonstrated anatomically. Since many of the muscles supplied by the cranial nerves functionate bilater- ally — e. g. the eye-muscles and the muscles of mastication — the suppo- sition is that in addition to fibers from its own nucleus each motor cranial nerve receives fibers from the corresponding nucleus of the opposite side. It was Broadbent who first pointed out that parts that func- tionate bilaterally are supplied from both sides of the brain. The course of the fibers of the posterior column is as follows : The ganglion-cells on the posterior roots give rise to two fibers, fused for a short distance from the cell, but soon bifurca- ting. The longer of the two, the centrifugal fiber, extends to the surface and terminates in pointed or bulbous endings in the epi- dermis, or in special sensory nerve-endings in tactile cells, tactile corpuscles, or end-bulbs. The centripetal fibers or axons penetrate the cord, and divide in the white matter into ascending and descending fibers. The for- mer may be either long or short. The short fibers are vertical at first, but finally bend into the gray matter, and end in relation with certain cells of the anterior cornua, forming perhaps a part of the reflex arc. Their collat- erals end in a similar manner. The long fibers extend up the cord to the medulla, ending in the usual manner in the gray nuclei of the columns of Goll and Burdach ; these are known as the viwleus (/racilis and nucleus cuneatus, respectively. They also give off col- laterals in their course. The descending fibers, on the otber hand, are all short, and probably constitute the so-called coimna tract of Schultze. Since fibers continue to enter the cord at different levels, those that have entered below are pushed more and more toward the median line. It will thus be seen that the column of Goll is made up almost entirely of long fibers, and that the column of Burdach also contains long fibers, although it is probable that the short ones predominate. The long fibers are concerned in muscular coordination and equilibrium. It is likely that the fibers of pain and temperature sense, although entering by the posterior roots, do not pass up through the posterior columns, but rather through the gray substance of the spinal cord. Sacral Fig Diagram showing the groupings and plex- uses of the spinal nerves (redrawn after Balcer). DISEASES OF THE NERVOUS SYSTEM. 1023 Since the post-natal growth of the vertebrae is more rapid than that of the cord, it follows that the spinal nerves assume a more and more oblique position, until finally the spinal segments, each of which con- sists of an anterior and posterior nerve-bundle with a transverse plane of white substance, lie considerably above the vertebrae after which they are named (see Fig. 67). The following table (Starr, modified by Mills and Dana from the experimental and clinical studies of Thorburn and others) shows the localization of function (not organs) in the different segments of the cord : Localization of the Inunctions of the Segments of the Spinal Cord. Segment. First cervical. Second and third cervical. Fourth cervical. Fifth cervical. Sixth cervical. Seventh cervical. Eighth cervical. First dorsal. Second dorsal. Muscles. Rectus laterales. Rectus capitis. Anticus and posticus. Sterno-hyoid. Sterno-thyroid. Sterno-mastoid. Trapezius. Scaleni and neck. Omo-hyoid. Diaphragm. Diaphragm. Deltoid. Biceps. Coraco-brachialis. Supinator longus. Rhomboid. Supra- and infra-spi- natus. Deltoid. Biceps. Coraco-brachialis. Brachialis anticus. Supinator longiis. Supinator brevis. Deep muscles of shoul- der-blade. Rhomboid. Teres minor. Pectoralis (clavicular part). Serratus magnus. Deltoid. Biceps. Brachialis anticus. Subscapular. Pectoralis (clavicular part). Serratus magnus. Triceps. Pronators. Rhomboid. Latissimus dorsi. Triceps (long head). Extensors of wrist and fingers. Pronators of wrist. Plexors of wrist. Subscapular. Pectoralis (costal part). Serratus magnus. Latissimus dorsi. Teres major. Triceps (long head). Flexors of wrist and fingers. Intrinsic hand-muscles. Extensors of thumb. Intrinsic hand-muscles. Thenar and hypothenar muscles. Reflex and Centers. Hypochondrium (?). Sud- den inspiration pro- duced by sudden pres- sure beneath the lower border of the ribs. Pupillary (fourth cervi- cal to second dorsal). Dilatation of the pupil produced by irritation of the neck. Scapular (fifth cervical to first dorsal). Irrita- tion of skin over the scapula produces con- traction of the scap- ular muscles. Supinator longus. Tap- ping the tendon of the supinator longus pro- duces flexion of fore- Triceps (fifth to sixth cervical). Tapping el- bow tendon produces extension of forearm. Posterior wrist (sixth to eighth cervical). Tap- ping tendons causes extension of the hand. Anterior wrist (seventh to eighth cervical). Tap- ping anterior tendons causes flexion of wrist. Palmar (seventh cervical to first dorsal). Strok- ing the palm causes closure of the fingers. Sensation. Back of head to vertex and neck. ^Occipitalis major, occipitalis mi- nor, auricularis mag- nus, superficialis colli, and supraclavicular.) Neck. Shoulder, anterior sur- face. Outer arm. (Supracla- vicular, circumflex, external musculo-cu- taneous, cutaneous.) Back of shoulder and arm. Outer side of arm and forearm to the wrist. (Supraclavicular, cir- cumflex, external cu- taneous, internal cu- taneous, posterior spi- nal branches.) Outer side and front of forearm. Back of hand, radial distribution. (Chiefly external cu- taneous, internal cu- taneous, radial.) Radial distribution in the hand. Median distribution in the palm, thumb, in- dex, and one half of the middle flnger. (External cutane- ous, internal cutane- ous, radial, median, posterior spinal branches.) Ulnar area of hand, back, and palm, in- ner border of forearm. (Internal cutaneous, ulnar.) Chiefly inner side of forearm and arm to near the axilla. (Chiefly internal cutaneous and nerve of Wrisberg or 1 e s s- er internal cutane- ous.) Inner side of arm near .to asid in the axilla, (Intercosto-numerai.) 102i DISEASES OF THE NERVOUS SYSTEM. Segment. Muscles. Second to twelfth Muscles of back and ab- dorsal. domen. Erectores spinse. First lumbar. Second lumbar. Third lumbar. Fourth lumbar. Fifth lumbar. First and second sacral. Third, fourth, and fifth sacral. None. Vastus internus. Rartorius: adductors of thigh. Flexors of thigh. Extensors of knee. Abductors of thigh. Outward rotators. Flexors of knee. Flexors of ankle. Peronei. Extensors of toes. Calf-muscles. Glutei. Peronei. Extensors of ankle. Small muscles of foot. Perineal. Muscles of bladder, rec- tum, and external genitals. Reflex and Cknteus. Epigastric (fourth to sev- enth dorsal). Tickling mammary region causes retraction of the epigastrium. Abdominal (seventh to eleventh dorsal). Stroking side of ab- domen causes retrac- tion of belly. Vaso-motor centers. Sec- ond dorsal to second lumbar. Cremasteric (first to third lumbar). Stroking in- ner thigh causes re- traction of scrotum. Patellar. Striking pa- tellar tendon causes extension of the leg. Gluteal (fourth to fifth lumbar). Stroking buttock causes dimp- ling in fold of buttock. Achilles tendon. Over- extension causes rapid flexion of ankle, called ankle-clonus. Plantar (fifth lumbar to second sacral). Tick- ling sole of foot causes flexion of toes and retraction of leg. Genital center. Vesical center. Anal center. Sensation. Skin of the chest and ab- domen, in bands run- ning around and downward, corre- sponding to spinal nerves. Upper gluteal region. (Intercostals and dor- sal posterior nerves.) Skin over groin and front of scrotum. (Ilio- hypogastric, ilio -in- guinal.) Outer side and upper front of thigh. Lum- bar region. (Genito- crural, external cuta- neous.) Front and outer side of thigh. Inner side of leg and foot. Inner side of thigh, leg, and foot. (Internal cutaneous, long sa- phenous, obturator.) Back of thigh and outer side of leg and ankle ; sole ; dorsum of foot. (External popliteal, external saphenous, musculo- cutaneous, plantar.) Back of buttock and thigh, side of leg and ankle: sole; dorsum of foot. Circumanal region, anus, rectum, penis, urethra, vagina, per- ineum. (Small sciatic, pudic, inferior hemorrhoidal, inferior pudendal.) To the foregoing table, which illustrates spinal localization, should be added another, showing what functions reside in the pons and medulla, as follows : Nuclei. III. IV Sphincter iris. Ciliary muscles. Levator palpebrse superioris. Rectus internus (in convei'gence) Rectus superior. Rectus inferior. Obliquus inferior. Obliquus superior. (Upper facial group.) Y f (Associated movement of levator palpebrae.) ■ I Muscles of lower jaw. i Rectus externus. Rectus inter, of opposite side in lateral movements. yjj J (Lovrer facial group.) ■ "* Muscles of tongue. VII. — Facial muscles. IX. { Muscles of pharynx. X. I Muscles of esophagus. XL [ Muscles of larynx. Sensory Cortical Area. — Owing to the extensive compensation of sen- sory fibers, by means of which each side of the brain sends fibers to both sides of the body, it is impossible to map out the center with precision. DISEASES OF THE NERVOUS SYSTEM. 1025 It is generally believed, for reasons already stated, that the central convolutions (motor area) contain muscular and tactile sensory functions. These are also spread out over the parietal lobe, and it is possible, in- deed probable, that the sensory zone extends to the mesial surface of the hemisphere, as does the motor area. That this is the chief sensory center, as claimed by some observers, is, however, very questionable. From the cuneus, fibers pass to the pulvinar, forming an optic radia- tion of the Gratiolet. From the pulvinar they apparently pass to the external geniculate bodies, and thence to the anterior corpus quadrigemi- num. The optic tracts arise by two roots that curve round the crusta on either side and unite immediately in front of the tuber cinereum. Fibers from the two tracts pass to the homologous sides of both retinae ; therefore the lesions posterior to the chiasm give rise to blindness of half of the retina on the same side. Visual Centers. — The exact center for ordinary vision is in the cor- tex of the occipital lobe of the inner surface in the region of the calca- rine fissure. A higher center exists, probably located in the angular gyrus, and a lesion of which produces mind-blindness : this is a condi- tion in which vision is not lost, but the seen objects are not recognized by the individual. Ferrier says that a lesion in this region sometimes gives rise to crossed amblyopia. The eye opposite to the lesions is chiefly afi"ected, though vision is also restricted in the eye on the same side of the lesion (visual tract). Olfactory Center. — This is located in the anterior part of the uncinate convolution, on the inner surface of the temporal lobe. It is possible, too, that fibers pass from this region through the anterior commissure to the cortex of the opposite hemisphere. Auditory Center. — A lesion in the posterior part of the first temporal convolution produces a deafness in the opposite ear that is transient in cha- racter, owing to compensation. Bilateral lesions produce complete deaf- ness. Mind-deafness, or an inability to understand spoken words, has resulted from a lesion in the first temporal convolution of the left side. Speech Center. — The articulate speech center is located in the poste- rior part of the left third or inferior frontal convolution, and in the ad- jacent part of the ascending frontal in right-handed people (but on the right side in left-handed persons). It is not known exactly what part the island of Reil plays in articu- late speech. Word-blindness results from a lesion in the angular gyrus. Word-deafness results from a lesion in the posterior part of the first left temporal convolution. Taste Center. — The area of cortical representation is unknown. By some it is located in the gyrus hippocampus. Psychic Centers. — It is possible that the frontal lobes, anterior to the precentral fissure, contain the psychic centers. Such extensive compensation probably exists that no ordinary lesion produces mental aberration, but these centers are probably represented by the whole cortex. The function of the cerebellum is that of coordination. Fibers pass from its cortex to that of the cerebrum, and vice versa. The impressions derived from the cerebrum are believed to be inhibitory. Peripheral impressions reach the cerebellum through the direct cere- 65 1026 DISEASES OF THE NERVOUS SYSTEM. bellar tracts of the lateral columns of the cord, and also from fibers de- rived from cells in the nuclei of the columns of Goll and Burdach. Motor impulses run from the cerebellar cortex to the motor region of the cerebral cortex by w^ay of the superior or middle peduncle, and by way of the inferior peduncle"^ (restiform body) to the multipolar ganglion- cells of the anterior horns. GENERAL AND TOPICAL DIAGNOSIS. Nervous diseases are usually spoken of either as being functional or organic ; but, as our methods of research become more refined and our technic more perfect, the breach between these two groups is being gradually but steadily lessened. Granting this, they all really become organic diseases, though some in which neither macroscopic nor microscopic change has ever been discovered are called functional for the sake of convenience. Organic nervous diseases may be produced by two types of lesions : 1. Irritative, causing an increase of function, continuous or inter- mittent. 2. Destructive, resulting in paralysis of motion or sensation, or both. Irritative lesions are prone to become destructive in course of time. They may be operative in the upper segment, which includes the brain and fibers leading to or from it as far as the ganglion-cells of the cord ; or in the lower segment, including the multipolar ganglion-cells of the anterior horn, together with the peripheral motor and sensory nerves. When a complete pathway is involved a systemic disease is said to be produced. When two or more paths or neuron complexes are simul- taneously involved combined systemic disease results. Brain-lesions may be (a) focal or (b) diffuse. Cord-lesions are either (a) ti-ansverse, (h) focal, or (c) insular (a series of foci). Cord-lesions result in ascending or descending degeneration, the de- structive process travelling, as a rule, in the direction in which impulses are normally transmitted. In the fillet degeneration may extend up or down. The theory has been advanced that the vulnerability of the tracts of the spinal axis is in direct proportion to the degree of their functional activity ; hence the reflex (sensory and pyramidal) tracts are more likely to deg'enerate under nutritional disturbances or toxic processes than other parts. It has been supposed that the tardy myelination of the pyra- midal tracts predisposes to various nervous maladies, and particularly to those of a convulsive type. The following may be accepted as a general rule : the motor-nervous system is the last to develop, the first to lose, and the last to regain, its function ; while the sensory nervous system is the first to develop, the last to lose, and the first to regain, its function. In makincr a diagnosis it is, therefore, of the utmost importance to try to determine the locality and extent of the morbid process, and to ascertain whether the lesion is a focal or systemic one. The symptomatology of systemic diseases is pretty constant, and, except in their very incipiency, they are usually not diflicult of diagnosis. The symptoms of focal dis- eases, on the other hand, vary, of necessity, according to the location GENERAL AND TOPICAL DIAGNOSIS. 1027 of the focus. They are often difficult and at times impossible to diag- nose. Especially is this true of lesions occurring in the frontal lobes of the cerebrum, in the basal ganglia, and in the cerebellum. Since the study of the motor centers and tracts has been pursued with so much more success than that of the sensory system, positive or negative motor phenomena occurring in the course of nervous diseases furnish us with much more valuable information than do sensory mani- festations. Further, motor symptoms are objective, and consequently appeal to us in a much greater degree than the sensory symptoms, which are purely subjective, and the elicitation of which depends so much upon the mental capability of the patient. Irritative motor-lesions produce, according to the degree of irritation, either fibrillary muscular twitchings or mild or severe convulsions, tonic or clonic in character. Destructive motor-lesions, according to their extent, produce mere muscular weakness, paresis, or actual paralysis of a single muscle, groups of muscles, or of the entire musculature of one or more limbs. Irritative sensory lesions give rise to neuralgia, hyperesthesia, or hyperalgesia. Destructive sensory lesions cause a more or less complete absence of sensation, as analgesia, anesthesia, or loss of temperature-sense. Upper-segment or Upper-system Diseases. — A lesion occurring in the motor pathway anywhere between the cortex and the multipolar cells of the anterior horns (but not including the latter) gives rise to the following symptom-complex : Loss of motion, both automatic and vo- litional, and chiefly on the side of the body opposite to the lesion. The paralysis is usually spastic in type. The muscles resist passive move- ments, showing that their tone is increased. This is relative, and is due to the removal of cerebral inhibition, which allows the lower centers free play. They also tend to undergo shortening, and contractures re- sult. Reflexes are increased chiefly on the side opposite the lesion, but also on the same side, the increase being the result of the removal of cerebral influences. Owing to inactivity, the muscles of the paralyzed members undergo a more or less marked atrophy, though there are no degenerative changes, since the neuron bodies are intact. For the same reason the response to electric stimulation is not iaterfered with. An irritative lesion of this upper system, particularly when operative in or upon the cortical region, gives rise to tonic or clonic convulsive movements. When the lesion is localized to a single center, focal or so- called Jacksonian epilepsy results. The cortex is wonderfully tolerant, when the lesion is of gradual onset and the parts accommodate them- selves to the slowly increasing pressure. However, a local irritative le- sion may at first cause Avidespread symptoms, due, as Nothnagel pointed out, to pressure, vascular disturbances, or irritative inhibition. Loiver-segment or Lower-system Diseases. — This includes the periph- eral neuron system. Since there is no crossing of the fibers, the lesion and resulting paralysis are on the same side of the body. The paraly- sis, however, is of the flaccid, flail-like variety, hypotonus being present. The muscles offer no resistance whatever to passive movement, contrac- 1028 DISEASES OF THE NERVOUS SYSTE3L tures do not occur, and reflexes are lost. Extreme degrees of wasting occur in this type of paralysis, owing partly to disuse, but chiefly to the fact that the neuron body, the nutritional or trophic center for the fiber, is injured. Pathologic changes therefore take place in the muscles themselves, and form a true degenerative atrophy. The protoplasm first becomes granular, and then fatty ; it then breaks down and is absorbed. Its place is taken by the connective tissue, which is both relatively and absolutely increased, so that in the course of time fibrous masses alone remain. Electric changes also occur. The muscles first cease to respond to the faradic current, and soon respond in an abnormal manner to the galvanic. Instead of short, sharp contractions, they react in a slow, wavy manner, ACC being stronger than KCC. Irritative lesions of this system cause fibrillary muscular contractions and periph- eral convulsions, of which laryngismus stridulus is a type. I. DISEASES OF THE PERIPHERAL NERVES. NEURITIS. Definition. — An inflammation of a nerve or of its fibrous envelope. Pathology. — A true neuritis is almost always an inflammation of the nerve-sheath or of the septa between the fasciculi, and usually begins as a perineuritis. The so-called parenchymatous neuritis is really a degen- erative process ; it is prone to follow neuritis, and is the result of ex- cessive or prolonged irritation or of pressure by the products of inflam- mation. The aff"ected nerve becomes red and sAvollen. The sheath be- comes hyperemic and the seat of a round-cell infiltration. We may have a perineuritis or an interstitial neuritis. Again, these mav \>Q focal or diffuse {disseminated), involving limited patches or con- tinuous areas of a nerve. Finally, many nerves may be simultaneously afi'ected, constituting a multiple 7ieuritis. In the parenchymatous form the ordinary signs of inflammation are absent. The nuclei of the sheath increase in size and number, and the protoplasm about them increases in amount. The white substance of Schwann becomes segmented, breaks up into droplets, then becomes granular and fatty, and is finally ab- sorbed. The axis-cylinder becomes discontinuous at the site of disorgan- ization of the myelin. Ultimately, there may be seen scattered promis- cuously among the more or less healthy fibers the withered nerve-sheaths, containing many nuclei, some granular debris, and pigment. Occasion- ally fatty aggregations occur along the nerve. Leyden has termed this condition lipomatous neuritis, but it is not worthy of a special name, as it is only a stage in the ordinary degenerative process. Parenchymatous degeneration is similar to the secondary or Wallerian deofeneration previously mentioned. It is the chief lesion in multiple neuritis, though in this disease changes have also been found in the mul- tipolar ganglion-cells of the anterior horns. Ktiology. — («) Focal neuritis may be due to — (1) Exposure or cold (the so-called rheumatic neuritis). (2) Extension of inflammation from NEURITIS. 1029 neighboring parts. (3) Traumatism — wounds, compression, excessive stretching resulting from fractures or dislocation. (4) Microbic and autogenetic poisons. (6) Multi])le neuritis may be due to — (1) Poisons of extrinsic origin — alcohol, carbon bisulfid, lead, arsenic, mercury, ether. (2) Poisons resulting from the infectious fevers (typhoid, diphtheria, variola, typhus, leprosy, beri-beri, measles, syphilis, tuberculosis, septicemia, malaria, in- fluenza). (3) Cachexias, anemia, carcinoma. (4) Auto-intoxication. (5) Cases arise in which no definite cause can be ascertained ; these are the so-called idiopathic or spontaneous cases. Symptoms. — (a) Focal Neuritis. — In localized neuritis the symptoms vary according to the function of the nerve in-solved. In the case of a sensory nerve there is paiji, usually of a boring or shooting charac- ter, along its course and distribution. There is also tenderness on pressure along the nerve, and especially at its point of emergence from bony canals. Weir Mitchell believes this to be due to irritation of the 7iervi nervorum. The skin is generally hyperalgesic (though tactile sensation is often lowered), reddened, sometimes edematous, and local sweatings may occur. In the more chronic cases trophic symptoms eventually arise, as glossiness of the skin and an impaired growth of the nails. When a motor nerve bears the brunt of the attack fibril- lary twitchings will be observed in the muscles it supplies, and are soon followed by more or less impairment of motion, even amounting to paral- ysis ; sometimes contractures occur, and ultimately wasting of the mus- cles, and even reactions of degeneration, take place. When both motor and sensory nerves are simultaneously involved the symptoms will neces- sarily partake of a mixed character. The constitutional symptoms are, as a rule, of little moment. (h) Multiple neuritis is an involvement of the peripheral nerves in various parts of the body, afi"ected simultaneously or in quick succession, and due to endogenous or exogenous poisons. Lettsom's paper, pub- lished in 1789, embodied the first description of the disease. Among cases due to poisons of extrinsic origin is alcoholic neuritis. In 1822, James Jackson of Boston clearly gave its clinical history, though Dumesnil in 1864 was the first to publish the result of an autopsy upon a case. Other pioneers were Leyden, Buzzard, and Ross. This is the most common type of multiple neuritis, and occurs oftener among wo'men than men. It results from spirit-drinking in moderate amounts and continued over a long time. The onset is generally slow, being preceded by gastric catarrh, insomnia, tingling of the extremities, a rapid, weak heart, and a tendency to sweating on exertion. Some mus- cular twitching and paresis may exist contemporaneously, but the loss of power soon becomes more marked — first in the lower and then in the upper extremities, the extensors being chiefly aff'ected. Wrist-drop and foot-drop follow. Occasionally paraplegia and, more rarely still, a loss of control of the bladder and rectum take place. Fever is rarely pres- ent. Sensory symptoms may vary from the tingling or numbness already noted to burning or boring pains of great severity. The skin is hyperesthetic at first, at all events. Later, paresthesi?e develop, with anesthesia and a more or less decided loss of muscular sense. The mus- cles are tender when touched. 1030 DISEASES OF THE NEMVOUS SYSTEM. The cutaneous reflexes are preserved unless the anesthesia is marked. The knee-jerks are generally lost, though exceptionally they may be in- creased. In the less severe cases a certain amount of incoordination may be present. "When this is the case the absence of the knee-jerk, the loss of muscular sense, ataxia, and the pains in the extremities sim- ulate locomotor ataxia, and the term liseudo-tahes has been applied to the condition. Vaso-motor and trophic symptoms appear, and in some cases the special senses are involved (impairment of vision, amblyopia, limitation of the color-field). The cerebral symptoms are important. They may be so slight as to consist merely of loss of memory, irri- tability, perhaps an hallucination or illusion (particularly after night- fall, and especially if the patient has had insomnia), or they may be of the type and degree seen in general paralysis. The duration of an attack varies from a few weeks to a year or so. Arsenic neuritis differs from the above in that the head-symptoms are generally absent. The onset may be much more abrupt and the course is usually shorter. Carbon bisulfid neuritis occurs chiefly in workers in rubber-factories. There are noted intense frontal headache, giddiness, marked excitability, muscular cramps, and possibly convulsions. Saturnine neuritis is con- fined to motor nerves, and especially to those of the upper extremities. Very rarely some disturbance of sensibility may result. Lesions of the anterior cornua are more likely to occur in saturnine multiple neuritis than in any of the other varieties. Head-symptoms are not common, but optic neuritis and convulsions may occur. Cases due to an attack of some infectious disease may be local or multiple, and generally present the same symptoms as neuritis due to any other cause. (1) Malarial Neuritis. — According to Romberg, malaria gives rise at times to "intermittent paraplegia." The legs of the patient suddenly become paralyzed, with or without alteration of sensation or loss of control of the sphincter. That the cause is probably malarial is shown by the fact that the condition is periodic, each attack subsiding with a critical sweat, and finally yielding to quinin. (2) Recurring Multiple Neuritis. — A few cases have been reported in which attacks of more or less widespread paralysis, due to neuritis, have recurred. Spontaneous or the so-called idiopathic neuritis does not differ from the general type of the disease, except that no cause can be discovered to account for it. Diagnosis. — This does not present any difficulty, as a rule. The spontaneous cases, in the early stages, may simulate acute spinal paraly- sis or acute ascending paralysis. The fever, palsy, electric change, and the loss of knee-jerks are common to both, but in acute spinal paralysis there are never any sensory symptoms. The palsy in idiopathic cases rapidly spreads, but soon subsides again. In other forms of peripheral neuritis the onset is not only apt to be less abrupt, but some sensory symptoms are almost invariably present ; the distribution of the palsy is more symmetric bilaterally, and after it has reached its acme no improvement takes place for a few weeks or months. In ascending paralysis there are no sensory symptoms, the knee-jerks are preserved, there is neither muscular ati'ophy nor electric BEBI-BEBL 1031 change, and the order in which the paralysis supervenes differs from that of peripheral neuritis. Cases of pseudo-tabes are sometimes confounded with locomotor ataxia. The main points of differentiation are included in the following table : Pseudo-tabes. Locomotor Ataxia. The course is shorter, and often results The course is progressive from bad to in recovery. worse, and chi-onic in nature. Pain is never of the fulgurant type. Fulgurant pains often are present. Pain- crises are almost diagnostic. There is tenderness over the nerve-trunks. There is no tenderness over the nerves. Sensory disturbances are more marked Sensory disturbances are less marked. (tingling and numbness). Argyll-Robertson pupil is absent. Argyll-Robertson pupil is present. There is a "foot-drop,'' with the typical No ''foot-drop." The toes are raised, and "steppage" gait. the foot is brought down flatly, with the heel first. Paralysis is often present. There is no actual loss of power. Prognosis. — Peripheral neuritis may terminate in one of the fol- lowing ways, according to Drs. Gibson and Fleming^: 1. In complete recovery ; 2. With damaged peripheral nerves ; 3. With injury to the central nervous system, such as to cause symptoms of ataxia, spastic paraplegia, or disseminated sclerosis ; 4. In death, from failure of the organic centers, especially that of respiration. The prognosis is gen- erally good, though in the acute variety (from any cause) it should be guarded, and occasionally is grave. Exposure and chill, alcohol, diph- theria, and beri-beri give rise to the most serious types, and often cause death by failure of the heart or respiration or by coagula in the vessels. Mild cases may entirely recover in a few weeks, while severe ones often require a year or two. Treatment. — First ascertain the cause, and, if possible, remove it. It may be unwise in alcoholic cases to stop the alcohol suddenly, but each case must be judged on its merits. Kest is very important, and all sources of worry should be stopped. Locally, anodynes may be em- ployed and the part wrapped in cotton wool. In febrile cases, especially in the earlier stages, the salicylates are valuable. The general health should be toned up by strychnin and tonics, and by nourishing but eas- ily digestible food. Further medication will depend upon the etiology, quinin being demanded in malarial, and mercury or the iodids in syphi- litic cases. As soon as the acute symptoms have subsided massage and passive movements should be begun, galvanism applied to the muscles, and warm-water or. sulphur baths administered. BERI-BERI This is a tropical disease, characterized by weakness, wasting of the muscles, paralysis, anasarca, anemia, numbness, pain, areas of anes- thesia, and diminution or loss of tendon-reflexes. There are two forms, the aoute and the chronic. Its etiology is obscure, though it is apt to supervene upon any condition that impoverishes the physical or nervous ^ Edinburgh Hospital Reports, vol. iii. 1032 DISEASES OF THE NERVOUS SYSTEM. vitality. Intestinal parasites have been said to cause it. Ogata of Tokio'has described a specific bacillus ; Pikelharing and Winkler, hoAV- ever, claim that it is due to a micrococcus. Whatever its cause, the researches of these latter observers, together -with those of Baelz and Sheube in Japan, prove it to be a peripheral multiple neuritis. The symptoms of the acute form are fever, anemia, general edema, effusion into the serous cavities, dyspnea, precordial pain, vomiting, and periph- eral paralysis. Death often results, even in a few days, from emboli or thrombi in the pulmonary or systemic circulation. In the chronic form the symptoms are less pronounced. The face is apt to be puify, and palpitation and serious cardiac dilatation may occur. The gait is totterinw, the muscles are somewhat wasted, the tendon-reflexes are lost, and paresthesiae develop. The cases associated with the cachectic states may be general ; though usually they are local and of the interstitial variety of neuritis. The cases due to auto-intoxication are usually associated with fever, and at first simulate rheumatism or some infectious disease. Soon, hoAvever, the tingling, pain, palsy, loss of the knee-jerks, and anesthesia reveal the neuritis. Death may result from cardiac or repiratory paral- ysis. When life is spared the convalescence is exceedingly slow. NEUROMATA. Neuromata, or tumors of nerves, have been described as (a) true and {h) false. (a) True neuromata consist of medullated or non-medullated nerve- fibers (the myelinic and amyelinic varieties — Virchow), and rarely of ganglion-cells also. {b) False neuromata contain no nerve-elements. The growth is situ- ated on the nerve-trunk itself, and consists of either fibrous, myxoma- tous, gliomatous, or sarcomatous tissue. Neuromata have also been classified according to their situation as (1) Stump neuromata, or bulbous nerves ; (2) Subcutaneous neuromata, or tuhercula dolorosa; (3) Nerve-trunk neuromata; (4) Plexiform neuromata. (1) Stump neuromata develop on stumps or on the ends of divided nerves as the result of traumatism. They may consist of fibrous tissue, but are usually myelinic. (2) Subcutaneous tumors, or tubercula dolorosa, are painful, as the latter word implies, and are apt to be multiple. In individuals so afilicted nerve-trunk neuromata may coexist. (3) ISferve-trunk neuromata are usually multiple. In one case quoted by Gowers as many as 3020 were found. They may be true or false. In the former case the nerve-fibers are less apt to be interfered with than in the heterologous growth. (4) Plexiform neuromata consist of beaded and tortuous, interlacing neural cords. They are usually congenital. Etiology. — Neuromata may be due to traumatism. When multiple, NEURALGIA. 1033 however, thev are usually hereditary, occurring in families of a neurotic or strumous diathesis. They are most commonly found in men. Symptoms. — There may be none. When present their character necessarily depends on the nature of the nerve involved and whether the lesion is an irritative or destructive one. More or less pain, numbness or tingling, paraesthesia, and palsy are among the most common symp- toms. Various reflex manifestations have been described, and epilepti- form convulsions have been attributed to their presence. Treatment. — Apart from anodynes, operative measures are alone of value, except when the tumors are the result of syphilis, as occasion- ally happens ; in such cases specific treatment must be employed. It must not be forgotten, however, that stump neuromata may occur in those hereditarily predisposed, in which case, as Bowlby has pointed out, their removal will almost surely be followed bv a return. NEURALGIA. Definition. — Neuralgia {nerve-jpabi) is the result of some irritation directly or indirectly applied to a nerve. While this is true of all pain, yet the special nerve-pain under consideration presents the following characteristics : 1st. In its distribution it follows the course of a nerve- trunk or its branches. 2d. It shows a tendency to shift from place to place. 3d. The presence of painful points [points douloureux). 4th. Intermission and remission of pain. The pain of neuralgia varies both as to character and intensity. It may be merely a mild ache, or, on the other hand, it may give rise to the most excruciating agony ; it may be of a throbbing, boring, tear- ing, shooting, or burning character, or it may come on in shock-like paroxysms. Any nerve in the body may be affected. Quite often one can find no definite cause of the neuralgia, and as we are not certain as to its ultimate pathology, it may be due to some slight inflammation of the nerve, or to hyperemia, ischemia, exudation, and the like. Among the loredisposing causes are — (1) Age, the condition being most common in those between thirty-five and fifty years, and less so above that age. It is least common in children. (2) Sex. On the whole, neuralgia is most common in women, though the severer grades are found quite as frequently in men. Sciatica is more common in men, while trigeminal neuralgia occurs more frequently in women. (3) Heredity. Neuralgia is very prone to occur in a family in which hysteria, epilepsy, or other neurosis or psychosis is present. (4) The general physical condition. In persons reduced by illness or by mental or physical exertion, and in anemia, neuralgia is common. (5) Occupation. Painters and workers among metallic dust are specially predisposed. The exciting causes are — (1) Exposure to cold and wet. (2) Me- chanical, chemical, or thermal irritation, including compression. (3) Traumatism. (4) Neuromata. (5) Infectious diseases. (6) Rheuma- 1034 DISEASES OF THE h'ERVOUS SYSTEM. tism and gout. (7) Endogenous or exogenous poisons. (8) Local dis- ease in the course of the nerve, or of the mouth, nose, or orbit. We are hardly justified to-day in speaking of idiopathic neuralgia. Such cases probably result from some endogenous or exogenous poison, an auto-intoxication, or malaria, rheumatism, syphilis, some metallic poison, or alcohol or tobacco. Finally, a form exists Avhich we speak of in no certain manner as " reflex neuralgia," and which is said to re- sult from disease of the sexual or other organs often remote from the painful nerves. General Symptomatology. — Neuralgia may be of sudden or slow on- set, with or without prodromata. When the latter exist they consist of a sense of uneasiness, perverted sensations, chilliness, and stinging or slight burning pains. The pain may be of the character previously de- scribed, either strictly localized or radiating to neighboring nerves, and may be aggravated by drafts, movements, or mental perturbation. On pressure certain tender or painful spots Avill be found, especially where the nerves emerge from deeper parts and become superficial. The affected part is usually hyperesthetic ; occasionally, however, it is anes- thetic, and may continue so for some time after an attack. Reflex muscular contraction may be present in proportion to the in- tensity of sensory irritation. A^aso-motor symptoms manifest them- selves in the flushing or blanching of the affected part and in increased secretions, as sweating. Tropliic disturb a 7ices may result in temporary or permanent changes. To the former belong the herpetic and urticarial eruptions, while the latter groups include change of color in, loss of, or overgrowth of the hair, various changes in the skin (as pigmentation and morphea, and even ulceration, though in the latter instance there is probably a more pro- found pathologic change than that which we regard as the cause of neur- algia). Unless the attacks are severe or prolonged, however, the general system seldom suffers. Neuralgia may be divided into the following groups : neuralgia of the head, neck, trunk, upper and lower extremities ; neuralgia of the genitals and rectal region ; and visceral neuralgias. NEURALGIA OF THE HEAD. Trigeminal neuralgia (^Tic douloureux) may manifest itself in any one or all of the branches of the fifth nerve. Neuralgia of the First Branch (Ophthalmic Neuralgia). — The chief points of pain in this variety are the supra-orbital foramen (the exit of the nerve), the nose, the eyeball, and parts around the eye. Supra-maxillary neuralgia (involving the second branch of the fifth, the supra-maxillary nerve). The tender points here are the infra-orbital foramen (the exit of the nerve), the cheek, side and cavities of the nose, the upper lip and gums, and the zygoma. The infra-maxillary division, the third branch of the fifth. The men- tal foramen is the point of greatest tenderness ; other spots, however, are the temporal region, and along the tongue and lower lip. NEURALGIA OF THE EXTREMITIES. 1035 NEURALGIA OF THE NECK AND TRUNK. The cervical branches of the dorsal and lumbar nerves are involved in this group. 1.. Cervico-oecipital neuralgia, occurring in the occipital and posterior pai-ietal region, is apt to be quite severe, but when not due to spondylitis (the result of caries) or neoplasms the prognosis is fair. It is sometimes the result of direct pressure, as in carrying heavy loads on the neck and shoulders. The painful spot is found between the mastoid process and upper cervical vertebrae. Falling of the hair may also occur. This is much more apt to take place, however, when the occipitalis minor is in- volved, as it is said that the latter is generally a syphilitic neuralgia. 2. Phrenic neuralgia has been described, but is a rare condition. The pain is in the lower anterior thoracic region, at the points of inser- tion of the diaphragm. 3. Intercostal Neuralgia. — The middle intercostal nerves are most liable to be affected, and generally on the left side. The posterior dorsal branches are seldom involved. When specially severe and persistent, intercostal neuralgia may be a symptom of disease of the cord or its membranes, aneurysm of the aorta, neoplasms, or disease of the vertebrae or ribs. Traumatism and cold also give rise to it. This form of neuralgia is most common in women, the painful spots being at the extremity and at the middle of the ribs. The pain is of a sharp, lancinating cha- racter and radiates along the nerve. It is intensified by all movements of the chest ; hence the affected side is more or less fixed. Herpes may develop, but in such cases it is probable that a true neuritis exists. 4. Mastodynia is really a variety of intercostal neuralgia, and occurs almost solely among women. It is very painful, and gives rise to the development of tender "lumps" in the breast, simulating malignant disease. The paroxysms are often accompanied by vomiting. 5. Lumho-ahdominal neuralgia is not a common form. The pain is chiefly in the lumbar region, though the hypogastrium, genitals, and buttocks may also be involved. NEURALGIA OP THE EXTREMITIES. Cervico-hracJiial neuralgia occurs in the distribution of the four lower cervical nerves. When the condition is bilateral we should look for disease of the cord or membranes, for new growths, or for disease of the vertebrae. When unilateral, any of the causes already enumerated may be operative. The radial and ulnar nerves are more frequently aff"ected than the median. The pain is most apt to be distributed along the whole course of the nerve, but painful points are found in the following sit- uations — in the axilla ; over the brachial plexus ; on the shoulder, Avhere the cutaneous branches of the circumflex nerve emerge through the deltoid muscle ; about the middle of the outer surface of the upper arm ; over the ulnar nerve ; in the sulcus between the olecranon and epitrochlea ; also near the wrist and at the bend of the elbow over the musculo-spiral nerve. Femoral or crural neuralgia is a someAvhat rare type that attacks the anterior surface of the thigh, the knee-joint, and the inner surface of the leg and foot. 1036 DISEASES OF THE NERVOUS SYSTEM. Obturator- yieuraJgia is distributed along tlie inner side of the thigh down to, and including, the knee-joint. This form is common in women subject to ovarian diseases. Sciatica stands next to trigeminal neuralgia in the order of fre- quency, and is by far more common in men than women. In addition to the ordinary causes of neuralgia — exposure, compression, trauma- tism — the condition may be an early symptom of tabes or it may be due to constipation or hemorrhoids. The painful points are in the gluteal region and the popliteal space or malleolar region, though ten- derness may be elicited along the whole course of the nerve. The pain is sharp and shooting, or more often of a tearing variety. Fine or coarse tremors or spasms may be present, together Avith some disturbance of sensation and loss of power. Herpes occasionally develops along the course of the nerve. This form of neuralgia is quite common, and is generally easy to recognize, but it may be simulated by hip-joint disease, psoas abscess, or lumbago. Sciatica may also be caused by neuritis, the result of exposure or compression by pelvic growths, or by the fetal head during labor. In such cases there is, as a rule, slight fever, and the tenderness on pres- sure and the degree of pain are infinitely more severe than neuralgia. In severe cases the patient is bed-ridden, but in m.ilder attacks he can be about ; w^alking greatly increases the pain, however. It is slightly mitigated b}^ relieving the tension on the nerve, by bending the knee, and walking on the toes. It is an obstinate condition, and relapses are common. The diagnosis is generally not difficult. The distribution of the pain, the location of tender points, and the character of the gait suffice to pre- vent error, as a rule. A rectal or vaginal examination should be made to determine whether it is a primary disease or secondary to some pel- vic condition, for clearly, if the cause can be removed, the prognosis will be good. Neuralgia of the Genitalia and Rectum. — These varieties are not met with frequently. The former is sometimes a symptom of stone, prostatic disease, or stricture, and in women ovarian and uterine neu- ralgias are generally hysteric manifestations. Coccydynia, unless of traumatic origin, is almost solely found in women. The pain in the region of the coccyx is excruciating at times, and may even call for operation. Visceral Neuralgia. — As implied by the name, these forms are neuralgias resident in the various viscera. They most frequently attack the stomach or bowel, and are recognized as colic. Other viscera may also be involved (liver, kidney). Treatment of Neuralgia. — The first requisite in the treatment of neuralgia is to ascertain whether it is due to local or general causes. That of the former class may be caused by a cicatrix, neuroma, aneur- ysm, neoplasm, or by caries or traumatism ; and the treatment must necessarily be directed toward the removal of the cause when possible. When the fault is a general one, the neuralgia may occur either as the immediate result of the systemic disease or remotely, as the result of the altered blood-state (anemia). This is particularly well illustrated DISEASES OF THE CEASIAL NERVES. 1037 by an attack of malaria, in ^hicli it is palpable that success can only be obtained by attention to the underlying cause. It is sometimes necessary to use an analgesic, of ?rhich morphin is certainly the best. Its thera- peutic value is most decided when the drug is given hypodermically. and if injected directly over the track of the painful nerve [e. g. supraorbital branch of the fifth), it not only affords immediate relief, but also obviates recurrences of the painful paroxysms in many instances. It is, however, scarcely necessary to urge the exercise of caution, for the morphin-habit is readily formed in these cases. The following may also be used ; anti- pyrin. phenacetin, codein. veratrum viride. aconite, also counter-irritants and vesicants, including the galvanic current. The general tone of the system must be attended to. bad habits prohibited, the state of the bowels regulated, and the eves examined and corrected for errors of refraction. Rest is a valuable adjunct to any form of treatment. In neuralgia of the upper extremities and in sciatica I have often obtained good results from putting the limb in splints. Sciatica is often very intractable. If it fails to yield to the salicyl- ates, counter-irritation, leeches, and the rest-treatment of AYeir Mitchell may be used, or nerve-stretching, either by flexing the thigh upon the abdomen or, as a last resort, by cutting down upon the nerve itself. Other nerves are sometimes subjected to this method of treatment also, but less frequently than the sciatic. Absolute rest in bed, with the limb kept perfectly still by means of sand-bags or a long splint, always gives relief, and in some cases seems to cure. Alternating hot and cold douches also give great relief in some instances. Deep injections of thein, ether, or chloroform are sometimes used, and even distilled water may give relief when injected into the nerve. The use of guaiacol (mj— ij — 0.066-0.1332) in association with chloroform (TTLx — 0.666) by this method has yielded very encouraging results in my hands. ^ DISEASES OF THE CRANIAL NERVES. OLFACTORY NERVE. The following morbid conditions have been desci'ibed in connection with the sense of smell : (a) Hyperosmia or Olfactory Hyperesthesia. — The sense of smell is abnormally acute, so that objects, and even persons, can be recognized by this means. It occurs in hysteria and insanity. (h) Parosmia (perverted sense of smell) is due to irritation either of the center or of the nerve-trunk. This perversion may occur for one or for many odors, and is often associated with an obtunding of the normal sense. (6) Subjective sensations of smell are due to the same causes as the above. An olfactory aura may precede an attack of epilepsy. Olfac- tory hallucinations occur occasionally in the insane. (cZ) Anosmia or olfactory anesthesia (loss of the sense of smell) may be caused by — (1) injury to the peripheral filament by local disease of 1 "The External and Internal Use of Guaiacol," Therapeutic Gazette, Mar. 15, 1895. 1038 DISEASES OF THE NERVOUS SYSTEM. the nasal mucous membrane. (2) Injury to the nerve-trunk or bulb, bone-disease, and meningitis. Anosmia may occur during locomotor ataxia. Pungent and powerful odors have been said to cause loss of the sense of smell, due to excessive stimulation. There may be a congenital absence of the olfactory nerves. (3) Centric lesions, as tumors in the anterior part of the temporo-sphenoid lobe. Hughlings Jackson has reported cases of unilateral anosmia associated with aphasia, believed to be due to simultaneous involvement of the outer limb of the olfactory nerve as it passes the island of Reil to reach the center and Broca's region. Opposite unilateral anosmia has been described, due to a lesion in the posterior part of the internal capsule. In testing the sense of smell it is advisable to use aromatic oils, as they only stimulate the olfactory nerve, while ammonia and such strong substances also stimulate the fifth nerve. It is obviously necessary to make a rhinoscopic examination. Treatment is generally unsatisfactory, though the cause must be removed Avhen possible. When the disturbance is due to some general condition, as hysteria, it may of course be disregarded, as it will improve •with the disease. DISEASES OF THE RETINA, OPTIC NERVE AND TRACT. Since the intra-ocular changes are an index of what is going on in the system in certain blood- and kidney-diseases, syphilis, and brain- troubles, and, indeed, as they sometimes foreshadow coming events, thereby proving a most valuable aid in diagnosis, the following brief description of the lesions, as seen with the ophthalmoscope, is given : The Retina. — Hemorrhage into the retina may be venous or arterial, single or multiple, monocular or binocular. It may be part of a general vascular change ; occasionally it occurs during parturition, but more often at the menopause ; it may be an indication of renal trouble or of some primary or symptomatic anemia, as in leukocythemia, pernicious anemia, or malaria. Hemorrhage is prone to occur also in depraved nutritional conditions, in purpura, and in scurvy. More or less complete loss of vision develops in these cases, either suddenly or gradually. If the hemorrhage is superficial, the eye-ground is red and swollen ; if deeper, the blood escapes between the fibers of the retina, spreads them out, and assumes a flame-shaped appearance. Mr. Hutchinson thought this was characteristic of gout, but it is now known to be absent in many undeniably gouty cases, and present in others in which no suspicion of gout exists. When multiple hemor- rhages occur the irritation consequent thereon causes a turbidity of the retina between the blood-spots (" retinitis apoplectica "). Hetinitis. — Three forms of this condition are commonly described — the (1) albuminuric, (2) sj'^philitic, and (3) pigmentary, though Brudenell Carter regards the last named as the only true retinitis, and believes that if the other conditions are inflammatory, they are due to irritation in- duced by the presence of adventitious deposits. (1) Albuminuric retinitis is probably not a distinct aff'ection, but part of a general fibro-vascular change associated with nephritis. The fail- ure of vision may precede the advent of albuminuria, but more often DISEASES OF THE BETINA, OPTIC NERVE AXD TRACT. 1039 the two conditions are coincident. It occurs in chronic nephritis, espe- cially in the interstitial variety. The retinal changes, according to Gowers, are either hemorrhagic or degenerative. In the former the arterial blood occupying the interstices between the fibers assumes a striated or feathery aspect, while in the degenerative form white patches of fatty degeneration or deposits of cholesterin are dotted over the fundus ; they may also be grouped about the macula lutea, or around the disk. Occasionally the latter appears swollen, owing to the effusion of serum into the fiber-layer. (2) Syphilitic retinitis generally occurs in the later stages of ac- quired syphilis, and particularly in neglected cases. Failure of vision directs attention to the eye-ground, Avhich is found to have either scat- tered or uniformly distributed whitish or slightly opalescent filmy patches upon it. The vitreous may be turbid also. Retinitis is far less common than choroiditis or chorio-retinitis. (3) Pigmentary retinitis, as stated above, is believed by Carter to be a true inflammation, attacking the retinal elements themselves and not the fibrous layer. It is essentially a chronic process, usually attacking young adults, and, as a rule, more than one member of a family. It may also occur in inherited syphilis and in low grades of vitality. The affected parts receive a deposit of pigment which specially follows the course of the main arteries. At the same time a circumferential an- nulus of pigment forms. This gradually encroaches more and more upon the disk, until finally atrophy ensues. Among retinal affections occur also — (a) Toxic Amblyopia. — This is due, as a rule, to tobacco or alcohol, and more rarely to certain drugs or lead-poisoning. Failure of vision is gradual and progressive, though it rarely reaches absolute blindness. The center of the field is chiefly affected, and a central scotoma for red and green exists ; this is said to be caused by a chronic neuritis begin- ning in the fibers that are distributed to the macula lutea. (6) Hemeralopia, or day-hliyidness, may either be functional or a symptom of some retinal affection — e. g. hyperesthesia or albinism. Objects can either not be seen at all or only indistinctly during the day or in a strong artificial light ; but at night vision is excellent. (c) Nyctalopia, or night-blindness, may either exist without apparent cause or it may be symptomatic. It occurs rarely during the course of wasting diseases, as in scorbutus, albuminuria, and anemia. Far more commonly it exists in connection with syphilitic retinitis or choroiditis, separation of the retina, or some congenital defect, and is always pres- ent in retinitis pigmentosa. In this condition vision may be normal during the day or in a strong artificial light, but after nightfall or in a darkened room objects can be seen only with difficulty or not at all. Hemeralopia and nyctalopia are often used in an entirely opposite sense from that employed here, but the definitions given are etymolog- ically correct, and have been adopted in the nomenclature of the Royal College of Physicians of England. Optic Nerve. — Three distinct pathologic conditions of the nerve ex- ist — viz. (1) Perineuritis, (2) Choked disk, and (3) Neuritis. They may merge into one another, and after lasting some time may lead to (4) Atrophy and complete blindness. 1040 DISEASES OF THE NERVOUS SYSTEM. (1) Perineuritis is met with in meningitis, and was suggested by Bouchut as a valuable diagnostic sign in obscure eases. It is also found in certain cases of insolation, and may occur in any fever in which im- pairment of vision is a sequel. The sheath of the nerve is supplied by the blood-vessels of the pia, while the nerve itself derives its blood-sup- ply from the anterior cerebral artery ; therefore in perineuritis, in the early stages at least, the disk remains normal, but is surrounded by a zone of congestion and inflammation. If the action has been severe or prolonged, either the direct pressure or that due to the contraction of the inflammatory material causes partial atrophy of the nerve and conse- quent interference with the vision. (2) Choked disk is almost always bilateral, and occurs in cases of intracranial granulomata or tumors, also in Bright's disease and syph- ilis. The disk is at first merely congested ; soon, however, both the arterial and venous circulations are interfered with, and especially the return venous flow ; then exudation of serum takes place. Sometimes secondary inflammatory changes folloAv. In the early stages vision is not impaired, but as the exudative elements contract, the interference with the circulation becomes more exaggerated, and in time atrophy of the disk supervenes. Should the process be arrested, the retinal dropsy subsides, and it will then be seen that the vessels are thickened and tor- tuous, and stand out in relief near the margins of the disk. White patches of atrophy may be scattered over the fundus. When the in- flammation and a dropsical effusion into the disk exist simultaneously, it is difficult or impossible to differentiate the condition from primary or descending optic neuritis. (3) Neuritis. — The optic nerve derives its blood-supply from the an- terior cerebral artery. Evidently, then, in cerebral hyperemia (arterial) from any cause we have an increased injection of the disk, but no venous engorgement ; hence there is no dropsy and no tortuosity of the veins. Inflammation may begin in the disk or descend from above, giving rise to plastic deposits on the retina. Sight is early interfered with, owing to involvement of the conducting fibers, which atrophy in time unless the condition ceases. Then the disk appears white, and the vessels show upon it as thin filaments. This condition is met with in syphilis, Bright's disease, intracranial tumors, and rarely in anemia and lead- poisoning; it may be an advanced stage of perineuritis or choked disk. (4) Optic Atrophy. — This may occur as an hereditary affection known as Leber s disease, which chiefly attacks young males, or it may occur during the course of locomotor ataxia, certain toxemias, and diabetes. It may also be brought about either by conditions that produce brain- disease or as a result of the cerebral disease itself. In any case there is alteration of the field of vision, color-perception is abnormal, and there is more or less dimness of sight. In the hered- itary form the disk is less white than in the other, and the vessels are almost normal in appearance (Fig. 73). The Optic Tract. — The lesions of the optic tract are important rather on account of their situation than their nature. They may exist without corresponding changes in the retina, although when they have lasted for a long time there is usually some consecutive atrophy resulting from a descending degeneration of the optic nerves. Lesions of the chiasm Fig. 73.— Diagram of the visual apparatus (after Vialet) : LO, LO', rceipital lobes ; 0, cuneus ; Sad. opt., optic radiation ; TQa, anterior corpus quadrigeminus ; PU, PU', pulvinar; CGe, external geniculate ganglion ; 50, optic tract : Cff, optic chiasm ; A'O, optic nerve; OZ), right eye : OG, left eye; Py, nasal half of retina (supplied by the opposite hemisphere); RT, temporal half of the retina (supplied by the homolateral hemisphere) ; M, macula lutea. A total transverse lesion at 1, 2, or 3 would cause total blindness of the right eye. A lesion at 4, destroying the central part of the chiasm, would cause blindness of the nasal halves of the retinK, and therefore bitemporal hemianopsia. A lesion at -5 would cause blindness of the right halves of the retinae, and therefore left homonymous hemianopsia. The pupillary reflex would be lost in the affected half of the eye in all these cases. A lesion in the optic radiation would cause symptoms similar to those of the corresponding optic tract, excepting that the pupillary reflex would be preserved. Lesions of the cortex cause various disturbances of vision according to the part affected. 66 1042 DISEASES OF THE NERVOUS SYSTEM. usually affect the decussating fibers, causing blindness of the nasal halves of the retina, and, in consequence, temporal hemianopsia. This condition occurs in basal tumors especially of the hypophysis, and has therefore been observed in acromegaly, in tuberculous basal meningitis, and in hy- drocephalus. Lesions of either optic tract, if complete, causes homony- mous bilateral hemianopsia ; if incomplete, there is irregular disturbance of the visual field, sometimes bilateral, sometimes unilateral. It may be involved in hemorrhage, tumors, softening or basilar meningitis ; ordi- narily other structures are also involved, giving rise to symptoms of focal disease. Lesions anterior to the anterior corpora quadrigemina usually cause more or less destruction of some of the other cranial nerves, with the production of ocular palsies, or disturbances of the other special senses, or anesthesia? or neuralgias of the face. A very valuable sign, that, however, cannot always be elicited, is the failure of the pupil to contract when light is thrown upon the blind half of the retina. This is explained by supposing that the pupillary reflex center is situated in the anterior corpus quadrigeminus. If the lesions affect the optic thal- amus or the internal capsule, hemiplegia and hemianesthesia are also often present or may form the most important symptoms. Lesions pos- terior to the anterior corpora quadrigemina produce hemianopsia without disturbance of the pupillary reflex. These lesions are divided into two groups, the cortical and the subcortical and they may be of two varie- ties, either irritative or paralytic. The irritative lesions give rise to hallucinations of sight, which may vary from the scotomata of migraine to most complex visions. Paralytic lesions ordinarily lead to hemian- opsia. Occasionally curious symptoms are produced, the visual field being sometimes irregular, whilst at others only certain elements of sight are affected, cases having been reported in which the hemianopsia only involved the recognition of colors, not of form. In all these cases the pupillary reflexes are not affected. Bilateral lesions do not always lead to total blindness : sometimes the macula lutea escapes and the patient is able to see only by direct fixation. Occasionally a single lesion will produce total blindness in one eye, but this is rare, and no satisfactory explanation has been found to account for it. Cortical lesions are those involving the occipital lobe. The center of visual perception appears to be in the cuneus and calcarine fissure ; if this is destroyed, blindness occurs. The center for the recognition of the object seen is apparently upon the convex surface of the occipital lobe, probably in the second and third convolutions, but it may extend also into the temporal lobe. When this is destroyed the patient can see objects, but fails to recognize them; this is called mind-blindness ; if total, this is the result of a bilat- eral lesion. Hemianopsia is very frequently merely a temporary symp- tom, and as such it may occur in uremia, apoplexy, migraine, and cer- tain intoxications, especially that of lead. It may also occur in brain- tumor, and disappear if the pressure is relieved, as by trephining. It is a permanent symptom only when the visual tract has been involved by some destructive lesion. If the patient is perfectly conscious and intelligent, it is not difficult to recognize it ; nevertheless, its pres- ence can often be detected in young children and in those who are only partially conscious or unable to speak. This can be accomplished by taking a bright object, placing it behind the head, and ihen bringing it DISEASES OF THE MOTOR NERVES OF THE EYEBALL. 1043 forward sloAvly, first on one side and then on the other. It will then be noted that the patient perceives it on the hemianopsia side only when it has been brought to the middle line, Avhilst when moved on the other side the eyes will turn toward it Avhen it is still a considerable distance from this point. Another method is to bring a blunt object (a wisp of cotton) very nearly in contact Avith the cornea, first on the one and then on the other side of the median line. The palpebral reflex will occur upon the normal side Avhilst the object is still some distance aAvay ; on the blind side only when it has come in contact Avith the conjunctiva (see Fig. 73). DISEASES OF THE MOTOR NERVES OP THE EYEBALL (THIRD, FOURTH, AND sixth). The extrinsic ocular muscles are supplied by these three nerves, Avhile the intrinsic are supplied by the third and the sympathetic. I. The motor oculi, or third nerve, is purely motor, and sup- plies all the muscles of the eye except the superior oblique and external rectus, and controls in part also the ciliary muscle and the sphincter of the iris. Its apparent origin is from the inner side of the crus cerebri just anterior to the pons. It can be traced through the crus, hoAv- ever, to its deep origin in a nucleus beneath the corpora quadrigemina, situated in the floor of the aqueduct of Sylvius. Above the crus it pierces the dura, passes between the tAvo clinoid processes of the sphe- noid bone, along the outer wall of the cavernous sinus, Avhere it receives some filaments from the cavernous plexus of the sympathetic ; it then divides into two branches that enter the orbit through the sphenoid fissure. The superior and smaller division supplies the superior rectus and levator palpebrse superioris, while the inferior and larger branch subdivides into three portions, one going to the internal rectus, another to the inferior rectus, and the third to the inferior oblique. Lesions of the third nerve result in (1) spasm or (2) paralysis. Spasm rarely if ever occurs in all the muscles simultaneously. Any muscle may be aff'ected, but the internal rectus and levator palpebrae are specially liable. The condition is met with in meningitis, hypermetropia, and hysteria ; also in nystagmus, in which the spasm is clonic and bilat- eral ; it also occurs in albinism, occasionally in coal-miners, or it may be congenital. When the levator palpebrse is aff'ected {lagophtTialmus) inability to close the eye results. Stimulation of the center or nerve may cause contraction of the pupil (miosis), as occurs in locomotor ataxia. The same result is brought about by paralysis of the sympathetic. Paralysis. — Usually the nerve is involved as it passes through the dura or at the orbital foramen by some inflammatory process, rheumatic or syphilitic, or it may be the result of meningitis. Pressure due to a gumma or other tumor or to an aneurysm, and sometimes traumatism will bring about the same result. Paralysis may also be due to a neur- itis the result of diphtheria or some other infectious disease, toxemia, or locomotor ataxia. More rarely the nucleus is damaged by hemorrhage or inflammation. In such cases, hoAvever, OAving to their intimate rela- tionship, the nuclei of the other eye-muscles Avill usually be iuA^olved, 1044 DISEASES OF THE NERVOUS SYSTEM. oriving rise to general ophthalmoplegia. When the intra-ocular muscles alone are affected it signifies a central lesion. Relapsing and recurring palsy are two peculiar varieties. The former occurs chiefly in syphilitic subjects. One nerve becomes affected and partially recovers ; the other one then becomes paralyzed, and par- tiallv recovers, relapses, and so on. The internal muscles may be involved. Recurring or periodic palsy, the migraine ophthalmique of Charcot, is a rare form. It occurs in both sexes, but women are especially sus- ceptible. It may begin in infancy and recur at intervals for years, the attacks being periodic, lasting a few days to six or eight weeks, and ending in complete recovery. They may be precipitated by some emo- tional disturbance, by menstruation, or by exhaustion. Their exact nature is not understood, but they resemble migraine in that there is severe headache or pain, usually over one eye, and in their association with, vomiting. Generallv paralvsis of the extra-ocular muscles is partial, and the svmptoms will vary according to the muscles affected. When they are all involved there are ptosis, divergent strabismus, diplopia, and con- tracted pupil, with loss of the light-reflex and accommodation. Intra-ocular Paralyns. — {aj Cycloplegia, or ciliary muscle-paralysis, gives rise to a loss of the power of accommodation, so that "'far-sight" is orood. Avhile '• near-sight " is blurred and indistinct. This can be corrected bv a convex glass. Bilateral cycloplegia is usually due to a nuclear lesion. It occurs sometimes in diphtheria and in tabes dor- salis. {b) Iridoplegia. — The pupil may be dilated {mydriasis) from palsy of the sphincter or spasm of the dilator, or it may be contracted (myosis) from the antithesis of the above. The iris has three actions — two reflex and one associated : First, a reflex contraction of the sphincter on exposure of the eye to light ; second, a reflex dilatation of the radiating fibers on stimulation of some cutaneous nerve ; and, third, a contraction on accommodation, usually, but not necessarily, associated with convergence (Gowers). First, light-reflex iridoplegia. The iris reflex is lost in locomotor ataxia, and may be also in syphilis. Accommodation and convergence are, however, usually preserved {AryyU-Bohertson impil). When these also are lost the condition occurs to which Jonathan Hutchinson gave the name ophthahnopJegia interna. In testing this reflex care must be taken to avoid the contraction of accommodation. The patient should look at a remote part of the room; then a liorht is brought suddenly in front of, and three or four feet dis- tant from, the eve. One eye should be examined at a time, the other being covered, but not closed. Gowers has reported unilateral reflex iridoplegia occurring in tabes. It is extremely rare, however. The reflex path is as follows : the retina, optic nerve, chiasm, both optic tracts, corpora quadrigemina, third-nerve nucleus, third-nerve trunk, ciliary ganglion, and the ciliary nerves. Second, skin-reflex iridoplegia. Normally, painful stimulation of the skin of the neck causes reflex dilatation of the pupil, the afferent impulse being carried along the sympathetic. In locomotor ataxia DISEASES OF THE MOTOR NERVES OF THE EYEBALL. 1045 myosis often exists. In such cases Erb showed that the skin-reflex was lost (spinal myosis). Third, accommodation iridoplegia, in which the power of accommo- dation is lost. The pupil does not become smaller when looking at near objects. Westphal and Piltz have recently discovered independ- ently, that in certain pathological conditions the pupil contracts strongly upon closure, or attempted closure against resistance, of the eyelids. This reflex occurs most constantly in general paresis. Its exact sig- nificance is not known. II. The fourth nerve, or patheticus, the smallest cranial nerve, supplies the superior oblique muscle. Its superficial origin is to the outer side of the crus cerebri, just in front of the pons. The fibers can be traced backward to the valve of Vieussens, in the substance of Avhich it decussates with its fellow. Its deep origin is in a nucleus in the floor of the aqueduct of Sylvius, immediately behind and in close connection with the third-nerve nucleus. After piercing the dura mater the nerve runs along the outer wall of the cavernous sinus and enters the orbit through the sphenoid fissure. Since the superior oblique muscle directs the eyeball downward and rotates it, paralysis causes defective down- ward and inward movements, and consequent diplopia with inclination of the head forward and to the sound side. When occurring alone it is probably due to a nuclear lesion. III. The sixth nerve, or abducens, has its deep origin in the floor of the fourth ventricle in close proximity to the seventh-nerve nucleus. Its superficial origin is from the lower part of the pons, in the groove between it and the medulla. Emerging, it pierces the dura, runs in the cavernous sinus, and enters the orbit through the sphenoid fissure to supply the external rectus. Owing to its long course, this nerve is specially liable to injury, usually from pressure due to tumors or from syphilitic or other forms of meningitis. Paralysis of the muscle causes convergent strabismus, OAying to an inability to rotate the eye outward and consequent diplopia. In nuclear lesions the external rectus of the same side and the internal rectus of the opposite side are paralyzed, conjugate deviation resulting, the eyes being directed away from the side of the lesion. This is due to the fact that the sixth nerve gives off" a twig that runs to that region of the opposite third-nerve nucleus governing the internal rectus. This muscle is not wholly controlled by the sixth nerve, however, for in nuclear lesions of the latter no degenerated fibers are found in the third nerve; and, further, when the eye with the paralyzed external rectus is covered the opposite internal rectus will act, though less readily than normally. General Symptomatology of Paralysis of the Bye -muscles. — Loss of poAver in the ocular muscles is indicated by five kinds of symp- toms (Gowers) : (1) Limitation of Movement. — The amount of limitation in the movement of the eyeball is in direct ratio to the degree of palsy. In complete palsy the globe is ultimately fixed, owing to contraction of the unopposed muscle. In partial paralysis, as the limit of movement is approached the motion is often jerky [paralytic nystagmus). (2) Strabismus. — Owing to defective movement the axes of the eyes- 1046 DISEASES OF THE NERVOUS SYSTEM. do not correspond. " The deviation of the axis of the paralyzed eye from parallelism with that of the sound eye is termed the primary deviation." (3) Secondary Deviation. — " If the sound eye is prevented from see- ing the object, and the patient looks at this (is made to ' fix ' it) only with the affected eye, the sound eye is moved still farther in that direc- tion, and hence the deviation of the visual axes is increased. This is called tlie ' secondary deviation,' and depends on the fact that two mus- cles normally acting in unison are equally stimulated (innervated) for any given movement. When one is weak, the amount of nerve-force employed to move the sound eye acts equally on the impaired eye, and hence the over-action. In paralytic strabismus fixation with the sound eye shows the primary deviation, while fixation with the affected eye reveals secondary deviation. In ordinary strabismus due to spasm this does not hold good ; it matters not which eye is used, deviation remains the same." (4) Erroneous Projection. — We judge of our relation to surrounding objects by the position of the eyeball as indicated to us by the degree of stimulation necessarily brought to bear on the ocular muscles. When one of these muscles is weak, the additional stimulation (innervation) necessary to move it in fixing an object impresses us with the idea that it is really farther away than is actually the case, and in attempting to touch it the finger goes beyond. This erroneous projection, or inter- ference of visual sense-impressions, causes a disturbance of equilibrium and gives rise to vertigo, which has been named "ocular vertigo." (5) Double Vision. — This is not due alone to a difference in the axis of vision, causing images on non-corresponding portions of the retina, but also to the erroneous projection. '^ If the patient looks with both eyes, the field of the unaffected eye, being normally projected, does not correspond with the field of the affected eye ; the images formed in the two eyes are mentally referred to different positions; objects are seen double " (Gowers). The " true image " is that one formed in the sound eye, while the retina of the affected eye receives the "false image." Homonymous or simple diplopia is that in which the false image ap- pears on the "same side of the other as the eye by which it is seen." This is due to paralysis of an abductor muscle — convergent strabismus. Crossed diplopia occurs in divergent strabismus, the result of paralysis of an adductor. The false image appears to be on the other side of the real object — i. e. toward the sound eye. Gowers' mnemonic is, " When the visual lines (prolonged ocular axes) cross, the diplopia is not crossed." Ophthalmoplegia, a paralytic condition of the eye-muscles, may be partial or complete. Either the internal or the external muscles may be involved, constituting ophthalmoplegia interna or externa, and, when both are affected, total ophthalmoplegia. The lesions may be nuclear or pe- ripheral. Pressure due to neoplasms, gummata, aneurysms, or basilar meningitis may produce it, or it may follow diphtheria. It also occurs in general paralysis, progressive muscular atrophy, and locomotor ataxia. It may be (a) of sudden onset, due to some vascular disturb- ance ; {b) acute — the polio-encephalitis superior of Wernicke — develop- DISEASES OF THE FIFTH NERVE. 1047 ing in a few days or weeks ; or (c) chronic. In the latter case symptoms of bulbar palsy are apt to be present also. Von Grraefe has described a form of bulbar palsy limited to the ocular nuclei under the name of progressive ophth a Im op legia. The symptoms vary necessarily according to_ the muscles involved. The treatment consists in the removal of the cause when possible. In inflammatory cases counter-irritation is employed by blisters placed on the temples, behind the ears, or at the occiput, or by leeches. Inter- nally, the salicylates, mercury, iodids, and general tonics are useful. Rarely a case will recover spontaneously. Electricity is probably of little value. The diplopia, unless it can be obviated by a suitable lens, should be met by means of an opaque glass. DISEASES OF THE FIFTH NERVE. The trigeminus nerve has an extensive origin from the floor of the fourth ventricle. It supplies with sensation the whole region innervated by all the other cranial nerves except the first and second. It resem- bles a spinal nerve in that it has two roots, a motor and sensory, and on the latter a ganglion (Gasserian). From the latter arise three sensory branches — viz. the ophthalmic, superior maxillary, and inferior maxillary. A motor root joins the last named, the largest branch of the fifth nerve. Morbid conditions of the fifth nerve cause sensory, motor, or gusta- tory symptoms. The lesion may be — (1) Pontine hemorrhage, softening, sclerosis, or tumor. (2) Disease or injury at the base of the brain — e. g. meningitis, gumma or other tumor, caries of bone. (3) Disease or injury of the branches, as neuritis, pressure due to aneurysm of the internal carotid or to a tumor in the pituitary or spheno-maxillary region, orbital cellulitis, and punctured w^ounds of the mouth and nose. (4) Rarely fracture of the skull. Symptoms. — Sensory Portion. — In the irritative stage the chief feature is pain ; this may be shooting, boring, or burning in character. Tenderness along the course of the nerve and hyperesthesia may also exist. Later anesthesia develops in the mucous membrane of the nose, mouth, lips, tongue, and, in some cases, of the hard and soft palate also. Muscular movements are slower than normally, due to sensory interference. The secretions are often increased, though at first they are lessened ; hence the anosmia, due to dryness of the nasal mucosa. Loss of sense of taste may also occur. Other trophic changes are — inflammation and ulceration of the gums, looseness of the teeth, and inflammation of the eye. Corneal opacities, ulceration, sometimes perforation, and finally complete destruction of the eye — neuro-paralytic ophthalmia — are noted. This is especially apt to occur when the Gasserian ganglion is involved. Painful and intractable herpes may develop. Hemifacial atrophy may result from disease of the fifth nerve (Mendel). Motor Portion. — Spasm or Paralysis. — Partial or complete inhibition of the movement of the muscles in the region supplied — i. e. those of the jaw, the masseter, temporal, pterygoid, mylo-hyoid, and the poste- rior belly of the digastric. The degree of palsy can be ascertained by 1048 DISEASES OF THE NERVOUS SYSTEM. placing a finger on each masseter or temporal muscle while the patient alternately opens and forcibly closes the mouth. In external pterygoid paralysis movement toward the sound side is impossible, and on de- pression of the lower jaw it deviates toward the affected side. Ulti- mately wasting of the muscles, with deformity, tates place. The spasm (the so-called "masticator}^ spasm" of Romberg) may be tonic or clonic. In tonic spasm — trismus or lockjaw — the jaw is firmly set and the muscles are hard, rigid, and sometimes painful. This occurs in tetanus, in certain cases of tetany and hysteria, in caries of the teeth, occasionally after exposure, and in irritative centric or peripheral lesions. Clonic spasm is more or less continuous or intermittent. The former consists of short, quick, vertical or rarely lateral movements (e. g. chattering of the teeth), usually associated with some other con- dition, as paralysis agitans, general convulsions, and the like, or it may exist alone, especially in Avoraen late in life. The intermittent form is rare and occasionally occurs in chorea. Contractions are single, forci- ble, and are separated by some little time. The tongue and cheeks may be bitten in the attack. Gustatory Portion. — S'l/mptoms referable to this portion are not always present in disease of the fifth nerve. There may be a loss of taste with- out sensory disturbance, or vice versd, or both may exist contemporane- ously. Lesions of the nerve-root or middle-ear disease may cause it, but pontine lesions, as a rule, do not. A perverted sense of taste — parageusia — may be present in hysteria and insanity. Increased sensi- tiveness — hypergeusia — and subjective sensations of taste may result from irritative lesions, and the latter may precede an attack of epilepsy (as an aura). The diagnosis is not difficult as a rule. Anesthesia in the area sup- plied by the nerve, with loss of taste, is fairly conclusive. Spasm may be simulated in cases of rheumatism or rheumatoid arthritis involving the temporo-maxillary articulation. Treatment. — The underlying cause should be attacked when pos- sible, and mercury, the iodids, and the salicylates should be administered in specific cases and in those due to exposure. Analgesics, and even opiates, may be necessary. Sometimes vigorous counter-irritation is of value. Attention must be paid to the condition of the general system. The battery may be tried, preferably with the faradic current, or by means of electricity short and extremeh' rapid blows may be made over the nerve. DISEASES OF THE SEVENTH OR FACIAL NERVE. The nucleus of this nerve in the floor of the fourth ventricle is in relation with those of the sixth, eighth, and twelfth nerves. Like the spinal nerves, it has an upper and lower neuron or motor segment, the former extending from the cortical center in the lower Rolandic region to the nucleus, while the latter runs from the nucleus to the periphery. Lesions may involve any part of the tract, producing either spasm or paralysis. Spasm. — This may be idiopathic or organic, and either general or DISEASES OF THE SEVENTH OB FACIAL NERVE. 1049 partial, aiFecting only the orbicularis palpebrarum {Me pharo spasm). It is soEQetimes called tic eonvulsif or mimic spasm. Patliology. — The commonest cause appears to be some psychic dis- turbance. Next in frequency are peripheral irritations, and particularly those that involve the trigeminus, as carious teeth, conjunctivitis, or some nasal irritation. Less frequently irritation in some other part of the body, as intestinal parasites or uterine disease, may be the exciting cause. Finally, there may be lesions in any part of the motor tract supplying the face, either in the cortex (meningeal tumor, exostoses, or focal soften- ing), in the facial nucleus in the medulla, or along the course of the facial nerve (aneurysm or atheroma of the vertebral artery). Morbid changes in the nerve itself or in the muscles have not been observed. Ktiology. — As in other functional diseases, neuropathic heredity plays an important part. Sometimes, indeed, tic eonvulsif has ex- isted in a parent or has occurred in several children of the same fam- ily. Emotional disturbances have frequently been the exciting cause ; besides these, there are the various reflex irritations. The organic causes are irritative lesions, situated in some portion of the facial motor tract. According to Gowers, the functional form occurs only in adult life. It occasionally follows facial palsy. The symptoms of the disease include, first, the spasm : this is usually a sudden clonic convulsion of the muscles of one side of the face, with closure of the eyelids and retraction of the angle of the mouth. Rarely there are associated movements of the palate and eyeballs. The spasms may be single or they may occur in groups frequently repeated, or recur constantly at more or less irregular intervals. Less frequently the con- traction may be tonic in character, lasting several seconds or even minutes. These forms are frequently associated with clonic spasms. Ordinarily the spasm is painless, though there are certain sensitive points, as where the branches of the trigeminus issue from the skull, and particularly over the supraorbital foramen. Sometimes there is also tinnitus aurium. Taste and the muscles of the palate are rarely affected. The immediate exciting cause of an attack may be fatigue or excitement, or it may occur as an associated movement, as in a case that I observed, in which spasm always accompanied the beginning of speaking. The diagnosis is usually easy. It may be occasionally confounded with chorea, especially when the latter is chiefly localized in the face, or with athetosis due to infantile brain-lesions. Recognition of the cause is often very difiicult, and a careful examination of the whole body should be made for any possible source of irritation. The prognosis is extremely unfavorable for cure, since only in cases of recent occurrence, and with a distinct source of peripheral irritation, is permanent recovery likely. Ordinarily, the disease, even if commencing in a mild forua, gradually progresses to the most severe type, the intervals between the attacks become shorter, and the attacks themselves more severe. The treatment consists in the removal of any source of irritation and the application of electricity, particularly the mild galvanic currents, with the anode over the sensitive points. Operative interference, as stretching the facial nerve (which rarely produces any result unless paral- ysis ensues) or cutting the tendons of the facial muscles, may be tried ; 1050 DISEASES OF THE NERVOUS SYSTEM. and finally, use of antispasmodics, as conium, gelsemium, morpliin, and the bromids, may give temporary, but rarely permanent, relief. Paralysis (Bell's Palsy). — Depending on the seat of the lesion, Ave have — {(t) supra-nuclear, {b) nuclear, and {e) infra-nuclear palsy. The following table presents the general difierences between upper and lower neuron palsy : SCPRA-NUCLEAR PaRALVSIS. NuCl.EAR AND InFRA-NUCLEAR PaRALYSIS. The upper part of the face is not af- All parts of the face involved, including fected, the muscles of the angle of the the orbicularis and frontalis. mouth being chiefly concerned. Voluntary movements arc more impaired Voluntary and emotional movements than the emotional. equally affected. All reflex movements are normal. All reflex movements are lost. Electric reaction is normal, or only Reactions of degeneration are present. slightly impaired to both galvanic and faradic currents. There is no wasting. Wasting is present. {a) Supra-nuclear paralysis is generally associated with hemiplegia, the palsy of face and limbs being on the same side — i. e. opposite the lesion, which may consist of a hemorrhage, tumor, abscess, softening, or which may be the result of injury, and may be situated in the cortex, corona racliata, or the internal capsule. When the cortical face-center is alone involved, the limbs escape {monoplegia facialis). This form is rare. {h) Nuclear paralysis is due to hemorrhage, tumor, or softening at the site of the nucleus in the medulla. It may also result from an attack of diphtheria, and very rarely occurs in cases of antero-poliomyelitis. As already noted, the symptoms are similar to those of infra-nuclear paralysis. {c) Infra-nuclear paralysis is caused by pressure on the nerve at the base of the brain by tumors, meningitis, aneurysm, or hemorrhage. In the Fallopian canal the nerve may be damaged by bone-disease or some form of otitis. This is the seat, too, of the so-called " rheumatic neur- itis," the result of exposure. Fracture of the base of the skull or injury to the nerve as it emerges from the stylo-mastoid foramen may result in facial palsy. Diplegia facialis is rare, but may be caused by a single lesion in the pons, where the facial paths cross, or by two lesions, one on either side. The causes enumerated above, when bilateral, beget double facial paralysis. Lesions in the lower part of the pons may result in crossed hemi- plegia, the fibers being involved in their course between the nucleus and the point of emergence of the nerve, the side of the pons. The face will be paralyzed on the same side as the lesion, since this latter is below the decussation of the facial tracts, and involves the outgoing nerve, to- gether with opposite hemiplegia. In alternate or crossed hemiplegia the facial palsy is of the infra-nuclear type, while in ordinar}^ hemiplegia the supra-nuclear type is met with. Certain symptoms of nerve-irrita- tion may precede the actual palsy or may be concomitant, such as slight pain and tenderness, some swelling in front of the ear, muscular twitch- ing, and occasionally vertigo. jSyinptoms. — The affected side is immobile and expressionless, and the DISEASES OF THE AUDITORY NERVE. 1051 normal lines are diminished or abolished. This is seen most markedly in those above middle life. The eye cannot be closed, owing to droop- ing of the lower lid, and, as the tears are not directed into their proper channel, the eye waters. Voluntary and emotional movements are lost. Whistling and smoking are performed Avith difficulty, if at all, and food collects between the teeth and cheek of the affected side, owing to paral- ysis of the buccinator; in drinking the patient inclines the head to the sound side to prevent escape of the liquid from the corner of the mouth. The dilator naris is paralyzed ; hence sniffing is interfered with, and the sense of smell is lowered on that side. When the tongue is protruded it seems to be drawn toward the pal- sied side. This is not the case, hoAvever, the effect being due to con- traction of the unopposed muscles on the sound side. AH reflex move- ments are lost. The palate is not affected, and sensation is not impaired. When the nerve is involved between the intumescentia gangliformis and the origin of the chorda tympani, taste is lost in the anterior part of the tongue. When other parts of the nerve are diseased, taste is not inter- fered Avith, unless an ascending — or, more rarely, a descending — neur- itis develops. Hearing may be increased, OAving to paralysis of the stapedius, with consequent unopposed action of the tensor tympani. In ear-disease and in disease of the base of the brain, involving both facial and auditory nerves, hearing is lessened. Some degree of Avast- ing takes place in the affected muscles, and both quantitative and qual- itative electric changes quickly follow the palsy. The duration of an attack varies from a fcAv days to several months or a year, and in rare cases it is permanent. The onset is usually prompt, and the acme of the attack may be reached in from a feAv hours to a couple of days. Diagnosis. — From the table previously given it Avill be easy to differ- entiate supra-nuclear from infra-nuclear palsy. In cases of long stand- ing, Avhen contractures have taken place, oAving to the furrows thus pro- duced the affected side may be taken for the sound side, but on getting the patient to whistle the true state of affairs Avill manifest itself. Treatment. — Search for the cause. If ear-disease is present, make provision for free drainage ; if syphilis, give iodid of potash, mercury, or both. In cases due to cold, the so-called rheumatic palsies, counter- irritation is especially called for, and cantharidal collodion, fly-blisters, or the actual cautery behind the ear or over the occiput are very useful. The boAvels should be freely opened, and diaphoretics or hot baths and alkaline diuretics administered ; in the inflammatory stage small doses of mercury are of value, and later mercuric iodid or general tonics. Galvanism may be employed to stimulate the nerves and to help in maintaining the tone of the muscles. When contractures threaten in late cases the use of electricity should be dispensed with. DISEASES OF THE AUDITORY NERVE. The eighth nerve has its deep origin in the medulla. The center is connected by fibers Avith the cerebellum, probably by means of an equi- libria! mechanism. The auditory fibers decussate in the region of the nuclei, passing in the posterior extremity of the internal capsule to the 1052 UISEASES OF THE NERVOUS SYSTEM. opposite hemisphere. The cortical center is in the middle of the first temporo-sphenoid convolution. Destruction of that of the left side re- sults in uwrd-deafness ; thus, spoken words may be heard, but are not recognized as such. This is not a common condition. Rarely the audi- tory tract may be involved between the cortex and the nucleus. The nerve may be implicated at the base of the brain by tumors, aneurysms, hemorrhage, meningitis, and traumatism. Erb has described a primary nerve-degeneration in tabes dorsalis. Disease may attack the laby- rinth, either primarily or secondarily to ear-disease. Drugs — quinin, apiol, salicylates — may cause deafness similar to the labyrinthine variety. In anemia and in other conditions in which the general health is below par, also in hysteria, hearing may be affected. The lesions give rise either to an increased or diminished sense of hearing : (rt) Hyperacusis^ in which certain or all sounds are intensified. Paral- ysis of the stapedius muscle causes low notes to be heard Avith great in- tensity. Auditory hyperesthesia may also occur in hysteria or during the course of cerebral or general disease. {h) Dijsacusis — difiicult hearing — may be due to middle-ear disease, or it may exist as a "nervous deafness," the result of labyrinthine or nerve-disease. These may be differentiated by means of the tuning- fork. Normally, air-conduction is better than bone-conduction, and if in a deaf person a tuning-fork can be heard vibratins: lonojer when held against the skull-vault or temporal bone than in front of the ear, there is some impairment of conduction in the meatus or middle ear. When the patient is deaf, and yet the normal relation is maintained between air- and bone-conduction, the labyrinth or the nerve is at fault. (e) Tinnitus aurium — irritation of the auditory nerve — a condition in which subjective sounds occur, such as whirring, buzzing, ticking, or ringing in character. In certain subjects they are worse at night than during the day, and at times they are paroxysmal ; as a rule, in any case they are intensified when the general system is below par. Tinnitus may be caused by anemic or depraved nutritional states, intra-cranial aneurysm, pressure on the cervical sympathetic by enlarged glands, tumor, or aneurysm, impacted cerumen, otitis media, labyrinthine disturbance, blows upon the head, excessive auditory stimulation, loud noises, or it may occur during an attack of migraine or as an epileptic aura. In a neurasthenic individual the subjective noise, no matter what the cause, will be accentuated. The more complex and elaborate the sound, the greater the probability of its being of central origin. Treatment. — Careful search must be made for the cause of any of these morbid conditions just described, and when practicable they should be removed. The system should be brought into as good a condition as possible. In hyperesthesia bromids occasionally avail. In dysacusis little can be done when the cause is labyrinthine. The same is true when the nerve or its centers are involved. Counter-irritation and electricity may be tried externally, and iodids internally. These meas- ures should be employed in tinnitus, but M'ith more hope of relief; in addition, sedatives are generally called for. and even morphin may be necessary in paroxysmal attacks. MENIERE'S DISEASE. 1053 MENIERE'S DISEASE. Definition. — An aural or labyrinthine vertigo — originally described by Meniere in 1861 ; the cardinal symptoms are vertigo, deafness, noises in the ear, and sometimes vomiting. Pathology. — There may be an inflammation or atrophy of the nerve-endings. There are also changes in the labyrinthine membrane from any cause or from hemorrhage. etiology. — Meniere's disease is most common after thirty, and is rarely met with before that age. It is twice as common in men as in women. The precise lesion is labyrinthine, and is the result of exposure, gout, syphilis, senile change, congestion, and, more rarely, hemorrhage. Any cerebral disturbance or gastric or other irritation is apt to induce an attack. Symptoms. — Vertigo is present, and varies from an extremely slight transient attack, and one that is entirely subjective, to one of almost explosive violence. The patient may have a sensation of having been struck, and then of falling heavily to the ground. The slight form may be continuous with more or less frequent severe attacks, or a complete intermission of days, weeks, or months may transpire. The attacks may arise without apparent cause, or as a result of a blow^ or even a sudden movement, and occur during both working and sleeping hours. The giddiness, when severe, causes nausea and vomiting, and, if pro- longed, bile is vomited as in ordinary bilious attacks. AVhen the attack is very acute momentary unconsciousness supervenes. N^ystagmus and diplopia may occur during an attack. Tinnitus and deafness usually exist together, the former being constant, but of slight degree, and pos- sibly worse during an attack ; it may be entirely absent between the attacks. The latter (nervous deafness) is constant and of varying severity in different individuals. Diagnosis. — The occurrence of vertigo and tinnitus in a person with more or less nervous deafness, with or witliout gastric symptoms, establishes the diagnosis. The tinnitus and the character of the deaf- ness usually suffice to distinguish this from other forms of vertigo. In epilepsy with auditory auras the period of unconsciousness is generally much longer, and on regaining consciousness the patient is dull and drow^sy for some time. It is possible also, as a rule, to elicit a history of convulsions. Prognosis. — In some cases the condition grows progressively Avorse until deafness supervenes, when it ceases. Often, however, arrest or improvement, or even complete recovery, may be secured. In heart- disease the shock may prove fatal, and in the very acute but, fortunately, rare cases the prognosis is always bad. Treatment. — Counter-irritation over the mastoid process and the internal use of bromids to lessen the morbid sensibility Avill prove valu- able. The emunctories must be gotten in good condition, and any un- derlying disease, as syphilis or gout, must be treated. Charcot suggested the use of drugs that produce tinnitus — quinin, for instance. The cases were worse at the time, but some of them seemed to improve subse- quently. Gowers employs sodium salicylate in 5-grain (0.324) doses, thrice daily, believing that more good arises Avhen such drugs are given 1054 DISEASES OF THE NERVOUS SYSTE3L in moderation. Apiol might be tried in this connection. Nitroglycerin and the nitrites are sometimes of value in cases associated with arterio- sclerosis. DISEASES OF THE GLOSSO-PHARYNGEAL NERVE. The ninth cranial nerve has its origin in the posterior part of the floor of the fourth ventricle, in close relation with the pneumogastric nerve. Our knowledge as to its function is not exact, both because it is seldom if ever involved alone, and also, on account of its many connec- tions (with the trigeminus, the facial, the pneumogastric, and the sym- pathetic nerves), it is difficult to say whether the terminal fibers in- volved represent the functions of its roots or of one of its connections (Gowers). Its fibers are distributed to the tonsils, the back of the tongue, the soft palate, the pharynx, the Eustachian tubes, and the tympanic cavity. It supplies both motor and sensory fibers, but not those of taste. This nerve is involved in the nuclear degenerations that are spoken of as bul- bar palsies. It may be also affected by meningitis or new growths. DISEASES OF THE PNEUMOGASTRIC NERVE. As already stated, the origin of the tenth cranial nerve is in intimate relation with that of the ninth. It is also continuous below Avith that of the eleventh, and all three are associated with the center for the hypoglossal nerve. The nerve proper arises from the side of the me- dulla, and runs on either side of the neck in the sheath of the carotid artery, lying behind that vessel. It enters the thorax in front of the subclavian artery on the right side, and between the subclavian and the carotid on the left ; then it courses beside the esophagus, and is distrib- uted to the pharynx, larynx, lungs, heart, esophagus, and stomach, and sends fibers to the intestines and spleen. The esophageal fibers are both motor and sensory, gastric fibers being chiefly sensory. The vagus is in part the motor nerve of the intes- tines. It also contains both accelerator and inhibitory fibers for the respiratory center, is the cardiac inhibitory nerve and a vaso-dilator, and is said to contain trophic fibers for the heart and lungs. Btiologfy. — The nerve may be involved at its nucleus either by hemorrhage or softening. The nuclei of the ninth, eleventh, and twelfth nerves are simultaneously attacked, either wholly or in part, giving rise to a group of symptoms known as bulbar palsy. The tenth nerve at its superficial origin may be compressed by neoplasms, aneurysms, and the products of meningitis ; in its course down the neck it may suff"er pres- sure, or may either be tied in ligating the carotid artery or cut in the removal of a tumoi* or enlarged glands. Very rarely it may be injured by incised or punctured wounds, or be the seat of neuritis due to expo- sure or to some toxemia. The moi'bid conditions of the pneumogastric are best studied by considering the branches of distribution separately. [a) Pharyngeal Branches. — The muscles and mucous membrane of the pharynx are supplied by branches of the pneumogastric and glosso-pha- ryngeal nerves, constituting the pharyngeal plexus. The pharynx may DISEASES OF THE PNEUMOGASTBIC NERVE. 1055 be the seat of spasm or paralysis : this is purely a " functional " condition, and usually occurs in hysteric {globus hystericm) or in nervous indi- viduals. One of my own patients (a woman) after some domestic trouble became extremely nervous. She complained of increasing difficulty in swallowing, until finally she could scarcely take liquids, this symptom becoming aggravated when any one was watching her. She was cured by the daily passage of graduated esophageal bougies. Paralysis of the pharynx causes difficulty in swallowing, so that food remains in the mouth instead of being passed into the esophagus. Par- ticles often enter the larynx and give rise to paroxysms of coughing, and at times cause choking. When the soft palate is also paralyzed, the food is regurgitated into the nose. The lesion is generally nuclear, causing bulbar paralysis. The root of the nerve may be involved as it leaves the side of the medulla by meningitis or by pressure from a neo- plasm or an aneurysm. Rarely it may be caused by a toxic neuritis. {b) Laryngeal Branches. — The superior laryngeal nerve furnishes sensory fibers to the mucous membrane of the larynx above the vocal cords, and supplies also the crico-thyroid and epiglottidean muscles. The inferior or recurrent laryngeal nerve, which takes its origin in the superior thoracic region, winds around the arch of the aorta on the left side and around the subclavian artery on the right, reaching the larynx by running up between the trachea and esophagus. It is the sensory nerve of the larynx below the vocal cords, also of the entire trachea, and supplies all the muscles of the larynx except those named above. It has been shown that the motor fibers of the larynx come from the glosso-pharyngeal nucleus, the pneumogastric fibers being sensory. Spasm of the larynx is due to over-action of the glottis-closers (the adductors), though some cases described in this category are probably instances of abductor paralysis. The condition is rather rare in adults, but quite common in children (laryngismus stridulus), and particularly in rachitic subjects. An attack may also be induced in those predisposed by any form of nerve-irritation or catarrhal condition of the respiratory tract. It may be part of a general neurosis ; it is sometimes seen in tabes dorsalis {laryngeal crisis) ; and Liveing reports that he has seen it take the place of an attack of migraine. Sj^astic aphoria consists of a spasm induced whenever an attempt to speak is made. Laryngeal spasms occur most frequently at night. Dyspnea is the most striking symptom, and is so intense in some cases that suffocation seems immi- nent. The patient may be cyanotic. Soon the retained carbonic acid gas causes relaxation, but, as the cords open slowly, the inspiration is accompanied by a crowing sound, and the expiratory sound is harsher than normal. Paralysis of the larynx may be the result of a nuclear degeneration (glosso-pharyngeal), producing chronic bulbar paralysis, as already mentioned ; this form may occur in disseminated sclerosis, tabes dor- salis, general paralysis of the insane, and in certain toxemias. The paralysis is generally bilateral ; rarely it is unilateral. Very rarely a cerebral cortical lesion in the laryngeal center may cause pseudo-bulbar paralysis. Since the two centers are compensatory, the lesion must be bilateral. The nerve may be involved at its root or in any part of the trunk, 1056 DISEASES OF THE NERVOUS SYSTEM. and such lesions are usually unilateral. The recurrent laryngeal nerve, especially the left, is more apt to be diseased than the superior, on account of its position. Thus, the arch of the aorta is more frequently the seat of an aneurysm than the subclavian ; enlarged thoracic glands, neoplasms, and an enlarged thyroid can also damage these nerves. The peripheral filaments may be attacked as part of a multiple neuritis. In certain cases the muscles become weakened without being para- lyzed, this possibly being due to a local neuritis, or to a congestion and inflammation of the mucous membrane from over-use {clergymen s sore throat), or as the result of exposure. The following are the chief forms of paralysis : (1) Complete Paralysis. — By this is generally understood paralysis of all except the crico-thyroid and epiglottidean muscles, though occa- sionally these may also be involved. Since the cords are paralyzed, phonation is impossible. As a rule, there is no interference Avith respi- ration, though the pressure of the in-going air may bring the cords nearer together, and thus produce a certain amount of inspiratory harshness. « As the cords cannot be closed, coughing is impossible, as the air escapes through the glottis, and no expulsive force can be given to it. When the paralysis is unilateral these symptoms will of necessity be modified, and some degree of phonation may be possible. The most common cause of this condition is an involvement of the recurrent laryngeal nerve : the lesion may, however, be nuclear or in the course of the nerve-trunk. (2) Paralysis of the Abductors. — The only special abductor muscles are the posterior crico-arytenoids. When they are involved the glottis fails to open in inspiration, and the unopposed adductors bring the vocal cords together. They are still more closely approximated during inspi- ration by the column of air, and hence the prolonged, stridulous inspi- ratory sound. Phonation and expiration are practically unchanged. It is quite likely that many cases supposed to be instances of hysteric spasm of the glottis are really cases of abductor paralysis. In unilateral paralysis the normal movements of the unaffected vocal cord prevent any marked degree of dyspnea and stridor : phonation is usually hoarse and of a low pitch. In cases of long duration the symp- toms become more marked as the unopposed adductors undergo second- ary contracture and still further naiTOw the glottis. This condition may be due either to central disease or to some local change. The abductor muscles mav be desenerated, while all the other laryngeal muscles are healthv, or one or both recurrent nerves mav be affected. These nerves innervate both the abductors and adductors, and it is not clearly understood why the abductors alone should suffer when the parent nerve-trunk is involved. At any time it might be a very grave condition, for should any swelling of the cords supervene nothing but a prompt laryngotomy could prevent suffocation. (3) Adductor Paralysis. — The cords move normally during respira- tion, and hence there is no stridor : as they cannot be approximated, however, phonation is impossible. This condition is met with in hys- teria, pi'oducing hysteric aphonia, in public speakers who overtax their voices, and also in laryngitis. BISEASBS OF THE PNEVMOGASTBIC NERVE. 1057 The following table, from Gowers' text-book on Diseases of the Ner- vous System, enables one to get a comprehensive idea of the subject; Symptoms. No voice ; no cough ; stri- dor only on deep inspi- ration. Voice low-pitched and hoarse ; no cough ; stri- dor absent or slight on deep breathing. Yoice little changed ; cough normal ; inspiration diffi- cult and long, with loud stridor. Symptoms inconclusive ; little affection of voice or cough. No voice ; perfect cough j no stridor or dyspnea. Signs. Both cords moderately ab- ducted and motionless. One cord moderately ab- ducted and motionless, the other moving freely, and even beyond the mid- dle line in phonation. Both cords near together, and, during inspiration, not separated, but even drawn nearer together. One cord near the middle line, not moving during inspiration ; the other normal. Cords normal in position, and moving normally in respiration, but not brought together on an attempt at phonation. Lesions. Total bilateral palsy. Total unilateral palsy. Total abductor palsy. Unilateral abductor palsy. Adductor palsy. Sensory disturbances of the larynx are rare, and especially hyperes- thesia. Anesthesia may be due to hysteria, or to bulbar paralysis, or to disease of the superior laryngeal nerve. It is dangerous, as food may enter the windpipe. (c) Cardiac Branches. — These with branches from the sympathetic form the cardiac plexus. The vagus contains both accelerator and in- hibitory fibers, but the latter predominate ; therefore irritation of the nerve, either centric or peripheral, will sIoav the heart's action. Czermak was able to slow the action of his heart by pressing a small tumor in his neck against the vagus nerve. When the function of the nerve is lowered, inhibition is removed and the heart's action becomes rapid. This may be brought about by a toxemic neuritis, by pressure, accidental ligature, or by incised or punctured wounds. Various emotions and nervous states may bring about the same result. {d) Pulmonary Branches. — Both accelerator and inhibitory fibers ex- ist, but in this case the accelerator influence predominates, so that irri- tation results in increased respiratory movements or even in bronchial spasm, since the bronchial muscles are also supplied by this nerve. It is this nerve that is supposed to be concerned in the production of asth- matic paroxysms. Therefore, when the nerve-function is lowered the respirations become much slower. The nerve is supposed to contain trophic fibers for the lungs. (e) Esophageal, (/) Gastric, and {g) Intestinal Branches. — The esoph- ageal branches are rarely damaged, and irritation (spasm) occurs niore frequently than paralysis. The pneumogastric gives the sensory, and in part the motor, nerve-supply to the stomach, and irritation gives rise to increased contractions with some pain. The sensation of hunger is supposed to be associated with the vagus nerve, and vomiting may result from direct or reflex irritation. Par- 67 1058 DJSEAS>ES OF THE NERVOUS SYSTEM. alysis causes some diminution of the gastric contractions. Normally, the vagi accelerate intestinal peristalsis. Treatment. — It is almost always impossible to remove the cause of the above conditions. Syphilitic lesions are probably the most amen- able, and in the various laryngeal palsies electricity may be employed, though it is of somewhat doubtful utility, and in abductor palsy may possibly exert a harmful influence by stimulating the adductors. Strych- nin and general tonics should be administered. Massage of the larynx may be tried, and in spasmodic conditions attention should be directed to the general physical state. All sources of nerve-irritation should be removed if possible, and bromids, or even chloral, should be given. DISEASES OF THE SPINAL ACCESSORY NERVE. This nerve consists of two parts — an external or spinal, and an in- ternal or accessory, portion. The latter has already been described in connection with the pneumogastric nerve. It forms the motor portion of that nerve, and is distributed to the laryngeal and pharyngeal mus- cles. The spinal element arises from the multipolar ganglion-cells in the anterior gray horns of the cervical cord, ascends and enters the cranium through'the foramen magnum, and leaves it, after joining with the accessory part, through the jugular foramen. It supplies the sterno- mastoid muscles and in part the trapezius. Injury or disease of the nerve may result in spasm or paralysis. Only the spinal part is considered in this section. TORTICOLLIS. ( Wry-neck.) This may be a congenital or an acquired condition. Congenital torticollis, or "fixed wry-neck," is the result of an atrophy and shortening of the sterno-mastoid muscle, brought about by some intra-uterine condition or, possibly, by an injury at birth. The right muscle is most commonly affected. The head turns slightly to- Avard the sound side ; the eye may deviate, and curvature of the cervical spine may develop. Facial asymmetry is a usual concomitant of this condition. The face on the same side as the lesion develops less rapidly than the other side, and in time secondary contracture of the unopposed muscles takes place. The torticollis can be cured by tenotomy, but the facial asym- metry persists. Fixation is necessary for a while when contracture exists. Spasmodic wry-neck may be tonic or clonic. These forms may co- exist, alternate, or occur independently in different individuals. The condition is met with almost exclusively in adults, and occurs most frequently in middle-aged men. Pathology. — No macroscopic or microscopic evidence of any lesion has been discovered, and the condition is probably dependent upon an over-activity of the neurons in the various centers that control the muscles of the affected part. Ktiology. — The influence of sex and age has been mentioned ; a n^EASES OF THE SPINAL ACOESSORY NERVE. 1059 neurotic heredity may also predispose. Torticollis may follow habit- spasm, or some injury to the head or neck, or exposure to cold, the latter constituting the "• rheumatic " type. In a case of my own, a man of 23, it followed an attack of acute articular rheumatism and was associated with high arterial tension. Rarely, robust, healthy-looking individuals are at- tacked without any apparent cause. Cervical caries may cause rigidity of the neck, simulating torticollis. The spasm is usually tonic in such cases, as it is in those of the "inflammatory " type, where, in children partic- ularly, enlarged and painful glands are found under the sterno-mastoid. Symptoms. — The occiput is drawn toward the shoulder of the affected side, the chin is elevated, and the face rotated more or less toward the sound side. The sterno-mastoid may alone be affected, or the trapezius may also be involved. In the latter case greater depression of the head takes place. Spinal curvature may ensue, the convexity being toward the sound side. This only takes place in cases that have existed for some time. Clonic spasm is infinitely more distressing and more apt to be permanent. Some pain and muscular twitching may precede the onset of the attack, though, as a rule, muscular contractions are the first indication. These are mild at first, and rarely abruptly, more commonly slowly, they increase in severity. As the case progresses other muscles, and even those of the arm, become involved. Cases have been described in which certain muscles or groups of muscles in the hand or arm have been primarily affected, the condition gradually spreading from them. The spasm usually ceases during sleep. An attack may cause pain, but, as a rule, it induces merely a feeling of fatigue in the muscles ; it is worse if the patient is excited or emotional. Bilateral spasm may occur, the muscles of both sides being equally affected (retro-coUic sj^asm). Gowers speaks of a case in which the backward displacement of the head was so great that the face was horizontal and looked directly upward. Diagnosis. — As a rule this is not difficult. When spasm is in- duced by enlarged and painful glands beneath the sterno-mastoid the age of the patient will be of value in determining the true condition. This usually occurs in children ; true wry-neck, on the other hand, very rarely commences before the thirtieth year. Hysteric spasm may also simulate spasmodic torticollis, but it generally occurs in young women, and usually other evidences of hysteria are also present. The rheumatic type and the rigidity induced by caries of the spine must be differentiated from one another and from spasmodic wry-neck. If the rigidity comes on suddenly, folloAving exposure to cold or wet, and the pain is not in- creased at night or by depressing the head upon the spine, and is re- lieved by hot applications, the condition is probably rheumatic. When the rigidity and pain are of slow onset, without history of exposure, and the pain is both worse at night and is increased by depressing the head upon the spine, but is relieved by elevating the head, the condition is very probably one of caries of the spine. Prognosis. — Very rarely the torticollis may diminish or even cease after an existence of months or years. Usually, however, it is persist- ent, either being stationary or slowly increasing in severity and widen- ing in range. The prognosis must always be guarded, and in severe cases grave as to recovery, though the disease does not shorten life. 1060 DISEASES OF THE NERVOUS SYSTEM. Treatment. — Generally very little can be expected from medica- tion. Bromids, morphin, chloral, hyoscyamus, or cannabis indica may be tried, as may the various forms of counter-irritation. Morphin ad- ministered hypodermically, has been most effectual in some cases, but the danger of establishing the habit should not be forgotten. Galvanism should be tried, the negative pole being placed over the occipital region and the positive over the affected muscles. Nerve-stretching and ten- otomy of the affected muscles is of very little value. The only surgical procedure that has proved of any distinct value is neurectomy, with excision of a part of the nerve to prevent reunion. This necessarily causes paralysis and atrophy of the muscles supplied ; but, since it often abolishes the spasm, the slight loss of power and the interference with the movement of the head are comparatively infinitesimal. The results, however, are not uniform even so far as the spasm is concerned. PARALYSIS OF THE SPINAL ACCESSORY NERVE. The accessory portion has been previously considered in describing the laryngeal branches of the pneumogastric. In the spinal portion the nuclei may be involved in degenerative lesions of the motor region of the spinal gray matter. The nerve-trunk may be damaged by pressure from exudative products (meningitis), tumors, or caries, with resulting paralysis and Avasting of the sterno- mastoid and, in part, of the trapezius. This latter muscle is also sup- plied by the cervical nerves. The patient has difficulty in rotating the head to the side opposite that on which the paralysis exists, and the affected muscle does not stand out in movements of the head. Unless secondary contraction of the unopposed muscle sets in, no deviation oc- curs when the head is at rest. The only portion of the trapezius that is involved in paralysis of the external part of the eleventh nerve stretches from the occipital bone to the acromion. The normal contour of the neck is lost in such cases, and the ability to raise the arm is in- terfered with because the trapezius cannot fix the scapula, the fulcrum of the deltoid. Bilateral paralysis may occur as in progressive muscu- lar atrophy ; if both sterno-mastoids are involved, the head falls back- ward ; if both trapezii, it falls forward. The treatment is that of the underlying cause. If the lesion is nuclear, practically nothing can be done. If the condition is due to pressure, in some cases relief may be obtained. Electricity and mas- sage should be employed during the recovery of the nerve. DISEASES OF THE HYPOGLOSSAL NERVE. The nucleus of the twelfth cranial nerve is in the most posterior por- tion of the floor of the fourth ventricle. It is said by some observers that the nuclei of the fibers for the palate and vocal cords that run in the spinal accessory nerve may be in the lower part of the twelfth- nerve nucleus. The cortical center for this nerve is in the lower part of the ascend- ing frontal convolution, in the neighborhood of the cortical facial cen- ter. This propinquity probably explains the simultaneous involvement DISEASES OF THE HYPOGLOSSAL NERVE. 1061 of the facial and lingual muscles in some cases. The hypoglossal is the motor nerve for the tongue and for most of the muscles attached to the hyoid bone. Spasm or paralysis may follow disease of the nerve. Spasm may be either unilateral or bilateral. It is probably met with most commonly in hysteria, or as a part of some general convulsive condition, as epilepsy or chorea. It may also be associated with facial spasm, as mentioned above. Irritation of the fifth nerve (dental caries, ulceration of the gums) seems to be responsible for some cases. "Paroxysmal clonic spasm " is a form in which the tongue is rapidly thrust in and out. Various sensations in the affected region may pre- cede the attack. A rare form — aphthongia — is induced when an attempt to speak is made. The prognosis in this condition is good, and a gen- eral tonic treatment is indicated. Paralysis may result from supra-nuclear, nuclear, or infra-nuclear lesions. Supra-nuclear. — The lesion may be anywhere between the cortex (lower part of the ascending frontal gyrus) and the medulla, and causes paralysis on the opposite side. In this condition the affected muscles do not atrophy nor do they show any electric change. Nuclear. — The lesion is usually degenerative. It may either be of sudden onset (vascular), less rapid, but still acute (inflammatory), or it may be chronic, as in bulbar palsy or tabes dorsalis. The nuclei are so close together that the condition is almost invariably bilateral. Infra-nuclear. — The fibers may be injured by the pressure of neo- plasms or by the products of meningitis or of syphilis. Disease of the bone may also involve the nerve in its passage through the foramen. More rarely, some traumatism or disease of the upper cervical vertebrae may simultaneously injure the eleventh and twelfth nerves. Symptoms. — Paralysis and atrophy of one or both sides of the tongue and fibrillary twitchings may be noted, and if the condition be unilateral, the tongue when protruded deviates toward the affected side. Articulation, mastication, and swallowing are but very slightly interfered with. In the bilateral form, however, these are very much impaired ; the tongue cannot be protruded and lies motionless on the floor of the mouth. The atrophy is muscular. This throws the mucous membrane into deep folds. Sensation and taste are unaltered. Diagnosis. — If the lesion is supra-nuclear, there is hemiplegia on the same side as the lingual paralysis, without atrophy of the tongue- muscles. When nuclear, it is, as has been said, generally bilateral and forms part of a bulbar paralysis. There is also wasting of the lingual muscles. When the fibers are involved in the medulla, there is paral- ysis of the tongue on one side, of the limbs on the other, and the tongue deviates from the paralyzed side of the body. Outside the medulla the condition is, as a rule, unilateral, and the spinal accessory fibers are frequently involved. In the nuclear and infra-nuclear varieties there is wasting of the muscles. The prognosis is usually unfavorable, and the treatment consists of a course of general tonics and of mercury and the iodids, with counter-irritation. Electricity may also be tried. 1062 DISEASES OF THE NERVOUS SYSTEM. DISEASES OF THE SPINAL NERVES. DISEASES OF THE CERVICAL PLEXUS. Phrenic Nerve. — This nerve is usually involved as a result of some lesion of the ganglion-cells in the anterior gray horns at the level of the third or fourth cervical nerve. The trunk may be damaged by pres- sure, as by aneurysm or neoplasms, or by traumatism, or it may be the seat of neuritis. More or less immobility of the diaphragm follows, amounting in some cases to complete paralysis. This is not readily seen with the patient at rest, and in women it is specially hard to ob- serve, as their breathing is chiefly of the costal type. The abdomen moves in in inspiration, and out in expiration, forming the reverse of the normal movements. Immobility of the diaphragm may also occur in peritonitis, diaphragmatic pleurisy, and in large pleural efiusions. Exertion readily causes dyspnea, and pulmonary diseases are apt to be exaggerated as the products of secretion accumulate. This is most apt to occur when the condition is bilateral, as it usually is in the presence of cord-lesions. Other muscles always suffer in this form in addition to the diaphragm. When the nerve alone is involved the affection is generally unilateral. DISEASES OF THE BRACHIAL PLEXUS. This may either be involved m toto, or any of its branches may be affected separately, or the nerve-roots that unite to form the brachial plexus. Considering first the roots, the only nerve worthy of notice arising from them is the posterior thoracic, which supplies the serratus magnus muscle. This may be injured directly by pressure, as in the carrying of heavy loads on the shoulder or by a fall or other traumatism. Rarely, it follows exposure to cold. Its involvement may be a part of an ante- rior polio-myelitis or of progressive muscular atrophy. When the muscle is paralyzed the posterior edge of the scapula stands out prominently, and particularly when the arm is moved forward. Neuralgic pains in the neck generally precede the neuritis. The course of the disease is always slow. During the early stage counter-irritation, the iodids and mercury internally, and later electric stimulation to keep up the tone of the muscles, constitute the treatment. Combined Paral7/sis. — Two or more nerves, or even the entire plexus, may be involved at one time by new growths in the cervical region, neuritis, stretching or rupture of the nerves by wounds, fractures, or dislocations, and particularly by subcoracoid dislocation. Duchcnne has described a form of palsy produced in infants during birth by pres- sure due to some malposition or to injury by the finger or a hook. Brachial neuritis may follow some injury to one of the nerve-branches (ascending neuritis), or it may be primary. The latter variety is rare, and usually occurs after middle life, especially in cases Avith a gouty history. Paroxysmal or continuous pain, increased by any movement of the arm and tenderness on pressure over the affected nerves, is the chief symptom. If on the left side, it simulates angina pectoris. Individual Nerves of the Arm. — These may be damaged by pressure DISEASES OF THE BRACHIAL PLEXUS. 1063 due to a tumor, an aneurysm, or to callus. Sleep-'palsy and crutch-palsy are both pressure-palsies. The nerves may also be contused or torn in fractures or dislocations, and palsy may follow a fall or blow upon the shoulder ; I have seen it occur in a heavy man after a fall upon the hand. Primary or secondary neuritis may develop, and, very rarely, neuromata appear. The supra-scaindar nerve supplies the supra- and infra-spinati mus- cles. Paralysis causes imperfect outward rotation of the humerus and rotation of the scapula, Avith elevation and inversion of the lower angle. Various movements of the arm are thereby interfered with, and the limb tires very readily. More work is thrown on the deltoid, and in time it hypertrophies, causing it to stand out more prominently against the infra-spinatus. The skin over the scapula is usually anesthetic. The circumflex nerve supplies the deltoid and teres minor and the skin over the deltoid and the shoulder-joint. Paralysis results in inability to raise the arm and in wasting of the muscles, wnth or with- out anesthesia. Adhesions may form in the joint. The musculo- spiral nerve is more often paralyzed than any other nerve of the arm, its position rendering it particularly liable to pressure. It supplies the triceps and supinator muscles, and is the extensor nerve of the arm. It also supplies the skin on the radial side of the dorsal surface of the hand, the back of the thumb, and the index and radial side of the middle finger. A lesion high up results in paralysis of the extensors of the elboAV, wrist, and hand, and of the supinators. Prob- ably the point most commonly attacked is about the middle of the humerus. In such cases the triceps escapes. The characteristic symp- toms, how^ever, are wrist-drop and finger-drop, consisting of an inability to extend the hand on the forearm, also the first phalanges of the fingers and thumb. In pressure-palsies the power of supination is usually lost also. Sensory symptoms vary, and are seldom pronounced. There may be slight impairment or tingling or burning sensations. This condition can usually be differentiated from lead-palsy by the rapidity of onset — by the fact that pressure-palsies are almost invari- ably unilateral, and that the supinators are involved. Lead-palsy has a slow onset and is bilateral, generally without supinator involvement. Loss of sensation precedes the pressure-palsy. The history too wall generally throw some light on the case. I have seen a case of right- sided unilateral wrist-drop in a man who worked in lead with his right hand only. Bilateral Avrist-drop may occur in any form of toxic neur- itis, but the involvement of other nerves, the manner of attack, and the history of the case Avill serve to simplify the diagnosis. Recovery follows in almost all cases of musculo-spiral nerve-involve- ment, though in cases in which qualitative nerve-changes have taken place it is necessarily delayed. The treatment is that of neuritis. The median nerve supplies the pronators, digital flexors, except the ulnar half of the deep flexor, the radial flexor of the wrist, the abduc- tor and flexor muscles of the thumb, and the two radial lumbricales. It furnishes sensation to the radial side of the palm and front of the thumb, and to the front and back of the first and second and half of the third fingers. This nerve may be the seat of an injury or of neuritis, but is 1064 DISEASES OF THE NERVOUS SYSTEM. seldom involved alone. The most striking symptoms are wasting of the thenar eminence and an inability to oppose the thumb to the tips of the fingers. Further pronation is only possible in so far as the supinator longus subserves that function — viz. the misposition. Ulnar flexion of the Avrist alone remains. Flexion of the phalanges is interfered with. Sensation may or may not be lost. The ulnar nerve supplies the ulnar flexor of the wrist, the ulnar half of the deep flexor of the fingers, the muscles of the little finger, the adductor and inner head of the short flexor of the thumb, the inter- ossei, and some of the lumbricales. It supplies Avith sensation the front of one and a half and the back of two and a half fingers on the ulnar side. Paralysis causes radial deviation of the hand in flexion of the wrist, loss of adduction of the thumb, and inability to move the little finger. The hypothenar prominence disappears. The first phalanges cannot be flexed, and the second and third can- not be extended. This is exaggerated in old cases, though still it is not so marked as the " claAv hand" of progressive muscular atrophy, since the first two lumbricales escape, being supplied by the median nerve. Sensory symptoms vary. The diagnosis is usually easy. It is well to remember that, since this nerve is the lowest in its point of origin of any considered in this group, ascending cord-diseases will involve it before any of the other brachial nerves. It may also be damaged by disease limited to the low- est part of the cervical enlargement of the cord. DISEASES OF THE LUMBAR AND SACRAL PLEXUSES. The lumbar plexus or its branches may be involved by abdominal growths, enlarged glands, psoas abscess, disease of the vertebrae, neuritis, and rarely by wounds or dislocation of the hip or during parturition. The Obturator Nerve. — When the power of adduction of the thigh is lost and the aff"ected leg cannot be crossed over the other, outward ro- tation is somewhat impaired. Anterior crural 7ierve paralysis causes loss of power and wasting of the extensors of the knee, loss of knee-jerk, and anesthesia of most of the thigh and the inner side of the lea; and foot. The superior gluteal nerve supplies the gluteus minimus and medius muscles. When it is involved adduction and circumduction of the thigh are lost. The sacral plexus and its branches may be damaged by pelvic neo- plasms or inflammation, neuritis (generally secondary to sciatic nerve- involvement), pressure during labor, wounds, dislocations, aneurysms, and diseases of the bone. The small sciatic nerve supplies the gluteus maximus muscle. It is seldom involved alone. Lesions cause difficulty in rising from the sit- ting posture and anesthesia of the back of the thigh and of the upper part of the leg posteriorly. The great sciatic nerve supplies the flexors of the leg and the mus- cles below the knee, and also sensation to the outer half of the leg, the sole, and part of the dorsum of the foot. Paralysis causes more or less ACUTE ASCENDING PARALYSIS. 1065 interference with the act of walking, anesthesia in the part supplied, and wasting of the muscles. The external popliteal or peroneal nerve supplies the tibialis anticus, the peronei, the long extensor of the toes, and the extensor brevis digitorum ; it also supplies sensation to the outer half of the front of the leg and to the dorsum of the foot. Paralysis causes foot-drop and toe-drop, rendering it necessary to lift the leg high in walking, so that the foot will clear the ground; this constitutes the stepp>age gait referred to in the section on Neuritis. The region supplied is anesthetic. ^he internal p>opliteal nerve ?,Vi'^^\\es, the popliteus, tibialis posticus, the calf-muscles, the long flexors of the toes, and the muscles of the sole. When paralyzed, flexion of the foot and toes is impossible, and sensa- tion is lost over the back of the leg in its lower part and over the sole. In old cases talipes calcaneus results. The plantar nerves are rarely, if ever, involved alone. ACUTE ASCENDING- PARALYSIS. (.Landry's Paralysis.) Definition. — An acute paralysis, beginning in the legs and ascend- ing by way of the trunk and upper extremities, and ultimately involving the medullary centers. It usually runs a short course, and, as a rule, terminates in death. Pathology. — Although in many cases neither gross nor microscopic lesions have been found, either in the cells, peripheral fibers, or muscles, it is believed to be either an acute myelitis or an acute polyneuritis, the weight of opinion seeming to favor the latter view. Ross arrived at the latter conclusion after an analysis of 93 cases. Nauwerck, Barth, and Centanni hold the same belief, and the latter has discovered a bacillus in the lymph-spaces of peripheral nerves. Remlinger ^ has reported a case occurring in a young man in whom paraplegia developed acutely, and eleven days later death resulted from bulbar involvement. Postmortem the cord was found congested in the region of the anterior horns. Microscopic examination revealed the presence of inflammation in the cervical cord. The multipolar ganglion-cells of the anterior horns were degenerated, and between them were found streptococci. Pure cult- ures of streptococci were obtained from the cord at various levels, but they were non-pathogenic for the rabbit. R. and F. Schultze and Sinkler have also reported cases in which the only postmortem lesion was mye- litis, yet, as stated, the majority of observers believe it to be a neuritis. That it is primarily due to some toxemia, however, as originally claimed by Westphal, cannot be gainsaid. The prodromes, Avhen present, are suggestive, and the enlargement of the spleen, which is a constant con- comitant, and more rarely the lymphatic enlargement and albuminuria, are all confirmatory. That the poison should have a selective tendency, since the nervous involvement is chiefly or solely motor, is not unique. We meet with toxic paralysis of the motor muscles of the eye, also with lead-palsy. ^ Gazette hebdomadaire de Medecine et de Chirurgie, No. 27, 1896. 1066 DISEASES OF THE NERVOUS SYSTEM. Ktiology. — Xo definite cause is known. It has followed cold and exposure, traumatism, and the infectious fevers, including influenza. Remlingers case, quoted above, followed malaria. It occurs in males chiefly between twenty and forty years. Symptoms. — In the most acute cases there are practically no pro- dromal symptoms other than malaise and possibly chilly sensations. Weakness, followed in a few hours or a day or two by paralysis, de- velops in the lower extremities. One may be involved a few hours earlier than the other. It sjareads toward, and soon involves, the trunk also, and in quick succession the arms. The third and usually fatal stage is reached when bulbar symptoms develop. Very rarely the upper extremities may be first attacked. Death may occur in forty- eight hours. The paralysis is a flaccid one ; the muscles can be passively moved without offering any resistance. Wasting sets in, but no electric changes. In less acute cases a decided febrile stage precedes the onset of paralysis, chills, fever, malaise, and possibly formication or even sharp pain. In any case the later symptoms are pre-eminently or solely motor. Sensory symptoms when present are very slight. Sensation may be delayed, and the reflexes are generally absent ; accordingly, there is edema or sweating. The bladder and rectum are not implicated, nor do bed-sores develop. As stated, when the bulb is attacked death gen- erally follows, due to cardiac or respiratory failure or to interference with deglutition. There are no cerebral symptoms. Course. — Death may occur in from forty-eight hours to a few weeks. A few cases of recovery have been reported, however, in some of which paralysis had been widespread, even reaching the bulb, judging from the labored respiration. When improvement takes place, it does so in the reverse order to the onset, so that the part last affected is the first to recover. It is much slower than the invasion. Diagnosis. — The rapid onset of a paralysis that usually ascends, the relaxation of the muscles, slight wasting, if any, and the absence of electric changes and of sensory symptoms, with or without fever, serve to make the diagnosis, and to distinguish Landry's disease from polio- myelitis, neuritis, and spinal hemorrhage. For the diff"erential diagnosis between Landry's paralysis and acute myelitis, see page 1072. Progfnosis. — Always grave, particularly if bulbar symptoms occur, and especially if they appear early. The treatment is essentially the same as that for any acute disease of the cord or nerves — i. e. rest, freedom from all excitement or worry, moderate purgation and diaphoresis ; ergot, belladonna, and iodids in- ternally. Should the patient survive, electricity and massage should be administered. DISEASES OF THE SPINAL CORD AND ITS MENINGES. 1067 II. DISEASES OF THE SPINAL CORD AND ITS MENINGES. DISEASES OF THE MENINGES. Mexixgitis is very rarely a primary condition. Both the dura and pia may be involved. In the former case the inflammation is usually due to some morbid condition of the vertebrae, vrhile in the latter it is sec- ondary to some toxemia, as in pyemia, sepsis, pneumonia, typhoid, or the acute exanthemata. It may be part of a tuberculous condition {vide Tu- berculosis, p. 278) or of epidemic cerebro-spinal meningitis. Injuries and, it is said, exposure to cold, also lead to inflammation of the me- ninges of the cord. PACHYMENINGITIS . Definition. — Inflammation of the dura mater. The dura may be involved on its outer or inner surface [iJ a cliy meningitis externa or in- terna), or the loose connective tissue bet-«-een the dura and bony canal may be the seat of a peripachymeningitis. "Pacliymeningitis externa is always secondary, and usually results from syphilitic or carious aff"ections of the bone, or from pressure due to tumors or to traumatism. It may either be acute or chronic. Of the latter type, those cases due to Pott's disease are most common. The membrane is involved to a greater or less extent. The internal surface may escape entirely, or it may be slightly roughened and adherent to the arachnoid ; externally, however, the dura is usually thickened, rough, and covered with a cheesy material. Pachymeningitis interna was first described by Charcot in 1871, and named ^'■pachymeningitis cervicalis Jiypertrophica." It is of obscure origin. The dura is generally much thickened, and gives the impres- sion of being made up of a number of concentric layers. The pia is only involved to a slight degree as a rule. Areas of degeneration may occur in the cord, as may also dilatation of its central canal. As implied by the name, this variety of pachymeningitis is found chiefly in the cer- vical region, and the clinical symptoms result from involvement of the nerve-roots. It is a chronic process, and has been divided into three periods, as follows : (rt) The painful period, lasting, as a rule, two or three months, in which severe neuralgic pains exist, their location being determined by the roots involved. They are mostly in the occiput and upper extremities, however. Early there may be hyperesthesia, numbness, tingling, and, rarely, an herpetic eruption. (5) The Paralytic Period. — As a result of compression of the motor roots an atrophic paralysis of the upper extremities develops. A peculiar selective tendency is manifested, the radial nerve being spared, while the median and ulnar nerves are involved. This results in a modified "claw-hand" deformity and in an over-extension of the wrists, Avith flexion of the fingers. Anesthesia may be noted, {e) Spastic Paraplegia. — This results when the compression has produced degeneration of the cord. Generally, there are paresis of the lower extremities and increased reflexes, but no muscular wasting, since the trophic centers are intact. Occasionally, hoAvever, anesthesia 1068 DIS]i!ASES OF THE NERVOUS SYSTE3I. and paralysis of the legs and bladder develop, bed-sores following, with death from exhaustion. The prognosis must be guarded, each case being carefully looked into and diagnosed fi-om amyotrophic lateral sclerosis, syringomyelia, and from pressure by tumors. From the latter the condition is very difficult to differentiate, cervical spondylitis and neoplasmata often giving rise to the same symptoms. The first-named condition does not give rise to sensory disturbances ; moreover, bulbar symptoms are often present, the lower extremities atrophy, and the bladder functions are preserved. Syringo- myelia induces characteristic changes in thermic sensibility, and oftea anesthesia, but rarely severe neuralgic or radiating pains. Pachymeningitis haemorrhagica interna, or hematoma of the dura mater, may occur in any part of the cord, and is usually associated with a similar condition in the cerebral dura. Cysts may be found in the inner surface of the dura, containing broken-down blood-cells and hematoidin crystals, and in their neighborhood an increase of fibrous tissue may be noted. The condition occurs most frequently in alcoholics or general paralytics. Treatment is not of much avail. Counter-irritation, potassium iodid, and electricity are the chief measures. LEPTOMENINGITIS . Definition. — Inflammation of the pia mater. This may be either acute or chronic. ACUTE LEPTOMENINGITIS. {Acute Spinal Meningitis.) Pathology. — The vessels are injected, the membrane becomes cloudy, a sero-fibrinous or purulent exudate either surrounds the cord or may only exist in patches, and in the more severe cases the cord itself is involved {meningomyelitis). The spinal meninges alone may be in- volved to a greater or less extent, but as a rule, the cerebral meninges are similarly involved. Ktiology. — Rarely is this a primary disease. It may be met with — (1) In tuberculosis, in which the cerebral symptoms predominate. (2) In cerebro-spinal meningitis, an epidemic, specific infectious disease. (3) As a condition secondary to one of the infectious fevers, as pneumonia, typhoid, and influenza. This, however, is very rare. It should be re- membered that many cases presenting clinically the picture of meningitis show absolutely no postynortem lesions of the cerebral or spinal membranes. This is especially true of pneumonia and influenza. The condition in such cases is probably a toxic encephalopathy. (4) In myelitis. In certain cases the pia becomes involved, due to extension from the cord. (5) In injuries. (6) As a result of cold and exposure, though probably rarely. Symptoms. — These are chiefly pain in the back, often excruciating, with fixation, retraction of the head, tenderness on pressure along the spine, tremors or spasm of the muscles, and various sensory disturbances. Reflexes are early increased, and later diminished or absent. Should the cord be involved, paralysis, incontinence of urine and feces, and even bed- sores, may develop. The symptoms are more fully discussed in speaking of the tuberculous and epidemic varieties. Diagnosis. — It is often very difficult to diffei'entiate the several HEMOBBHAOE INTO THE SPINAL MENINGES. 1069 varieties of spinal meningitis, and equally so to decide whether the case is actually meningeal when some other disease is present. Even bulbar symptoms may be present without postmortem lesions ; I have seen this typified in a case of Bright's disease. The tuberculous form is readily diagnosticated, especially if any collateral evidence of tuberculosis ex- ists. It is a point of some value in the diagnosis to note the absence of marked leukocytosis in tuberculous and its presence in purulent men- ingitis. The presence of Kering's sign is in favor of cerebrospinal meningitis. Spinal paracentesis or lumbar jjuncture, first introduced by Quincke of Kiel in 1891, is a most valuable diagnostic measure and simple of ap- plication. He was first led to adopt it by the knowledge that a free communication exists between the subarachnoid spaces of the brain and spinal cord through the foramen of Magendie ; hence he conceived the idea of a lumbar puncture supplanting the older method of tapping the lateral ventricles in cases of hj^drocephalus. Later, he used it in menin- gitis. Therapeutically, it is of little value. The patient should be in a sitting posture with a slight forward inclination of the trunk. The punc- ture is then made between the third and fourth lumbar vertebrse and a little to one side of the middle line. Absolute cleanliness should be observed, and the needle introduced slowly until the fluid begins to flow by its own pressure. The prognosis is unfavorable as a rule, particularly in the tuber- culous form. The treatment is the same as that of cerebro-spinal meningitis (vide p. 131). CHRONIC LEPTOMENINGITIS. This disease may follow the acute form or be due to chronic alcohol- ism, syphilis, trauma, or disease of the cord. Pathology. — The pia is cloudy and swollen, and often adherent to the arachnoid, or all three membranes may be glued together. They are usually injected. An exudate fills the meshes of the arachnoid. The periphery of the cord is occasionally affected at the same time. Symptoms. — These are not well marked. Unless the nerve-roots are involved the symptoms are slight or none at all exist ; however, pains of a radiating character, stiffness, tremors, hyperesthesia, herpes, and even paralyses, may occur. The course is slow, and may extend over many years. The prognosis is unfavorable ultimately. The treatment consists in the use of iodids and mercury internally, and the application of baths, and counter-irritation along the spine. HEMORRHAGE INTO THE SPINAL MENINGES. (^Meningeal Apoplexy ; Hematori'achis. ) (a) Extrameningeal hemorrhage occurs when the blood is between the dura and spinal canal. (b) Intrameningeal hemorrhage is that in which the bleeding takes place within the dura. 1070 DISEASES OF THE NERVOUS SYSTEM. Large hemorrhages are very rare in any case, but are more common in the extrameningeal form ; they result from trauma or rupture of an aneurysm. The peridural space will accommodate a large amount of blood without giving rise to pressure-symptoms. Caries of the vertebrae or carcinoma may cause hemorrhage by erosion and rupture of a blood- vessel. The intra-raeningeal form is somewhat more common, and may either result from meningitis or occur as a complication of any of the infectious diseases. In such cases the hemorrhages are small and scat- tered. It may also occur in convulsive disorders or in strychnin-poison- ing. Rupture of an aneurysm at the base of the brain may give rise to extensive hemorrhage, and in a case of syphilitic ventricular apoplexy in a young man I found, postmortem, that the blood had leaked out and infiltrated the spinal meninges for some distance. Symptoms. — AN^hen the hemorrhage is large enough to cause pressure, the symptoms are very acute, apoplectiform indeed, but consciousness is preserved. Generally, however, they are quite indefinite. In any case they depend upon the degree and location of the compression. At first they are irritative — viz. hyperesthesia, paresthesia, neuralgic pains that are radiating in character, herpes, muscular irritability, tremors, or con- tractions. Later, paralytic symptoms may develop, as anesthesia and bladder- and bowel-symptoms, girdle pains, or, when the lesion is high up, interference with respiration, and pupillary changes. The diagnosis is often difficult, unless the onset is sudden and explosive. The prognosis depends on the cause and extent of the hemorrhage. If small in amount, absorption is usually prompt, with little or no dis- turbance of function remaining. The treatment consists of rest, ice to the spine, counter-irritation, wet- or dry-cupping, leeches or venesection, ergot, opium or gallic acid internally, and later the iodids and electricity. In certain cases operative procedures, with a view to removing the clot, may be justifiable. DISTURBANCES OF CIRCULATION IN THE CORD. These include (jualitative and quantitative changes in the blood, and morbid conditions of the vessel-walls. The blood-vessels may be the seat of peri- or endarteritis, and rarely miliary aneurysms may develop. Embolism and thrombosis also occur, the former much less frequently than the latter, which is prone to follow sclerotic changes in the vessels, giving rise to ischemia and ultimately to softening. Congestion. — We are justified in noticing this as a possible cord-lesion, but it is questionable if it has any clinical significance. It is safe to as- sume that it occurs in the general stasis of circulatory disorders, yet no characteristic symptoms develop. It is very rarely met with jjostmortem. Anemia. — This condition, like the preceding, rarely gives rise to symptoms. Dr. William A. Hammond has described a certain group of S3'mptoms as due to spinal congestion, and another to spinal anemia. DISTURBANCES OF CIRCULATION IN THE CORD. 1071 but his teachings on this point are not generally accepted. Simple anemia of the cord, per se, cannot be recognized clinically. During the past few years, however, many observers have reported certain and distinct j^osf- mortem findings, with or without clinical evidences that the same have occurred during life, in cases of grave anemia, particularly in pernicious anemia and to a lesser extent in leukemia. Whether the anemia is the direct cause of the cord-lesions, or, what seems more likely, whether the anemia and cord-lesions are both produced by some toxemia, remains to be proved. Lichtheim was the first to recognize and call attention to the subject, although Leichtenstern in 1884 reported 2 cases of "tabes " associated with anemia. He was unable to elicit any history of syphilis, nor had crises occurred. In 1887, Lichtheim reported 3 cases of perni- cious anemia that presented at the same time symptoms pointing to a lesion of the cord. The first had weakness, ataxia and rigidity of the legs, low- ered knee-jerks, paresthesise, and normal pupillary reaction. The second case was similar, but the third had lancinating pains and absent knee- jerks. Autopsies were made upon the first two. More or less complete degeneration of Goll's columns was found, and the pyramidal tracts were also involved, but to a lesser extent. Small foci of degeneration were also found in the anterior and lateral columns. He regarded it as due to a toxic process. Later, his pupil Minnick published several cases in which no evidence of spinal-cord disease occurred intra vitarti, yet in none of them was a normal cord found postmortem. Some showed the same changes that occur in hemorrhages of the cord, while others presented degenerative changes of varying degrees in the posterior columns. In all of them Clarke's and Lissauer's columns and the posterior roots were normal. Dr. K. Petren, a Swedish physician, has described a case in which Lissauer's column was also involved. He holds the same view as Lichtheim with reference to the cause, and significantly mentions the changes that take place in the nervous system in certain cases of diabetes evidently toxic in nature. Since then Williamson has reported 3 cases of diabetes mellitus in which degeneration of the posterior columns was found. Cord-changes have been found also in leukocythemia, chronic jaun- dice, and in persons reduced by other long-standing illnesses. Dr. Putnam has published a series of 8 cases belonging to this latter category. They were adults past middle life, the majority being women in an enfeebled condition. Postmortem he found system-sclerosis of the spinal cord, asso- ciated with diffuse collateral degeneration. He also found some degener- ation of the cells of the gray matter, and, to a less extent, of the periph- eral nerves. Nonne and Eisenlohr in Germany, Taylor and Bowman in England, and Burr in this country, have also reported cases of cord- lesions associated with grave anemia. The chief symptoms described have been progressive weakness, paresis of all the extremities (particu- larly the lower), ataxia, and in some cases weakness of the bladder. The knee-jerks are either increased, diminished, or absent. There are sen- sory disturbances (paresthesia) and lancinating pains occur very rarely. Whatever part the anemia plays, it seems that the fundamental cause is a toxemia, and I venture to say that this fact may throw some light on those cases of tabes, and even of chronic myelitis, in which no history of syphilis or other predisposing cause can be obtained. Further, it seems to me that they may be compared with those toxic conditions described by Duke 1072 DISEASES OF THE yERVOUS SYSTEM. in England and McLane Hamilton in this country that have their chief incidence upon the cellular elements of the brain. Treatment. — The indications are to keep the emunctories active. High enemata should be given, flushing the bowel with large amounts of sterile normal salt^-solution. Internally, calomel, salol, beta-naphtol, arsenic, and iron may be employed. HEMORRHAGE INTO THE SPINAL CORD. {Uematomyelia ; Spinal Apoplexy.) This is a very much less frequent occurrence than cerebral hemor- rhage. It is usually due to traumatism, but may follow cold or exposure or some severe strain or over-exertion (in the latter probably only when the vessels are atheromatous). Hemorrhage may occur in cases of mye- litis, epidemic cerebro-spinal meningitis, syringomyelia, tumors of the cord, convulsive disorders, and infectious diseases ; it is, however, usually small. If the hemorrhage is extensive, disruption of more or less cord- substance necessarily follows. An area may exist large enough to cause distention of the cord without rupture, and from this extravasations may take place in the cord-substance above and below. Unilateral hemorrhage may occur, the gray matter being chiefly involved. If of recent origin, fresh blood will be found postmortem ; but if of long standing, a brown or brownish-yellow area will be noted, consisting of disintegrated blood- corpuscles, cell-detritus, and hematoidin crystals. The symptoms necessarily vary according to the region involved. The hemorrhage may be sudden, giving rise to an apoplectiform onset ; or gradual, with slowly increasing symptoms. There is generally a back- ache, followed by paralysis, a loss of sensation and of the reflexes, and in some cases a loss of control of the bladder and bowel. In less grave cases the early symptoms will be those of irritation, while later paralytic symptoms supervene. If the hemorrhage is slight, absorption soon takes place, with complete recovery ; but quite often more or less paralysis re- mains. Myelitis develops in some cases, the patient growing progressively worse and dying of exhaustion. Dr. C. E. Riggs has reported a rather unique case in a woman forty-five years of age, who developed paraplegia after a nervous shock three years before comingr under his observation. When he first saw her she had impaired sensation of the lower limbs and of the trunk as far up as the xiphoid cartilage. The legs Avere spastic, with increased reflexes. She had neither lancinating pains nor ataxia, but was profoundly anemic, and grew progressively worse until death ensued from exhaustion. Postmortem, an area of extravasated blood was found in the mid-dorsal region of the spinal canal, and hardening degeneration was noted in the anterior and crossed pyramidal tracts, direct cerebellar and posterior columns, and in Lissauer's tract. The degeneration ex- tended from the first cervical to the fifth lumbar vertebra. This case was remarkable — first, from the fact that the hemorrhage of the cord was due to anemia ; secondly, on account of the extent of the degeneration, and particularly because of the fact that Lissauer's column was involved. ACUTE MYELITIS. 1073 The diagnosis is always difficult, for when of sudden onset, unless aided by the etiology, it will be impossible to diagnose the condition from spinal meningeal hemorrhage. In other cases it must be differentiated from myelitis and multiple neuritis. Treatment. — Rest, ice locally, and the internal use of ergot and opium make up the treatment. ACUTE MYELITIS. [Myelitis; Acute Diffuse Myelitis ; Transverse Myelitis; Spinal Malacia.) Definition. — An inflammation, with softening, of the cord, giving rise to various groups of symptoms depending upon the region or regions involved, and not, therefore, as constant in its symptomatology as the systemic nervous diseases (tabes dorsalis, lateral sclerosis). Pathology. — The cord may present little or no change to the naked eye, or in the most acute cases it may be diffluent. Between these ex- tremes many grades exist in which the pia will be found congested and adherent, the cord being more or less ingested and areas of softening, and even cavities, being found. Three forms of softening are spoken of by some writers — the red, yellow, and gray — depending upon the pre- dominance of blood, fat, or connective tissue respectively. The postmor- tem finding depends upon the duration of the disease ; the more chronic the course, the greater the amount of nervous connective tissue (neurog- lia), and in consequence sclerosis Avill be the predominant feature. The nerve-cells and fibers are found in various stages of disintegration, the former being swollen, vacuolated, granular, and their processes broken and in many cases missing ; while the latter swell, the myelin breaks up, un- dergoes fatty change, and is removed, and the axis-cylinders finally break up and disappear. A single area of degeneration may exist cen- trally, in one half of the cord, transversely, or many localized or widely- disseminated areas may be found ; but above and below all of them will be found degenerated fibers — ascending and descending degeneration — due to a solution of continuity between the cell-body and its axis-cylinder process. Ktiology. — Myelitis may follow exposure (especially in alcoholics), the infectious fevers (chiefly measles and small-pox), and it may be due to traumatism or disease of the vertebrae (caries, malignant disease). Syphilis is also said to cause it, though it may only act as a predisposing agent. It has also been described as following peripheral neuritis, ascending neuritis, and we meet with some cases in which pregnancy seems to act as the predisposing cause. Embolism and thrombosis may rarely cause it. It is most common in males, generally from fifteen to thirty years of age. Symptoms. — These Avill vary according to the seat and extent of the lesion. In the most acute form the course of the disease is quite rapid, reminding one of hemorrhage into the cord or membranes ; the onset, however, is not so explosive, and, though rapid, it is not sudden. It is 1074 DISEASES OF THE NERVOUS SYSTEM. most apt to follow cold or exposure. The most acute case I have ever seen occurred in an alcoholic who had lain out one night in a drunken stupor. There may be chills and fever, malaise, backache, pains in the limbs, and, rarely, convulsions ; quite often, however, there is no Avarn- ing. Motor weakness develops, and is rapidly followed by paralysis. Some irritative sensory symptoms appear, as hyperesthesia and pares- thesia, and then more or less complete anesthesia supervenes. The re- flexes are generally lost ; there is incontinence of urine and feces, and bed-sores and cystitis develop Avith frightful rapidity. The temperature now rises to 105° F. (-1:0.5° C) or even higher, and typhoid symptoms, exhaustion, and death close the scene. I have seen 1 case that developed in a woman a few days after delivery and proved fatal in six days. Acute transverse myelitis is the type most frequently met with, how- ever, the lesion being generally situated in the dorsal cord. The consti- tutional symptoms marking the onset are more pronounced than in the previous type and are of longer duration ; but they are much less pro- nounced in the later stages. They are apt to simulate a rheumatic attack, with malaise, fever, muscular pains, anorexia, chills, and possibly sweating. In from a few days to a week spinal symptoms reveal them- selves, the motor generally appearing before the sensory symptoms, though they may be contemporaneous, or the sensory symptoms may even appear first. In any event, they are apt at first to be irritative. The limbs will feel tired and heavy and drag in walking, and tremors or twitching occur, even cramps, and later paralysis, partial or complete, in the region involved. The lower limbs may alone be involved, or when the lesion is in the cervical region paralysis and atrophy of the upper with a spastic condi- tion of the lower extremities may develop. The breathing is generally diaphragmatic in cases in Avhich the intercostal muscles are involved. If the lesion is still higher up, death Avill quickly take place from failure of respiration. Such cases, however, are more apt to occur in the type known as disseminated myeUtis, in Avhich bulbar symptoms are prone to appear. The sensory symptoms at first are those of a tingling or burning character, or formication. Later, certain or all forms of sen- sation may be lost, and, roughly speaking, the upper level of anesthesia corresponds to the level of the cord involved. This " boundary re- gion " is apt to be hyperesthetic, and in it the "girdle-feeling" is ex- perienced. The reflexes may be lost at first, but soon return, and be- come exaggerated below the lesion. The condition of the trunk-reflexes may enable one to locate the position of the cord-lesion. There is not much wasting of muscles, as a rule, nor does the reaction of degeneration develop, unless the lesion is in the lumbar or cervical cord, when both will occur. Loss of control of the boAvel and bladder may be among the earliest sj'mptoms, though this is not the rule. While superficial ulcer- ation may occur in any neglected case, the most marked trophic changes take place in those in which the lumbar cord is involved, either directly or by extension. In such cases, despite the most assiduous attention, extensive bed-soi'es develop. The course of the disease depends on the cause and the extent of the lesions. Death may occur in a few Aveeks from exhaustion, heart or respiratory failure, or from kidney-disease sec- ondary to cystitis. Recovery is the rule, though a\ itli more or less per- manent damage due to degeneration of some of the paths of conduction. CHRONIC MYELITIS. 1075 Diagnosis. — Tlie distinction from hemorrhage into the cord or mem- branes has already been mentioned. From Landry's paralysis it can be separated by a reference to the subjoined table : Acute Myelitis. Landry's Disease. Paralysis is sudden and generally be- Paralysis begins in the feet and rapidly comes complete. spreads to the muscles of respiration and deglutition. Wasting and bed-sores are marked. Trophic disturbances are absent. Reactions of degeneration are distinct. No reactions of degeneration. Early involvement of the sphincters. Bladder and rectum are not involved. Girdle-pains sometimes mark the height „. ,, of the lesion. Girdle-pains are absent. Ajiterior poliomyelitis is not accompanied by sensory symptoms. In jye- ripheral neuritis pain of a shooting character is more apt to be present, and is almost invariably the first symptom to appear. Motor symptoms may not appear for some days. This is not the case in myelitis. In compression of the cord sufficient collateral evidence can usually be ob- tained to differentiate it from myelitis. Hysteric ijaraplegia is occa- sionally misleading. The character of the patient and the previous his- tory should be thoroughly considered ; moreover, in this form there are no trophic changes, and as a rule no bladder-symptoms ; at any rate, there is no cystitis. Retention of urine may occur, but not incontinence. The diagnosis of myelitis can usually be made without great difficulty from the motor and sensory symptoms, the preservation of the knee-jerk, the vesical, rectal, and trophic symptoms, and often from the presence of the girdle-sensation in addition. Prognosis. — The most acute cases are fatal in from three days to a week. Less acute cases generally recover with more or less loss of motor power. Treatment. — Very little can be done to arrest the process in acute myelitis. The actual cautery should be tried as a counter-irritant, or an ice-bag may be applied to the spine. The patient should be placed on an air- or water-bed. Trophic changes should be looked for daily, and at the first sign of their appearance alcohol or some stimulating liniment should be employed. If the skin is broken, absolute cleanliness must be observed, and the wounds dressed antiseptically. It is well, also, to change the patient's position from time to time to avoid too long-continued pressure in any one spot. Ergot or ergotin should be given internally, and, especially in specific cases, potassium iodid. A general tonic and sup- portive treatment is indicated, and later massage, electricity, and baths. CHRONIC MYELITIS. That there are both a subacute and a chronic form of myelitis is gen- erally conceded, though these types are not sharply circumscribed. As has been previously mentioned, it is quite likely that many cases exist in Avhich the clinical symptoms do not seem to warrant the diagnosis of 1076 DISEASES OF THE NERVOUS SYSTEM. myelitis, and yet extensive areas of degeneration *"may be found post- mortem. Even some cases of supposed hysteria may have a distinct pathology. Pathology. — The lesions are most apt to be disseminated or diffuse, though there may be a single focus. Histologically, the chief differences from the acute variety consist in the greater amount of sclerosis, the thickened blood-vessels with contracted lumen, and an entire absence of recent hemorrhage. In some cases also the pia is much thickened in patches and firmly adherent. The nerve-cells are either seen to be in advanced stages of degeneration or they have actually disappeared. Secondary degenerations, above and below, proceed from the primary foci. Ktiologfy. — Any of the causes capable of giving rise to acute mye- litis may cause the chronic variety, either by acting sloAvly over a long period of time or by their influence upon a person whose tissues are re- sistant. A process originally acute may become chronic, or a succession of acute attacks may give rise to a chronic condition. Gout, alcohol, and syphilis seem especially prone to cause chronic lesions. The condition may also be secondary to meningitis and to certain toxic blood-conditions other than those that have been mentioned. Symptoms. — Any symptom occurring in the acute may be dupli- cated in the chronic form, though the onset of the latter is gradual. The symptoms are more or less obtrusive according to the region of the cord that is affected. If the cervical and lumbar regions are not impli- cated, no definite symptoms will be present, and probably there will be nothing more than subjective sensations and progressive weakness, with possibly some muscular wasting. The most characteristic features of a Avell-marked case are the irregular and successive involvement of various parts. There will be motor weakness, possibly of an arm, followed sooner or later by sensory impairment. Then one of the lower extremities may become involved, and ultimately paralysis will supervene. When the lesion is single this irregular onset is less apparent. In chronic trans- verse myelitis of the lumbar region, for instance, there will be paresis of the lower extremities, simultaneously or successively involved. The on- set, however, is gradual, and months may elapse before the paraplegia will be complete. A girdle-sensation is apt to be present, together with lowered sensibility, and loss of sensation is very rarely absolute. The knee-jerk is increased, ankle-clonus is present, and in time the muscles become spastic. The sphincters are frequently implicated. Atrophy of the muscles is most pronounced when the anterior gray matter of the cervical or dorsal region is involved, but this may occur in any case. The reactions of degeneration can rarely be elicited. Diagnosis. — The gradual, and in many cases the irregular, onset characterize this disease. In its various phases it may simulate almost any spinal-cord disease, and it is most apt to be confounded with tumor, pressure (carious or malignant), primary lateral sclerosis, progressive muscular atrophy, and syringomyelia. I^ressitre, whether due to a tumor, to caries, or to malignant disease, is apt to cause pain radiating in character, and the last two usually present collateral evidences in the deformity and cachexia. The symptoms, too, are always bilateral, while those of myelitis may be unilateral. From progress/re muscular atrophy ANTERIOR POLIOMYELITIS. 1077 it may generally be diagnosed by the irregular course it pursues. Apart from the painless ulcerations and the dysesthesia that usually occur in syringomyelia, it may be impossible to diagnose it from the latter disease. The prognosis is necessarily grave. Recovery may be possible, but it is extremely rare. The process, however, may be arrested in some cases, and the strictly focal forms are less apt to prove fatal than the dis- seminated or diffuse. Treatment. — More can be expected from general hygienic measures than from the use of drugs. In the early stages rest is indicated, but it is well also to employ passive exercise, to prevent, if possible, a too great contraction of the muscles. As soon as expedient — each case being judged on its merits — the patient should be taken out of doors. Change of air and of scene is advisable, as are also baths and massage. Mild counter-irritation may be applied to the spine, but care should be taken to avoid the areas of anesthesia. General tonics, iron, quinin, arsenic, and strychnin, should be given, also mercury or the iodids. The greatest possible care of the bladder should be taken in order to avoid cystitis. ANTERIOR POLIOMYELITIS. ESSENTIAL PARALYSIS OP CHILDREN. {AtropMc Spinal Paralysis.) Definition. — A febrile disease of more or less rapid onset, associated with muscular paralysis and atrophy, occurring chiefly in children, and most frequently in those under three years of age. Pathology. — The condition is generally unilateral, and is a true focal myelitis ; hence we find congestion, softening, and even cavity- formation. Microscopically, the chief feature observed is the de- struction of the multipolar ganglion-cells of the anterior horn. If the examination is not made until months or years have elapsed since the onset, the condition will be about as follows : More or less asymmetry of the cord in the region affected, with sclerotic changes at the site of the lesion, and probably in the pyramidal tract also. The anterior nerve- roots of the same side will be found atrophied, and the muscles wasted, having undergone fatty degeneration and fibrous change. etiology. — The precise cause is not known, but the following pre- dispose to the affection — viz. age, exposure, acute diseases (particularly those known to be infectious), and warm weather. The disease may occur at any age, but by far the greatest number of cases occur before the third year of life ; they are about equally distributed between the two sexes. Later in life the condition is more common in males, chiefly between the ages of ten and twenty-five. It is rare after this period. Epidemics have been described, and, notably, one occurring during the summer of 1894. Dr. Caverly of Rutland, Vt., then reported 126 cases occurring in Otter Creek Valley, a limestone region of Vermont. At the 1078 DISEASES OF THE NERVOUS SYSTEM. same time domestic animals — liorses, dogs, and hens — were affected with a paralytic disease, this fact still further supporting the idea of an infec- tious origin. A similar epidemic has occurred in Ohio. Symptoms. — The onset is generally acute, and may be sudden, in which case it is due to hemorrhage. Such cases do not strictly belong to this category, but they have been included, since the nervous symp- toms are similar. Constitutional symptoms are absent as a rule. More- over, when prodromal febricula precede an explosive onset of paralysis (hemorrhagic), we are justified in regarding it as a case of poliomyelitis. Generally, the sequence is as folloAvs : Fever (usually slight), malaise, possibly vomiting (especially in children), muscular twitching, headache, and restlessness. In a few hours, or after one or two days, paralysis su- pervenes and quickly spreads, involving a greater or less area ; it then re- mains stationary for from two or four days to from five to 'eight weeks, when improvement takes place, beginning in the part last affected. In some cases, after a most trifling indisposition over night, paresis is met with in the morning. In a few weeks only that portion remains paralyzed that is to be permanently damaged. Wasting of the muscles will be noticed a week or two after the onset of paralysis ; these become flaccid and give the reactions of degeneration. Sensory symptoms are very rarely present — so seldom, indeed, that they need not be reckoned Avith. The reflexes are lost, both superficial and deep, and later contractures develop and result in various deformities. The growth of bone is seriously im- paired in some cases. Complete recovery rarely takes place, nor is it to be expected when we consider the destruction of the neuron-body. Diagnosis. — Usually this is not difficult, except, possibly, for the first few days in some cases. Close scrutiny will enable one to differen- tiate between this disease and a pseudo-palsy the result of pain on active or passive motion, as seen in rickets, scurvy, and in hip-joint disease. Prognosis. — Some impairment of motion and more or less wasting of the muscles almost invariably remain. Danger to life, however, is very remote, though the subjects of infantile paralysis are predisposed to intercurrent affections, since their natural degree of resistance is lowered. The more rapid the loss of faradic irritability the less the extent of recovery. Treatment. — I think we are justified in regarding this disease as infectious, probably caused by a specific micro-organism, although it is possibly an auto-intoxication. If this is granted, it behooves us to act promptly and render the emunctories in good condition. If the case is seen early, a few doses of calomel may be given, and these followed by a saline. Copious enemata of boiled water thrown high up into the bowel should also be employed. Should the fever be high, it must be met, as in any other case, by sponging or even by a cool bath, cold compresses to the head, and internally by the bromids, aconite, and the spirits of nitrous ether. During the febrile stage, or at least for a few days or a week, it is advisable to keep the patient in bed. The affected parts should be wrapped in cotton, and countei'-irritation may be applied to the spine. As soon as possible the child is to be taken into the fresh air. It is of vital importance to keep up the general systemic tone, and hence the ne- cessity for fresh air, change of scene, and for nourishing but easily digest- ible food. During this period massage and electricity should be employed, togrether with the administration of strvchnin. In the later stages, when ABSCESS OF THE SPINAL CORD. 1079 contractures have set in, mechanical appliances may be necessary to cor- rect deformity and to give support. ACUTE, SUBACUTE, AND CHRONIC POLIOMYELITIS IN ADULTS. 1. Acute atrophic spinal paralysis of adults, as the acute form is called, has essentially the same symptomatology as the corresponding disease in children, except that the onset is apt to be more pronounced. Convulsions, however, scarcely ever occur. When pain is a prominent symptom we should be guarded in making a diagnosis. Initial pain is significant of a nerve-lesion, particularly if sensory disturbances can be found, and such cases would indicate a neuritis and not a poliomyelitis. Presumably the incidence of the poison has been on the axon, and not on the neuron-body, this view being consonant with the complete recov- ery that is sometimes seen in adults. When true poliomyelitis has ex- isted complete recovery probably never occurs. 2. The subacute form has been described by Duchenne as ^'•paralysis general spinale anterieure subaigue." It comes on, as a rule, without apparent cause, and the initial symptoms are very slight. In a few weeks failure of power is noticed in the limbs and paralysis gradually supervenes. After lasting for some time partial recovery follows, the paralysis and mus- cular atrophy remaining in a limited region only. 3. That chronic poliomyelitis exists has been proved by Oppenheim and other observers ; yet it is probable that most cases described under this heading have been due to peripheral and not to central lesions. In neuritis, however, the paralysis is either unilateral or bilateral, and in the latter case it is symmetric, differing in this point from the irregular dis- tribution of centric disease. Pain is common, and there is also tenderness along the nerve-trunks as a rule. Recovery from neuritis may be perfect ; at all events, it does not present the tendency that is met with in poliomyelitis to clear up per- fectly, except in a limited area. Treatment. — The general line of treatment that I have given for the infantile type is equally applicable in these forms. Ergot and bella- donna may be used in the early stages, and, later, mercury or the iodids in small doses. Electricity and massage are of the greatest value. ABSCESS OP THE SPINAL CORD. It is rare for inflammation of the cord to give rise to pus, yet a few cases have been described. The suppuration is necessarily micro-organ- ismal in origin, and as a rule is either due to some septicemia or trauma- tism, or secondary to purulent meningitis. The symptoms are those of myelitis, but may be masked by any associated condition. 1080 DISEASES OF THE NERVOUS SYSTEM. UNILATERAL LESION OF THE SPINAL CORD. {Broivn-S^quanVs Spinal Paralysis.) This is not a distinct disease, but rather a grouping of certain symp- toms, first studied by Brown-S^quard,^ and hence bearing his name. It is met with particularly as a result r2f 3' 2 1 Itl t tl of injuries (knife-thrusts and the like), though it may also be due to tumor or caries of the cord, to syph- ilis, or to any process causing compression of one-half of the cord. Such lesions intercept the motor impulses of the same side; the fibers having crossed in the medulla, the sensory fibers cross in the cord soon after entering, and hence sensation will be absent on the side opposite to the lesion {vide Fig. 74). A lesion in the cervical cord above the arm-nuclei causes motor paralysis of both arm and leg of the same side (spinal hemiplegia) and sensory paralysis on the opposite side. If in the dorsal or lumbar cord, the leg on the corresponding side is para- lyzed, while that of the other is anesthetic. Lesions are seldom strictly confined to one side of the cord, but overlap a trifle, so that there is apt to be some loss of power on the anesthetic side ; this, however, may be due to the redecussation of a few motor fibers at a lower level. The side of the lesion is hyperesthetic — a fact for Avhich no satisfactory explanation has ever been advanced. Muscular sense is diminished or lost on the same side. Above the hyperesthetic region an area of anesthesia commonly exists, and above this, again, an area of hyperesthesia. The reflexes are increased on the side of the lesion (inhibition being removed), and the temperature of that side is usually higher. On the anesthetic side the motor power, reflexes, muscle-sense, and temperature are all normal. Sometimes the sensory symptoms are limited to loss of pain and tem- perature sense. > Med.-Ckir. Trans., 1889. Fig. 74.— Schematic representation of course of main tracts In tiie cord, represented for a single pair of roots (Erb): v, anterior roots; h, posterior roots : 1 , patlis for motor and vaso- motor conduction ; 2, patlis for muscular sense ; 3, paths for cutaneous sensibility on the right; 1', 2', 3', the same paths on tlie left. The arrows indicate the direction of physiologic conduc- tion. LOCOMOTOR ATAXIA. 1081 LOCOMOTOR ATAXIA. (Tabes Dor sails ; Posterior Sclerosis.) Definition. — A systemic sclerosis alBfecting the posterior columns of the cord. In many cases foci of degeneration occur in the basal ganglia. The disease is characterized by a loss of coordination, ab- sence of the knee-jerk, fulgurant pains, and the Argyll-Robertson pupil. Pathology. — Macroscopically, it may be observed — 1. That the posterior roots are more or less atrophied and grayish in color. 2. There is a thickening and adhesion of the spinal membranes, with some degree of congestion, particularly noticeable in the posterior region (not a constant change). 3. There is a slight change in the shape of the cord, and the affected regions assume a grayish tint. Change of color is well seen after the cord is hardened. Microscopically, degeneration of the peripheral sensory nerves will be found in certain cases to be more marked at the periphery and to diminish as the main trunks are reached. Rarely, changes in the motor nerves will be met with also, but only in cases in which the anterior horns are affected. The spinal ganglia are usually normal. Fig. 75. — Diagram of primary degeneration-areas and secondary degeneration of the fibers in the beginning stage of tabes (Leube) : ps&, pyramidal tract; ksb, cerebellar tract; hwf, posterior root-fibers ; Iff, lateral entrance of delicate root-flbers ; k, area of earliest degeneration ; r, marginal zone; sg, substantia gelatinosa; cv, Clark's columns; i. anterior zones (remaining free) ; sc, sensory collateral fibers ; hrc, collateral reflex of posterior column ; src, collateral reflex of the lateral column; , healthy fibers; , degenerated fibers. 4. There are degenerative changes in the posterior, and occasionally in the anterior roots (vide Fig. 75). 5. Cord-changes are present, consisting in the early stages of a de- generation of the fibers of the Spitzka-Lissauer column, of the post-root zone of Charcot, of the fibers going to the column of Clark, and of the comma tract. As the disease progresses more and more of the posterior columns — Goll and Burdach — is claimed, with the fibers of Gowers' col- umn, the intermedio-lateral tracts and even the direct cerebellar tract. 1082 DISEASES OF THE NERVOUS SYSTEM. This latter is onl}^ affected, however, when the cells of Clark's column are involved. While the chief incidence of the poison, whatever this may be, is upon the nerve-fibers, yet we do meet with cases in which the posterior root-cells are diseased ; as already stated, the cells of the anterior horn may be diseased also. There is an overgrowth of neuroglia that takes the place of the degenerated fibers, and when the membranes are thickened the strands of connective tissue dipping into the cord take on added growth. 6. There are cerebral and medullary changes. There may be some change in the nuclei of the columns of Goll and Burdach and in those of some of the cranial nerves. In addition to changes in the nervous system, certain cases present some morbid condition of the osseous sys- tem, consisting of erosion of the interarticular cartilages and atrophy and absorption of the bony articulating surfaces. Htiology. — Mace. — White races are more susceptible than negroes ; and the disease is less frequently met with among the Jews than among other white classes. Sex. — Males are more liable to the disease than females, in the proportion of 10 to 1. -V/^- — Most common between the ages of thirty and forty. S't/philh. — Since Fournier in 1875 first pointed out the relationship between these two diseases, the opinion has steadily gained ground, despite the view of Leyden and other German authorities, that a large majority of tabetic cases (observers differ as to the proportion) have an antecedent history of syphilis. It must be clearly borne in mind that locomotor ataxia is not syphilis of the cord and brain, but a distinct entity, in most cases of which, however, syphilis stands as a predisposing factor. It will be remembered that in the description of anemia of the cord, lesions resembling those of tabes are found as a result of various toxemias, and it Avas suggested that this might throw some light on those cases in which no syphilitic history can be obtained. Exposure and sexual excess are possible factors: likewise traumatism. Alcohol is said to cause tabes, but this is very doubtful ; it may certainly give rise to pseudo-tabes, the peripheral form. In England, Growers has noted that locomotor ataxia occurs more freemen tlv among urban than among rural populations. Symptoms. — These may be grouped according as they occur in the early or late stages. The early or preataxic stage is one of variable duration ; lasting, possibly, but for a few Aveeks in some cases ; but as a rule it is distinctly chronic, even extending over many years. During this time pains of a peculiar type (fulgurant) develop. They are sharp and shooting, of sudden onset, and of just as sudden cessation ; they do not recur in precisely the same place, but may occur in any part of the nervous supply of the affected region of the cord. Herpes may ap- pear along the course of the nerves. The knee-jerk is either diminished or absent in by far the largest number of tabetics, though should hemi- plegia occur later it Avill reappear. Ocular symptoms are characteristic — the myosis and the absent light- reflex, with normal response to accommodation, constituting the Argyll- Robertson pupil. Other ocular symptoms may be present, however, and one of the earliest to develop may be strabismus with or without ptosis. LOCOMOTOR ATAXIA. 1083 Diplopia may be the first evidence pointing to ocular involvement. Other eye-muscles may be affected also, producing ophthalmoplegia. Atrophy of the optic disk may be noticed at this stage. It usually begins as a circumferential change, and only gradually encroaches on the center ; hence vision may not be noticeably impaired for some time. If an ex- amination be made, however, during this period, it will be found that the field of vision is contracted. Rarely the auditory nerve becomes diseased, causing deafness. After a variable period of time certain motor symptoms are super- added. The patient may notice that he experiences some difiiculty Avhen walking in the dark. He will stagger or stumble, or, while Avashing his face, he may observe that he cannot balance himself properly with his eyes closed. Romberg's sign can now be elicited — viz. when the eyes are closed, and particularly if the feet are held close together, it will be noticed that station is imperfect. Later he finds that even in the day- light he has difficulty in maintaining his equilibrium. At first he can- not stand with his feet close together. This difficulty is greatly accen- tuated when the eyes are closed. Ere long the characteristic gait is manifest. The legs are spread wide apart, the patient leans forward, using one or even two canes, and.Avith eyes fixed upon the ground a few feet in front of him thro avs one leg around, at the same time lifting the foot higher than is really necessary and bringing it down on the heel. As a general rule there is no muscular wasting, and hence there is no loss of motor powder. A certain degree of incoordination of the arms is present in many cares, but is unobtrusive. Sensory Symptoms. — Apart from the pains already noted, these con- sist of paresthesia, numbness, tingling, burning ; anesthesia and hyper- esthesia of irregular distribution : retardation of the transmission of sen- sory impulses ; in some cases a peculiar condition in which a pin-prick on one leg, for instance, will be referred to the other {allocMria^, or in which one point of contact made by some one is felt in many places at once {polyesthesia). Usually the patient feels as though he were walk- ing on cotton or felt. Muscle-sense is more or less impaired in every case ; hence the difficulty experienced by these cases in recognizing any position in which a limb may be placed. Sexual power is usually lost early. Certain visceral symptoms., or crises, as the French term them, are prone to occur. They are chiefly gastric (sometimes accompanied by vomiting of acid material), but laryngeal, nephralgic, and rectal crises have also been described. The pain is usually intense. Constipation is the rule, though in some cases incontinence of feces occurs, particularly if the stool is loose. There may also be retention of urine, with inconti- nence. TropMc Changes. — Apart from the herpes previously mentioned, the most striking trophic changes are those occurring in and around the large bony joints (the so-called tabetic arthropathies). Special attention was called to these by Charcot ; they are not a common condition, and are probably due to the influence upon the nerves that supply the joints. Occasionally the condition would appear to be excited by traumatism. The affected joints are not painful; they may be the seat of exudation which is rarely purulent. Arthropathies may supervene at any period 1084 DISEASES OF THE NERVOUS SYSTEM. of the disease, even the preataxic. These conditions aflFect primarily and chiefly the bones and cartilages entering into the larger joints. The in- volved osseous tissue becomes atrophied, brittle, and is finally destroyed. Muscular Avasting is rare as an early condition, though it may occur later; it is due either to neuritis or to involvement of the anterior horns. Since the disease does not of itself prove fatal, these symptoms may last for years and the patient eventually die of some intercurrent afl"ection. In other cases paralysis finally develops and the patient becomes bed- ridden. Hemiplegia may develop as a complication at an advanced stage, as may general paralysis or other forms of nervous disease. Course. — Rarely the disease runs a very rapid course. The preataxic symptoms — pain, loss of knee-jerk, Argyll-Robertson pupil with or with- out ptosis and diplopia — may only exist a few weeks before incoordina- tion develops. The latter will then reach its acme in twenty to thirty days. This is very unusual, however. As a rule, the first or preataxic stage extends over a period varying from months to even as long as twenty-five years. Dr. Wm. Egbert Robertson has related to me the case of a man aged fifty-eight who for fifteen years has had fulgurant pains and an absence of the knee-jerk, but neither ocular nor any other symptoms. In some cases the first stage may be absent. The second or ataxic stage — that of incoordination — is generally slowly progressive, finally reaching a point at which it remains ; rarely, more or less improve- ment may follow. When optic atrophy develops, ataxia either does not appear, or, having done so, fails to advance. The final stage in a few cases is only reached when the patient has become paralyzed and bedridden. Diagnosis. — This is readily made when we have a combination of the absent knee-jerk, fulgurant pains, and the Argyll-Robertson pupil. However, the loss of knee-jerk, associated with one of the other symp- toms in an otherwise healthy man, is, to say the least, highly suggestive of the disease ; the addition of incoordination serves, of course, to clinch the argument. Diflferential Diagnosis. — Peripheral Neuritis. — The symmetric dis- tribution of symptoms, tenderness in the muscles, frequent herpetic rashes, motor weakness and wasting, pain (not fulgurant in type), greater prominence of parasthesia, absence of the Argyll-Robertson pupil, knee- jerk often increased (absent in diphtherial form, but other symptoms and history serve to distinguish it), and later, either diminished or absent, and the history of the case, are sufficient. Alcoholic and more rarely arsenical poisoning give rise to a condition closely resembling true tabes in that there is the loss of knee-jei'k, often sharp pain, and incoordina- tion, though the latter symptom is never as marked as in advanced tabes. The gait, however, is totally different, and consists of the high " steppage " gait described in the discussion of Peripheral Neuritis. G-eneral jjaralysis of the insane may present much difficulty. Spinal symptoms may occur in general paresis, and conversely in certain cases of tabes symptoms of general paresis develop. Time alone will solve the problem. Ataxic Paraplegia. — Apart from the absence of pain and anesthesia, incoordination is followed by a spastic condition. The knee-jerk is much exaggerated and the so-called ankle-clonus develops. LOCOMOTOR ATAXIA. 1085 Cerebellar Disease. — The incoordination does not resemble that of ataxia ; optic neuritis is present ; also headache and vomiting appear in well-marked cases. The knee-jerk is always present. There are certain conditions, already described under Anemia of the Cord, in Avhich lesions of the posterior columns of the cord occur. Some of them are very much like tabes, but do not present the " combination of symptoms " seen in locomotor ataxia. xVs a rule, the Argyll-Robert- son pupil is absent, and less frequently the lightning pains also. ■ The crises may be mistaken for disease of the various organs involved. Repeated attacks of acute pain, tabetic in character, and particularly in adult males, should, however, excite suspicion, and an absence of the knee- jerk and other characteristic evidences will always be present in ataxia. When the chief lesion is in the dorsal region the pain ma}^ be mistaken for that of spinal caries or even neuralgia or rheumatism. From caries it may be differentiated by the fact that in vertebral disease the pain is more or less localized, and that it is much increased by movements. More- over, the other symptoms of ataxia are wanting — e. g. ocular troubles, incoordination, and absence of the knee-jerk. The latter point also holds good in cases of rheumatism and intercostal neuralgia. For the diagnosis from hereditary ataxia vide p. 1084. Progfnosis. — The outlook is not particularly bright. AYhile, as already stated, the disease does not cause death, perfect recovery is never obtained. Of course the prospect is much brighter the earlier the case is taken in hand, and some improvement may be expected in most cases. The fact that the patient has had syphilis does not modify the prognosis one way or the other. Treatment. — Rest (first suggested by Weir Mitchell) is imperative when the patient commences treatment, and especially when pain is early complained of, massage and electricity being employed meanwhile to keep up the tone of the muscles. In my opinion the rest-treatment retards the progress of ataxia more effectively than any other measure, but it cannot be used with the expectation of producing a cure. The bowels should be moved daily, and the urinary functions especially looked to. In certain cases catheterization is necessary. The patient should then be taught, first, what surgical cleanliness means ; and secondly, hoAv to use the instrument. Counter-irritation along the spine is of very little more value than suspension. The diet should not be heavy, and if gas- tric crises occur special care should be taken in this direction. In cases giving a previous history of syphilis, mercury and the iodids should be used ; it is, however, doubtful if they are of any direct benefit, although when the venereal disease is of comparatively recent date some improvement in the tabetic lesions is possible. Potassium iodid should be used freely. Mercury is best introduced into the system by inunction, and it is my custom to order one dram to be rubbed into the arm-pits, flanks, or inner surfaces of the thighs daily until the gums show the spe- cific influence of the remedy. Then the inunctions are discontinued, and the potassium iodid and mercuric chlorid are administered in combination three times per diem. The dose of the latter remedy should be small (gr. -^ — 0.0027), but the iodid may be used in ascending dosage. Electricity is of doubtful utility. The galvanic current is to be 1086 DISEASES OF THE NERVOUS SYSTE.M. chosen, and Erb advises placing the medium-sized cathode over the cer- vical sympathetic, and the larger anode near to the spinal column on the opposite side, moving it at brief intervals in thedo\vnward direction. This method must be continued for many months. Frenkel has recently advocated the systematic education of the muscles in coordinated movements. Hydrotherapy is a serviceable measure if judiciously em- ployed. Neither cold nor hot baths are free from deleterious effects, but tepid baths (80°-90° F.— 2G.6°-32.2° C), combined with gentle friction of the body-surface, are signally useful. Among the numerous natural springs enjoying more or less popularity there are two in especially high favor — the carbonic-acid thermal saline springs of Oeynhausen-Rehme in Minden and Aix-la-Chapelle in Germany. The chief benefit may, after all, be credited to the invigorating effect of the changed environments. The fulgurant pains, or those of the various crises, are occasionally so severe as to require bromids, codein, or even morphin, though the use of the latter agent is always to be postponed until other means are exhausted. Antipyrin or salol and phenacetin may also be tried in this connection. In any case the patient should live a simple, regular life, avoiding ex- cesses'^ of all kinds, and particularly sexual and alcoholic indulgences. HEREDITARY ATAXIA. {Friedreich's Disease.) Definition. — An hereditary disease, first described in 1861 by Fried- reich. The symptoms are primarily manifested in early life, and the dis- ease is characterized by ataxia, defective speech, nystagmus, absence of the knee-jerk, and more or less secondary deformity, as spinal curvature or talipes. Pathology. — The postmortem findings are essentially those of loco- motor ataxia and ataxic paraplegia. The spinal membranes are some- what thickened and adherent, especially over the posterior part of the cord, and that, too, chiefly in the lumbar region. The posterior nerve- roots are generally atrophied and sclerosed. The columns of GoU and Burdach are degenerated, particularly in the lumbar region, and to a lesser extent in the cervical. Degeneration is also found in the lateral, and to a slight degree in the anterior, columns. The chief microscopic change is a marked neurogliar overgrowth, as shown by D^jerine. The nerve-cells of the cord are generally normal. Frequently the cord is abnormally small. Cerebral lesions also have been found in this disease. etiology. — 1. Family tendency (heredity) has a strong influence. A single case, however, may develop in a family. Age. — Most commonly the disease appears between the third and twelfth years, though it may appear earlier. Infectious fevers (in particular) and other acute diseases frequently precede the evolution of this complaint. Trauma and many other con- ditions have been described as exciting causes. SPASTIC PARAPLEGIA. 1087 Symptoms. — The first evidence of the disease is impaired coordi- nation, first in the legs, and, later, in the arms ; it is most marked when the eyes are closed. Attention is often called to this symptom by the fact that the child stumbles, ambles, and staggers, and cannot walk prop- erly. The gait, however, lacks the pronounced stamp of true ataxia. Rutimeyer has pointed out that in many cases the great toes are turned upward. Some children never learn to walk. Romberg's symptom is generally present. Movements of the arms, when these are ataxic, are irregular and jerky, and jerky movements of the head may also be ob- served. Bilateral nystagmus develops and the speech becomes affected. At first there is a mere impediment (a stuttering), but later syllables, or even whole words, are omitted and an unintelligible jargon results. The knee-jerks are almost always absent. There is no optic atrophy, nor are any sensory symptoms present as a rule. The sphincters are normal. There are no trophic changes in the skin or the joints, and no visceral crises. Vaso-motor symptoms — flushing, sweating — are sometimes ob- served. There is no mental change. Talipes and spinal curvature are generally met with after the disease has existed for some time. In old cases muscular weakness and wasting are present, but there is no electric change in the muscles. The course is always slow. It may last for many years, thirty or even more. Diagnosis. — Usually this is not difficult, and especially when more than one case exists in a family. The age, incoordination, shambling gait, nystagmus, scanning speech, and deformity are strikingly charac- teristic. Differential Diagnosis. — Locomotor ataxia appears later in life, and the preataxic stage (pain, absent knee-jerk, and ocular symptoms) is gener- ally well marked. It is absent in hereditary ataxia, nor does the latter present the sensory and visceral symptoms met with in the true form. Further, the gait is very different. Ataxic jmrajjlegia shows an exaggerated knee-jerk, the presence of ankle-clonus, and an absence of the ocular symptoms, nystagmus, and the scanning speech. Disseminated Sclerosis. — Tremors are almost always present, but these are fine and never coarse as in hereditary ataxia. There may be nystagmus, incoordination, and imperfect articulation, but the cases are isolated (i. e. they do not run in families). The prognosis is necessarily bad. The disease is progressive, though it does not kill directly. It may last thirty years or more. Treatment. — Little or nothing can be expected from it. The same general treatment should be pursued as for locomotor ataxia. SPASTIC PARAPLEGIA. {Primary Lateral Sclerosis ; Sjyastic SiJinal Paralysis.) Definition. — A disease of the spinal cord characterized by loss of power, contractures, exaggerated reflexes, a peculiar gait, and by pre- cipitate micturition. Spastic paraplegia (spasm plus motor paralysis) is 1088 DISEASES OF THE NERVOUS SYSTEM. met with as the result of the various pathologic substrata. Any trans- verse cord-lesion above the lumbar region may cause motor paralysis, spasticity, exaggerated knee-jerk, and ankle-clonus. The same condi- tion results from a lesion in any part of the upper segment, from the cor- tical motor cells to the terminal arborization of the axon in the cord. It is believed that fibers of the pyramidal tracts may be primarily in- volved, and, since they course chiefly through the lateral cord-region, the resulting condition has been named primary lateral sclerosis. This is purely hypothetic, however, for only two uncombined cases have been found. This may be due to the fact that the disease does not tend to shorten life, and that therefore the same condition that caused degenera- tion of the pyramidal fibers may subsequently act on other fiber-systems. Since in the case of the lower segment it is the peripheral portion of the axon that, in many cases at least, first yields to the morbific influence, so may it be with the upper segment. In such an event, however, the de- generation would be an ascending one, and the converse of that which is usually met with in the motor tracts. Thus we see that the same clinical condition may be etiologically quite difterent. The following are the chief varieties : PRIMARY LATERAL SCLEROSIS. That this condition exists alone is questioned, as I have already stated. Von Stofella has reported a case, but no microscopic examination was made. Morgan's and Dreschfeld's case, published in 1881, seems to be the only one that may be regarded as a true type. The only pathologic change observed was in the pyramidal tracts of the anterior and lateral regions. Ktiology. — It is most apt to occur when there is a neuropathic family tendency. Age, generally between twenty-five and foi'ty, exerts an etiologic influence. Exposure, acute disease, and traumatism are all predisposing causes. Syphilis has been said to predispose to the condition, but if so it is rather rare. Symptoms. — In typical cases the onset is slow. The patient com- plains of feeling tired, and is less capable of exertion than formerly. Weakness of the legs develops, and with it increasing difficulty in walk- ing. Even at an early stage some rigidity of the muscles will be present when the limb is extended ; later this becomes a prominent symptom. The spasm is at first of little moment. It may only be noticed in the morning. When the disease has advanced, however, it becomes pro- nounced, so that it may not be possible to flex the limb, or, if flexed and an eff'ort is made to extend it, it will often spring forAvard like a knife- blade in clasp-like rapidity. This spasticity is often so marked that in walking, so long as the ball of the foot touches the ground, clonic con- tractions occur ; these also appear when the individual is in a sitting posture unless his legs are extended. The gait is characteristic ; the legs are stiff, and move with an evident eff'ort, while the toes scrape the ground. In some cases the adductor spasm is so great that the legs can- not only not be separated, but are actually overlapped in walking {cross- leg progression). In course of time the power of w^alking may be lost. The flexor muscles are usually weakened. The knee-jerk is very much ATAXIC PARAPLEGIA. 1089 exaggerated, a mere tap causing a sharp, quick response. Ankle-clonus can always be elicited. Pain and other sensory manifestations are often absent, though dull and fleeting pains in the back and limbs may be com- plained of. The arms are frequently unaffected. The sphincters are rarely involved, and ocular symptoms do not occur, though nystagmus is occasionally met with. Seguin states that the ability to retain the urine is lessened and precipitate micturition results. The diagnosis is not difficult. Certain hysteric cases may occa- sionally simulate it very closely, but these do not present the character- istic spasticity of the true form, nor is the knee-jerk increased quite as much, and ankle-clonus is either slight or absent. Then, too, in hysteria spots of anesthesia are commonly met with. Drs. Bastian and Russell Reynolds have described "paraplegia dependent on idea," in which no hysteric element entered. SECONDARY SPASTIC PARALYSIS. As I have already mentioned, transverse lesions above the lumbar region (caries, tumor, sclerosis, myelitis) are followed by degeneration of the pyramidal tracts, and as a result there are weakness in the limbs, increased reflexes, and more or less rigidity. In certain cases the latter may be absent, as Bastian has shown, and the limbs will be flaccid. CONGENITAL SPASTIC PARAPLEGIA. This condition, the symptomatology of which is practically that of the adult types previously described, is almost always the result of some in- jury at birth, either instrumental or due to a malposition, as first pointed out by Dr. Little and since abundantly confirmed by Spencer, Dr. Sarah McNutt, Sachs, and others. The disease is probably always due to men- ingeal hemorrhage. In recent cases more or less extravasated blood is always found over the central convolutions and often at the base. Later, cases show atrophy and sclerosis of the motor region, the blood having been absorbed. Nothing abnornal may be noticed for a few days Or weeks, though rarely convulsions, or even bulbar symptoms, may early manifest themselves. Generally, the child is several months old when the mother first notices some impairment of movement, and not until the child tries to walk will she observe anything out of the way. The abnormality varies from a slight difficulty in walking, in which the toes barely scrape the ground, to a total inability to walk, owing to the high degree of adduc- tion spasm. Between these extremes are various grades of talipes equinus and cross-legged progression. Sensation is usually normal. The bladder and rectum are not implicated. Some cases present evidences of impaired cerebral development — idiocy and imbecility. Some observers have also described what they believe to be an hereditary form of spastic paraplegia (notably Drs. Gee and Sachs). ATAXIC PARAPLEGIA. This name was given by Gowers to a condition in which spastic para- plegia and ataxia coexist, owing to simultaneous involvement of the lat- 1090 DISEASES OF THE NERVOUS SYSTEM. eral and posterior columns. The posterior root-zones escape, and hence the retained reflexes. This same morbid condition may be met with in Friedreich's disease (hereditary ataxic paraplegia), or primary lateral or posterior cases may extend and involve the posterior or lateral col- umns respectively. Disseminated sclerosis may possibly present the same symptoms. The type Gowers describes occurs chiefly in males of middle ago. Traumatism and exposure seem to predispose to the dis- ease, as does syphilis very rarely. Symptoms. — These develop insidiously. The patient tires rapidly, and some impairment of the power of walking is observed. In turning quickly he stumbles, and there is difiiculty in walking in the dark, or even in standing when the feet are close together. The reflexes are in- creased at an early date, and spasticity supervenes and is progressive, though it never becomes as marked as in uncombined lateral sclerosis. The gait is somewhat similar to that met with in locomotor ataxia, but it lacks the forcible stamp already described. When the arms are in- volved the same ataxia, with Aveakness, spasticity, and increased reflexes, is met with. Sensory symptoms are generally absent, and fulgurant pains are never present. When pain occurs at all, it is of a dull charac- ter and often in the sacral region. Optic atrophy does not occur. Nys- tagmus is often seen, though other eye-symptoms very rarely appear. Sexual power is lost. The sphincters are not usually involved, though retention of urine may occur. Ultimately, the case generally partakes more of the nature of a lateral sclerosis, but the features of a posterior sclerosis may rarely predominate. Mental symptoms often develop in the late stages. The diagnosis is easy in typical cases. The ataxia, with myotatic irritability and spasticity in the absence of sensory and ocular symptoms, is characteristic. COMBINED SYSTEM SCLEROSIS. Ormerod and Dana have published valuable treatises on this subject. In 1891, Dr. James Putnam of Boston described a group of system scleroses, with diffiise collateral degeneration, occurring in enfeebled persons past middle life, and more particularly in women. He had had 8 cases, and made autopsies on 4. In the white columns of the cord he found both recent and old degenerations and disintegration of the cells of the gray matter. In 1 case he found some degeneration in the pe- ripheral nerves. The chief symptoms were motor weakness of all four extremities, but especially the lower, with some impairment of sensation and general muscular wasting. In 3 cases there was an exaggerated knee-jerk with ankle-clonus; in 1 lancinating pains, and in another incoordination. The fatal cases ran a course of three or four years. Several of them showed lead in their urine, and Putnam thinks that this may have been an etiologic factor in some instances. The si/mpfoms of combined sclerosis partake of the nature of loco- motor ataxia and spastic paraplegia, but are less marked than either of these diseases. The onset is slow, there is more or less incoordination, and Romberg's symptom can be elicited as a rule. There is loss of motor power, and the sensory symptoms are slight. There may be dull sacral pain. Optic-nerve atrophy very rarely occurs, though there are MULTIPLE SCLEROSIS. 1091 certain eye-symptoms. The reflexes are generally exaggerated, and "ankle-clonus" is present. The diagnosis is based upon the presence of paraplegia with in- creased reflexes, associated with sensory symptoms — paresthesise — and rarely pain. REFLEX PARAPLEGIA. Since this was at one time so warmly put forward by Brown-S^quard as a distinct entity, it seems justifiable to speak of it, though in the light of our present knowledge we are not disposed to give it any nosologic distinction. It was supposed to be due to anemia of the cord, and to be the result of irritation reflected from a sensory nerve to vaso-motor nerves. The so-called "urinary paraplegia" was included in this category. INTERMITTENT PARAPLEGIA. Romberg was the first to call attention to this condition. His orig- inal case was that of a woman aged sixty-four, in whom paraplegia de- veloped suddenly with involvement of the sphincters. The sensations were normal. In about twenty-four hours she was so much better as to be able to walk ; micturition was normal, but there was some weakness. Next day, hoAvever, the paraplegia returned. These attacks, with almost normal intervals assuming a periodic character, induced him to give qui- nin, which he did. Recovery was the prompt result. Erb and others have since reported cases, but it is now believed that they are due to involvement of the peripheral nerves rather than of the cord. Treatment of Spastic Paraplegia. — In general the treatment is the same as that of locomotor ataxia. This is especially true if syphilis is suspected. Little can be done, as a rule, for the disease is usually progressive in spite of all treatment. Belladonna or hyoscin seems to lessen the spasm in some cases. Attention should be given to the blad- der and bowel, particularly to the former. In the congenital form ope- rative measures are often requisite to overcome deformity. MULTIPLE SCLEROSIS. {Insular or Disseminated Sclerosis.) , Definition. — A disease due to the development of sclerotic patches, occurring in an irregular manner throughout either or both the brain and spinal cord. It is characterized by paresis, intention-tremors, scanning speech, and mental disturbances. Pathology. — The sclerotic tissue occurs especially in the white matter, though any part of the cerebro-spinal axis may suff"er. The cortex is rarely implicated. The spots are usually well circumscribed, gray or grayish-red in color, and on section may be level with, raised from, or depressed beneath the normal line of section according as to whether it is in the early, hypertrophic, or cirrhotic stage. The cranial nerves may be involved at their origin, the first, second, and tenth being 1092 DISEASES OF THE NERVOUS SYSTEM. particularly vulnerable. The medullary sheath of nerve-fibers in the affected region degenerates early, but the axons are markedly resistant. Since they are not cut off from their trophic center, secondary de- generation is rarely met Avith. The blood-vessels show more or less proliferation of the adventitia, and endarteritis is not an uncommon condition. Whether this vascular change is primary or secondary is unknown. Microscopically, the sclerotic areas are made up of an over- growth of neuroglia-cells and fibers and of the ordinary connective tis- sue. In certain cases these patches exhibit some tendency to involve special parts of the nervous system, as the lateral or posterior columns. Ktiology. — There is no definite and known etiologic factor. Among the possible predisposing causes may be mentioned emotions, trauma, heredity, exposure, infectious and exhausting diseases of any kind, and perhaps hysteria. It is important to remember, moreover, that it is frequently impossible to diagnose this disease in its early stage from hysteria. This point is dwelt upon particularly by Buzzard and Bastian, and many cases of supposed hysteria have subsequently proved to be cases of multiple sclerosis. The difficulty is manifestly greater when the patient is a woman. Age and sex are also, in a sense, predispos- ing causes. The majority of cases occur between twenty and thirty years of age, though the condition may occur in children. Pritchard has collected over fifty published cases occurring between the ages of fourteen months and fourteen years, and about equally divided as to sex. Among adults disseminated sclerosis is met with someAvhat more fre- quently in women. Sytnptotns. — These may be described under two headings : first, the general symptoms, or those common to all cases of the disease, and not explicable from the position of the sclerosis ; and, secondly, those dependent on the locality of the lesions. The disease is always chronic, and either remissions, or one or more intermissions occur, and in some cases may extend over several years. The first evidence of the disease is loss of "poiver, first in one, then in the other, lower extremity. Later, paresis develops in the upper extremity. Sooner or later other general symptoms appear — viz. tremors, nystagmus, scanning speech, increased reflexes, and optic-nerve atrophy. The tremor is volitional (intention- tremor), and when the patient is at rest no abnormal movement is mani- fest, as a rule. On attempting to use the hands, or in walking, a fine, trembling motion of the limbs results. The head may be similarly in- volved, and some incoordination is commonly associated therewith. The nystagmus, too, is brought out when the eyes are in use. It is more marked in lateral than in vertical movements. Speech is slow and deliberate (staccato or scanning), the tendon-reflexes are increased, ankle-clonus may be present, and optic-nerve atrophy is of frequent occurrence. No alteration of sensation occurs, other than perhaps some numbness or tingling. There is no wasting of, nor electric change in, the muscles, nor do bed-sores occur. Vertigo is usually present. The mental phenomena are at first hysteroid, and they may never progress beyond this point. In 'other cases dementia, or even acute maniacal out- bursts, are met with, but these are rare. During this stage epileptiform or apoplectiform attacks may occur. The symptoms directly resulting from the local lesions cannot be given in detail. Certain types result, MULTIPLE SCLEROSIS. 1093 however, that depend upon the tendency of the sclerotic areas to involve certain tracts, and these are — first, a form resembling lateral sclerosis, due to implication of the lateral tract ; and, secondly, a form similar to locomotor ataxia, in which the posterior columns especially suffer. The diagnosis is generally easy after the disease has lasted some time. The intention-tremor and the gradual and progressive loss of poAver, with increased reflexes, scanning speech, and mental deteriora- tion, are sufiicient. The following table gives the differential points between this disease and paralysis agita7is, locomotor ataxia, and hered- itary ataxia : Disseminated Sclerosis. Rarely occurs in children. Gen- erally between the twentieth and thirtieth years. No sensory symp- toms, as a rule. Sight may be im- paired, the hear- ing less frequent- ly' The Argyll- Robertson pupil is absent. Nystagmus is pres- ent, as a rule. Reflexes are exag- gerated ; ankle- clonus is present. There may be muscular rigid- ity. Scanning speech. A tremor is gener- ally present on voluntary move- ments only. If the tremor occurs during rest, it is fine. Oscillations of the head are frequent ; of the trunk, less so. Mental disturbance is frequent. Gait is usually spas- tic and paretic, and often uncer- tain. Paralysis Agi- TANS. Locomotor Ataxia. Occurs in persons Rarely before the over forty years twentieth year, of age. No sensory or spe- cial-sense symp- toms of any im- portance. A r - g y 1 1 - Robertson pupil is absent. No nystagmus. Reflexes are nor- mal : very rarely they may be plus. Permanent mus- cular rigidity. Speech is slow and deliberate on com- mencing a sen- tence, but soon it becomes hurried. Tremor when at rest. Voluntary movement may make it cease temporarily. The head may shake, Avith rather a vertical than an oscillatory move- ment. No mental phenom- ena. The head is bent back and arched ; the face is immo- bile and mask- like. The gait is propulsion, fes- tination, retro- pulsion, or latero- pulsion. Fulgurant pains an early symptom. Sight and hear- ing are commonly affected. Often diplopia and Ar- g y 1 1 -Robertson pupil are pi'esent. No nystagmus. The kn ee-j er k, ankle-clonus, and rigidity are all absent. No speech-defects. No tremor. Inco- cirdination is marked. No os- cillations of the head or trunk. Romberg's symp- tom is present. Trophic disturb- ances are com- mon. Mental disturbance is rare. The gait is stamp- ing in character ; the legs are moved stifily. There is difficulty in urination. Hereditary Ataxia. Usually before the twentieth year. Generally afi^ects several in the same family. Sensory symptoms are rarely pres- ent. Diplopia and Argyll-Rob- ertson pupil are absent. Nystagmus is fre- quent. The knee-jerk is lost in the course of the disease ; it is rarely increased. No rigidity. Speech is slow and irregularly scan- ning. Incoordination is present, but is not increased by closing the eyes. Static ataxia may be noted. No mental disturb- ance. The gait is swaying and irregular, like that of a drunken man. The legs are not kept wide apart as in locomotor ataxia. 1094 DISEASES OF THE NERVOUS SYSTEM. The course usually extends over five to ten or even fifteen years, and death is generally the result of some intercurrent affection, though it may occur during an apoplectiform or convulsive attack. Rarely it is due to failure of the heart or respiration. The prognosis is always bad. Treatment. — No remedy is of any avail. Silver nitrate, mercury, the iodids, and arsenic may be tried. Rest and easily assimilable food are also of prime importance. PSEUDOSCLEROSIS. In 1883 Westphal described a case characterized by disturbance of speech, slowness of the movements, decrease of both intelligence and irritability, apoplectiform attacks, pronounced tremor, spasticity and in- creased reflexes, slight disturbance of sensation, and no involvement of the sphincters. The autopsy was entirely negative. Since then similar cases have been reported, especially by Strlimpell. The disease usually begins in childhood and causes death in the course of several years. The dia(/)iosis cannot be made from multiple sclerosis during life. Treatmetit is useless. BULBAR PARALYSIS. (Glosso-labio-lari/ugeal Paralysis.) Definition. — An acute or chronic disease, due to involvement of the motor nuclei of the medulla oblongata. It is generally secondary to some condition affecting other portions of the motor path, and is characterized chiefly by a difficulty of speech or of deglutition. Three varieties have been described : 1. Sudden or apoplectiform, this being due to hemorrhage, embolism, or softening. The onset is always sudden, often with vertigo, and pos- sibly vomiting, with or without loss of consciousness. The power to articulate is impaired or lost. The lips and tongue are involved, and hence the pendulous lower lip, the dribbling of saliva, and the atrophy of the lingual muscles. There are dysphagia and generally frequent attacks of choking. The symptoms are less characteristic than those of the degenerative form. They are less regular in type, and usually are Avidespread at first ; later, some improvement takes place. In other cases, after more or less of a respite, degeneration sets in and they grow progressively worse. The diagnosis of this type is not usually difficult. " Pseudo-bulbar paralysis " must be borne in mind, hoAvever, and is a condition due to a bilateral lesion of the motor cerebral cortex in the lower frontal parietal region or of the motor fibers in the course. There is great danger to life for some little while in these sudden cases. Later the prognosis is rather more favorable than in the other forms. 2. Acute Inflammatory. — Here the onset is less abrupt, requiring a AMYOTROPHIC LATERAL SCLEROSIS. 1095 few days to a week to develop. But for this fact the symptoms are much the same as in the preceding form. 3. Chronic Bulbar Paralysis. — This condition occurs chiefly in males beyond middle life. The cause can seldom be discovered, though cer- tain cases seem to be of toxic origin. It may develop in the course of progressive muscular atrophy, amyotrophic lateral sclerosis, insular sclerosis, or other disease of the cord. The symptoms are bilateral, the tongue being usually the first to suffer. The patient may notice that he cannot speak for any length of time without fatigue, and that he will then articulate indistinctly. Soon he observes that there is a marked and progressive ivipairment of speech. The muscles of the lips and other muscles of the lower part of the face atrophy. He can no longer whistle. Speech is rendered still more defec- tive, owing to paralysis of the lips. The lower lip drops, and the saliva constantly dribbles • from the mouth and may be greatly increased in amount. Difficulty in swallowing is always present to a greater or less degree. Owing to the lingual paralysis, the tongue can neither be protruded nor can it be used to manipulate the food and make a bolus. It is atrophied and the mucous membrane is wrinkled. Fibrillar trem- ors are present. The larynx is involved, so that phonation is imperfect, but it is not so marked as the implication of other parts. Particles that enter the larynx cannot be ejected, owing to motor paralysis. There are no sensory symptoms, and the power of taste is normal. The mind generally remains clear, though the patient is often emotional, and cries or laughs Avithout apparent cause. This type of bulbar palsy is particularly liable to develop in the course of progressive muscular atrophy. The course of the disease is sIoav, and death is usually due either to inspiration-pneumonia or to interference with respiration or circulation. The diagnosis is not difficult, as a rule, the bilateral character of the symptoms rendering them distinctive. In the pseudo-hidhar form previously mentioned the limbs are often paralyzed also (double hemi- plegia). Tumors rarely, if ever, give rise to such regular bilateral symptoms. I have met with 2 cases of chronic bulbar palsy, and 1 occurring in the course of Bright's disease, in which no postmortem lesion could be found that would account for the condition. In neither of the cases was there much atrophy, though otherwise they conformed to the regular type. Treattnent. — The disease is incurable. Hypodermics of strychnin, or of strychnin, morphin, and atropin, are of value in controlling the salivary flow. Electricity is of no value. Semi-solid food is probably the most readily taken, and it is often necessary either to use an esopha- geal tube or to employ rectal alimentation. AMYOTROPHIC LATERAL SCLEROSIS. {CharcoVs Disease.) Definition. — A disease of the entire motor system, from the cere- bral cortex to the muscles : characterized by loss of power, spastic symp- 1096 DISEASES OF THE NERVOUS SYSTEM. toms, and muscular atrophy. The first clear and thorough description of the- clinical symptoms and pathological anatomy was given by Charcot in 1872. Patholo§3^. — The pyramidal tracts are degenerated, the process commencing either in the cortex, crura, or medulla, and extending to the termination of the neurons in the cord. The ganglion-cells of the ante- rior cornua are atrophic, there is degeneration of the anterior roots and of the muscle-fibers, the blood-vessels in the affected parts are dilated, and in the early stages granular cells are present. Ktiology. — The disease is more freciuent in males and usually begins in early adult life. Exposure has sometimes been noted in the previous history, but neuropathic heredity does not appear to have any influence. Symptoms. — Three stages are generally recognized : (1) The in- volvement of the upper extremities. (2) The participation of the lower extremities. (3) The appearance of bulbar sv'mptoms. At first there are weakness of the upper arms, atrophy of the muscles, and moderate exaggeration of the reflexes ; in the course of a few months the symptoms of spastic paraplegia develop, all the reflexes are greatly increased, and there are chin- and ankle-clonus and dragging of the toes. The Avasted muscles show fibrillarv twitchino;s and s^ive the reactions of defeneration. Contractures then occur, the forearms are flexed on the arms, the hands are held in pronation, and the proximal phalanges of the fingers bent backward, giving rise to the so-called claw-hand. From time to time there are tonic spasms in the muscles, particularly in the calves {spinal tetanus). Sensation is not disturbed, excepting for the occurrence of slight paresthesia from time to time, and the sphincters continue to functionate normally. Finally the bulbar symptoms appear, and there is paralysis of the lower part of the face, which becomes rigid and expres- sionless, with the mouth partly open and saliva dribbling from the angles. Deglutition and articulation become diflficult or impossible, and death finally occurs from exhaustion or inspiration-pneumonia. During the course of the disease the intellect is slightly involved. Memory is impaired, the conduct becomes childish, and there is a tendency to weep or laugh without cause. Atypical cases occur in which either the lower extremities are fii'st involved, or the paralytic symptoms are more prominent than the spastic symptoms, or the bulbar symptoms appear very earh\ The course is steadily progressive, and death usually occurs within two years. The differential diagnosis is to be made from niultij^le sclerosis by the absence of nystagmus, of the intention-tremor, and of sensory dis- turbances, and bv the degenerative changes in the muscles ; from trans- verse myelitis by the absence of sphincter disturbance and of pain, and the involvement of the upper extremities and head ; from progressive spinal muscular atrophy by the presence of spastic symptoms ; from syringomyelia by the absence of sensory disturbances, trophic lesions of the skin and joints, and the greater regularity of the course ; from pressure upon the spinal cord by the absence of pain and sphincter disturbance and the involvement of the head and upper extremities. It must be remembered that amyotrophic lateral sclerosis may be associated with multiple sclerosis or infantile spinal paralysis. SYRINGOMYELIA. 1097 Prognosis. — It will be understood from the foregoing description that death is the invariable termination. The course is progressive, and even temporary amelioration rarely occurs. Treatment. — The patient should be rendered as comfortable as pos- sible. Arsenic and mercury are useless, but the hypodermic injection of strychnin (see Progressive Spinal Muscular Atrophy) may be tried. SYRINGOMYELIA. Definition. — A neurogliar overgrowth of more or less vertical extent, and situated in the gray matter of the cord in the neighbor- hood of the central canal. Its symptomatology is not constant, but the following have come to be looked upon as typical of most cases : viz. progressive muscular atrophy and dissociated anesthesia {i. e. impairment or loss of temperature — and pain-sense, with retention of the tactile and muscular sense and trophic and vaso-motor dis- turbances). Pathology and Btiology. — Tubular cavities of greater or less extent are met with in the cord as a result of two conditions existing separately or in conjunction — viz. (1) hydromyelia^ a dilatation of the central canal (proved by the cubical cells lining it). This is either (a) congenital, according to Leyden, or {h) acquired, due to pressure (tumor), dilatation taking place above the point of obliteration. (2) Syriyigo- "myelia, a name given by Olliver to a neurogliar overgrowth situated within the gray matter of the cord. In this cavity-formation takes place as a result of hemorrhage or degeneration. The cavity is entirely without the central canal ; it never possesses an epithelial lining, and is not, therefore, as Leyden supposed, the remains of congenital hydro- myelia. While the new growth in many instances is gliomatous, being probably a rejuvenescence of some vestigial remnant, with subsequent hemorrhage or degeneration and cavity-formation, yet in others the structure is not identical with such neoplasms. The latter have been described particularly by Joffroy and Achard. They speak of it as a gliosis, a secondary overgrowth, and sclerosis of the neuroglia. In any case, however, the disease is most prone to develop in the cervical and upper dorsal region, growing and invading the posterior and postero- lateral tracts. Breaks and crevices in the diseased material radiate from the main cavity. The onset of the trouble generally takes place some- where between the fourteenth and twenty-first years of age. Symptoms. — Owing to the fact that diiferent levels of the cord are involved, and that the extent claimed by the process varies in different cases, it will readily be understood that no account, however concise, will fit every case. The disease is of slow onset. Neuralgic pains develop in the muscles, and the latter progressively waste. The reflexes are increased and more or less spasticity is present. The lower ex- tremities usually escape, though they too may be involved, when the condition presents much the same appearance as amyotrophic lateral sclerosis. The temperature- and pain-sense are lost, but the tactile and muscular senses are preserved. 1098 DISEASES OF THE SERVOUS SYSTEM. The special senses and the sphincters are normal. Ocular symptoms develop only when the cervical cord is extensively involved. Joint- changes may be met with, and various ulcerations., bullous eruptions, or wounds may be present, the latter often being received without the pa- tient's knowledge, since loss of sensation is complete. These constitute a special feature of a type of the disease originally described by Morvan of Brittany in 1883. He had observed many cases prior to that time, but his attention was specially called to the matter by a case of whitlow which he incised, but to his surprise no pain whatever was experienced. He described the disease as affecting the upper extremities, with neu- ralgia, progressive paresis and wasting, dissociated anesthesia, and. later, painless Avhitlows and necrosis of the phalanges. Joffroy and Achard have made three autopsies upon cases dying of this disease, and in each syringomyelia was found. In Gombault's case neuritis was present, and the current view is that Morvans disease is a combination of svringo- myelia and neuritis. Diagnosis. — The loss of pain and thermic sense, Avith preservation of the muscular and tactile senses, in association with the muscular Avasting, which is most marked in the upper extremities ; and with the spasticity of the lower extremities, constitutes a group of symptoms that has come to be regarded as typical. Differential Diagnosis. — Hypertrophic cervical pachymeningitis may be mistaken for this disease, and vice versa. In this case, however, the pain is usually greater, the tactile sense is apt to be lost, and possibly the other senses also ; but there is not the dissociation met with in syringo- myelia. Amyotrophic lateral sclerosis presents neither sensory nor trophic symptoms, other than the muscular Avasting. Disseminated sclerosis, apart from the tremor that is always present, presents less trophic dis- turbance. The prognosis is always unfavorable, though the disease runs a very chronic course, lasting even fifteen or twenty years. Treatment. — ]S^othing can be done, except by attention to hygienic and dietetic details. COMPRESSION OF THE SPINAL CORD. It is of importance to be able to recognize this condition. To be sure, it is not always possible to diagnose it with certainty, but when there is a reasonably surety the question of operation may arise. Since it has so many features in common with myelitis, the necessity for reserve and caution in arriving at a conclusion is manifest, since the latter condition woul usually favorable, nearly all cases tending to spontaneous cure. Death, however, may occur from chronic diarrhea, from respiratory failure when the diaphragm is involved, and from cachexia strumipriva. The treatment is purely symptomatic. The patient should be placed in the most favorable hygienic conditions and given plenty of nourishing food. During the spasm bromids or chloroform-inhalations seem to give the best results. The most important therapeutic measure is the correc- tion of the underlying cause. Thus, in children rachitis is almost invari- ably associated with tetany, and the most efficient remedies are iron and cod-liver oil. Intestinal disorders should be treated accordincr to the INFANTILE CONVULSIONS. 1159 principles laid down in the discussion of these diseases. The form due to removal of the thyroid gland always disappears under a course of thyroid- medication, while that occurring during pregnancy usually persists until delivery. INFANTILE CONVULSIONS. {Eclampsia Infantilis.) Under this term are grouped a number of conditions, with convulsive attacks as the common symptoms. Pathology. — The pathologic changes may be divided into two groups : (1) those bearing an etiologic relation to the convulsive attacks, and (2) those that are merely consecutive. Among the former are me- ningeal bleeding, tumor, gliosis (either hypertrophic or atrophic), and hydrocephalus. Then there are general conditions that seem to predis- pose to this condition or, at any rate, are frequently associated M^th it, such as rachitis. The consecutive lesions are hemorrhages into the meninges or into the substance of the brain and the spinal cord, an in- crease in the amount of cerebro-spinal fluid, and congestion of the pia or the substance of the brain. The causes are : 1. Organic brain lesions. 2. Neuropathic ten- dency, that is manifested later as hysteria or epilepsy. 3. Emotional disturbances, as fright. 4. Rickets, in about 30 per cent, of all cases. 5. Acute infectious disease, especially as an initial symptom of pneu- monia, and more rarely of scarlet fever, small-pox, and pernicious ma- larial infection. 6. Inflammation of the serous membranes, as menin- gitis, where the relation is direct, or pleuritis or peritonitis. 7. Kidney disease, in which they are uremic. 8. Peripheral irritation ; dentition has long been supposed to be a chief factor in their causation, but it is noAv believed that the chief cause is the presence of rickets. Intestinal parasites have also been found, particularly the ascaris lumbricoides, and the convulsions have ceased after their expulsion. 9. Debility, especially that resulting from gastro-intestinal disorders. The symptoms of the attack vary according to its intensity. In the most severe form they resemble in all respects those of an epilejDtic seizure. At first the eyes deviate upward or to one or the other side, and the gaze becomes fixed and staring; next there are twifchings of the muscles of the face, sometimes slight and limited to one side, and sometimes general, often involving the muscles of mastication and giving rise to trismus or gnashing of the teeth. Next there are tetanic contractions of the extrem- ities, the fingers being strongly flexed, the hands flexed upon the arms, and the feet in the position of pes equinus or sometimes in the dorsal flexion, and both legs and arms rigidly extended. Often the muscles of the trunk are involved, and there is either opisthotonos or respiratory cramp, with excessive hardness of the abdominal muscles. This rigid condition is interrupted at brief intervals by sudden twitchings, or occa- sionally the convulsion becomes clonic instead of tonic, and there are re- peated'^extensions and contractions of the extremities, shaking of the head, and quivering of the whole body. As a result of the respiratory cramp. 1160 DTSEASES OF THE NERVOUS SYSTEM. cyanosis rapidly develops and may reach an extreme degree. The forced respirations give rise to a foam that collects about the lips, and is often mixed with blood from the bitten tongue. Urine is often, and feces occa- sionally, passed involuntarily. In nearly all cases unconsciousness is complete. Many of the slight attacks are accompanied by a cry or by an attack of screaming. The tetanic state usually lasts for a minute or two ; then there are a few clonic movements, relaxation becoming rapidly com- plete, and the spasm is ended by a few deep respirations. The child may return to consciousness, although it is usually drowsy or stupid, or it may pass into a deep sleep from which it cannot be aroused. Often in the lat- ter condition attacks wnll recur at irregular intervals, and sometimes a single attack may continue for some time, although from time to time thei'e are slight twitchings followed by partial relaxation (status eclamp- ticus — Lewis). The attack may come on suddenly, or, as is more fre- quently the case, it may be preceded by a period of restlessness and irri- tability. A milder form of the spasm consists of sudden fixation of the eyes, slight twitching of the body, and a peculiar dusky pallor that passes away in a few moments. In other rare cases consciousness may persist, although the patient is aphasic. Laryngismus stridulus is an analogous condition (vide Diseases of the Larynx, p. 477). . The diagnosis of the condition is very easy. The recognition of the cause, however, is very important and often diificult. Every case should be first examined for rickets, and then the gums should be inves- tigated ; also the condition of the child's nutrition and the presence of symptoms of gastric or enteric irritations. If fever exists, it is import- ant to discover its cause. The character of the convulsion is often of value in distinguishing between the idiopathic or reflex type and that due to organic brain-disease. Convulsions beginning immediately after birth, or an injury, either persisting or else disappearing gradually, are prob- ably caused by meningeal hemorrhage. An attack of a Jacksonian type would, of course, indicate the presence of a focal lesion ; and if this be a tumor, there will probably be bulging of the anterior fontanel, severe headache, and the ophthalmoscope will reveal a neuro-retinitis. If, after the attack, pareses or paralyses are present, a focal lesion is still more likely. Hydrocephalus is usually recognized with ease. Some cases exist, however, in which it is impossible to discover any adequate cause. The prognosis varies according to the etiology. In cases with organic brain-disease it is unfavorable as regards cure. In those forms that precede epilepsy or functional nervous diseases the spasms usually disappear after the first dentition, and the patients appear to have recov- ered for a time. In those, however, in whom the symptoms are due to some peripheral irritation or to rachitis, the outlook is fair, althoucrh even these now and then develop into permanent epilepsy. The convul- sions themselves are either often immediately fatal, or so exhaustinof to the patient that he succumbs readily to the disease that produced them. In these cases the prognosis depends upon the frequency and severity of the attacks, death usually terminating those in which the status eclampti- cus has been established. The prognosis for ultimate cure depends also in part upon the length of time that the condition has existed ; if but for a short time before an arrest has been established, recurrence is much less OCCUPATION-NEUROSES. 1161 likely. Gowers, however, says that even after a year's duration perma- nent cure may sometimes be obtained. The treatment naturally falls into two parts — that of the attack and that of the interval. Unquestionably, the most efficacious antispasmodic that we possess for this condition is chloroform. A few drops may be put upon a handkerchief and held carefully over the nose and mouth of the little patient. A very small quantity usually suffices, and the effect is almost instantaneous. In addition to this, chloral and the bromids may be given by the rectum, and it is often useful to add to these one of the coal-tar antipyretics, particularly antipyrin. Morphin may be given hypodermically. Formerly hot mustard-baths were much in favor, but unless they do good at once they are not likely to be of any use. In a very obstinate case under my care they were absolutely valueless, and were re- placed by momentary immersion in ice-cold baths and vigorous friction, which seemed to act very favorably. If any known source of irritation is present, as an overloaded stomach, it should be relieved at once, if pos- sible, by the stomach-tube or an emetic. An enteritis may be tempo- rarily benefited by an enema or by a moderate dose of calomel. The treatment during the interval depends upon the nature of the cause. If rachitis exists, it should be treated according to the principles laid down in my discussion of this disease. If dentition is suspected, the gums may be lanced, but this should only be done when they present distinct signs of irritation. Gastro-intestinal disorders of any kind should be relieved as soon as possible, and intestinal parasites must be expelled. In infec- tious diseases the convulsions usually disappear after the initial stages, and require no further attention. In organic brain-disease, providing it be not syphilitic in nature, very little can be done. Finally, in those cases in which no cause can be discovered bromids are the only resource, and should be given in sufficient doses: from gr. iij-v (0.194 to 0.324) per day to children of six months, and from gr. v to x (0.324 to 0.648) to those between six and sixteen months. OCCUPATION-NEUROSES. Definition. — Conditions in which the performance of certain habitual coordinated movements is prevented by the development of cramp, tremor, paralysis, or pain. The commonest form is writers' cramp (graphospas- mus, mogigraphia, scriveners' palsy). The pathology of this condition is unknown. It is probably purely functional, and the discovery of appreciable lesions is not to be expected, though nodular thickening of the peripheral nerves has been described in a few cases. The etiology is various. Males are far more frequently affected than females, the condition usually occurring in early adult life, although children are not exempt. The condition always occurs in those whose occupation demands much writing, and Gowers lays great stress upon improper methods of holding the pen, particularly those in which most of the writing is done from the wrist ; that is, with the muscles of the 1162 DISEASES OF THE NERVOUS SYSTEM. forearm and hand. As scrivener's palsy occurs sometimes in those that write properly, and as a similar condition is not uncommon in other oc- cupations, it seems unlikely that this is the most important cause. A person with a neurotic temperament is far more apt to be affected by the disease than one with a normal nervous system ; we, therefore, frequently find it associated with hysteria, neurasthenia, or great bashfulness, and not infrequently it is possible to elicit a neuropathic heredity in the fiimily history. It is"^ also met with in certain other nervous diseases (epilepsy, locomotor ataxia — in the early stage.) Often the patients admit that at the time the disease developed they were suffering from severe anxiety. Symptoms. — Motor. — When the patient attempts to write there is usually a cramp of the flexor muscles of the forearm, so that the pen is held more or less rigidly, and it is almost impossible to control its mo- tions. Less frequently there is a cramp of the extensor muscles, so that the fingers are spread and it is impossible to hold the pen at all. Some- times there is a sudden twitching, and the pen may be thrown altogether out of the hand. The spasm is nearly always tonic in character, but often it is associated with a fine tremor, and at times there are clonic movements. In some cases, and particularly those occurring in patients showing hysteric stigmata, there is a coarse, irregular tremor, most marked when the patient is under observation. Paresis is frequently associated with the cramp, so that the arm soon becomes tired and it is almost impossible to write. This fatigue may in a few moments progress to almost complete paralysis of the arm, but, curiously enough, both fatigue and paralysis disappear as soon as some coordinated movement other than writing is undertaken. Sensory. — Pain is very common, and is neuralgic or cramp-like in character, being referred either to the muscles, bones, or joints. In intensity it varies from a dull ache to the most excruciating burning, and may form the only symptom, the muscles performing their work perfectly. At times it is sharply localized to one particular joint, affecting either the metacarpal bones or the fingers. Quite often the patient complains of a tingling or burning sensation in the limb, or it may be numb and the hand feels, when writing, as if a heavy weight were attached to it. Often there is tenderness either of the muscles or the nerves, which may be localized in certain points. In very severe cases vasomotor disturbances occasionally occur. The disease ordinarily commences slowly. At first the subject notices that the handwriting is not quite as perfect as before, a stroke occasionally going astray ; later distinct spasms appear, and these are finally associated with pain. The diagnosis is usually easy. Care must, however, be taken not to call every disturbance of writing writer's cramp ; thus in paralysis agitans, in slowly-developing hemiplegia, in multiple sclerosis, and in locomotor ataxia disturbances of writing frequently — in fact, almost in- variably — occur. Moreover, those cases in which hysteria or neuraresthesice include the common varieties of formication, dead fingers, and the like. Psychic Symptoms. — These have already been mentioned among the prodromal symptoms — violent and capricious changes of temper, mental depression and unrest, melancholia, and a notable lack of volitional power whereby the patient becomes especially open to the suggestions of the hypnotist. Such patients may develop into that strange condition known as "double consciousness." (b) The Digestive System. — Among the usual clinical manifestations of this group may be mentioned anorexia (which may be complete), a strange and persistent perversion of taste, occasional uncontrollable vomit- ing without nausea (hysteric vomiting, anorexia nervosa), marked dyspep- sia, and at times extreme emaciation with dryness and a parchment-like feel of the skin. Excessive flatulence and the peristaltic unrest of Kiiss- maul may be marked symptoms, as may also either diarrhea or constipa- tion. Hysteric hematemesis is the result of swallowing blood ; this is usually drawn from the gums or tonsils, or it may be taken secretly by the patient from other external sources. (c) The Respiratory System. — Difficulty of respiration [hysteric dys- pnea) is not uncommon, and is characterized by an extreme rapidity and shallowness of the respiratory movements. These are much out of pro- portion to the heart-beats, and are unassociated with cyanosis. In other cases the disturbance assumes the form of uncontrollable yawning, sneez- ing, or hiccoughing, due probably to a spasmodic action of the involun- tary muscles of the bronchial tubes and diaphragm. Hysteric cough is a troublesome, and very often a stubborn symptom, occurring espe- cially in young females. It is dry and barking, and, as a rule, unaccom- panied by expectoration. At times it may be followed by hysteric hemoptysis, in which there is an escape of light-red fluid from the pharyngeal mucosa. Hysteric aphonia is also frequently noted ; in this condition the patient scarcely speaks in an audible whisper. In such cases restoration of the voice is as of sudden occurrence as is its loss. In one of my own cases aphonia manifested almost true intermittence for a period of five years, Avhile during the last two years or over it has stubbornly persisted even without remission. HYSTERIA. 1171 (d) The Vascular System. — Hysteric tachycardia is often noted, and much less frequently hysteric bradycardia appears. A variety of pseudo- angina is not of rare occurrence (vide Angina Pectoris, p. 671). Very frequently the patient exhibits a localized flushing of the skin (hysteric erythema), and especially of the face and neck, or, as has already been noted, there may be an apparent bloodlessness of a part. Profuse general or localized sweating is not uncommon, and may at times be bloody. Hysteric fever may be mentioned here as a rare manifestation, the bodily temperature usually being normal in hysteria. The elevation of temperature may be moderate or there may be an extreme hyperpyrexia (110°-120° F.— 43.3°-48.8° C), without grave results. If this be associated with localized neuralgia, it becomes a difficult matter to diagnose between the neurotic condition and organic disease of the apparently affected part. (e) The Urinary System. — An excessive flow of urine {hysteric polyuria) is of very common occurrence, while the opposite condition {anuria) is much rarer. Diagnosis. — The diagnosis of hysteria must depend largely upon the history of the attack, the previous history of the patient, and the recognition of the features of the neurotic temperament. Individuals possessing this habit are generally spare of body, of quick movements, brilliant and changeable eyes, an emotional disposition, and unstable men- tal equilibrium. Close and judicious inquiry among the friends will, as a rule, elicit a history of previous hysteric seizures of laughing and crying. The great tendency of the profession, unfortunately, is to over- look true organic conditions and ascribe the patient's symptoms purely to an hysteric attack. Moreover, it must not be forgotten that even genu- ine hysterics may develop true organic disease, either during an attack of hysteria or in the intervals, and these intercurrent affections may, though rarely, terminate fatally. Differential Diagnosis. — Very important is it to distinguish between hysteric and true paralyses, and between hysteric and organic abdom- inal tumors. In the following tables the most striking points of differ- ence between these conditions have been set down : Hysteric Palsies. Organic Palsies. Occur without a previous history of or- Are always secondary to organic spinal ganic disease, but with a neurotic his- or brain-disease or to traumatism. tory. Traumatism may be the cause. Are accompanied by other hysteric stig- Hysteric stigmata are absent. mata or perversions of sensation. Are not accompanied invariably by wast- Are always accompanied, sooner or later, ing of the muscles involved. by muscle-wasting. Reactions of degeneration are absent. Reactions of degeneration are present. The paralysis is apt to be more or less The paralysis is permanent and marked. transient and shifting. The power of motion returns before sen- Sensation first reappears. sation. In hysteric hemiplegia the facial muscles The facial muscles of the same or oppo- are not involved. site side are always involved in true hemiplegia. Anesthesia generally causes relaxation of Organic paralytic contractions are not hysteric contractions. aifected by anesthesia. 1172 DISEASES OF THE NERVOUS SYSTEM. Hysteric Abdominal Tumors (Pseudo- Organic Abdominal Tumors. CYESIS). Almost invariably occur in neurotic Occur irrespective of sex. women near the menopause. The percussion-note is invariably tym- The percussion-note over the swelling is panitic. duUj or a dull tympany. Anesthesia causes a disappearance of the Anesthesia has no effect upon the tumor. tumor. Is variable as to size and tonicity. Slowly but steadily progresses in size. Is accompanied by tympany and flatu- The bowels are not always distended by lence. gfi-s- The diiferential diagnosis between hysteria and true neurasthenia, and epilepsy, will be found in the discussion of the latter two affections. Prognosis. — As regards death, the prognosis in hysteria is good; true hysteric patients never die of the disease, nor does the hysteric spasm ever result fatally. As to an ultimate cure, however, the prognosis is very doubtful. If the disease occur early in life and if there is a marked congenital neurotic tendency manifested in the patient, there is almost no hope of effecting a permanent cure. In the acquired cases, under proper moral and hygienic control great benefit may be effected or even an absolute cure recorded. Treatment. — Of the Temperament, — Accurately speaking, the treat- ment of hysteria should be begun before birth. Neurotic women bearing children should be subjected to a course of rest-cure and mental and moral suasion, and the condition of their nervous systems should receive the careful attenti(m of the attending physician. Neurotic children re- quire the greatest care during the developmental period. A strong phy- sique must be secured by proper attention to out-of-door exercise, and, for the time being, even at the expense of mental culture. Such children should not be subjected to the "cramming" process so common in our modern courses of education, but should be trained, if possible, at home, where the element of competition may be eliminated. Systematic hours of study and of recreation (with absolute rest from study during the summer months), and opportunities of travel and change of air and scene, will work wonders in these hyperesthetic little individuals. Especially at the time of puberty is the greatest of care required in order to avoid an additional strain upon the already seriously taxed nervous system. In addition to the foregoing a strict watch must be kept over the moral nature of the child. The satisfaction of every Avhim and the lack of moral suasion are the surest ways to develop the hysteric temperament. When possible the child should be taken away from the enervating in- fluences of city life. The diet should be plain, but nutritious, and all over-indulgence is to be absolutely prohibited. Frequent bathing and friction of the skin are very beneficial, as well as careful regulation of the emunctories generally. The Hysteric Convulsion. — During the hysteric seizure the patient must be carefully watched, and suitable measures should be adopted to cut short the attack ; all extreme measures, and severity, however, are unwarrantable. Cold plunge-bathing, the dashing of cold water into the face, or the hypodermic injection of apomorphin, thereby producing a profound mental shock, may have a beneficial effect. Pressure over the HYSTERIA. 1173 ovary or upon one of the large vessels (as the carotid) will sometimes promptly induce a termination of the attack. Internal Treatment. — In this period of the disease it is probable that most can be done to improve the condition of the patient. In addition to the general laws of mental and physical regimen already advanced, the patient should be taught, as far as is possible, the undignified condition into which she is sinking, and advised and encouraged to exert powerful efforts to control her nervous organism. To this end she should also be given full doses of the nerve-sedatives and antispasmodics (valerian, asa- fetida, sumbul, musk, and camphor), together with the general tonics (iron, arsenic, strychnin). I have repeatedly found the rest-cure of Weir Mitchell especially beneficial at this time ; it is fully described under Neurasthenia (vide p. 1177). Hypnotism has commanded considerable attention during this stage of the disease, and it is claimed that under the suggestion of the hypnotist an absolute cure very frequently follows. This is not altogether true, however, for while many patients are undoubtedly benefited by this pro- cedure, the good result must be attributed not alone to the suggestion of the operator, but also to the profound mental effect produced upon the patient by the mysterious process. In the treatment of the organic manifestations, which, it must be re- membered, are dependent entirely upon the general nervous condition, the physician is called upon to exercise the greatest amount of tact. As far as is possible the mind of the patient must be directed away from the affected part. The irritable bladder must be treated by internal remedies, as boric or benzoic acid, salol, or the compound infusion of buchu, and not by local irrigation and catheterization. Hysteric vomiting may not require any special medication. Occasion- ally, however, it may be relieved by rectal alimentation. Cocain hydro- chlorate in the form of a 10 per cent, solution (dose internally), and the application of mild counter-irritation or of a small fly-blister over the epi- gastriurh will be useful. Cannabis indica, acetanilid, phenacetin, and antipyrin, in small doses and only when absolutely needful, will relieve hysteric neuralgias, especially the cephalalgia. For the pseudo-angina pectoris, digitalis, strophanthus, caffein, amyl nitrite, or nitroglycerin, or a combination of these drugs in suitable doses, may be exhibited. For the pelvic hyperesthesia of hysteric females local applications (tinc- ture of iodin, croton oil, or a small fly-blister) over the ovarian region may prove very beneficial. Hysteric palsies, either general or local, and hysteric disturbances of the special senses, must be treated on general principles. As far as is possible the patient's attention must be directed from the affected part or parts, and an occasional local blistering, the use of galvanism and massage, with daily friction, will be of service, especially when they are supple- mented by an appropriate course of internal medication. 1174 DISEASES OF THE NEEVOUS SYSTEM. NEURASTHENIA. Definition. — Functional exhaustion and irritability of the nerve- centers. Neurasthenia is the expression of an abnormal sensitiveness (irritability) in response to stimuli, and of weakness of the nerve-centers presiding over the organic functions. Several varieties — cerebral, spinal, cardiac, and gastric — have been distinguished, owing to the fact that the predominating features may be manifested by single organs or systems of the body. That the disease is essentially generalized in all instances, however, I do not doubt. It is not a psychosis. Pathology. — A variable degree of weakness of the sympathetic cen- ters, permitting congestions on trivial provocation, is obvious, but there are no discoverable lesions (coarse) in the nerve-centers that are peculiar to the affection. C. Y. Hodge ^ has invited attention to certain chauo;es in nerve-cells during the active exercise of their function, and something of pathologic importance has been added to our previous knowledge by his observations. There are many causes and associated affections that present a variety of morbid lesions, but they are purely incidental. It should be pointed out here that neurasthenia is often found in association with other functional nervous disorders — a fact that has not only caused mental confusion among certain authors, but has also led to the belief among others that as a distinct affection it does not exist. Ktiology. — The causes are divisible into — 1, predisposing ; and 2, exciting. Among the former (a) heredity heads the list. A clear history of nervousness or morbid irritability in one or both parents (oftener the father) is at times obtainable. Ancestors that were sufferers from gout, rheumatism, syphilis, tuberculosis, and chronic alcoholism, all diseases that exhaust vitality, may have transmitted to their offspring a strong neurasthenic disposition. The latter have inherited a small stock of ner- vous energy with which to begin life's unceasing struggle. Of other predisposing factors may be mentioned in particular [h) im- proper training, mental and physical, and (c) the character of the mental pursuits, those entailing strains being especially deleterious, {d) Age and sex are not without appreciable effect, most cases occurring between the twentieth and fiftieth years, Avhen the work and worry of life are maximal ; they are more frequent in men than in women. Exciting Causes. — According to my own observations, traumathm has an active potency, though it is probably not the most frequent cause. Overu'ork, at least in America, is responsible for a greater number of cases than any other single fiictor, and in estimating its effects the rela- tivity of individual nerve-capital must be carefully considered. Asso- ciated causes are to be observed in unpleasurable emotional excitement, mental worriment, particularly if dependent upon love-affairs, and sexual excesses. Abuse of the sexual organs, excessive venery, masturbation, and the like are powerful in producing neurasthenia. Finally, as stated under Pathology, the condition may be induced by other functional and organic affections (symptomatic neurasthenia). Symptoms. — The subjective symptoms are protean and varied, but these are often learned only after close interrogation, the patient being unduly reticent as a rule. Among the more prominent and numerous ^ Journal of Morphology, vol. v. No. 11, p. 95. NEURASTHENIA. 1175 features entering into the symptom-complex of neurasthenia are great irri- tability, physical fatigue without adequate reason, even to a feeling of utter exhaustion on rising in the morning, disturbed sleep, headache, with a sense of weight and constriction, impairment of memory, anorexia, and constipation ; the patient is very irritable, dispirited, is fearful, and fre- quently sinks into a state of absolute dejection. Female sufferers — and less frequently males also — may manifest strong emotions, and in such cases the condition presents many points of resemblance to the milder forms of hysteria. The external appearances may be indicative of sound, vigorous health : oftener, however, the physiognomy is worn and anxious. The motor phenomena include, besides readily oncoming exhaustion of the muscular strength under exercise, a variable condition of the tendon- reactions. On the whole, however, they are increased. Muscular tremors (fine) are sometimes present, and particularly "v^-hen neurasthenia is the result of trauma or fright (Dercum). and spasmodic contractions (usually brief) of small isolated groups of muscular fibers of the face, trunk, or extremities are observed. The sensory disturbances are varied and sometimes striking. The patient makes constant complaint of feeling "'tired" or "never rested," and indeed sometimes betakes himself to bed for this reason. A feeling of "lightness," giddiness, and even true vertigo, may occur and recur, and rarely the latter symptom is wellnigh continuous. The headache (pre- viously mentioned) is often wholly dependent upon mental work, since it disappears with the cessation of the latter. Another form of pain is a dull aching that may be generalized, though more commonly it is con- fined to the small of the back and limbs. Spincd tenderness, when sought for, may often be elicited over certain circumscribed areas or mere points, and it may be combined with a deep-seated ache or an exacerbating pain ("spinal irritation "). Cutaneous hyperesthesia is common, but anesthe- sia is not found in uncomplicated neurasthenia. Numbness, either spon- taneous or as the result of slight pressure, is a conspicuous feature for a variable period upon or near to the nerve-trunks, and linked with it there may be a generalized or localized feeling of coolness of the body- surface, or of pricking sensations (formications) and circumscribed sub- jective sensations of heat and burning. The psychic symptoms grow out of the same fundamental conditions as do the physical symptoms — i. e. fatigue of the nerve-centers. As would be expected, then, the capacity for sustained mental work is gener- ally lessened, and the power to concentrate or rivet the attention upon any subject as well. The patient is self-centered, sensitive to a degree, easily angered, and is morbidly suspicious. His emotional nature is unstable, and the mental depression (before mentioned) deepens until it approaches true hypochondria. Insomnia, varying in form, is frequent, and disturbances of the organs of special sense are not wanting. The eye presents the most important fa- tigue-symptoms. Vision may be imperfect (blurred), and continuous close use of the eyes be impossible. There is a lack of power of accommodation and retinal hyperesthesia may supervene. The pupils may be unnaturally large. All forms of tinnitus constantly arise in neurasthenia, and may lend so vivid a coloring to the clinical picture that the real nature of the attack is liable to be overlooked. I have recently seen a case of the sort 1176 DISEASES OF THE NERVOUS SYSTEM. occurring in a clei'gyman (thirty-six years old), in Avhom the diagnosis of aural disease had previously been made. This symptom, like all others due to neurasthenia, may, however, be associated with genuine organic diseases of the ear (otoneurasthema). Disturbances of taste also tend to appear, but they are of minor importance. Vasomotor disorders, such as hot flushes and profuse sweats, commonly arise in consequence of the diminished tone of the arteries ; these form quite distressing fatigue- symptoms. Visible throbbing of the superficial vessels and of the ab- dominal aorta, and rarely also of the veins and the capillary pulse, occur in the affection [vide Aortic Regurgitation, p. 597). The urinary phe- nomena maj'^ excite particular attention owing to their prominence, and this remark applies especially to the frequent combination of neurasthenia and lithemia {Jithemic neurasthenia). Oxaluria and transient glycosuria and albuminuria may also be present. The daily amount of urine is often small, and less frequently it is large. The sexual apparatus is weak and irritable, as shown by frequent seminal emissions (nocturnal) and incomplete erections, and, if the subject be married, by premature ejacu- lation. The fear of becoming impotent often renders the mental attitude of those really potent such as to excite the keenest compassion. The orgasm in the female and the emission in the male are followed by a sense of prostration and mental depression. The somatic disturbances referable to the heart (palpitation, precordial pain) have been considered under Neuroses of the Heart, and the various gastro-intestinal features in the discussion of Neuroses of the Stomach. Reference has already been made to several clinical varieties based upon the predominance of special and localized groups of symptoms — e. g. when the reigning features are spinal the variety is termed spinal neurasthenia ; Avhen these are pi'esented by the sexual apparatus, sexual neurasthenia ; and so on ; but I am in entire accord with Dercum Avhen he avers that groups of symptoms cannot be considered as sufficient ground for the division of neurasthenia into separate forms. ^ Diagnosis. — That cases of neurasthenia are misdiagnosed as other conditions, and the reverse, I feel convinced. An important matter at the outset is to avoid confounding the neurasthenic symptoms (secondary) of various local and general organic diseases with the primary form by a careful exclusion of the latter. From hysteria the diagnosis is as follows : Hysteria. Neurasthenia. By nature a psycho-neurosis. A true neurosis. Occurs in individuals presenting a marked Occurs as the result of nerve-tire, over- hereditary taint. work, and the like in individuals not necessarily presenting hereditary taint. The onset is frequently abrupt. The onset is always gradual. The clinical features are dependent upon Is characterized by a notable lack or in- an excess of nervous energy. sufiBciency of nerve-force. Presents the characteristic stigmata, as These are absent, paralysis and anesthesia in most cases. Is sometimes accompanied by violent con- Convulsive seizures never occur, vulsive seizures. Xeuralgic attacks are infrequent or alto- Neuralgic attacks are very common. gether absent. Insomnia is not marked. Insomnia is very common. ' Nervous Diseases by American Authors, p. 73. NEUBASTHENTA. 1177 Hysteria, it is to be remembered, may be a complication of neuras- thenia, and this association must be distinguished from simple hysteria. Prognosis. — Neurasthenia is a curable disease if appropriate treat- ment be commenced before secondary structural changes set in and render the use of the most approved measures of no avail. In long-standing cases deleterious habits (morphinism, chloralism, alcoholism) are some- times developed and prevent the possibility of a cure. Hysteria (the complication) tends to delay, but does not preclude, recovery. Treatment. — The first step should be, after locating the major cause or causes, to remove them, or, if this be impossible, to minimize their baneful influence so far as may be. For example, if the conditions have been induced by overwork of the brain, rest for the organ must be pro- cured ; if sexual excesses have been the obvious responsible factor, rest for the sexual apparatus is imperatively demanded. In the next place, the mental and moral environment must be conducive to contentment and to wholesome forms of exercise of the mind. In this way the exhausted stock of nervous energy can be often increased by the natural recuperative forces alone. Indeed, successful removal of the essential etiologic influ- ences is in the milder forms followed by prompt recovery. In not a few instances the symptoms disappear as the result of a prolonged sojourn in a suitable climate or by travel for a considerable period with its ever- accompanying change of scene, though it is well in doing so to avoid the din and excitement of large cities. The compulsory rest and complete isolation, combined with the purity of atmosphere, afforded by a sea-voyage sometimes work admirable results. Unfortunately, many subjects sufi"er- ing with neurasthenia, and particularly males, are either unable or un- willing to arrest the loss of nervous function by ceasing their excessive activities. In the majority of instances, for the reasons above stated, certain other measures — hygienic and medicinal — are to be advised. Next to the importance of removing the exciting agents, stands rest. In severe and long-standing cases this should be made as nearly absolute as possible, while in the milder forms merely lengthening the hours for sleep or rest in bed, as first pointed out by Dr. S. Weir Mitchell, often sufiices. The amount of rest must be accurately proportioned to the necessity of individual cases. To Dr. S. Weir Mitchell belongs the credit of having introduced the " rest-cure " in the management of this disease. This mode of treatment in very old, and in profound cases produces cura- tive eff"ects unobtainable in any other manner, though it does not give complete restoration to health, as a rule, and must be variously modified in individual instances. It embraces not only absolute rest, but also "passive exercise" and forced feeding. Both body and mind must re- ceive rest ; hence confinement often is not sufiicient, and the patient must also be strictly isolated from friends and relatives, particularly if hysteria be associated. The patient is to be put in charge of a properly selected nurse, who will afi'ord agreeable entertainment by suitable conversation and reading under the instructions of the physician. In desperate cases the patient should not be allowed to feed himself, must not rise to void the urine or feces, nor even turn in bed without the help of the nurse. The neurasthenic also demands a special dietary, that is to be made up at first of milk. This should be administered in small quantities at the 1178 DISEASES OF THE SERVOUS SYSTEM. beginning (siv or v — 120.0 or 148.0, every two hours), and slowly and gradually increased until at the end of a week or ten days large quanti- ties are taken (sviij-x — 236.0-300.0 every two hours). When whole milk cannot be readily digested skim-milk should be employed. To the milk, should the patient become decidedly hungry, may be added in the course of five or six days very light nutrients (plain boiled rice, a soft- boiled egg) and a little later meats (lamb-chop, steak). Constipation calls for the use of unbolted bread (graham), fresh and stewed fruits, and butter. This simple dietary is to be enriched until three large meals are taken daily — " such, for instance, as a breakfast of fruit, cracked wheat, one or two soft-boiled eggs, or a good-sized steak, well-served chops, bread and butter, and milk ; a dinner of a good slice of roast beef, with vegetables and boiled rice (in place of potatoes). The supper should remain as a light meal of bread, butter, fruit, light pudding, and milk " (Dercum). Tea, coffee, and alcohol should be avoided. Passive exercise, massage, and electricity form an essential part of the " rest-cure," though the former should not be commenced until the second or third day. At first it should be continued for a few minutes only, and consists of gentle rubbing or light strokes. As tolerance becomes estab- lished massage should be practised for a longer period (about an hour). Deeper rolling, kneading, and spii*al manipulations are then allowable. The direction of the venous blood-current — toward the center of the body from the periphery — is to be borne in mind, and all massage-motions are to be made in the same direction. This measure is to be carried out by the nurse, who should be a well-trained masseuse and thoroughly ac- quainted with the details of her work. Electricity, like massage, com- pensates for the lack of exercise. The slowly-interrupted faradic current is to be selected, and the aim should always be to induce satisfactory con- tractions with the least amount of pain. The current should be applied to the individual muscles, one of the extremities being selected, and the poles applied over the motor points, passing from muscle to muscle until all have been faradized. The time of each sitting should not exceed half an hour. The entire body should also receive the faradic current (rapidly interrupted). A large sponge moistened with salt water is applied at the nape of the neck, and another to the soles of the feet, and the strongest current tolerable is thus used. This process should be continued from fifteen to twenty minutes, and, like the faradization of the single muscles, it is to be repeated at intervals of twenty-four hours. The rest-cure in all of its details should be continued for a period ranging from four to eight weeks. The patient should leave his bed in the most gradual manner, and should sit up for a few minutes only at first, the time being gradually lengthened ; soon exercise may be commenced in a like manner and be cautiously increased. During this period of convalescence it is my custom to omit the electric treatment, while the massage is continued at intervals of two or three days for some weeks. After the patient has reached the point of marked improvement, as evi- denced by a large appetite, the disappearance of the most pronounced subjective symptoms, and especially by a substantial gain of weight (twenty to twenty-five pounds — 11.3 kgms.). he should be advised to make a change of air to the country, or t« the mountains or the sea- shore (if it be not the summer season). ACROMEGALY. 1179 Hydrotherapy is positively and rationally serviceable in the manage- ment of neurasthenia. The water may be employed in the form of the shower, spray, bath, or pack, and is most efficacious when quickly applied for a few moments and followed by vigorous towelling to reinforce the action of the cold. A portion of a garden-hose with a sprinkler is read- ily attached to the water-pipe in the bath-room and furnishes the read- iest means of applying cold water. Extreme caution is necessary at the beginning of the application of cold to the surface, since there are neur- asthenic subjects that not only fail to receive benefit, but are rendered worse thereby, in consequence of a highly sensitive organization. Drugs are of minor importance in the treatment, and their routine use is to be condemned. Laxatives are often needful, and in my experience broken doses of calomel, followed by a saline, or the fluid extract of cascara, have proved most effective. For a further consideration of the treatment of the gastro-intestinal symptoms the reader is referred to Neur- oses of the Stomach. Strychnin is constantly being employed in the treatment of this affec- tion, but its use should be limited to the more profound types. Full doses are required if we would expect good results. In cases in which anemia is marked arsenic may be employed with advantage. Phosphorus has also been recommended, but it tends to disturb the digestive organs and rarely gives striking general results. ACROMEGALY. ( Giantism.) Definition. — A disease first recognized and described by Marie, and characterized by a progressive and peculiar enlargement of the face and extremities. Pathology. — Those cases that have been examined ]}ostmortem have shown, as the most constant change, an enlargement of the pituitary body, with a corresponding dilatation of the sella turcica, and a persistence of the thymus gland. Less frequently there is fibroid degeneration of the thyroid ffland. A few cases, however, have been reported in which one or all of these organs were normal. The lips, tongue, and trachea are usually considerably enlarged, and the sexual organs may either be hyper- trophied or atrophied, the latter condition being more common in the uterus and testicles. The bones of the extremities and face are thick- ened, apparently chiefly as a result of hyperplasia of the spongy portion, and Klebs has shown that the peripheral vessels, particularly those in the affected bones, are also larger. Occasionally there are hypertrophy of the heart and enlargement of the spleen and liver. The etiology of acromegaly is unknown. Marie believes that it is a form of systematic dystrophy analogous to myxedema, and probably due to interference with the function of the pituitary body. Freund holds that it is a sort of inversion of groAvth associated with alteration in the sexual organs at puberty. Klebs believes that it is due to a neoplas- tic condition of the vascular tissues, associated with a functional persist- 1180 DISEASES OF THE NERVOUS SYSTEM. ence of the thymus gland. Various diseases have preceded the develop- ment of acromegaly, but none with sufficient regularity to indicate that the subsequent appearance of the latter condition was other than acci- dental. Both sexes are about equally affected, and the disease ordinarily commences in adolescence. The earliest symptom is usually an increase in the thickness of the fingers and toes, so that rings, gloves, and shoes are too small and can no longer be worn. This enlargement is chiefly in thickness, although there is also a certain amount of increase in length. Both the soft and hard parts are affected. The nails are flattened, longitudinally ridged, and more friable {spade-like hand). The face becomes considerably enlarged ; the supraorbital ridges project, giving rise to a rather simian aspect; the nose becomes broader and longer; the cheek-bones project ; but the most positive characteristic is the enormous enlargement of the lower jaw, so that it becomes broader and prognathous, and the lower teeth can no longer be brought in apposition with the upper. The spinal column is ordinarily kyphotic, the change affecting the upper dorsal and cervical regions. Frequently there is also an associated scoliosis. The rest of the skeleton remains unaffected for a long time ; finally, changes may be ob- served in the clavicles, sternum, ribs, pelvis, and particularly in the pa- tellae. The skin sometimes shows slight pigmentation ; the hair is rough and may become thinner; the muscles occasionally exhibit increased electric excitability, and less frequently there is muscular atrophy with reactions of degeneration. The lips, tongue, and tonsils are usually en- larged, and the larynx is increased in dimensions, so that the voice be- comes deep and rough ; this is a very characteiMstic symptom in women. Ordinarily, an area of dulness can be detected in the upper pai-t of the sternum that has been ascribed to the persistence of the thymus gland. The tendon-reflexes may either be normal, diminished, or abolished. They are never exaggerated. The urine is increased in amount, and glycosuria is often present. The secretion of siveat is also greatly increased. The subjective symptoms consist of severe intermittent or continuous head- ache and of a diminution of the visual power. There may be pare- sis of the third nerve, giving rise to external strabismus, and some- times to temporal hemianoj)sia as a result of pressure upon the central part of the chiasm by an enlarged pituitary body. Sometimes late in the disease there are occasional momentary general tremors. The patients often present polyphagia and polydipsia. Neuro-retinitis and subsequent atrophy of the optic nerve may also occur. Sexual power is usually abolished. In women menstruation ceases early in the disease, and the breasts atrophy. The mental condition is affected, and there are usually great apathy and diffidence (perhaps explicable by their changed appear- ance), loss of memory, and even, in some cases, imbecility. Diagnosis. — In the later stages the appearance is characteristic, and acromegaly can then hardly be confounded with other diseases. The pe- culiar enlargement of the extremities, the oval, prognathous, and distorted face, the deep, rough voice, the more or less pronounced pigmentation of the skin, the wasting of the muscles, and the profound cachexia give a per- fect clinical picture. In those cases in which the cachexia has become ex- treme there are from time to time peculiar tremors or spasms of the body. ASTASIA-ABASIA. 1181 Differential Diagnosis. — In the earlier stages the disease is most easily confounded with the Ayj9er^rop^^'c pulmonary osteo-arthropathy of Marie. In this both hands and feet are greatly enlarged ; but the fingers are club- shaped, the face is not involved, and there usually exists some chronic pul- monary complication. In a case that I observed there Avere bronchiectasis and bronchorrhea. From osteitis deformans it may be distinguished by the fact that in this condition chiefly the long bones of the limbs and the flat bones of the skull are hypertrophied and very painful. ^ lejjhantiasis may be distinguished by the fact that it attacks the lower limbs, does not involve the bones, and the skin presents a granular or a nodular appear- ance. From arthritis deformans acromegaly may be distinguished by the fact that the disease develops late in life and is associated with great de- formity of the joints, the face ordinarily escaping. The following table (after Dercum) will serve to distinguish two diseases that are apt to be confounded with one another : Acromegaly. Myxedema. Occurs most commonly in early adult life. A disease of mature life — forty to fifty years. In males and females equally. Five times as frequent in females as in males. Enlargement of the bones characteristic. No enlargement of the bones. Marked prognathism of jaw and flatten- Face full-moon-shaped. ing of cheeks. Skin brownish-yellow ; hair coarse and Skin pale, waxy, shiny, and boggy ; hair unwieldy ; nails short and striated. falls out ; nails not affected. Fingers symmetric and sausage-shaped. Fingers clubbed at the end. Administration of thyroid extract is of Thyroid treatment of the greatest benefit. the smallest benefit. The prognosis is hopeless for cure and doubtful for duration. The disease is progressive, although it remains stationary for a longer or shorter period. Retrogression never occurs. Ordinarily, the patients die of some intercurrent condition ; although death may be due to the cachexia of acromegaly itself. Life, however, may last for twenty years after the appearance of the first symptoms. Treatment of the condition itself has proved unavailing. Certain cases have been reported in which there was slight temporary improve- ment after the use of extract of pituitary body or of thyroid gland, but the results are contradictory. The cephalalgia can be more or kss com- pletely controlled by antipyrin or cafi'ein. Phosphorus, mercury, the iodids, and arsenic have been wholly useless. ASTASIA-ABASIA. ASTASIA-ABASIA is rather a symptom than a disease sui generis. It consists of an interference with the power of walking, although the limbs shoAV no trace of paralysis and are capable of performing perfectly other complicated movements. In this respect it is somewhat allied to the functional neuroses. In a case reported by Burr, complicated with severe anemia, changes were found in the posterior and lateral columns of the cord ; ordinarily, however, no gross lesions can be discovered. The dis- 1182 DISEASES OF THE NERVOUS SYSTEM. ease usually attacks either sex in early adult life, and is sometimes asso- ciated with hysteria and neurasthenia. The symptoms consist either of a /c)?rfcw(??/^o/o//"\\"hen standing up- right or attempting to walk, or of great difficulty in locomotion, the feet being dragged along the ground for short steps, the body swaying or mak- ing various contortions to maintain the balance, whilst the patient grasps eagerly at any possible support and exhibits every manifestation of fear. Blocq recognizes three degrees. In the (a) first or most severe, the upright posture and, above all, walking are absolutely impossible. If the patient is lifted up and supported on either side, the legs hang powerless. These patients, however, when lying in bed show neither loss of power nor inco- ordination, and are perfectly able to crawl on their hands and knees. In the (b) second degree the patient is able to stand if supported on either side ; if an attempt to walk is made, the feet are dragged with difficulty along the ground. In the (c) third degree locomotion is possible, but the feet are di'agged along for short steps, often exhibiting deviations such as occur in ataxia ; moreover, the patient is usually unable to proceed as soon as the eyes are closed. In this degree the patients are able to re- main standing, but from time to time they exhibit sudden giving way of the legs, followed by equally sudden recoveries. Hysteric stigmata are usually present, although in some cases they fail completely ; in two of the cases that I have observed there was complete cutaneous anesthesia. The diagnosis is usually easy, and, though certain cases resemble the movements of the more violent forms of chorea, they may be distin- guished by the fact that their limbs become quiet as soon as they lie down. In certain early forms of locomotor ataxia also this symptom may be pres- ent, and can then only be distinguished from the true form by the lack of coordination in bed and the presence of other tabetic symptoms. The prognosis is fiivorable, although some cases are quite obstinate. The treatm.ent is chiefly suggestive. Cases complicated by neuras- thenia are often cured by the rest-treatment ; those in whom anemia is present should be treated for that condition. Hypnotism also may be of use, but the most important element is to encourage the patient to make an effort to walk ; it is astonishing then to note the rapidity with which he will ordinarily impi'ove. CAISSON DISEASE. {Diver's Paralysis; Paralysis from Lessened Atmospheric Pressure.) Definition. — A paralytic condition caused by sudden transference from an abnormal atmospheric pressure to one of normal intensity. The pathology of the disease is obscure. Leyden has foundtears in the substance of the dorsal region of the spinal cord filled with white blood-cells, but without hemorrhagic foci. Other authors have found minute hemorrhages in the substance of the cord and the meninc^es. It has been supposed by some that as a result of sudden reduction in pres- sure the nitrogen gases that have been forced into solution in the blood CAISSON DISEASE. 1183 are suddenly liberated, with the formation of air-emboli ; others have believed that the changes are due to a sudden disturbance of the gaseous metabolism. In cases in Avhich death has occurred after a considerable in- terval the lesions of disseminated focal myelitis have been discovered. The etiology of the disease is very clear, and certain predisposing factors are worthy of note. Divers are more apt to suifer if they have been working at extreme depths, particularly if the period of exposure to great pressure has been prolonged ; even moderate pressure will some- times produce symptoms if continued for a sufficient length of time, and short periods of rest do not prevent the development of the disease. Ordi- narily, it can be said that unless the pr-essure exceeds two and one half or three atmospheres no danger may be apprehended. The symptoms vary greatly in intensity. In the mildest form they consist of neuralgic pains in the joints, sometimes with slight articular swelling, headache, giddiness, and a little tinnitus. These pains may be- come more violent, particularly in the loins, and be followed by a gradual loss of poiver and by anesthesia in the limbs; these symptoms may disap- pear in a few hours or become more severe, with the development of com- plete paralysis and interference with the action of the sphincters. This paralysis usually assumes the form of paraplegia ; monop)legia and hemi- plegia also occur, and sometimes there are complete paralysis and anesthesia of all four extremities and of the trunk. In the most severe cases cere- bral symptoms are also present, consisting of sudden loss of consciousness, profound coma, irregular respiratory action, and finally, after a short time, death from cardiac failure. The diagnosis is very easy. It is possible, however, that an attack of apoplexy should occur in a man who has been under water, and the patient should always be examined for the presence of this or some other organic lesion. The prognosis varies with the intensity of the symptoms. The lighter forms consist merely of joint-pains and slight dizziness that usually pass away in the course of a few hours. Paraplegias or hemiplegias, develop- ing slowly and not assuming a severe form, are also transient in character. A more severe paraplegia is usually permanent, although some improve- ment may be expected. The apoplectic forms are almost invariably fatal in the course of a few hours. The treatment consists, firstly, of prophylactic measures. In all places where caisson-work is carried on one or more locks should be provided in which the pressure can be gradually reduced until it is approximately that of the atmosphere. Divers should be instructed to come slowly to the sur- face. If the pressure exceeds three atmospheres, the maximum length of the working-period should not be more than one hour, and several hours should be permitted between the descents. A chamber should also be provided in which a man Avho exhibits symptoms of the disease can be once more subjected to a pressure greater than that of the atmosphere, as this usually causes an arrest of the process. When, however, the condi- tion resembles that of acute myelitis, the treatment is purely symptomatic. It consists of rest, careful hygiene, and a stimulating diet. Potassium iodid may also be administered in the later stages, but its value is very doubtful. In some of the acute forms with more or less respiratory fail- ure inhalations of oxj'gen have been recommended. 1184 DISEASES OF THE XERVOUS SYSTEM. V. VASOMOTOR AND TROPHIC DISORDERS. ANGIONEUROTIC EDEMA. {Acuie Circumscribed Edema of the Skin; intermittent Angioneurotic Edema.) Definition. — A disease characterized by the appearance of an edematous swelling of the skin or mucous membranes. In general it is not accompanied by constitutional symptoms. The pathology of the disease is obscure. It is supposed to be due either to venous stasis or to some nervous influence upon the lymph- channels, causing them to exude liquid. No lesions have as yet been described. Ktiology. — Neuropathic heredity appears to have some influence upon the disease, but nervous manifestations in the patient himself are more important. Occasionally the condition follows infectious diseases or severe hemorrhage. The most important exciting causes are cold and emotional disturbances. The disease occurs most frequently in males, and almost exclusively in early adult life. Symptoms. — The edema usually appears suddenly, is sharply cir- cumscribed, and the skin of the affected area is slightly elevated and reddened, or else somewhat paler than the surrounding tissue. Ordinarily, subjective sj^mptoms are absent ; occasionally there are slight jiai'esthesice. The edema may appear in any part of the body, but usually it is most common on the backs of the hands or legs and in the face, especially the eyelid. Occasionally it may appear upon the mucous membranes either of the lips, tongue, or glottis ; in the latter situation it sometimes pro- duces severe dyspnea, and at least in one case it has caused death. Its presence has also been suspected in the mucous membrane of the gastro- intestinal tract. Ordinarily the patient has no symptoms Avhatever of disease ; occasionally, however, there are severe colic and sometimes vomiting. In one case hematuria was observed, and in another hemor- rhage from the swollen gums ; of course in the latter case the diagnosis Avas doubtful. The patient may exhibit a certain degree of anxiety during the attack. Ordinarily the swelling persists a few days, and then disappears, but relapses are exceedingly common, and may recur very frequently for many years. The differential diagnosis has to bemadefromurticaria, to which it bears a great similarity. According to Osier, giant urticaria is the same disease. The prognosis is of course favorable for life ; for cure it is more doubtful, as the disease is sometimes exceedingly obstinate. The treatment consists of rest, the use of tonics particularly directed to the nervous system, and the correction of any gastro-intestinal dis- order. Quinin has occasionally proved very valuable. Hypnotism has also been suggested. BAYNAUD'S DISEASE. 1185 HYDROPS ARTICULORUM INTERMITTENS. Definition. — A condition characterized by periodic effusions into one or more of the large joints, and usually the knee. The pathology is unknoAvn, but it is suspected that it depends upon some nervous disturbances of the vessels or lymph-channels in the joints. The etiology is also doubtful. The disease occurs in nervous indi- viduals, and has been found associated with other nervous diseases, as ex- ophthalmic goiter, or in patients suffering from other vascular diseases, as angina pectoris. The symptoms consist of the sudden development of a s-welling in the affected joint, Tvhich, however, does not present any symptoms of inflam- mation and is rarely painful. This swelling lasts from three to eight days and then disappears as suddenly as it came. At regular intervals of from one to four weeks it is repeated, and this repetition may continue for years. The diagnosis must be made upon the symptoms and the periodicity of the condition. The prognosis is doubtful, most cases being exceedingly obstinate. Treatment. — Electro-therapy in various forms has been recom- mended. Among the drugs that have been suggested are salicylic acid, quinin, arsenic, and ergotin. None, however, have proved particularly valuable. RAYNAUD'S DISEASE. {Symmetric Gangrene.) Definition. — A condition apparently of vasomotor nature, affecting symmetric parts of the body, and chiefly the tips of the extremities. The pathology is by no means definitely made out. It is supposed that alterations must occur in the vasomotor centers of the medulla and cord, but none have as yet been found, partly because the disease is rarely fatal. In some cases peripheral neuritis has been observed and in others peripheral endarteritis. The gangrene is usually superficial, and resembles closely that caused by cold ; rarely it causes an extended loss of substance. The etiology of the condition is obscure and complex, largely, no doubt, because a number of different conditions have been confounded under this designation. The disease occurs in children and in neurotic women, less often in men. A neuropathic heredity seems to predispose to it, and occasionally it exists in connection with other nervous dis- eases, as epilepsy, migrain, hysteria, and mental disorders. The occur- rence of paroxysmal hemoglobinuria has led to the suspicion that malaria is an etiologic factor. I am not aware, however, that plasmodia have been found in any case, and the asserted good results following the ad- ministration of quinin are insufficient to establish the contention. Syph- ilis and various other infectious diseases have also been mentioned as etiologic factors, and more recently a form has been described that is sup- 1186 DISEASES OF THE NERVOUS SYSTEM. posed to be purely hysteric in nature. The most important exciting cause is exposure to cold, although attacks may also be brought on by severe emotional disturbances. Symptoms. — The disease presents three grades of severity : first, anemia or local syncope ; second, cyanosis or local asphyxia ; and third, gangrene. Local syncope consists in a vasomotor spasm in one or more extremities, the fingers being most frequently affected, and rarely more than one at a time. They become white, almost waxy in appearance, cold, and hard to the touch, and they may be either dry or covered with a cold perspiration. The finger is perfectly numb, but severe neuralgic pains may be felt in the arm ; if the skin be pricked with a pin, no blood flows. Ordinarily this syncope disappears gradually, the reaction being accompanied by tingling and formication in the affected digit, which ulti- mately returns to a normal condition. Local asphyxia is a further stage of this condition : in this the finger is blue and swollen, and there is a sense of discomfort that is apparently due to the stretching produced by the engorged veins. This cyanotic condition may also affect the ears, toes, and the tip of the nose, and, like the preceding stage, it may dis- appear without leaving any trace of its existence. Patients that have reached this stage seem to be more liable to a recurrence upon slight ex- posure than those who only present local syncope. The attacks are more likely to recur constantly in the same digit, and not to appear first in one and then in another. During the existence of this stage a not infrequent associated symptom is hemoglohinuria ; this is especially apt to occur in children, and has led to the suspicion of malarial influence. In some cases, when hemoglobinuria is not found, the urine contains an excess of urates. If the attack lasts for several days, trophie changes take place in the finger-nail, giving rise to a transverse ridge, which per- sists until that portion of the nail has grown beyond the end of the fin- ger. If local cyanosis, however, continues sufficiently long, gangrenous changes take place. These appear first as small black spots or vesicles filled with serum upon the end of the fingers or about the root of the nail ; these gradually slough off, leaving a small ulcer that may slowly cicatrize. Often patients subject to recurrences of the disease show a number of cicatrices on the ends of the fingers, or if the ears are affected there may be slight shrivelling of their edges. The gangrene, however, may be more severe, in which case the distal phalanges of the affected fingers may become black or dark red, covered with blebs, and finally mummified. The line of demarkation then forms, and ultimately the gangrenous portion falls off, leaving an ulcerated stump that slowly cicatrizes. This form may not be limited exclusively to the hands and feet or ears, but symmetric patches sometimes appear in the skin of the breast. During the time that the gangrene is present the patients suffer from excruciating pains in the limbs that interfere with sleep, often causing transient melancholia, and seeming, more than the gangrene itself, to depress the general condition. Fever is rarely present ; sugar is some- times found in the urine, but not constantly. The diagnosis is necessarily difficult when it is remembered that all clinicians do not agree that such a disease exists. According to Raynaud's definition, it is a neurosis characterized by enormous exaggeration of the excito-motor energy of the gray parts of the spinal cord that control the PROGRESSIVE HEMIATROPHY OF THE FACE. 1187 vasomotor innervation. If this be accepted, then all cases in which lesions of the nerves and arteries have been found are not properly of the same nature ; and there are a number of other conditions that may produce gangrene, often somewhat symmetric in type and perhaps due to vasomotor spasms (particularly syringomyelia and hjjrosy). The so-called "dead finger" is a common symptom, and its occurrence is by no means sufficient justification for a diagnosis of Raynaud's disease. In fact, the typical forms of this condition should advance to slight superficial and symmetrically placed patches of gangrene. Gangrene may also occur in diabetes, and hence the urine should always be examined to exclude this condition. Hysteric gangrene is rarely symmetric, and the patients pre- sent various hysteric stigmata. The prognosis is very favorable. Only in marasmic children do the attacks ever lead to death. Ordinarily they become in time less frequent and ultimately disappear, but in a few cases the tendency to recurrence is obstinate. The treatment consists of improvement in the general condition during the intervals. During the attack the most eff'ective measures are a mild massage, the use of local lukewarm baths, and electricity very cautiously applied, either in a constant descending stream to the spinal column or by the application of the anode to the spine and of the cathode to a vessel containing water into which the hand has been plunged. Amyl nitrite, which might be expected to relax the vasomotor spasm, fails to have any effect ; on the other hand, pilocarpin has been employed with good results. If the pains are very severe, they must be combated by morphin — although gangrene may occur at the site of the injection — administered hypodermically, if necessary. Sleep should be obtained by means of narcotics. The gangrenous parts should always be carefully protected by a local dressing. PROGRESSIVE HEMIATROPHY OF THE FACE. {Progressive Facial Atrophy.) Definition. — A rare disease, characterized, as its name would indi- cate, by a progressive atrophy of one-half of the face, stopping sharply at the middle line, and in the severer forms involving the skin, muscles, and bones. The pathology of the condition is unknown. Rarely symptoms indicating inflammation of the cervical sympathetic, such as dilatation of the pupil or flushing, have been present, and symptoms indicating inflammation of the trigeminus have been equally infrequent. Mendel, however, has reported a case in which he found chronic interstitial neuri- tis of the branches of the trifacial, and other cases have been reported in which the Gasserian ganglion was diseased. Microscopic examination has shown a disappearance of the subcutaneous fatty tissue and a general atrophy of the elements of the skin itself, often associated with the pres- 1188 DISEASES OF THE NERVOUS SYSTEM. ence of an abnormal quantity of pigment. As a rule, the vessels are relatively enlai-ged. The etiology is unknown. The condition usually commences early in life and shows no predilection for either sex. An hereditary tendency does not appear to exist, but the disease occurs frequently as a complica- tion of, or rather in connection with, other neurotic conditions. Of these the most frequent are neuralgia, migrain, epilepsy, and mental disorders ; less frequently, tic convulsif and chorea, particularly if the latter affects the muscles of the jaw and tongue. Occasionally it has been recorded as occurring in patients suffering from locomotor ataxia or multiple sclerosis. It does not appear, however, that progressive facial atrophy has any ana- tomic connection with these conditions. In a few cases the disease has been preceded by an injury to the skull or face, and in others it has fol- lowed an acute infectious disease. Ordinarily it occurs in early life — i. e. between the tenth and fifteenth years — and in these cases it usually pro- gresses to the most severe type. The earliest symptom is a flattening of the skin on the affected side, constituting the lightest furm of the disease, which may remain station- ary at this point ; if, however, it progresses, the muscles and bones also become involved, so that the afiected half of the face is distinctly smaller than the healthy side. The objective changes that take place in the skin are the development o^ioliite spots in which the pigment has disappeared, and which have the appearance almost of scar-tissue, or, what is more commonly the case, of an increase in pigmentation with a formation of yellowish or brownish blotches, the skin being depressed in these areas, which usually lie along the course of the nerve-trunks, especially the infraorbital. The hair becomes thinner, dryer, and often falls out. The secretion of the sebaceous glands is diminished and the skin dryer. Rarer phenomena are the disturhance of blushing, so that the affected side of the face remains unchanged in color Avhen, as a result of some emotional dis- turbance, the other is distinctly reddened. Disturbances of sensation are not common. In some cases electric and tactile sensibility have been diminished ; in others the patients have complained of slight paresthesise. The special senses remain unaffected, and even when the atrophy extends to the tongue, taste remains perfect on the affected side. In one case there were a slight disturbance of hearing and occasional tinnitus. The diagnosis of the condition is easy both when it is suspected and when it is far advanced. The only condition with which it could be con- founded is congenital facial asymmetry. In facial hemiatrophy, however, the skin is shrunken and wrinkled, and the hair is dryer and thinner, contrasting markedly with the healthy side, and there is usually a history of commencement some years after birth. In congenital asymmetry the difference between the two sides is slight, and the skin over the smaller side is normal in every respect. Commonly in this condition we also find differences in the development of the extremities. In a case that I recently observed with marked facial asymmetry, the left side being smaller, the hand and foot on the same side were distinctly smaller than the corresponding members. The prognosis is unfavorable as regards cure. The disease itself is not in the least dangerous, and cases have been recorded that have been under observation for thirty years or more. SCLERODERMA DIFFUSUM. 1189 Treatment is unsatisfactory. The prolonged use of electricity lias been said to arrest the process, and sometimes this arrest occurs sponta- neously ; it is not certain that the treatment is of any use. An allied condition is hemihypertrophy of the face. This is an ex- ceedingly rare condition, and is apparently always congenital. It involves chiefly the soft parts, the ear, skin, tongue, and tonsils being all enlarged. There is an increased secretion from the sebaceous glands, which may appear as small elevations upon the skin. Usually, as in congenital asymmetry, there is enlargement of the extremities on the same side. The only case that has come to autopsy presented no lesions. Treatment is of course unavailing. SCLERODERMA DIFFUSUM. Definition. — A peculiar hardening of the skin, with areas of pig- mentation and depigmentation, associated in the more advanced stages with trophic lesions, muscular atrophies, and aifections of the bones. Pathology. — The affected skin is characterized by an increase of the connective tissue and of the elastic fibers, and by a narrowing of the ves- sels as a result of perivascular infiltration. The etiology is not clear. Some of the cases are associated with joint-affections that resemble those of chronic rheumatism ; others follow exposure to a very low temperature. The presence of trophic lesions in the skin and the development of myopathies lead to the supposition that it is properly classed with the trophic neuroses. The disease usually occurs in middle life, although cases have been observed among children. Women are more frequently affected than men. Symptoms. — Three stages are recognized : First^ a rather dense edema. Second^ a true sclerosis, in which the skin appears thicker, with an absence of the normal folds ; it becomes firm and hard, so that it can- not be pinched between the fingers and lifted from the flesh. Moreover, there are always pigmentary changes, certain parts being darker than normal, while others become a dead white, appearing almost as if com- posed of alabaster. The disease, as a rule, attacks first the upper por- tion of the body — i. e. the face, neck, hands, and arms, or the surface of the thorax, and is most pronounced in those regions where the bones are subcutaneous. The diminished elasticity considerably interferes with the movements of the body. If the neck is affected, it is diflficult to turn the head ; if the skin over the joints is involved, their normal flexion and extension cannot be perfectly performed. The subjective sensations are those of tension, the patient complaining that the skin has become " too small " for him. If any forcible action is attempted, there is severe pain, accompanied by slight tears in the skin. The skin is paler and cooler than normal, and the slightest exposure to cold causes great discomfort and cyanosis. The secretion of sweat may be normal, but is usually di- minished. Tactile sensibility is unimpaired. The third stage is that of atrophy ; the skin becomes thin as paper ; the other symptoms, however, remain as before, except that the secretion of sweat is abolished and 1190 DISEASES OF THE SEE VOUS SYSTEM. uleeratiotis appear that either heal slowly or not at all. In addition, there are muscular atrophies associated with contractures. Often there is con- siderable atrophy of the bones, or there may be a development of exos- toses from the periosteum. Occasionally the end-phalanges of the fingers undergo a process of gangrene that is similar, in some respects, to that of Raynands disease. Ch-onic joint-affections may also be observed in this stage, particularly of the fingers. The course of the disease is variable. Usually it develops slowly and lasts for many years. The diagnosis is usually easy, though occasionally it has been con- fused with Addison's disease on account of the excessive pigmentation. There is, of course, some resemblance to Raynaud's disease, although the condition of the skin itself is very different. In the atrophic stages it may be confounded with xeroderma pigmentosum. The progfnosis is always doubtful. In the later stages the patients become emaciated, and pass into a cachectic state, in which death may occur. Pulmonary complications may develop. Complete cure may, however, occur, and particularly in cases that have a rapid course. The treatment is unsatisfiictory. The unpleasant tension of the skin may be somewhat diminished by ointments and massage ; warm water or steam baths may also give considerable I'elief. The most import- ant thing is to maintain the general condition of the patient by tonics and a change of climate. Sodium salicylate has been recommended, but is probably valueless. MORPHEA. ( Sclerodenna Circumscrii)tum.) This disease consists of the development of small areas of sclerosis that are distinctly related to the distribution of the nerves. These areas are round or oval, brownish or violet in color, and as they increase in size there develops in their centers more or less sclerosis. In these scle- rotic areas there are often punctiform collections of pigment, the hairs fall out, and superficial ulcerations may be present Occasionally they may go on to atrophy of the skin. There are no constitutional symptoms. The diagnosis is usually easy. The prognosis as regards life is favorable ; as regards cure it is doubtful. The local treatment is the same as for the difi'use form of sclero- dei'ma. AINHUM. This is a disease characterized by an enlargement of the little toe and the formation of a line of demarkation at its base. The pathology is not known, but it appears from a Rbntgen-ray picture that the bones are absorbed. There is some dispute as to whether EBYTHBOMELALQIA. 1191 it is one of the manifestations of leprosy or not. At any rate, it does not appear that typical lepra bacilli have been found. Etiology. — The disease may occur in childhood or early adult life, and is most common in negroes. It occurs almost exclusively in tropical regions — e. g. Brazil and Syria. The symptoms of the condition consist in the formation of ^furroiv at the base of the little toe of one of the feet. This grows deeper and deeper until spontaneous amputation has occurred. Rarely the other toes on the same foot become progressively involved. Certain vasomotor disturbances may be observed ; the foot is usually swollen, bluish-red, and cold ; sometimes the other foot may exhibit similar changes without the formation of furrows at the base of the toes. There is some diminu- tio7i of sensation to touch, temperature, and electricity, and ordinarily the patient complains of vague pains in the limbs. The diagnosis is to be made from leprosy, with which, indeed, it may be identical, and congenital amputation : the latter only occasions difficulty when the disease commences in early life. The prognosis is favorable to life, but the disease is usually slowly progressive. No effective treatment has been discovered, but the parts should be protected against injury, and the patients may be given tonics and ano- dynes as required. ERYTHROMELALGIA ( Weir Mitchell). {Paralytic Vaso-motor Neurosis of the Extremities.) Definition. — A disease characterized by paresthesia, redness of the skin, and by pain, usually in the toes and heels, associated with more or less severe general disturbances. The pathology is unknown, but the disease appears to be due to some disturbance of the vasomotor centers or nerves. Htiology. — The cause seems to be exposure to cold, but a nervous temperament or a previous attack of rheumatism appears to have some predisposing action. Men are more frequently affected, and the disease usually develops in early adult life. Symptoms. — The earliest symptom, as a rule, is the occurrence of severe pains in the feet. Objectively, there are swelling and reddening of the skin, and the sensitiveness is so severe that the patient is unable to walk. The general symptoms consist of headache, dizziness, palpitation of the heart, or even fainting. The attacks occur more frequently during the summer months, and are always aggravated by exposure to heat or a vertical position of the limbs. The diagnosis is easy, the condition being really a symptom rather than a disease. It may occur in the course of hemiplegia and in some organic diseases of the spine, and these should be excluded. The prognosis is favorable ; often, however, the disease will recur at irregular periods for a number of years. The attack can usually be cut short by plunging the limb into ice-cold water. 1192 DISEASES OF THE NERVOUS SYSTEM. Treatment. — This should always be tonic, and employed during the intervals ; massage, hot and cold douches, and the faradic current may be used upon the affected extremities. The pain may call for anodynes. ACROPARESTHESIA. {Spastic Vasomotor Xeurosis of the Extremities.) Definition. — A disease characterized by abnormal sensations in the hands, slight vasomotor disturbances, and slight stiffness of the fingers. The pathology and etiology are not understood. Possibly the condition is due to some disturbance of the peripheral nervous system. It occasionally occurs after injury or as a result of prolonged exposure to cold, hence is common among laundresses. It is more frequent among women than men. and usually develops in middle life. The symptoms consist in the more or less sudden development of formication and tingling or numhnem in the fingers and finger-tips, usu- ally bilateral, but sometimes occurring only on one side. Less frequently the toes are affected. These pains are more severe in the night and early morning, and worse in summer or after exposure to heat. The vaso- motor disturbances are variable. Sometimes nothing can be observed, and sometimes the extremities are bluish and cold, sometimes pink and warm. Sensibility is rarely affected. In some cases, however, there is considerable hyperesthesia; in others moderate anesthesia. In a few cases there is stiffness of the hands. Slight trophic disturbances have been reported in a few cases. The attacks may last from a few minutes to several hours, and may recur frequently or only at considerable inter- vals. Usually during the attack the abnormal sensations are continuous, but occasionally they are intermittent in character. The condition known as tender toes., that occasionally occurs after an attack of typhoid fever, is probably a form of this disease. It is ascribed to the Brand treatment, but incorrectly. The diagnosis is usually easy. Care should be taken, however, not to confuse these acroparesthesine with commencing locomotor ataxia, tetany, or hysteria. In Raynaud's disease cold increases the intensity of the symptoms. The prognosis is, in general, favorable, the disease usually disap- pearing after some months ; sometimes, however, the condition is ob- stinate. The treatment is rather unsatisfactory. Laundresses should be advised to adopt some other vocation. Local stimulation with the faradic brush has sometimes been of value, and hydrotherapy may also be em- ployed. At the same time, the patient should be given tonics, particu- larly if anemia is present. Alkaline washes are almost a specific for the tender toes. Saturated solutions of sodium or lithium carbonate should be emplo3'ed. MERALGIA PARMSTHETICA. 1193 MERALGIA PARESTHETICA. [Bernhardt' s Disturbance of Sensation.) Definition. — A disease characterized by paresthesia and disturb- ance of sensation on the outer side of the thigh, in the region supplied by the external cutaneous femoral nerve. Pathology. — Nawretsky has examined one case, and found chronic interstitial neuritis. There is reason to believe that this is not always present. !^tiology. — This is very various ; some of the cases have been pre- ceded by injury, excessive exercise, or infectious disease. Alcoholism, constipation, and pregnancy are also common predisposing causes ; cold douches have been blamed in several instances. The exposed situation of the nerve is supposed to render it more liable to this peculiar dis- turbance. Symptoms. — These are of two varieties : First, the jyaresthesice. There may be burning, tingling, or stabbing pains that are severe enough to disable the patient ; or there may be only a feeling of cold or numbness. Second, the sensory disturbances. These vary from slight hyperesthesia to total anesthesia. The diiferent senses are not always equally involved ; pain, temperature, and electro-cutaneous sensibility being usually more profoundly affected than the others. Frequently both thighs are affected. There is often a tender point just inside the anterior superior spine of the ilium. The diagnosis is easy. The prognosis is doubtful. Some of the cases recover rapidly, but the majority become chronic. Treatment. — But little can be done. Locally, the dry brush seems to do good in some cases, and the general health should be improved if possible. PART IX. DISEASES OF THE MUSCLES. MYOSITIS. Rheumatic myositis and the suppurative form observed in pyemia, and rarely in other acute infectious diseases, have been appropriately described in connection with the diseases to which they are secondary manifestations. There remain to be discussed two rare forms of the disorder. INFECTIOUS MYOSITIS. {Acute Polymyositis). Definition. — A primary acute or a subacute inflammation of the voluntary muscles due to an unknown microbic agent. Pathology. — The disease is a true inflammation of all the volun- tary muscles, involving chiefly the muscular fibers, and to some extent, also, the interstitial connective tissue. Beginning with marked hyper- emia, there next occurs an exudation of leukocytes. The muscles are firm, fragile, and later undergo fatty degeneration. Serous infiltration occurs and there is a slight hyperplasia of the intermuscular connective tissues. Hueppe records a case that showed nothing definite beyond a hyaline degeneration of the muscular fasciculi. !^tiology. — We are no less ignorant of the predisposing influences than of the specific exciting agency, though, perhaps, young males are most often the victims of this malady. Symptoms. — As a rule, first the muscles of the extremities, and later of the trunk also, become swollen, firmer than normally, and stifl", rendering locomotion somewhat difficult and painful. The involved parts may also be tender to the pressing finger, and a slight edema may be noticed that is at first more or less localized, but finally becomes generalized, and extends even to the face. An erythem- atous eruption then appears, Avhich is irregularly disseminated over the skin-surface, and may tend to more or less pigmentation. Moderate pyrexia and splenic enlargement are among the early and constant symptoms. In the advanced stage the muscles of deglutition and of respiration become involved, rendering the act of swallowing difficult, and inducing marked dyspnea. Among the complications may be enumerated bronchitis and broncho- pneumonia, the latter often being a terminal condition. Diagnosis. — Taken in the aggregate, the symptoms are of little diagnostic importance and the previous history is invariably negative. 1195 1196 DISEASES OF THE MUSCLES. Triehiniasis must be discriminated, since this disease produces an iden- tical clinical picture. The distinction may rest upon the examination of an excised piece of affected muscle, which will not only discover the trichinae, if present, but also enable the microscopist to detect the posi- tive evidences of polymyositis. In a recent supposititious case of infec- tious myositis of my oAvn, a portion of muscle, examined for me by Dr. Babcock, showed neither trichinre nor the histioid changes of myositis. Multiple neuritis presents neither swelling nor edema. Course and Prognosis. — The course of the disease may either be comparatively rapid (two or three months), or it may be slow (chronic) and continue over two or three years. It usually terminates in death, which is caused, in the immense majority of cases, by paralysis of respira- tion. Occasionally, since the heart-muscle has been rarely found to be implicated, the end may be preceded by cardiac failure. The treatment is simply palliative and supportive. PROGRESSIVE OSSIFYING MYOSITIS. Definition. — Myositis, either general or local, in which the affected muscles undergo progressive ossification. Pathology. — Following the changes that ordinarily characterize myositis (swelling, leukocytic exudation, etc.), a calcification that is often complete takes place. The process may extend to and involve the heart. The etiology is obscure, though males are especially the subjects of the complaint, which usually begins about the time of puberty. Diagnosis. — The muscles are represented by plates of bony hard- ness, leading to more or less complete ankylosis of the joints and vertebrae. The course of myositis ossificans is very slow, and treatment has afforded only negative results. PROGRESSIVE SPINAL MUSCULAR ATROPHY. {Amyotrophia Spinalis Progressiva ; Type of Buchenne-Aran.) Definition. — A disease of the peripheral motor neurons and the muscles they supply, usually beginning in the cervical region. Pathology. — There is atrophy of the anterior cornua of the cord, affecting chiefly the ganglion-cells, degeneration of the nerve-fibers and of the muscles. Occasionally there are small areas of sclerosis that may involve the pyramidal columns for a short distance. Btiology. — The disease appears to be hereditary in a few cases, and in these may develop in childhood. A commonly accepted predisposing cause is prolonged severe muscular exertion. It is most common in males, and most frequently appears during the third decade of life. Symptomatology. — The first changes usually appear in the thenar and liypotlienar eminences of the hands. These become flat and soft; there are loss of power, some stiffness, and inability to perform deli- cate coordinated movements ; the thumb assumes a position parallel to the other fingers {ape-hand) ; the interossei muscles waste and grooves appear between the metacarpal bones. The degenerative changes do PROGRESSIVE NEURAL MTJSCVLAR ATROPHY. 1197 not ascend by continuity ; the deltoid usually being affected immedi- ately after the muscles of the hand. If the two hands have not been affected simultaneously, the other now begins to show characteristic changes. In the lower limbs the quadriceps femoris is usually the first muscle attacked. The disease gradually involves one group of muscles after another until a large part of the muscular system is affected. All the muscles exhibit the fibrillary twitchings, the reactions of degenera- tion, and the wasting. Hypertrophy never occurs, and the i^aralysis is nearly always flaccid. The fibrillary twitchings are characteristic, but not pathognomonic. They are not constant, but may be developed by slightly irritating the muscle. There is usually quantitative diminution to the faradic, and qualitative alteration to the galvanic current. The difjlegic reaction consists of the development of contractures in the op- posite arm when the anode is placed in the carotid fossa and the cathode over the spine. It is most common in this disease, but may occur in other conditions. The reflexes diminish in proportion to the atrophy of the muscles, and ultimately disappear completely; the patients grad- ually become almost incapable of voluntary motion ; but for a time they learn to overcome their disabilities by the compensatory use of other groups of muscles. In the late stage the diaphragm becomes paralyzed and bulbar symptoms appear ; usually the patients die from inspira- tion-pneumonia. Rare and probably accidental symptoms are disturb- ances of the pupillary reflexes and increase in the secretion of sweat. Differential Diagnosis. — In chronic antero-poUomyelitis groups of muscles are affected without any particular order, and total paralysis is a very early symptom ; in arayotropJdc lateral sclerosis the spastic symptoms are present ; in syringomyelia and pachymeningitis cervicalis hypertrophic a disturbance of sensation, pain, and trophic lesions occur ; in Pott's disease affecting the lower cervical region there are tenderness over the spine and sensory disturbances ; in peripheral neuritis the fin- gers are unequally affected and the deltoid does not waste ; in arthritic atrophy joint-symptoms are present ; and in the peculiar muscle-atrophies following excessive use of certain groups of muscles, rapid improve- ment occurs when the cause is removed. Prognosis. — This is unfavorable as to cure. The course is exceed- ingly slow, and the patients often live for a number of years after the first symptoms have appeared. They are, however, exceedingly liable to pulmonary complications, particularly a fatal form of bronchitis. Treatment. — Prophylactic measures, such as the avoidance of pro- longed excessive work, are rarely possible. Retardation may possibly be obtained by the systematic use of electricity, massage, and gymnas- tics. Gowers advocates the hypodermic injection of strychnin nitrate in ascending doses, commencing with yto c^'- ^^^^ rapidly increasing to -^q', one injection should be given daily. PROGRESSIVE NEURAL MUSCULAR ATROPHY. {CJiarcot-Marie-Hoffmann Type; Peroneal Type, Gowers.) Definition. — A degenerative process, apparently commencing in the nerves, and characterized by muscular degeneration, with subse- 1198 DISEASES OF THE MUSCLES. quent contractures, marked sensory disturbances, and a loss of the reflexes. Pathology. — Degenerations have been found in the muscles, the peripheral nerves, and the spinal column. In the former the muscle- cells show degenerative changes. The nerves exhibit a chronic inter- stitial neuritis with proliferation of the connective tissue, and destruc- tion of the myelin-sheaths and axis-cylinders. In the spinal cord degen- eration has been found in the posterior columns. The nature of the dis- ease seems to be akin to that of neuritis, the changes in the muscles and spinal cord being secondary to those of the nerves. Btiology. — Heredity seems to play an important part in the causa- tion of the disease, which may either occur in successive generations of a family or affect several members of the same generation. Sporadic cases occasionally occur for which it is impossible to trace any ancestral influence, though, as the disease has been known to skip a generation, it is not impossible that such cases are still hereditary. Males are much more frequently aff"ected than females, and the disease almost invariably commences between the ages of ten and twenty years. Symptoms. — As the name implies, muscular wasting usually begins in the muscles of the feet or hands, either the peronei, the common ex- tensors of the toes, or the small muscles of the foot itself, or else in the muscles of the thenar and hypothenar eminences and the interossei. Usually the atrophy is symmetric. In the feet it leads to an early development of club-foot, which is most pronounced when the extremity is at rest. Very early the atrophy of the small muscles causes the toes to assume the claw position, and the atrophy of the peroneals causes foot-drop, so that in walking the foot is dragged along the ground. In the later stages the foot becomes permanently fixed in a position of equino-varus or valgus. The hands have the characteristic appearance given by a flattening of the ball of the thumb and middle finger. The interosseal grooves also become deeper and the fingers gradually assume the claw-like position (" main en griffe "). The disease extends slowly upward, involving the muscles of the calf and thigh or the forearm and arm. The aff'ected muscles usually show distinct fibrillary twitchings that may be so severe as to give rise to an irregular tremor of the fin- gers. Spontaneous spasmodic contractions may also occur. When electrically examined the muscles either show a marked diminution in reaction to the galvanic and faradic currents, or distinct reactions of degeneration can be elicited. Similar electric changes are also found in the nerves. Mechanic excitability of the muscles is considerably diminished, these changes being found also in the muscles that are apparently healthy. The tendon-reflexes are usually absent, although in the early stages, when the muscles of the thigh are still unaltered, the knee-jerk may be merely diminished. Sensation is sometimes unal- tered, but ordinarily there is considerable diminution to touch. It is possible that some cases show an alteration in the pain and temperature sense ; often there are paresthesice, and occasionally, pains of consider- able intensity. The general condition of the patient, however, remains excellent. The vegetative organs are unaff'ected and nutrition is there- fore intact. The diagnosis can be made from other forms of progressive muscu- PSEUDO-HYPERTBOPHIC MUSCULAR PARALYSIS. 1199 lar atrophy (particularly the type " Duchenne-Aran ") by the sensory disturbances ; from locomotor ataxia by the absence of sphincter dis- turbances ; and from the eerehral palsies of childhood hy the fact that it begins late in life and is distinctly progressive, showing also a diminu- tion of the tendon-reflexes and reactions of degeneration in the muscles. The prognosis is good as regards life, but unfavorable as regards cure or even improvement. The course of the disease is extremely slow. The treatment employed in the other forms of amyotrophy may be tried, but so far nothing has succeeded in staying the course of the disease. A type of disease closely allied to the preceding has been described by Dejerine under the name of ^'■infantile hypertrophic and progressive interstitial neuritis y The muscular symptoms were the same, but there were in addition ataxia, lancinating pains in the limbs, consider- able sensory disturbances, Romberg's sign, myosis, with slow or absent pupillary reflexes and nystagmus. In addition to these a peculiar symp- tom in his case was the enormous hypertrophy of the nerve-trunks, which could be felt under the skin as large, firm cords. Pathologically the muscles showed degenerative changes and the nerves a pseudo-hyper- trophy due to the enormous proliferation of the connective tissue and degeneration in the posterior columns of the spinal cord. The dis- ease appears also to be due to old hereditary influence, the first 2 cases described being a brother and sister. PSEUDO-HYPERTROPmO MUSCULAR PARALYSIS. Definition. — A disease characterized by a progressive loss of power in the muscles without disturbance of their electric reaction, while at the same time one or more of them increases in size and firmness. Pathology. — Microscopic examination of the muscles shows that the hypertrophy has been produced by the hyperplasia of adipose tissue in the perimysium internum. The muscle-fibers may either be normal, atrophied, or hypertrophied, and there may be a relative increase in the connective tissue. The motor nerves are invariably intact. The etiology of the disease is obscure. It appears to be trans- mitted by females chiefly to males. Occasionally it has been associated with mental disturbances that appear to indicate that it may be indirectly a nervous condition. Consanguinity, according to Gowers, may be a pre- disposing cause if it continues through several generations. The disease usually develops in early life, and those forms that occur after puberty are more common in females. Symptoms. — The enlargement usually affects the muscles of the calves of the legs, although various muscles in other parts of the body may be involved, as the infraspinatus and masseter, or the muscles of the arms and thighs, giving the patient the appearance of an unequally de- veloped athlete. Fibrillary contractions may sometimes be seen, but are not frequent. The electric reactions show no qualitative alteration, but are quantitatively diminished in proportion to the loss of power. This 1200 DISEASES OF THE MUSCLES. loss of power is manifested first in the gait, which is uncertain and waddling ; next, by the difficulty the patient has in arising from the ground. He first gets on his hands and knees, then lifts his knees from the floor and, placing his hands first on his ankles, climbs up his legs until he assumes a more or less upright position (Fig- 78). In Fig. 78. — Mode of rising from the ground in pseudo-hypertrophic paralysis (Gowers). the later stages of the disease the volume of the muscles becomes less than normal. At this period contractures may occur leading to the de- velopment of club-foot or of lateral deviation of the spine. Lordosis may also be produced by weakness of the muscles of the back, and the spinal column, being no longer properly supported, may topple to one side or the other. Ultimately the patient may lose all power in the affected limbs and pass into a cachectic state, in which he dies. Few ever reach adult life. Some of the cases, however, seem to be milder in character, and may amount to nothing more than a slight weakness, which persists throughout life but does not seriously inconvenience the patient. Often signs of intellectual disturbance are present, the patient learning more slowly and showing an impaired intellectual coordination. At other times epilepsy may be present. A peculiar variety is known by the French as forme friiste ; this is characterized by a rapid atrophy of the hypertro- phied muscles, and consequently the course of the disease is more severe. The diagnosis is relatively simple, a typical case being easily recog- nized. In those cases, however, in which hypertrophy is slight, the dis- ease may be easily confounded with progressive muscular dystrophy, a disease of which, perhaps, this is only a variety. The prognosis is unfavorable, few of the cases living to adult life. Treatment. — No tonic or alterative drug has exhibited the power of arresting the progress of the disease, and electricity is equally value- less. Gowers believes that persistent, systematic exercise and massage sometimes retards the course, but never leads to arrest. This should be tried in every case. DYSTROPHIA MUSCULORUM PROGRESSIVA (Erb). ( Scapulo-fiumeral Type: Juvotih' Form of Progressive Muscular Atrophy.) Definition. — A primary myopathy, commencing usually in the mus- cles of the shoulder-blades and appearing about the period of puberty. Pathology. — There are irregular hypertrophy and atrophy of the DYSTROPHIA MUSCULORUM PROGRESSIVA. 1201 muscle-fibers, disturbances of the striation, and multiplication of the nuclei, with a relative increase of the entire fascicular connective tissue. The motor nerves, even in their finest terminations in the muscles, show no alteration, nor are changes found in the cord. Htiology. — Heredity plays an important part, although occasionally the disease may occur sporadically. As in the other forms, it sometimes develops from emotional disturbances, exposure or fatigue. The sexes are affected about equally. The first symptoms usually appear at puberty, or not later than the twentieth year, although in a few cases the condition has developed in early adult life. Symptoms. — The muscles first affected are usually the pectorals and the latissimus dorsi. From these the process rapidly extends to the muscles in the neighborhood — i. e. the serrati and the muscles of the back. The muscles of the arm, particularly the flexors in the lower arm and the long extensors, are usually most involved. In the thighs, the glutei and quadraceps femoris are particiilarl}^ subject to the atrophic process. The muscles that are most likely to escape are the sterno-mastoid, the spinati, and the deltoid in the upper part of the body ; and the sar- torius and the muscles of the calves of the legs in the lower part. The muscles gradually waste, and the wasting is accompanied by a correspond- ing loss of power, a diminution in the reflexes and of the electric reac- tions. Reactions of degeneration are not present. Certain peculiar appearances are produced by the atrophy of certain of the groups of muscles. As the shoulder-blades are no longer supported, they stand out from the back, giving rise to the so-called " winged " appearance, and as the result of the weakness of the muscles of the back lordosis is exceed- ingly common. Finally, weakness of the muscles of the back, and par- ticularly of the glutei, causes the patient, when he rises from the stooping posture, to go through the same actions that are carried out by children suffering from pseudo-muscular hypertrophy — i. e. climbing up his own legs. Finally, if the diaphragm is involved, dyspnea may develop to a greater or less extent, and may even lead to death. In certain rare cases the muscles of the face also show slight paresis, manifested by an inability to whistle, a disturbance of speech, and an imperfect closure of the eyelid. Motion is affected proportionately with the degree of atrophy. The gait is disturbed and becomes waddling, due to the alternate lifting of the sides of the pelvis in order to clear the foot of the ground. Sen- sation is never disturbed. The sphincters are not involved and bulbar symptoms do not appear, even late in the disease. The diagnosis must of course be made from the other forms of progressive muscular atrophy. The differential diagnosis is essentially the same as that for the infayitile type, excepting that from the latter [t can be distinguished by the different order of invasion and the period of life at which it occurs. It is exceedingly difficult, sometimes, to make a differential diagnosis if the muscles of the face are also involved. In certain rare cases, such as one described by Oppenheim, there may be a congenital absence or a weakness of certain groups of muscles, and par- ticularly of those most likely to be involved in this disease. In such instances the differential diagnosis may be made upon learning that the weakness has existed since birth and has not increased. The prognosis is hopeless as regards improvement. The course of 76 1202 DISEASES OF THE MUSCLES. the disease is slow, but progressive, though life is usually not threatened unless the diaphragm is involved. The patient ordinarily lives for twenty or thirty years after being first attacked. The treatment consists of systematic gymnastics, massage, and electricity. At the same time the general health of the patient must not be neglected. Apparent results are, however, rarely attained. DYSTROPHIA MUSCULORUM PROGRESSIVA {Dejerine- Landouzy). {Faeio-scapiilo-humeral Type; Infantile Type of Progressive Muscular Atrophy.) Definition. — This form is characterized by the development of mus- cular atrophy of the face, shoulder, and arm, giving rise particularly to the fades miiopatMca. Pathology. — The wasted muscles show in all respects the histologic changes found in the type of Erb, and essentially those found in the pseudo-hypertrophic form of muscular paralysis. Ktiology. — The disease is distinctly hereditary, and occurs ordinar- ily about the third and fourth years with equal frequency in both sexes, although a curious predisposition to one sex or the other is noted in cer- tain families. As many as ten generations in a family have been re- corded in which one form or other of myopathy developed. In, a few cases some acute infectious disease or disturbance of general nutrition has preceded the muscular wasting, but there is no reason to believe that the connection is other than accidental. Symptoms. — The disease usually begins in the muscles of the face. Of these the muscles of the eyelids and mouth first undergo degeneration, giving rise to a peculiar expression in which the eyes cannot be closed, the upper lid covering only half of the eyeball ; the under lip drops for- ward and downward ; the upper lip is wasted and expressionless ; all wrinkles disappear, and the patient has a peculiar and strikingly stupid expression. The ordinary movements of the face are considerably affected. Whistling cannot be accomplished, speech is imperfect, and when the muscles of the eyeballs are involved ocular fixation is impossi- ble. The shoulder-muscles next undergo atrophy. The earliest to be affected are usually the eiicullm-is, the rhomboids, and the pectoral mus- cles ; finally, the disease extends to the arms, where we find the deltoid, biceps, triceps, and some of the extensors involved. Ordinarily certain groups of muscles seem to escape, among these being the muscles of mastication and the muscles of the forearm and hand. As the result of these changes, the shoulder-blades become more freely movable and stand out from the back and the shoulders, and Avhen the patient is lifted by placing the hands under the arms, the shoulders show an abnormal degree of upward movement. The nutrition of the muscles is only affected in proportion to the atrophy. Electric reactions remain normal qualita- tively, but are diminished quantitatively. Fibrillary contractions occur with extreme rarity ; power is diminished in proportion to the wasting. Sensory disturbances do not occur. ARTHRITIC MUSCULAR ATROPHY, 1203 The diagnosis is to be made from the spinal and neural forms of muscular atrophy and from the congenital absence of certain groups of muscles From the two first-mentioned forms it can readily be distin- guished by the fact that the hand becomes involved, if at all in the last stages of the disease ; also by the absence of the reactions of degenera- tion and of muscular twitching. It is also diagnosed from the neural type by the absence of disturbances of sensation. From the congenital absence of certain groups of muscles the diagnosis is sometimes difficult for curiously enough, the groups of muscles affected are usually the same as those affected by the myopathy. A distinction can be made partly by the history partly by the more efficient and perfect compensatory hyper- trophy of the muscles that remain. J Ji _The course of the disease is slowly progressive, only occasionally ex- nibitmg a temporary arrest. The duration is variable, but patients may live thirty or forty years after the first symptoms appear. The prognosis is of course hopeless as regards cure or improvement As regards existence, however, it is the most favorable of all the forms of progressive muscular atrophy— a fact that is probably due to the ability of the patients to walk until the very last stages of the disease, so that tney are able to maintain a better physical condition. The treatment is the same as that for other forms, and consists of electricity, massage, and especially of systematic gymnastics. HEREDITARY MUSCULAR PARALYSIS {^Leyden). This commences in children, and usually between eight and ten years of age. It affects the muscles very much as they are affected in the pseudo-hypertrophic form, except that there is no increase in size. The disease is markedly hereditary in type. ARTHRITIC MUSCULAR ATROPHY. Pathology.— It has frequently been observed that after inflamma- tion of a joint the muscles that move it have undergone a certain degree of atrophy. This usually occurs in the extensors, and is severe in pro- portion to the duration of the inflammation. Microscopic examination of the muscles shows a rather uniform diminution in the breadth of the fibers, as well as a slight proliferation of the nuclei and occasionally an indistinctness of the striation. The nerve-trunks and cord have been re- ported to be normal. The etiology of the condition is not clearly determined. It has been supposed to be due to disuse, but if such were the case all the mus- cles moving the joint would be equally affected. Moreover, it sometimes occurs too rapidly to render this explanation acceptable. It has also been supposed to be due to the extension of the inflammation either to the nerves or directly to the muscles, but the other symptoms of neuritis are rarely present. Finally, Vulpian has suggested that it is of reflex origin, and this hypothesis is most generally accepted. 1204 DISEASES OF THE MUSCLES. Symptoms. — The -wasting usually occurs verv rapidly after the onset of the joint-affection. The muscles show a diminished contrac- tility to farad'ism and galvanism, but the reactions of degeneration do not occur. Occasionally there is fibrillary twitching. The mechanic irritability of the muscles is greatly increased, and the reflexes show a corresponding exaggeration, ankle-clonus being frequently observed when the knee- or ankle-joints are affected. The diagnosis may be readily made upon the existence of the joint affection, the local character of the muscular atrophy, and the absence of degenerative reactions with increased mechanical irritability. ""prognosis. — Ordinarily, as soon as the joint has recovered, improve- ment commences in the muscles and progresses rapidly to complete resto- ration of function. In some cases, however, atrophy persists, and in a few instances secondary contractures take place. The treatment consists, first, in the removal of the cause by the cure of the articular condition ; secondly, in gentle massage and electric stimu- lation of the muscles. As a rule this should not be commenced until the joint is well. MUSCULAR ATROPHIES. These may also occur as a result of other conditions, such as direct injury, fracture of the bones, or prolonged work with a single group of muscles, but they scarcely demand separate description. MUSCULAR HYPERTROPHY. This occasionally occurs as an idiopathic affection. In these cases microscopic examination shows an increase in the size of the fibers, although sometimes there are slight degenerative alterations, such as the presence of vacuoles or indistinctness of the striation. The cause of the disease is unknown. It occasionally appears in those of a neuropathic heredity, and one case is recorded that developed in an idiot. The symp- toms consist of enlargement of the muscles, which usually exhibit in- creased power, but, at the same time, great susceptibility to fatigue. Occasionally the power is diminished. The diagnosis from pseudo-muscular hypertrophy is sometimes difficult. The prognosis is unfavorable for any improvement in the condition. No treatment that has any influence upon it is known. THOMSEN'S DISEASE. [Myotonia Congenita.) Definition. — An hereditary disease of the muscles in which the groups that have been contracted by a voluntary influence remain for a short time in a state of contraction, and then relax slowly. Pathology. — Certain authors have described alterations in the ter- minal nerve-plates in the muscles, but it is difficult to determine whether these alterations are artificial or an actual part of the disease. The pe- ripheral nerves are normal. The muscles themselves exhibit the follow- THOMSEN'S DISEASE. 1205 ing alterations : The muscle-fibers are, on the average, of an increased transverse diameter — ^. e. the smallest are the size of ordinary muscle- fibers and the largest about twice the size. There is also a distinct and considerable increase in the number of nuclei. The protoplasm is not so clear as in normal muscles, but shows a fine granular cloudiness, rendering the striation less distinct. Occasionally, the muscle-fibers are vacuolated. The connective tissue between the muscle-fibers is normal. Ktiology. — Hereditary influence is the most important factor in the causation of the disease. Thomsen, who was himself a victim, has been able to trace the disease for five generations in his own family. Occa- sionally a generation is skipped. Other factors that have been supposed to act as predisposing or exciting causes are prolonged exertion (1 case having developed in a man without myotonic antecedents after two years of severe exertion) and emotional disturbance of the mother during preg- nancy. Exposure to cold, and fright, and a neurotic temperament have also been accused of exerting a predisposing or exciting influence. The disease is somewhat more frequent in males than in females, usually de- velops in early life, is often associated with manifestations of mental dis- turbance, and occasionally occurs in those whose ancestors have exhib- ited lesions of the nervous system other than myotonia. Symptoms. — The chief symptom of the disease is the so-called myo- tonic contraction. If the patient, after a period of rest, attempts to set a certain group of muscles in action, the first contraction is made, but is not followed by relaxation for a considerable interval — sometimes as much as a half minute ; during this period the muscles remain in a state of tonic contraction. Thus, if the patient attempts to shake hands, he clasps the other hand strongly, and the clasp persists. When he lets go, it is seen that a slight degree of tonic contraction still exists, for it is impossible for him to straighten out his fingers immediately. Upon a repetition of the movement the tonic contraction recurs, but not so sti^ongly, and if the repetition is continued, it disappears entirely, so that the muscular system of the patient behaves in all respects like that of a normal person, and long walks or other severe muscular exertion may be undertaken. In some cases practically the whole muscular system is affected, although, excepting the muscles of mastication, the muscles of the face usually escape. In others the disease is limited perhaps to the upper, perhaps to the lower, extremities. In the former condition the patient may, upon an attempt to make a vigorous motion after resting, suddenly become rigid and fall to the earth with considerable force, often injuring himself se- verely. He will then lie upon the ground perfectly conscious, but in- capable of relaxing his muscles. When the disease, as is more frequently the case, is limited to the lower extremities, the chief disturbances ob- served are in walking. The first step is accomplished, whereupon the patient halts, both legs having become fixed ; after a time they relax and another step is taken. The period of delay is now much shorter, and after a few more steps disappears entirely. The severity of the contrac- tion is diminished by moderate exercise, heat, and tranquillity of the spirits, and is increased by excitement, cold, and fatigue. The muscles of deglutition and the sphincters and the muscles belonging to the non- striated muscular system are never involved. Pain is not present, except perhaps a slight sensation of cramp, nor are there disturbances of sensa- 1206 DISEASES OF THE JfUSCLES. tion. Mental disturbances are frequent, and have been ascribed to the anxiety occasioned the patient by the disease. They consist of irrita- bility, the avoidance of society, and sometimes of melancholia. The reflexes show various modifications: the knee-jerks may be either nor- mal, increased, diminished, or absent. The most important pathogno- monic symptoms are the alterations in the electric reactions of the muscles. The changes are as follows : Mechanic irritation of the motor nerves is normal or diminished ; the mechanic irritation of the muscles is increased, and so modified that the contraction instead of being sudden is slow, with a long tonic after-contraction. The faradic irritability of the nerves is normal, and faradic excitation of the muscles produces a tonic contraction of long duration. The galvanic irritability is quantita- tively increased and qualitatively altered ; that is to say, ACC is equal to and sometimes even greater than KCC. AH the contractions are slow, tonic, and of long duration. Finally, the application of the constant gal- vanic stream gives rise to rhythmic contractions that pass along the body of the muscles in slowly moving waves at the rate of about one to three per .second. Occasionally qualitative galvanic alterations have been observed in the nerves. Finally, the appearance of the patient is of some value. The muscles are developed almost as much as those of an athlete, with- out a corresponding increase of power. The diagnosis is usually easy, and particularly if it be possible to examine the electric reactions. The condition might possibly be con- founded with p^eudo-hypertropJtie muscular paralysis, in which the mus- cles are also considerably developed ; but instead of being normal they manifest greatly diminished power and fail to give a myotonic reaction. From tetany the condition may be distinguished by the absence of Trous- seau's sign, by a briefer period of tonic contracture, and an absence of severe pains. From spastic parapler/ia and Little's disease it may be distinguished by the fact that in these diseases the spastic conditions are permanent and do not disappear after exercise. From occupation-neur- oses it may be distinguished by the fact that the cramps only appear upon the performance of a certain peculiarly coordinated movement. From hysteria it is differentiated by the absence of stigmata and the care an hvsteric patient exhibits to avoid injury to himself, and by the pecu- liar electric reaction. The prognosis is hopeless. The disease commences in early life and continues until death, with more or less frequent remissions and exacer- bations. It is possible that these remissions may be permanent, and one case has been reported of a young woman whom marriage greatly bene- fited. The disease is rarely dangerous to life, excepting in so far that those who suffer from it are much more liable to injury. Treatment is exceedingly unsatisfactory. Practically nothing can be done, although in a few cases systematic stimulation of the muscles has produced some mitigation. The patients often learn methods by which they can at least diminish the unpleasant symptoms. Certain movements seem to prevent or shorten the period of tonic contraction. Of course exposure to cold or emotional disturbance should be avoided as far as possible. PART X. THE INTOXICATIONS; OBESITY; HEAT- STROKE. THE INTOXICATIONS. ALCOHOLISM. {Alcoholic Inebriety.) Definition. — An acute or chronic intoxication due to the abuse of alcohol. It is a general degenerative condition, particularly of the brain and nervous system, characterized by a moderate (often progress- ively increasing) or excessive, continuous or periodic, craving for alcohol, leading to drunkenness. Alcoholism is often simply a variety of in- ehriety or narcomania^ a congenital or acquired brain- and nervous dis- ease, characterized by a resistless, permanent desire for alcohol {cdco- holic iyiehriety). Mania-a-potu, or "crazy drunkenness," is an acute maniacal condition occurring in an alcoholic drinker of a neurotic con- stitution. Delirium tremens is an hallucinatory manifestation that occurs in habitual drinkers of alcohol, either as the direct consequence of the long-continued action of alcohol on the brain, or because of its sudden withdraAval in an inebriate. Dipsomania is an alcoholic insanity in which an intense maniacal " drink-impulse " occurs in a periodic drinker (usually of spirits). Pathology. — In cases of death from acute alcoholism the brain and kidneys are found to be greatly engorged with blood. The gastro- duodenal mucous membrane is also markedly congested, injected, and covered with a thick, sticky, blood-tinged mucus. Clironic Alcoholism. — Since alcohol is physiologically a poison, and not a food, and essentially a drug, and not a drink, the eifects of its habitual ingestion are directly to produce degeneration of nearly all of the bodily tissues, and indirectly to increase the liability to many dis- eases by lessening the systemic powers of resistance, thus favoring fatality from such disease. The degree of pathologic change depends upon the innate vigor of the tissues, the age at which indulgence in alcohol is commenced, and upon the kind, degree of concentration, and the quantity of alcohol habitually taken. Ethylic alcohol is less dele- terious than the " fusel oil " that is sometimes used as an adulterant in spirits. The chief effects of chronic alcohol-poisoning are seen in the ner- vous and digestive systems, and in the kidneys. Fatty changes are prom- inent in the malt-liqiior intemperates, Avhile a connective-tissue over- 1207 1208 THE INTOXICATIONS ; OBESITY ; HEAT-STROKE. growth predominates in spirit-drinkers. The mucosa of the stomach presents the appearance of chronic gastric catarrh. Dilatation of the stomach is common in free drinkers of beer, ale, and porter. The liver shows the changes of chronic congestion, of fatty infiltration or degen- eration, or of cirrhosis and contraction. The renal changes are analo- gous to those of the liver, the chronic congested ("pig-backed") and fatty kidneys occurring mostly in those who have drunk excessively of malt liquors, while the small, sclerosed, and fibrous kidneys (chronic interstitial nephritis) are seen in those who have been spirit-habitues. The heart is often loaded with fat, and the muscular structure may re- veal fatty degeneration, being pale, flabby, friable, and dilated. The blood-vessels are atheromatous, thickened, tortuous, and sometimes vari- cose, and sudden death has been caused in inebriates by the rupture of small aneurysms of the middle cerebral artery. In the brain the vari- ous stages of sclerosis, with shrunken, narrow, and flattened convolu- tions, often appear. Chronic pachymeningitis, Avith slight hemorrhages, is not infrequent. The pia-arachnoid membrane also may be opaque and thickened, and serous effusions into the subarachnoid space and into the ventricles have been noted. The nerve-cells, nerve-centers, and nerve-fibers show degeneration, hardening, and atrophy. Alcoholic neuritis is especially prominent in many cases. Ktiology. — An impaired personal health and vigor, as well as the '• personal equation " and a deficiency of will-power, self-control, con- science, and conviction, are among the jyredisposing causes. Drunken or inebriate parents frequently transmit to their offspring a morbid im- pulse or desire for alcohol, and an environment of depraved morality and of depressing and corrupting social influences are usually potent dis- posing influences, particularly in those who are illy prepared, by hered- ity or training, to resist the temptation and insidious activities of such evil surroundings. Although some assert that poverty predisposes to intemperance, it is more likely that, in a great majority of instances at least, intemperance is the cause rather than the consequence of poverty, both of individuals and communities. The exciting cause is the misuse of alcohol in the form of distilled liquors or spirits (fermented li(iuors, wines, and malt liquors). "' The more concentrated the alcoholic liquor ingested, the more intense the inflammation of the tissue. At the same time, an equal quantity of any of the potable alcohols Avill sooner exhibit its characteristic symptoms if largely diluted with water." Symptoms. — The symptoms of acute alcoholism range from mild intoxication to an acute delirium or a profound stupor and coma. It begins with the stage of vascular relaxation and of feelings of warmth and exhilaration, due to the depressing and paralyzing effects of the alcohol upon the vasomotor tone. The second stage is one of partial functional jxiralysis of the nerve-centers., marked disturbance of the faculties, muscular incoordination, and delirious speech. In the third stage, of " dead- drunkenness," there are acute coma, stertorous breathing, a bloated and congested face, a slow and full, but weak, pulse, a cold and clammy skin, a heavy alcoholic odor of the breath, and, sometimes, incontinence of urine and feces. It frequently hap- pens that unconsciousness is not so profound but that the patient may be aroused, though replies to questioning are stupid and incoherent. ALCOHOLISM. 1209 Ordinary acute alcoholism seldom passes beyond a stage of exhilaration, ending in mild narcosis. Sometimes, however, the irritant action of the alcohol predominates over its narcotic action, giving rise to acute alco- holic gastritis or nephritis. Acute mental disorders ['■'acute alcoholic insanity'') are not infre- quently met with. Mania-a-'potu may come on quite suddenly in de- bauchees, or in those who have drunk hard during a short time, as in a night's carousal. The mental excitability increases until a violent mani- acal storm not unlike the mania of epilepsy possesses the drinker. While in this state of infuriated delirium homicide may be committed. Tremors are absent. Acute alcoholic melancholia develops suddenly in some cases, with a suicidal tendency. Delirium tremens is more common in alcoholic inebriates, and is also seen at times in those who drink greatly to excess, but are not habitues. Convulsive seizures have been noted in some cases, interrupting the coma (''acute alcoholic epilepsy"); these may or may not be accompanied by mania. An acute alcoholic 'paralysis from multiple neuritis (occasionally with ataxic symptoms) may attack hard drinkers, and may last for several weeks or months. Chronic alcoholism (alcoholic inebriety) I consider a true disease. While acute alcoholism may also be an occasional manifestation of the chronic affection, it is often a vice which, if indulged in to an excessive degree, or if too frequently repeated, becomes a disease, though it is difficult to determine at what point the transition occurs. Again, it is not always easy to learn whether the early acute alcoholic excesses are really vices or morbid, diseased cravings for alcohol in hereditary narco- maniacs. The disease of inebriety (alcoholic) is a condition in Avhich. as some one has said, it is not whether one "cannot" or "will not;" but in which one " cannot will " to resist the desire for alcohol. The steady, so-called " moderate drinker " who saturates his blood and tissues every day for years is much more apt to suifer from chronic alcoholic poisoning with its attendant degenerations than one who goes on a " spree " once a month for a day or two, and during the intervals is free from the toxic influence of alcohol. The symptoms develop very gradually, and are usually marked for some time by the deceptive sensa- tion of stimulation, warmth, and well-being, due to the vasomotor pare- sis and the anesthetic effects of the alcohol. Impairment of digestion is early noted. There are a coated tongue, foul breath, vomiting before breakfast, and gastric distress after eating. Constipation alternating with diarrhea is common. Muscular tremors gradually develop and often progress into an ataxic gait. Insomnia, mental impairment, and blunt- ing of the moral sense come on. "Alcohol dims the perception, con- fuses the judgment, paralyzes the will, and deadens the conscience " (Kerr). In his distress and degradation the inebriate seeks to relieve himself by taking more of the alcohol, only to find, on awakening from his narcosis, that body, intellect, will, and emotion are still more de- praved. In fact, the brain- and nerve-disorders are more grave, perma- nent, and extensive in the majority of instances than those of the viscera. This is owing to the delicacy of the nervous mechanism and to the ready degeneration under the influence of the altered blood, and the conse- quent impaired cellular nutrition, directly due to the toxic action and 1210 THE INTOXICATIONS ; OBESITY ; HEAT-STROKE. deficient normal pabulum, and indirectly to the lessened elimination of waste-products. Dementia is often the terminal state of the chronic inebriate. Delu- sions of persecution are quite masked in alcoholic insanit}-. The depu- rative organs manifest various symptoms due to the long-continued irritating action of alcohol. The liver is either fatty and enlarged, or cirrhotic and contracted, and jaundice, dropsy, and hemorrhoids, along with physical hepatic signs, are correspondingly observed. The watery eye, the injected conjunctivje, the swollen eyelids, the bloated and flabby or pallid and shrunken face, the dilated capillaries of the nose {acne rosacea) and cheeks, may now be seen. The urinary examination will show in many cases the deranged function of the kidneys and point to the nature of structural impairment. On account of the weak and flabby heart there are palpitations, dyspnea, and precordial distress, and occasionally sliarp pains. Chronic valvular endocarditis may be discov- ered. The pulse is soft and weak in beginning fatty degeneration of the vessels. Thickened arteries are common in old cases, and the pul- sations are often increased in tension and usually rapid. Muscular capacity and endurance are greatly diminished. Delirium tremens occurs in the majority of cases in inebriates or chronic drinkers during or after a debauch, and particularly from the use of spirituous liquors. It may occur, also, during abstinence from alcohol, on account of some mental perturbation, or fright, acci- dental shock, or acute inflammatory illness. It may either come on suddenly, or be preceded (often for a day) by some slight premonitory symptom, as anorexia, restlessness, or depression of spirits. The patient usually awakens at night with a tremor, becomes sleepless, wants to get out of bed to do some imaginary thing, talks constantly and incoherently, looks about uneasily and fearfully, and breaks gradu- ally into a cool perspiration. Hallucinations of sight, hearing, and smell develop. The patient sees terrifying and loathsome reptiles, and tries to escape from them, or to clutch them in order to cast them aAvay. The " horrors " may become so great that suicide may be attempted, as by falling out of the Avindow. Auditorj' hallucinations may take the form of enemies, policemen, or the roar of Avild animals. The mus- cular tremors increase, the pulse becomes frequent and weak, and the tongue coated Avith a thick Avhite fur. There is moderate fever, Avhich, if the delirium is prolonged, takes on a typhoid character, the tongue becoming tremulous, dry, broAvn, and fissured, Avith the onset of sub- sultus tendinum, carphologia, coma-vigil, and muttering delirium. In favorable cases improvement begins on the third or fourth day, from which time the symptoms gradually subside. Convalescence may be said to be established Avhen restful sleep can be obtained ; this is fol- loAved by a desire for food. In unfavorable cases the patient may pass from a typhoid state into exhaustion and death, or may die suddenly either during a paroxysm of cardiac failure or from some complication, as cerebral hemorrhage or pneumonia. Diagnosis. — The condition of persons found dead-drunk is seldom mistaken for any other. The reverse more often happens, and in this way apoplectic and uremic comas may be diagnosed as alcoholic coma. Cases picked up in the street in a state of apparent unconsciousness ALCOHOLISM. 1211 should be carefully tested in this regard. Instances in which, as the postmortem examination subsequently has shown, cerebral hemorrhage has followed a drinking-bout, render the diagnosis more difficult ; in such the patient should be given the benefit of the doubt and handled as though the case were one of apoplexy. An important early step is to ascertain whether the coma is complete, or whether the patient can be roused by shouting in the ear, by applying ammonia to the nostrils, or, better still, by pressing, with gradually increasing firmness, over a sensitive spot, as the supraorbital notch ; if the unconsciousness is alcoholic, he will come to his senses, if only for a moment. Ab- stemious apoplectics have been known to stagger and talk thickly, like drunken men (Kerr), and have been arrested and taken to a police- station instead of to a hospital. Congestion and lobar pneumo7iia affecting the bases of the lungs should be looked for, as they are com- mon causes of death in drunkards. A table giving the principal points in the differential diagnosis will be found under Uremia {vide p. 965). The diagnosis of chronic alcoholism is made from the history, and from the muscular tremors (worse in the morning), vomiting, mental restlessness, "mendacity," and involuntary "lying" (Kerr). The con- dition may resemble general paralysis, and if the habits of the patient are kept secret it may be very difficult to differentiate these affections. A prominence of disorder of the digestive tract usually points to alcohol- ism. Nervous excitement, tremors, fear, Avakefulness, and the distinctive physiognomy are more evident in chronic alcoholism, even when general paralysis has been caused by alcohol, which is apparently the case. Paralysis agitans, locomotor ataxia, epilepsy, and 7iervous dyspepsia may also be mistaken for chronic alcoholism by the unwary. Delirium tremeyis is distinguished by the history, by the restlessness, delirium, hallucinations, tremors, and terrors. Mania-a-potu differs from the preceding mainly in its usual association with acute alcoholism in neurotics, in the muscular contractions, the furious mania, and convul- sive movements. The delirium of apical pneumonia that obtains in some cases (as well as in meningitis) must be thought of in the diag- nosis of delirium tremens. The diagnosis of alcoJiolic neuritis from other conditions simulating it will be found elsewhere {vide p. 1029). Prognosis. — In acute alcoholism the prognosis is favorable in pri- vate, manageable cases. Many of the cases brought into hospitals are affected also with pneumonia, and usually die. The tissue-changes in chronic alcoholism are so profound, and they affect such delicate and vital tissues, that when the alcohol-habit thus becomes fixed permanent recovery never takes place. The treatment appropriate for the inebriate and forced abstinence from alcohol relieve many of the symptoms and some of the debility, but relapses are all too common and are almost certain to occur. Insanity and paresis are not infrequent terminations of chronic alcoholism. Many complications are apt to supervene, as Bright's disease, epilepsy, melancholia, fatty heart, pneumonia, and thrombosis. Alcoholic neuritis often clears up upon withholding alco- hol and stimulating the peripheral nerves both by appropriate drugs and external remedial measures. Recovery from delirium tremens is dubious in cases of severe injury, inflammatory troubles, or infections. Treatment. — In cases of acute drunkenness, which are onlv too 1212 THE INTOXICATIONS ; OBESITY; HEAT-STROKE. commonly met with, nothing special is required except to prevent the ingestion of any more alcohol and to allow the patient to sleep until the elimination of the poison is more or less complete. The effects of the intoxication, in the general depression, headache, anxious and irritable stomach, and various functional visceral and nervous disorders, may need careful corrective and sustaining treatment for a week or more. The diet should be light and nutritious. Aperient waters, hot baths, with liquor ammonii acetatis frequently repeated, and a combination of dilute mineral acid and bitter tonics (nux vomica, gentian), are also indicated. In profound cases of alcoholic coma, convulsions, or mania-a-potu no alcohol should be given. Trite though this injunction may seem, it is important to emphasize this statement, so that the physician may be sure to counteract a popular impression that the giving of more alcohol will cause a mania to subside permanently., and to guard against the smuggling of liquor to the patient by his misguided friends. It is often necessary to empty the stomach at once Avhen collapse is imminent by the use of the stomach-tube or -pump, washing out the organ with hot water, to which ginger or cinnamon has been added. To this end emetics may be used — viz. ipecac or apomorphin, hypodermically (gr. \ to ^ — 0.008-0.0108). The external application of warmth, friction, artificial respiration, faradism to the phrenic nerve, ammonia- or amyl- nitrite-inhalations, and hypodermics of atropin, strychnin, and digitalis, may all be tried. Hot rectal enemata or a calomel purge if the stomach will tolerate the drug should be used early. The maniacal attacks may be treated by hypodermics of morphin and hyoscin, and by such seda- tives as chloral, bromids in large (oj — -4.0) doses, and rarely such hyp- notics as paraldehyde, trional, chloralamid, and the like. Indeed, it is very important to secure sleep as soon as possible. An excellent for- mula in cases of medium severity is : I^. Sodii bromid., 5j (32.0); Tr. capsici, 5j (4.0) ; Tr. digitalis, 3ss (2.0) ; Elix. simplicis, q. s. ad gij (64.0). — M. Sig. 3j (4.0) every two or three hours, in water. As soon as some quietude and sleep have been obtained, it is in order to administer concentrated food in an easily assimilable form. The treatment of chronic alcoholism is more often best conducted in "homes" for inebriates, in hospitals, and similar institutions. At the outset there must be an "unconditional surrender" in the use of alco- hol. Its withdrawal should be enforced at once in many cases, and very rapidly in all others, according to the judgment of the physican as to the psychic and physical condition of the patient. Substitutes for alcohol are the strong fruit-juices, as hot lemonade or hot ginger, and cardamom tea often is useful. Coffee, milk, cocoa, and hot broths are also to be recommended. The diet should be carefully increased in nutritive strength as the gastric irritability diminishes. Some- times such sedatives to the stomach as the bismuth-preparations, effer- vescent alkaline drinks, and lime-water may be indicated. Peptonized food is often well borne at first in cases in which gastric distress is marked. Nutrient enemata are seldom reciuired, but should be resorted ALCOHOLISM. 1213 to in the gravest cases, particularly during the states of alcoholic dementia. The general health must be looked after by placing the patient in the best of fresh air, exercise, cold and warm bathing, by mental and social occupation, and by diversion. When the craving for alcohol is hereditary and intense, seclusion in an inebriate-house or some similar institution is often necessary for a long time, inasmuch as the danger of lapsing into the former drink-habit is so common in these cases. The insomnia of chronic alcoholism may be met temporarily by the use of large doses of bromids, chloral, hyoscin, or sulfonal. Morphin may be indicated at times, but should be used with great caution in order to avoid adding the morphin-habit to that of alcohol. Perhaps the best single agent to use in counteracting the symptoms of chronic alcoholism is strychnin, either as the nitrate or sulphate, hypodermically and by the mouth ; iron, arsenic, the hypophosphites, dilute phosphoric acid, quinin, avena sativa, and the like are often useful adjuvants in the tonic treatment. Atropin, hypodermically, may also be recom- mended when vascular dilatation and weakness are prominent. A "substitute" for alcohol, both for its local and mental effects may be prescribed to meet the occasional cravings. Tart fruits (as oranges and lemons), coffee, hot malted milk, ginger, gentian, and capsicum infusions may be tried. Tinctures should not be given in this form for obvious reasons. Sweating and purging the patient, and the administration of bromids, chloral, and gelsemium for a day or two in advance, may avert a "drink-storm" or the periodic cravings for alcohol that may be ex- pected by prodromal manifestations. Sometimes, however, as in the sudden outbursts of dipsomaniacs, there is no time to institute their treatment. It is claimed that hypnotic suggestion will abolish effect- ually the ardent desire for alcohol in a certain number of neurotic cases of alcoholic inebriety. Temperance revivals may be said to do perma- nent good only in those similar neurotic cases that are fortunately im- pressionable with appeals by total-abstinence orators, but, in order to maintain the reformed drunkard's pledge it is often necessary that in- terested persons continue to watch, guide, and inspire him, in order that a weakened will may not precipitate a cyclic lapse into his old habits. In all cases the treatment will be incomplete unless the highest part of the patient's nature receives due attention throughout. The reason must be enlisted in the treatment, and this is best attempted by sound teaching concerning the fallacy of the prevalent belief in the virtues of alcohol as a beverage. No pains should be spared to impress upon the patient the need of a persistent abstinence from all intoxicants as long as he lives. All the influence of culture, music, and the fine arts, of high-toned morality and pure, undefiled religion, should be enlisted to strengthen self-respect and to fortify volition and inhibition. Moral regeneration may thus in certain cases check indirectly the physical and mental degeneration, but it cannot efface the consequences of the alcoholic poisoning which it represents. Delirium tremens requires firm but tactful isolation and vigilant nursing. All alcohol should be Avithheld. If stimulation is needed, aromatic spirits of ammonia, strychnin, and atropin, with bland hot 1214 THE lyTOXICATIOXS ; OBESITY; HEAT-STROKE. drinks and broths, may be administered. Easily digested and nutri- tious food should be given to support the strength. Sleep must be procured by such means as are mentioned above in the treatment for mania-a-potu. The dosage required, however, is usually not as great, but must be kept up longer than in the maniacal condition. Cardiac weakness may need such stimulants as digitalis, strophanthus, and the ammonium salts. After the attack subsides, tonic doses of strychnin, chirata, gentian, asafetida, calumbo, and iron, together with graduated exercise out of doors, are to be employed. Turkish baths, industrial occupations, and the like are indicated to conserve the patient's strength and thus fortify him against yielding to temptation and a morbid appetite. GINGER AND COLOGNE-WATER INEBRIETY. Habitual drinkers of alcoholic ginger, capsicum, and lavender prepa- rations, and eau-de-Cologne are practically alcohol-habitues or inebri- ates. They drink these liquids for the alcohol that is in them. The so-called essence of ginger (Jamaica ginger), which contains considerable alcohol in some of its preparations, is often used primarily for relieving an attack of "cramps" or "colic," and if frequently re- peated, can readily induce a morbid habit of "ginger-drinking." In other cases the craving for alcoholic indulgence (often hereditary), may have been aroused by a social glass of wine, but. from a sense of shame the desire has been kept secret, and gratified by drinking eau-de-Cologne, lavender essence, or even tincture of capsicum. Perhaps many more such cases exist, and especially among neurotic Avomen in good circum- stances, than are usually recognized. MORPHINISM. ( Opium-inebriety.) Definition. — A chronic intoxication, due to the habitual use of morpliiii or of opium in some other form (ophunum). Pathology. — In cases of death from acute or chronic opium- or morphin-poisoning there is nothing distinctive in the pathologic appear- ances. In acute cases vascular congestion of the brain and membranes has been noted ; but even in chronic cases the tissue-degenei'ation and fatty and connective-tissue proliferations that are characteristic of alcoholism, are practically absent. Decided lesions are usually trace- able to associated affections. The [irincipal anatomic changes are those due simply to malnutrition. Thus, we have the emaciation and the shrunken appearance of cerebral anemia, and pallor and atrophy of the cardiac muscle and of the vascular walls. The dried and wasted struc- tures, due to tissue-starvation, are quite a contrast to the fat-infiltrated or degenerated, cirrhotic, and inflamed tissue of alcoholic inebriety. Direct destruction of parenchymatous cel^s is more evident in the later. Htiology. — The climate, country, and nationality have a certain disposing iutiuence in the development of opiumism and morphinism. In the opium-growing parts of Asia, as in China, India, and Persia, where the climate is Avarm. enervating, and conducive to physical and MORPHINISM. 1215 moral abandonment during the greater part of the year, and in Turkey also, opium-eating-and-smoking habitues are as numerous as alcohol- habitues are in Europe and America among the Caucasians. Morphin- ism is more common here than is opiumism, except among the poverty- stricken. Women are more commonly the victims of morphinism than men, except physicians and druggists as a class. Mattison has found 70 per cent, of his opiate patients to be medical practitioners. Many con- tracted the habit by using morphin for severe chronic neuralgia, in- somnia, and the like. Indeed, pain and sleeplessness have been the principal source of this drug-habit. Ennui and an idle spirit of irritation and adventure among the sen- sation-loving and luxurious sometimes sow the seeds of an indulgence in narcotics that bring forth fruitage in the form of a fixed, morbid, and uncontrollable craving for constant satisfaction, and a consequent phys- ical, mental, and moral decline. The incautious prescribing of morphin and the too ready hypodermic use of the alkaloid by physicians in treating various cases of pain are not infrequently the cause of morphinism. Overwork of the brain, great business or social strains, prolonged worry and anxiety either with or without work, insomnia, remorse, idleness, and secret vices, are the most common predisposing agents of the morphin-habit. Paregoric, laudanum, chlorodyne, and "soothing-syrup" are drunk to a frightful extent in large cities among the poor and miserable, and cause great disturbance of the health of the habitues. Symptoms. — These may be in abeyance for some time, while the habit is forming and the doses are still slight. As the craving increases, the dose and its frequency increase to keep pace with the desire. Anemia gradually develops, with sallowness of the skin, Avasting of the features and body, languor, weakness, functional deterioration, mental depression, anorexia, restlessness, insomnia, tremors, irritability, shyness, dilatation of the pupils (except Avhen under the influence of the drug), and a characteristic propensity to lying. Cardialgia is often complained of by those who use opium pretty constantly. The asso- ciated vices of opiumism are less violent and inflammatory than those of alcoholism, and more secretive and speculative, such as gambling and sexual perversions. Itching is frequent, and especially after taking the opium or morphin. Attacks of chills, followed by pyrexia, with de- lirium and transient albuminuria (renal congestion) occur in some cases. Diarrhea and dysentery have been observed in some instances. There may be also disturbances of the visual muscular apparatus. Suff'erers from painful carcinoma in whom opium or morphin is required for steady use do not become, except in rare cases, true morphinomaniacs. The course of morphinism is that of a progressive asthenia, in which cardiac palpitation, dyspnea, abdominal and muscular cramps, trembling, fear, sleeplessness, mental confusion, melancholy, slovenliness, and moral obtuseness come on. Some Avomen, knoAvn to be kleptomaniacs, have been found to be secret opiumists. Sexual impotence in the male, and amenorrhea and abortion in the female, are common results. The skin is wrinkled, dry, and harsh, and may shoAv numerous needle-scars and abscesses in those addicted to the hypodermic use of the drug. The 1216 THE INTOXICATIONS ; OBESITY; HEAT-STROKE. termination is the direct result of the extreme debility or marasmus or of some intercurrent affection. The diagnosis must be made from the history. When the latter is wanting because of a lack of veracity or deception, chronic alcohol- ism may have to be differentiated from opiumism. The more open and often periodic habits of the alcoholic habitue, and the general aspect of the physical and mental and complicating conditions, usually show marked differences between the two drug-intoxications. Prognosis. — The likelihood of a cure is exceedingly remote. On the other hand, under proper conditions much relief may be given the morphinomaniac, and although the habit may be suspended only for a time, life may thus be prolonged for years. The treatment is manifestly difficult and unpromising. Institu- tional isolation, rest, diversion, w^atchful care, regular and studied feed- ing, baths, and graduated exercise in the open air as far as possible, but under surveillance in order to prevent the smuggling of opium, morphin, or compound preparations containing either, are the most efficient measures. As to the manner of withdrawing the narcotic, much care, judgment, and tact form a sine qua non in the treatment. A sudden and absolute stoppage of the use of the drug sometimes leads to great distress, and even to collapse (" abstinence phenomena ") ; it is, therefore, not to be recommended, as in chronic alcoholism. On the other hand, the too gradual withdrawal is torturing. A middle course, the " rapid- gradual method " of Erlenmeyer, is usually resorted to, in which the reduction of the quantity of morphin or opium to nothing occupies but a Aveek or ten days. Various substitutes have been recommended that generally prove not to be substitutes at all, but simply act in a symp- tomatic Avay, and may lead to another habit as bad if not worse. Such drugs as cocain, hyoscyamus, belladonna, bromids, and chloral have thus been used. In the symptomatic treatment of the raorphin-habit moderate doses of bromids, with cannabis indica and some such vegetable bitter as gen- tian, may prove useful in allaying the nervous irritability and restless- ness at night. Sulfonal is a good hypnotic in these cases. Cathartics, stomach sedatives alternating with tonics, concentrated foods, massage, hot and cold bathing, electricity (general galvanization), and " complete control over the patient" are usually indispensable adjuncts in the treatment after the withdrawal of the opium or morphin. Cardiac stimulants, strychnin and physostigmin salicylate (gr. j^ — 0.0006) hypodermically, have been recommended recently as important in counteracting the functional depression of these habitues. Industrial activit}^ and mental and social diversion, aid in maintaining any im- provement made and in rendering the patient less liable to a relapse. PLUMBISM. (Chronic Lead-poi.ioninr/ ; Saturnism.) Definition. — A chronic intoxication due to the slow absorption of lead, either industrially or accidentally. Pathology. — The principal lesions are found in the muscles, periph- eral nerves, liver, kidneys, and mucous membranes. The affected mus- PLUMB ISM. 1217 cles are wasted, pale-yellow in color, and, in advanced cases, show a marked fibroid growth. The vessels in the muscles also reveal arterio- sclerosis. The peripheral nerves are affected with a parenchymatous neuritis, and are especially involved, with degenerative changes in the nerve-endings in the muscles. The nearer we approach the spi- nal cord along the course of an affected motor nerve, the less marked are the changes, although in some cases a very slight in- volvement of the anterior nerve-roots has been noted. The cord is usually normal. In the brain, the pathologic changes scarcely warrant us in attribut- ing lead encephalopathy to them. Aside from a slight meningitis and arteriosclerosis of the cerebral blood-vessels here and there, with a cor- responding connective-tissue growth and capillary hemorrhages, the evidences of lead-poisoning are practically ?^^7. Cerebral symptoms are most probably the outcome of functional disturbances. The liver and kidney show parenchymatous atrophy and cirrhosis. Ktiology. — (a) Personal suseeptibility to lead-poisoning is greater in some people than in others, all other things being equal, {h) Plumb- ism is more common in adults than in children, because of greater ex- posure. ((?) Sex. — Women are more susceptible than men. {d) Occupa- tion is the most frequent cause of lead-intoxication. Workers in white lead (plumbic carbonate), red lead, and litharge, all of which substances are used as paints, are especially to be mentioned as liable to saturnism. Among the most common industrial causes are the following : painting, plumbing, lead-mining, rolling sheet-lead, pottery-glazing, type-found- ing and setting, shot-making, dress-making (in which lead-dyed silk thread is used and the ends bitten off), lace-making, glass-grinding, and calico-printing. (e) An accidental source of lead-poisoning is found in the contamination of food and drink. Men employed in the manu- facture of white lead and eating lunches in dusty work-rooms may also suffer from plumbism in this way. Drinking-water stored in lead-lined cisterns and passed through lead pipes is frequently contaminated, espe- cially if the water contains a slight amount of acid. Flour, bread, bis- cuit, candy, butter, and milk may cause poisoning by adulteration with lead chromate, used to give a rich, yellow tint to these articles ; and to- bacco wrapped in lead- foil has, less commonly, resulted in symptoms of saturnism. The absorption of the lead takes place mainly through the gastro- intestinal tract, especially through the lungs, and much less through the skin. It may be deposited in most of the soft tissues and viscera, but especially in the nerves, muscles, and liver. Elimination takes place through the kidneys, and probably, though in very slight quantities, with the bile and saliva, and through the skin.4 Symptoms. — Depending upon individual susceptibility, it may be months or years before the first manifestations appear. Anemia is an early and marked symptom [saturnine cachexia). There is a moderate reduction of the corpuscles and of hemoglobin. The general nutrition is poor. The characteristic blue line at the borders of the gums is rarely ab- sent, especially in those who are not scrupulous in their attention to the teeth. It is, as a rule, most distinct at the roots of the lower ca- 7/ 1218 THE INTOXICATIONS ; OBESITY; HEAT-STROKE. nines and incisors, and is formed by a deposition of lead sulphid. Bluish patches may also be met with. Colic is very common and is also characteristic. The pains center around the navel, and are quite severe and griping. They are associated with retraction and rigidity of the abdominal Avails, and with obstinate constipation. The pains are paroxysmal, may be referred at times to the epigastrium, and may be accompanied by vomiting. Between the paroxj-sms a dull pain usually exists over the whole abdomen. During the attacks of colic the pulse-tension is increased and cardiac action lessened. Paralyses are common symptoms, and may either be acute, subacute, or chronic in nature. Although usually localized palsies, they are some- times oreneralized. The most characteristic lead-palsy is that known as wrist-drop (see also Multiple Neuritis, p. 1029). Both fine and coarse tremors occur, though not so commonly as in chronic mercurial poisoning. They usually begin in the hands and arms, are rather constant, and are aggravated by voluntary effort and emotional excitement. Cramps in the affected muscles and about the joints {had-arthralgia) are occasionally noted. Slight anesthesia, especially in cases of wrist- drop, is sometimes detected here and there, but may in certain instances be due to saturnine hysteria. The cerebral symptoms are important. The phrase "lead encephal- opathy " includes such manifestation as delirium and coma, neuro-retini- tis. aphasia, convulsions, hemiplegia, amaurosis, hysteria, and insanity. The delirium and coma are the commonest brain-symptoms, and may come on suddenly with tremors and hallucination. Epileptic convul- sions are often severe. Hemianopsia has been observed. Mania and melancholia occur in cases of mental unbalancing, and hysteric out- breaks are seen in girls. Intense headache is not uncommon. " Sat- urnine crout," so called, is described as a result of chronic plumbism. The kidneys are contracted, the heart is hypertrophied, and arterio- sclerosis is marked, with a diminution in the excretion of urea and uric acid. The pulse-tension is increased. These evidences show a simi- larity to gout, and favor the development of uratic deposits in the joints, but they are the effects of ''mineral," and not of essential or true gout. Lead may be discovered in the urine by laying a strip of magnesium in it and noting the deposit of metallic lead if present (Yon Jaksch). Abram asserts that the addition of a solution of ammo- nium oxalate (1 gm. to 150 c.c. of water) facilitates the test. Diagnosis. — The history of exposure to lead-poisoning is usually clear in those working the metal in its various forms. Accidental origins of saturnism are often obscure and very difficult to trace, although if the characteristic wrist-drop, the blue gingival line, colic, and cachexia be present, the diagnosis is readily made. Alcoholic paralysis of the lower extremities may be differentiated by the history, the greater prominence of sensory symptoms, and by the ab- sence of the blue line on the gums. Prognosis. — In the absence of the graver nervous, arterial, and renal symptoms, the prognosis is good. When there is profound paralysis, with reactions of degeneration, and especially in primary ARSENICISM. 1219 atrophy of the muscles, the prognosis is generally bad. In the severe encephalopathic forms, and in cases in which marked arteriosclerosis and renal cirrhosis are manifested, the prognosis is unfavorable, but depends upon the extent of damage done. Treatment. — The prevention of plumbism is difficult in lead-work- ing establishments, OAving to the carelessness and indifference of both employers and employees, and to the lack of any adequate antidote during exposure. Rigid cleanliness is absolutely necessary, especially of the hands and nails and before eating. Means to allay dust should be regularly and constantly employed. Milk and sulphuric-acid lemon- ade have been recommended for use by workers in lead, for their sup- posed antidotal effects. As perfect ventilation as possible should be secured, and respirators are in use in some lead-works, being worn as "snouts." Potassium iodid should be given in chronic plumbism, beginning with small doses (gr. iii— v — 0.1944—0.324), given preferably in milk, after meals. In lead colic hot applications to the abdomen and hypodermic injec- tions of morphin and atropin are often indicated. Efficient doses of Epsom or Glauber's salts are used to combat the constipation. Given in combination with dilute sulphuric acid (in order to form an insoluble lead sulphate) and with belladonna, the best and speediest benefits may be obtained thereby. Iron for the anemia, strychnin and galvanism for the paralysis, lithia-water for the renal deterioration, and nitroglycerin or sodium nitrite for the arteriosclerosis (enough to relieve increasing tension) are the symptomatic items of treatment that are usually indicated. Rarely, hopeless cases of saturnine encephalopathy need to be sent to asylums for the insane. ARSENICISM. [Chronic Arsenic-poisoning.) Definition. — A chronic intoxication resulting from the gradual absorption of arsenic. Pathology. — The peripheral nerves show a degenerative neuritis, and the anterior horns of the spinal cord may be similarly affected. Ktiology. — The causes of arsenicism may be habitual, industrial, medicinal, or accidental. The individual predisposition to arsenic-in- toxication varies in different persons. A neurotic diathesis usually underlies the habit of "arsenic-eating" in those who crave the drug for its alleged exhilarant or narcotic effects {cirsenic inebriety). Not a few women suffer from chronic arsenicism as the result of the ingestion of arsenic "to improve the complexion and brilliancy of the eye." Men employed in arsenic-works of various kinds often suffer from the chronic poisoning. For example, miners and smelters of arsenic pyrites, dyers and wall-paper workers using Scheele's or Schweinfurth's green, artificial-flower makers, shot-makers, glass-workers, and taxidermists, are all liable on account of their occupations. Sometimes the medicinal use of moderate doses of arsenic, as in Fowler's solution, even for a short time, may in very susceptible persons induce arsenical paralysis (Putnam ; Osier). Accidental arsenicism may come from living in rooms where Avall-paper, carpets, colored paper ornaments, toys, or 1220 THE INTOXTCATIONS ; OBESITY; HEAT-STROKE. curtains are contaminated with arsenic anilin dyes ; this does not oc- cur so fre«}uently as years ago. Symptoms. — There are anemia, loss of flesh and strength, dryness and irritation of the mucosa, of the eyes, nose, throat, and upper respiratory tract. Anorexia, nausea, and diarrhea indicate the pres- ence of a gastro-intestinal catarrh. In some cases, milder than others, the fat is Avell preserved. Slight puffiness of the eyelids or eyebrows may occur, and some epigastric distress may be complained of. Marked conjunctivitis, occasional dysenteric attacks, loss of the hair, and numb- ness and tino-lincr in the extremities form a commonlv observed svmptom- group. Cutaneous symptoms may appear, as pigmentation (''arsenic- bronzing "), and eczematous, herpetic, urticarial, and pemphigoid mani- festations. Albuminuria with casts and blood mark the renal irritation that sometimes occurs. The most characteristic evidence of chronic arsenic-poisoning is seen in the gradual increasing difi"use or multiple neuritis. Differing from lead-palsy, the leg-extensors and the peroneal group of muscles are in- volved first, although the arms may also become affected later (vide Mul- tiple Neuritis, p. 1030). Contractions in the lower and a fine tremor of the upper extremities are apt to occur. Arsenic-poisoning may also cause headache, vertigo, melancholia, and hvsteria. The drug is elimi- nated by the kidneys and may be found in the urine. Sometimes a great toleration of arsenic is observed in workmen and habitues, the only evidences being a clear, sallow, waxy complexion, a gloomy ex- pression, and some dyspepsia, perhaps, as in the well-known Styrmns. Diagnosis. — This is not difficult, when once the source of the pois- oning is determined. The clinical appearances are distinct from lead- intoxicatio7i, especially in the mode of progress of the paralysis, and in the more marked sensory symptoms combined with the motor-disturb- ances of arsenicism. The prognosis is fiivorable in most cases in which removal from the exposure to the influence of arsenic is possible. A few cases die from the grreat general debilitv. Treatment. — Abstention from the use of arsenic for cosmetic pur- poses, avoidance of its influence in the arts, care in its medicinal ad- ministration, and prophylaxis as regards the possible or discovered sources of contamination, form the first considerations in the treatment. Elimination of the arsenic may be promoted by the use of potassium iodid and purgatives. Gastro-intestinal and other irritations must be met by appropriate sedative remedies. The neuritis and palsies require — as soon as the tenderness and pain subside — massage and electricity. Judicious and wholesome alimentation and tonics are indicated. MERCURIALISM. ( Chronic Mercurial Poisoning.) Definition. — A chronic intoxication caused by the habitual inges- tion, or combined industrial absorption of mercury, in susceptible individuals. Pathology. — No marked pathologic changes have been noted in human beings, aside from the evidences of oral, gastro-intestinal, and MERCURIALISM. . 1221 renal irritation and inflammation. It is not improbable that the cere- bral cortical areas suffer more from metallic irritation than do the spinal or peripheral nerve-tissues. l^tiology. — Some persons are much more easily mercurialized than others, {a) Salivation and stomatitis from the therapeutic use of mer- cury form a variety that is not infrequent in these days, [h) Indus- trial origin. The chief cause of chronic mercurialism is the inhalation of the vapor of the metal by artisans in the industries in ^vhich it is used. Thus miners and smelters and those engaged in makino- mirrors, barometers, thermometers, amalgams, felt hats, vermilion-pigment, and artificial teeth sometimes suffer from chronic mercurial poisonino-. It should be pointed out here that mercury is volatile at ordinary tempera- tures, and is absorbed into the blood through the lungs, digestive tract, and skin. Calomel vapor-baths have caused poisoning in a few cases. {c) Purely accidental mercurialization also occurs, [d) Women and children are more susceptible to the action of mercury than men. In all cases the mercury exists in the tissues as an albuminate. Symptoms. — There are anemia, emaciation, gastro-intestinal dis- orders, stomatitis, salivation, maxillary necrosis, ulceration of the gums, loosening of the teeth, fetor of the breath, marked tremors, and paraly- sis. The oral symptoms are not as prominent, however, as in acute mercurial poisoning. The hair falls out, the nails become brittle, and pigmentation of the skin is seen. The tremor is characteristic. It is first felt or noticed in the tongue and lips, is usually fine, later coarse and choreiform, and spreads grad- ually throughout the muscular system. It is aggravated by voluntary effort, and may cease during sleep in mild cases. Speech is altered. Hysteric tremors may also exist. Great irritability and restlessness are common. Aphasia, hemiplegia, hemianesthesia, and peripheral neuritis with palsies, occur. There is no atrophy, nor are the reactions of de- generation present in the paralyzed muscles. Severe pains may be present in the extremities, including the joints, and grave cerebral symptoms occasionally develop (stupidity, headache, loss of memory, insomnia, hallucinations, delirium, coma, convulsions, and confusional insanity). Albuminuria with anasarca may occur. The effects of chronic hydrargyrism in women upon their offspring are also important', the children being rachitic, weak, sickly, and prone to tuberculosis. Diagnosis. — The history, the characteristic tremors, paresis, and mental irritability are significant. In the absence of a history of ex- posure to mercury, the differentiation from progressive general jjaresis, disseminated sclerosis, or paralgsis agitans may be more or less difficult. Prognosis. — Recovery is common upon the removal of the source or on removing the patient from the source of the poisoning. Fatal terminations rarely ensue, and then in cases of mercurial encephalop- athy of a grave type and with a tendency to idioc}-. Treatment. — Prevention of further poisoning is imperative, elimi- nation is to be promoted, and the symptoms are to be met as they arise. Potassium chlorate, with the tincture of myrrh, and astringents are use- ful for the occasional stomatitis and salivation. Potassium iodid, and also sulphur baths, may be used to aid in the elimination of the mer- cury. Iron, cod-liver oil, good food and fresh air, and a free activity 1222 THE INTOXICATIONS; OBESITY; HEAT-STROKE. of the emunctories are of positive value. Electricity may be resorted to for the paresis. FOOD-INFECTION AND PTOMAIN-POISONING. In recent years there have been reported an increasing number of cases of serious illness that have been traced to infected and contami- nated food. Undoubtedly many such instances are now brought to notice that in former times were attributed to other causes, or that were not diagnosticated because of a lack of knowledge. On the other hand, the increased consumption of canned and preserved meats has cer- tainly augmented the liability to poisoning from these products, as the reports of cases show. Lack of care in the inspection and selection of the meats, uncleanliness, and sometimes unscrupulousness, in their handling and preparation, must result in infection, putrefaction, and toxicity. The infection of the food may be due to (1) disease of the animal or plant from which the food is derived ; (2) microbic inoculation of the food after derivation and before ingestion by human beings; (3) infec- tion by toxicogenic bacteria, and the presence of ptomains or toxalbu- moses. The transmission to man of such affections in animals as tuber- culosis, anthrax, glanders, and pleuro-pneumonia, by eating the infected meat, has been sufficiently proved. Again, meat and milk may become infected, before being ingested by the patient, by pathogenic micro- organisms, as of typhoid fever and diphtheria, or from the production of toxins owing to the action of non-pathogenic putrefactive micro- organisms. A great many instances of food-infection, particularly of meat and milk, have been shown to be due to the presence of sapro- phytic germs, this happening even when the articles of food have been obtained from healthy stock and have been kept free from specific path- ogenic bacteria. It is not, however, the saprophytes themselves in all cases, but the poison developed in the food before it is eaten or formed in the body afterward, that produce the symptoms and sometimes death. According to Novy, some of the saprophytic bacteria with which food is infected outside of the body, under certain conditions, are capable of living in the body as parasites, especially on dead matter, and there become toxicogenic. The chronic poisons or ptomains resulting from the action of the saprophytes in foods are called "• putrefactive alkaloids ;" those bacterial products of a proteid nature are called " toxalbumins " or " toxalbu- moses." The latter, according to A^aughan, are more frecjuently present in infected foods. They are all al)sorbed from the digestive canal. Poisoning by Infected Milk and Milk-products. — It is now well known that the cause of the high mortality-rate among infants in hot weather is traceable directly or indirectly to the "summer diarrheas" in chil- dren fed artificially, wholly or partially, with milk infected by numerous varieties of saprophytic germs and thus poisoned by ptomains, such as tyrotoxicon. This special chemical poison has been isolated by Vaughan, and discovered by him in cheese. It has also been found in ice-cream, frozen custards, and cream-puifs, and has caused poison- ing-symptoms mainly of acute gastro-intestinal inflammation, "con- striction of the fauces," nausea and vomiting, sharp, griping intestinal FOOD-INFECTION AND PTOMAIN-POISONINQ. 1223 pains, headache, thoracic oppression, chilliness, dizziness, and sometimes purging, followed by relief in mild cases. In the severe and long-con- tinued forms, however, exhaustion may supervene, with subnormal tem- perature, coma, collapse, and death in the graver cases. No chemical or physiologic antidote is known. Elimination may be assisted, and stimulation is needed. Irrigation may be employed for the former in both stomach and bowels. Strychnin, nitroglycerin, atropin, and the aromatic spirits of ammonia are most effective as stimulants. Meat-poisoning. — Various tainted meats, as mince-meat " warmed over," veal pie, carelessly-kept chicken salad, badly-preserved and canned meats, partially-decayed sausages {botulismus) have caused violent symptoms of poisoning. Diseased raw and partially-cooked meat has also been eaten with disastrous results. It should be borne in mind that even prolonged cooking fails to destroy the toxic action of certain ptomains in infected meats ; also, that meat that has been cooked and kept under certain conditions may become infected with bacteria as well as when it is raw. On the other hand, bad, putrid meat has been known not to cause toxic symptoms. The symptoms caused by the poisoning are — " (1) those due to a true infection; (2) those due. to simple poisoning" (Mann). Cases of the former group run the usual course of an infectious disease, often simu- lating typhoid fever. Those under the second division manifest the symptoms of a violent gastro-enteritis, with vomiting, intense colicky pains, purging, fever, accelerated pulse, nervous prostration, great mus- cular weakness, and cramps in the calves of the legs. Often a subse- quent subnormal temperature, extreme depression, convulsive movement, vertigo, dimness of vision, dyspnea, somnolence, great soreness of the mouth, collapse, and sometimes death supervene. The mortality-rate varies from 15 to 55 per cent, of all the cases. The treatment is largely eliminative, symptomatic, and supportive. The prophylactic measures, private and public, are generally obvious. Poisoning by Fish (Ichthysmus) and Shell-fish. — Many instances of this serious form of intoxication have been produced. The fish may contain certain poison-glands, ovaries, etc. Especially is this true of certain species known in Japan, one of Avhich is believed to cause the disease called " Kakke," which prevails during the summer months in Tokio. A certain species offish [Clupea venenosa) inhabiting the West Indian waters is supposed to be always poisonous, although the source or true character of the poison is doubtful. In Russia, many cases of ichthyismus have resulted from eating both the fresh and preserved sturgeon and salmon meat that are affected with an infectious disease peculiar to the fish. In Germany and other parts of middle Europe a severe form of gastritis called " Barbencholera " follows the eating of sick barbels. The use of tainted preserved and canned fish, eels, oysters, mussels, crabs, lobsters, and the like, is more frequently the cause of symptoms of poisoning, however. Brieger's mytilotoxin, the active poison formed in some mussels, and the eating of which at Wilhelmshaven caused several epidemics, is probably developed only under certain favorable conditions of saprophytic infection. Devilled crabs, lobsters, and salad have also caused severe gastro-enteritis because of contamination with o-erms pro- 1224 THE INTOXICATIONS ; OBESITY ; HEAT-STROKE. ducing ptomains. Oysters have been accused of conveying typhoid in- fection {vide p. 26). The symptomH of fish- and shellfish-poisoning are variable. Sometimes marked cerebro-spinal manifestations predominate, •with convulsions and paralysis. Dryness and constriction of the throat, dizziness, labored respiration, disturbed vision, jerky speech or aphonia, perhaps rajiid pulse, loss of coordination, numbness, coldness of the extremities, dilated pupils, paresis, collapse, and death within a few houi's, may ensue. Other cases have a pronounced gastro-intestinal or choleraic group of symptoms, with nausea and vomiting, pain, tenesmus, and mucous and bloody stools. In some of them marked cutaneous irritation is shown by erythema, great heat and itching, urticaria, and swelling. Dyspnea, lividity, and sometimes delirium, have also been noted. The progno- sis is grave in many instances. The treatment is similar to the above — namely, emetics, purgatives, enemata, and lavage. The indica- tions are to be provided for as they arise. GRAIN- AND VEGETABLE-POISONING. Ergotismus. — Epidemics of ergotism have resulted from the con- tinued use of meal made from contaminated grains grown on virgin soil. The parasite {daviceps purpurea) is a fungus that infests rye and other grains : it does not, however, grow readily where the soil is well culti- vated, and epidemics of ergot-poisoning are much less frequent than formerly, if we except certain places in Spain and Russia. According to Robert, three poisonous substances are found in the ergot : ergotinic acid, sphacelinic acid, and cornutin. The first of these is not poisonous when taken into the stomach : the second is supposed to cause gangrene ; and the last produces grave effects on the nervous system, and is found only in fresh ergot, hence the greater prevalence of nervous manifesta- tions in sickness that breaks out .soon after harvest. The nervous symptoms are remarkable for their convulsive character- istics (ergotismus convulsivns). Prodromes of weakness, tingling in the extremities, and headache may exist for several weeks before the spasms come on. The formication increases, and cramps and contractures, with flexed wrists and extended feet and toes, seize the patient. In severe cases epileptoid convulsions occur and may prove fatal. Delirium and, in very chronic cases, dementia may supervene. Recovery is slow, and the contractures may persist for some time, with muscular atrophy and anesthesia. In some interesting instances there may appear nervous symptoms resembling locomotor ataxia ('' ergot tabes '), owing to poste- rior spinal sclerosis. Abortion results in pregnant women. Gangrenous ergotism (ergotismus gaugrrpnosus) is characterized by drv sancrrene of the hands and feet, usuallv of the finders and toes. Before the gradual blackening appears, there may be formication, pain, spasm, numbness, and coldness. As mortification and the line of de- markation progress, the parts drop off bit by bit, and fever may attend the sphacelation. Pneumonia (septic) may sometimes complicate this malady. The fatality has been considerable in some epidemics. The treatment of ergotism is entirely symptomatic. Maidismus or Pellagra. — This is a chronic nutritional disturbance OBESITY. 1225 due to poisoning from eating contaminated corn-meal bread. The dis- ease prevails extensively among the poorer classes in Lombardy, Spain, and southern France. The origin of the infection of the maize is said to be bacillary, the latter causing putrefactive or fermentative changes in the fresh, moist corn-meal, with the production of ptomains. The symjjtoms at the beginning are languor, debility, indigestion, anorexia, restlessness, and occasionally diarrhea. This is soon followed by erythema, pain, and roughness of the skin. Exfoliation of the latter reveals a suppurating surface. In severe cases, paresthesise, spasms, paraplegia, headache, backache, delirium, and a suicidal mania may occur. Idiocy and profound cachexia may result from numerous attacks. Structural changes have been found in the cord, and fatty degenera- tion and ulceration in the viscera. Prophylaxis by thorough drying and careful storing of the meal is to be aimed at. The symptoms are to be met as rationally as possible. Lathyrismus is an intoxication caused by the seed (used in the form of meal) of three varieties of vetch or chicken-pea, viz. Lathyrus cicera^ L. sativus, and L. clymenum, or, respectively, red, German, and Span- ish vetch. The meal is generally mixed with that obtained from other cereals. Its use for several hundred years has been observed to cause leg-stiffness, passing into a transverse myelitis, with sensory and motor paraplegia. Spasticity and exaggerated tendon -reflexes may remain for some time after the paralysis subsides. Slight fatty degeneration was noted by Cautain in excised bits of muscle. Very chronic cases may die in paralysis, from the toxic effects of the poison, which, thus far, has not been separated. Mushroom-poisoning. — Though not so common as formerly, poisoning from eating non-edible mushrooms occui's now and then, owing to ignor- ance or carelessness in gathering, keeping, and cooking them. Fresh morels are poisonoiis, while those that have been dried and boiled are not so, because of evaporation or solution of the contained poison. The red agaric {amanita muscaria), on account of the poisonous alkaloid muscarin that it contains, may cause very severe symptoms. These are nausea, vomiting, diarrhea, hemoglobinemia, hemoglobinuria, and jaundice {probably hepatogenous) in the case of fresh morel-poisoning (Striimpell). Tetanic and epileptiform convulsions give a slow pulse, dilated pupil, disturbed vision, salivation, coma, and death in the gravest cases of red-agaric intoxication, in addition to the symptoms of gastro- intestinal irritation. The treatvient is symptomatic. Emetics, purgatives, stimulants, and, in red-agaric poisoning, atropin, for its physiologic antidotal effect, are usuallv indicated. OBESITY. {Polysarcia Adiposa ; Lipomatosis Universalis.) Definition. — Corpulence, or the presence of an excessive amount of bodily fat, may be said to begin to take the form of a disease when it 1226 THE INTOXICATIONS ; OBESITY; HEAT-STROKE. becomes an inconvenience or impairs the bodily functions. Obesity is essentially a disease of nutrition. Pathology. — The chief alteration is the marked and, in some in- stances, colossal increase in the fat deposit throughout the body. Not only is the adipose tissue greatly increased in localities where it is nor- mally found or " preformed," as under the skin, but the various internal organs and tissues that are normally quite or nearly free from fat, may in obesity show a decided fatty infiltration. Toldt affirms that in the graver cases of corpulence, in which marked depositions of fat are found in the viscera around and between the parenchymatous elements, the fat-cells are nothing more than transformed connective-tissue cells. The round, fat face, " double chin," broad and deep chest, large waist, thick and prominent, sometimes overhanging, abdominal jyanniciilus adi- posiis, and bulky, cylindric, and apparently shortened extremities, are familiar appearances postmo7'tem as well as antemoi^tem. There may be differences in the number and size of the fat-globules in the histologic elements. Thus, in the plethoric form of obesity the cel- lular fat-globules are larger than those of the anemic or hydremic form. Qualitative differences in the fat may also occur. The blood in cases of obesity is increased in specific gravity to as much as 1065 or 1070. In a majority of cases the hemoglobin-percentage is also increased (plethora). The heai't is overlaid with fat, and the intermuscular tissue shows a decided fatty infiltration. Hypertrophic dilatation is frequently present. The arteries may show fatty changes in the intima and media, and in the older cases chronic endarteritis with thickening and sclerosis of the vessels. The veins are often affected with varicosities. Passive congestion and edema of the lungs are secondary to the car- diac weakness that is so common in advanced cases. For the same reason the liver and kidneys may be enlarged. Fatty infiltration may also affect and cause enlargement of the liver, and chronic interstitial nephritis may form a late complication of obesity. The stomach may be dilated, and often shows a catarrh of the mucosa. Catarrhal enteritis of mild type also occurs sometimes. The pathogenesis of obesity has not as yet been fully determined. Htiology. — Among the conditions predisposing to corpulence, the chief are heredity, climate, habit, occupation, temperament, age, and sex. In about one-half of the cases of obesity the tendency is inherited, and in these cases the abnormal increase of fat manifests itself early in life. Corpulence is much more frequent among the inhabitants of hot, moist climates, and of low countries of the temperate and arctic regions. Thus, it is commonly observed among Orientals, Dutchmen, South Pacific Islanders, Southern Italians, and certain African races. Sedentary habits and occupations form common predisposing factors. The sluggish, luxury- and rest-loving, phlegmatic temperament also favors an abnormal fat-deposition. As regards the age, polysarcia generally makes its ap- pearance in persons of advanced middle life, between forty and fifty years, while congenital obesity is seen in infancy and early childhood ; in women, it may appear at puberty and between thirty and forty years of age. Women, and especially Jewesses, seem to be more subject to corpulence than men. Congenital anomalies and monstrosities (idiots, cretins. OBESITY. 1227 acepliali), also anemics and hemiplegics, are often excessively fat. The prolonged use of arsenic may sometimes lead to fat-increase. The exciting causes of obesity are especially the ingestion of too much fat-making food, the intemperate use of alcoholic beverages, with or with- out deficient exercise. The ingestion of food in excess of the bodily requirement of proteids, fat, and carbohydrates (which varies in dif- ferent individuals), combined with insufficient assimilation or physical exercise, Avill result in an abnormal accumulation of fat. This is espe- cially the case where a predisposition exists. The fat may be derived from the excess of albumin, fat, or carbohydrates in excess. Alcohol, especially in the form of beer, ale, porter, and the like, promotes fatty infiltration and degeneration. An excessive diet of starches and suo-ars acts indirectly as a fat-producer by lessening the oxidation of the ingested fat and of the fat formed from proteids, because the carbohydrates them- selves are so readily oxidized. Symptoms. — Obesity is not accompanied by any bodily symptoms at first. Except some inconvenience, and a sense of burdensomeness dur- ing walking or working, nothing may be complained of for years. With the progressive development of the disease, however, and particularly with the involvement of the viscera, subjective manifestations increase in number and intensity, and objective symptoms and physical signs also become more numerous and more marked. Usually the earliest trouble- some symptom is breathlessness on exertion, due to a weak heart and to the hampering of respiration by heavy chest-Avalls and the upward-crowded diaphragm. In plethoric individuals the face is red and congested, as are also the mucous membranes (conjunctiva, labi^). In anemic subjects (usually women) the skin is pale, the muscles are flabby and weak ; the pulse is small and compressible, and dyspnea, palpitation, inclination to rest often and sleep much, and dizziness (symptoms of anemia and chloro- sis) are manifested. On the other hand, in plethoric, corpulent subjects (usually men), the muscles are firm and strong, and the pulse- and heart- beats vigorous ; later, however, the latter become weak. Brachycardia is not infrequent, and the pulse-rate may become as low as 50 beats per minute. The signs of fatty heart (vide p. 656) are obtained on physical examination. Muscular power may diminish very rapidly, the appetite often fails, and, oddly enough, great, fat men may consume very small quantities of food. Intercurrent acute febrile affections (typhoid fever, pneumonia) are badly borne, and hyperpyrexia is usually associated with them. The live?' may show enlargement on percussion and palpation. The passive congestion of the respirator^/ mucous membrane is often signalled by cough and by an increase of the dyspnea. Profuse sweating is com- mon. There may be polyuria or oliguria, according to the activity of the skin and kidneys at the same time. Uric acid and the urates are usually found to be increased. Symptoms of gastric catarrh and gastrectasia may occur. Great thirst and bulimia are noted in some instances. Constipation may be followed by chronic diarrhea. Sexual desire is often abated, and azo- ospermia is not rare. Corpulent women often suffer from uterine dis- placement and prolapse. Amenorrhea, sterility, endometritis (congestive), leukorrhea, and an aggravated climacteric are seen in obese women also. 1228 THE INTOXICATIONS ; OBESITY; HEAT-STROKE. The skin is often irritated (intertrigo) b\' the excessive sweating, and by the friction of cutaneous surfaces in the fohis of fat, as under the breast and axilh^, at the navel, at the abdominal and inguinal folds, and around the scrotum and labia. Painful excoriations, pruritus, furunculosis, acne rosacea (in alcoholics), and alopecia are not uncommon. Complications. — Hernia, cardiac asthma, bronchitis, pulmonary congestion, edema, arteriosclerosis, albuminuria, glycosuria, anginal attacks, Cheyne-Stokes respiration, cerebral hemorrhage, and coma may manifest themselves as the precursors of the final stage. Diagnosis. — This is not difficult in most cases. Care and Avatchful- ness must be exercised in detecting associated conditions, complications, and sequela^. The prognosis will depend upon the peculiar features of each indi- vidual case, the cause and its removability, and upon the variety, degree, symptoms, and prevailing complications. Treatment. — Prophylaxis is important in the earlier years of those showing an hereditary ])redisposition to corpulence. The fat-forming (farinaceous) substances must be diminished in the dietary. The propor- tions of fat and proteid in the food must be regulated according to the amount of muscular activity, and the latter should be encouraged in fresh air, along with cool bathing. At middle life, in those predisposed to polysarcia, all imprudences in eating and drinking should be cautioned against, and the quantities of various articles of food and the time of eat- ing regulated. Outdoor sports and gymnastics should be also gauged accordingly. The dietetic treatment of confirmed obesity is all-important. The ingestion of foods that lead to the formation of fat must be limited. Inseparable from this is the stimulation of the bodily forces that oxidize and destroy the fat. These two means are utilized in the principal methods of treating obesity, and that method must be selected which in- vio^orates. while at the .same time it involves neither injury nor weaken- ing of the patient. The principal systems of dietary are those known by the names of Banting. Ebstein, and Oertel. In all of them the total amount of food is gradually diminished as long as there is an increase of the body-weight or a continuance of the subjective distress. In '' Bantingism," sugars, fats, and starches are greatly reduced in the diet-list ; water, however, is not restricted, and vinous and spirituous liquors are rather freely permitted. In those of a lithemic, rheumatic, or gouty diathesis (often associated with obesity) Banting's heavy proteid and alcohol dietary is not to be recommended. It is best. I think, to exclude alcohol in most cases, owing to its effect in diminishing tissue-ox- idation and in retarding cell-metabolism. In Ebstein's diet-list more than double the amount of fat and car- bohydrates is permitted as compared with Bantings list, whilst the albuminous substances are diminished. Fat is freely allowed, Avhile sugar and potatoes only are strictly forbidden. Oertel of Munich also allows more fat than Banting, but less fat and more (about double the quantity) proteids and carbohydrates than Ebstein. The amount of free Avater permitted daily is only one pint : about one pint additional in other food is allowable. Fat. Carbohydrates. Calories. 25 75 1180 45 120 1608 OBESITY. 1229 Oertel^ writes : " The body stores up fat if more than 118 grams of albumin and 259 grams of fat, a total of 377 grams (2894 calories), are taken in. On the other hand, 110 grams of albumin and 600 grams of starch, a total of 710 grams (2944 calories), may be given without producing a deposit of fat. With a mixed diet the limit lies near 118 grams of albumin, 100 grams of fat, and 368 grams of starch, a total of 586 grams (2923 calories). If we want to bring about the decompo- sition of the fat already accumulated in the body, we do so best by diminishing the supply of fat and by permitting a certain quantity of carbohydrates." His diet-table for obesity is appended : Albumin. Minimum 156 Maximum 170 For fuller details, Oertel's tables,^ giving a special diet-list in circu- latory disturbances, may be consulted. On the basis of A^oit's laws, Striimpell recommends in the average cases 125 gm. (4 oz.) or more of albumin, 40 gm. (1^ oz.) of fat, and 150 gm. (4.62 oz.) of starch. Schwenniger's rule differs from Oertel's merely in the forbidding of liquids with the meals and in permitting their use only after two hours have elapsed. Yeo's diet-list is also a useful guide. Under any system of dietetic treatment the patient should be weighed accurately and frequently, and the food-limit be diminished or modified according to the results. The food may be weighed and measured at first, but the patient soon learns to estimate by bulk the requisite quan- tity of each substance. The following dietary illustrates Avhat may be ordered in some cases of obesity : Morning Meal. — Fine wheat-bread, 1;^ ounces (40.0); a soft-boiled egg; milk, 1 ounce (32.0); sugar, 77 grains (4.9); coff"ee, 4|- ounces (136.0). Noon Meal. — Soup, 3 ounces (96.0); fish, 3 ounces (96.0); roast or boiled beef, veal, or game or poultry, 6 to 8 ounces (192.0-256.0) ; green vegetables, 1^^ ounces (48.0) ; bread, 1 ounce (32.0) ; fruit, 3 or 4 ounces (96.0-128.0)^ no liquid (or only 4 or 5 ounces— 120.0-148.0 cc— of very light wine). Afternoon Meal. — Sugar, 77 grains (4.9); coff"ee, 4 ounces (128.0); milk, 1 ounce (32.0); occasionally bread, 1 ounce (32.0). Uvening 3IeaL — Caviare, ^ ounce (10.6); one or two soft-boiled eggs; beefsteak, fowl, or game, 5 ounces (160.0) ; salad, 1 ounce (32.0); cheese, 1 dram (4.0) ; bread, rye or bran, ^ ounce (16.0) ; fruit or water, '4 to 5 ounces (120.0-148.0). The mechanical treatment of corpulence, by exercise, is to be used in conjunction Avith the dietetic. The form of the exercise, and also the time and frequency, must be adjudged for each case. When cardiac dilatation and myocardial degeneration (fatty) are the cause of symp- toms of precordial distress, dyspnea (however slight), and palpitation, resort may be had to Oertel's system of graduated walking on the level 1 Twentieth Gent. Pract. of Med., vol. ii. pp. 698, 699. ^ Loc. cit. 1230 THE INTOXICATIONS ; OBESITY; HEAT-STROKE. or climbing along "health paths'" {vide Fatty Overgrowth, p. 65Tj. Or, the well-known Xauheim or Schott treatment may be used. Great care must be exercised in prescribing the mechanical treatment in obese persons who have atheromatous vessels. The medicinal treatment is neither satisfactory nor successful. The juice of the phytolacca berry may reduce the Aveight, but it usually does so at the expense of bodily strength. Recently, the use of thyroid extract has come into favor, and this, judiciously given, promises good results Leichtenstern, Wendelstadt, Ewald, and others have reported success in a number of cases, especially in those exhibiting the anemic, flabby, " myxedematoid " form of obes- ity. The loss of weight was from 2 to 3 pounds (1-1.5 kgms.) in one week, and as high as 20 pounds in two to four weeks. In two of my own cases belonging to this category the use of thyroid extract (desiccated) in small doses (gr. j — 0.0648, t. i. d.) caused a progressive loss of weight at the rate of 4 and 6 pounds per Aveek respectively, Avithout injury to the general health. Thyroidin, the active principle of the thyroid gland, as shoAvn by Baumann and Ross, gives results that are perhaps as good as those of thyroid-feeding. JeozykoAvski treated 10 cases of corpu- lence by thyroidin in doses from 5 to 8 grains (0.324-0.518) per diem. In 1 case more than 40 pounds (18.1 kgms.) were lost in tAvo months, and in another 30 pounds (13.6 kgms.) in three months. Symptoms of thyroidism are the signal for a reduction in the dosage of thyroid ex- tract {vide Myxedema, p. 464). HEAT-STROKE. {Siiiisfroke : Insolation ; Thermic Fever; Heat-exhaust ivn ; Heat-prostration.) Definition. — A diseased condition the eifect of exposure to exces- sive heat. Pathology. — Rigor mortis is marked and comes on early. The high temperature of the cadaver accelerates the putrefactive changes, Avhich also appear early. There is considerable venous engorgement of the brain and of the cerebral and spinal membranes ; also of the lungs, spleen, and conjunctiva. The blood is fluid and dark, and the corpus- cles are crenated and do not tend to form rouleaux. Ecchymoses and extravasations of blood are found in the skin, the serous membranes, and the cavities, around the superior (cervical) sympathetic ganglia and the vagus and phrenic nerves. Parenchymatous changes in the liver and kidneys may be found. Rigid contraction of the left ventricle is a notable feature, while the right ventricle is usually dilated Avith blood. Van Gieson's recent report of the cellular pathology of the cerebro-spinal system in 3 cases of sunstroke in Ncav York shoAvs an acute parenchym- atous degeneration of the neurons of the whole neural axis similar to that of, and, Van Gieson thinks, here actually due to, '' a species of auto- intoxication." He found the chromophilic plaques in the cortical cere- bral and cerebellar (Purkinje's) cells and also in the cells of the anterior horns of the spinal cord, diminished in number, changed in shape and HEAT-STROKE. 1231 position, sometimes finally broken up, and even entirely absent. The nuclei stain more deeply than normally. Ktiology. — Anything that lessens bodily resistance to external high heat predisposes to heat-stroke. Thus, privation, unsanitary surround- ings, fatigue of body or mind, emotional excitement, worry, and exces- sive fretfulness, overeating, indulgence in alcoholics (especially), and previous attacks of sunstroke, are all conducive to heat-stroke on expos- ure to high temperature. Males are affected more often than females. Sunstroke occurs in persons (on land) working hard under the direct rays of the sun, in an atmosphere that is very hot and humid, still, and sultry. Soldiers on the march and heavily accoutered, masons, brick- layers, hod-carriers, roofers, drivers, farmers, and other out-door labor- ers are particularly subject to insolation. Heat-stroke and thermic fever are terms more appropriately applied to those similarly affected in midsummer while Avorking in places not exposed to the sun, but yet close, confined, and excessively hot, such as glass-works, foundries, ocean steamers, stoke-holes, boiler-rooms, steam laundries, sugar-refineries, kitchens, and the like. Heat-exhaustion (prostratio thermica) is caused under similar condi- tions as the preceding, but manifests dissimilar, and sometimes almost opposite, effects. The majority of the cases of sunstroke occur between 2 and 5 p. m., although heat-stroke and heat-exhaustion may occur at night as late as 10 or 11 P. M., as among bakers, night engineers, and hotel cooks. It seems to be the consensus of opinion that the direct cause of the symptoms of sunstroke, heat-stroke, or heat-prostration is the action of the excessive heat upon the heat-centers, or upon the vasomotor center or nerves (H. C. Wood), the former of which, if paralyzed, produces ^^ thermic'' or ^^ heat-fever," while the latter, if paralyzed, produces heat-exhaustion. It should be stated, however, that Lambert and Van Gieson,^ after a clinical and pathologic study of 805 cases of sunstroke occurring in New York City during 1896, hold to the not improbable view that the immediate basis of sunstroke is autotoxic, with heat only as a contrib- uting cause. Symptoms. — Two forms of heat- or sunstroke are usually met with : (1) The asphyxial or a2:>oplectie form ; (2) the hyperpyrexial form. Flint believes that the majority of the cases of sunstroke are combinations of apoplexy and exhaustion. Vallin puts all cases of insolation into two classes : the first, sthenic or asphyxial, corresponding to our hyperpy- rexial or congestive variety; the second, asthenic or syncopal, corre- sponding to our heat-exhaustion. Mixed forms may occur quite fre- quently, the most prominent symptoms being referable to the organs suffering the most, as the cerebro-spinal system, heart, lungs. Heat-apoplexy [asphyxial sunstroke) is probably the least frequent form. There may be sudden premonitions, or dizziness, chromatopsia, throbbing headache, cessation of sweating, or dyspnea. Sometimes the patient, while at work in the sun, suddenly falls unconscious, a few convulsions may occur, and in this state he may die with .symptoms of cardiac failure. More often, insensibility is not so profound as complete ^ M>;d. iVews, July 24, 1897. 1232 THE INTOXICATIONS ; OBESITY; HEAT-STROKE. coma, there is much restlessness, epigastric "' cramp" may be complained of, also a sense of thoracic oppression, and occasionally there are nausea and vomiting. The headache may be intense, the face is flushed, the pulse is rapid and full, the temporal and carotid arteries are bounding, the breathing may be labored and stertorous, the pupils are conti-acted (except in grave cases), and urination is often frequent. The skin is hot and dry, and may show petechiae. The tongue is coated with a whitish fur. A wild delirium has been observed in some cases. The temperature may be subnormal, and is not higher than 102° F. (38.8° C.) in many instances. In others, a mild degree of thermic fever may be associated with the apoplectic condition, the ther- mometer registering 104°— 106° F. (40°-41.1° C). In fatal cases the coma becomes deeper and deeper, the pulse more rapid and feeble, and Cheyne-Stokes respi- ration may precede the termina- tion. A " mousey " odor about the body has been noted. In favorable cases the temperature falls to normal by lysis in three or four days, consciousness being rapidly regained at the same time. The hyperpyrexial variety comprises the numerous cases of marked sunstroke that re- semble the preceding type, with the addition of an intensely high temperature {thermic fever). The patient may suddenly become comatose and die in an asphyxi- ated condition, with a tempera- ture as high as 110°-llo° F. (43.3°-46.1° C.) or even higher. Sometimes prodromes, as an- orexia, progressively increasing physical weakness, cramp-like abdominal pains, irritability and restlessness, vertigro, colored and blurred vision, lack of sweating, a "bursting" headache, and an irritable bladder may exist for several days. A subconscious (automatic) state, in which the patient may be unaware of his surroundings, although walking or even Avorking. may be noted for hours before he is stricken down. The onset is marked by hyperpyrexia: the skin is hot. burning, dry, sometimes flushed and red, and sometimes cyanotic and clammy ; the eyes are suff'used or " staring and filling," with pin-point pupils. There is a full, rapid, and non- F., 112" 111° no" 109° ids'' 107° 106° 105° 104° 103° 102° ; 1 — 1 1 1 , , 1 1 ' 1 1 1 1 1 1 i ' ■ 1 i i ^ 1 [ 1 1 t • ■ 1 (^ ' 1 , — 1 ^ K' I ) I j_ L Li. ^ >. ' Tt 1 — ' \ -i \ "= i A — \ CL| 3 -^ a. < * "\ ■ '* "1 \ 1 1 1 o| \ \ 1 i_J N i 1 ■ S s ;£ E 5 ■§■ < E E E E E E E E E E E E E E ± IE E E E s 1 t 1 ■^ V o < SI < <- .< ? = 1 A o s E <- E E E f s o 2^ s i "ol E E o »» s t\ - ■s P ?Ts g- A -° - — _ — — _ _ _ _ -A — 1 — f — — — ' — — — — — — — — o K- -^ p- ^ — 1 — z ^ - : — :§: c — — — — — E — — ~ — ™ s — i i I J - 100° z E: ~ E E — E E ^ - E z E E - i < 5 ^ E 99° 98° - = -4 - — "( - — - - - — — - - - — .v. ~ v _ — ^ ^ LU 1 aj \ — 1— _l _ _ 97° 96° 95° 9i° DATE ~^ — "- — — — — — 1 — — — — — — — — - — — 1 — I- • 1 u., "^Z \^ "m" ^.1 \ "■ 1'" ^ J \/ y. "^ 1 10 11 AUGUST Fig. 80.— Chart of a case of sunstroke. C. B., aged twenty-nine years. Recovery. Some patients never rally, and die in a state of asphyxia. Retention of urine (suppression) is observed at times, and particularly in those accustomed to the use of alcohol. Leukocytosis is noted, besides the crenation of the erythrocytes (degeneration of the red cells). Fatal complications of sunstroke are pneumonia, meningitis, uremia, and cardio-respiratory paralysis. Heat-prostration or heat-exhaustion may come on gradually or sud- denly, with prodromal symptoms (dizziness, faintness, headache, nausea, 1 Lambert {loc. cit), reports a case in the N. Y. Hosp. of 117.8° F. (47.6° C). 78 1234 THE INTOXICATIONS; OBESITY; HEAT-STROKE. thirst, drowsiness, yaAvning, epigastric or lumbar pains, numbness and tingling of the hands and feet). These are followed by coldness, clam- miness, and pallor of the surface, marked muscular weakness and pros- tration, a small, febrile, rapid pulse, sighing breathing, syncope, and col- lapse in the graver cases. The temperature at first is subnormal (95° to 97° F.— 35° to 36.1° C), though mild thermic fever of from 100° to 102.5° F. (37.7°-39.1° C.) may be present. Consciousness is rarely completely absent and is regained early. Recovery usually takes place within one or two days, and in milder cases, under prompt and appro- priate treatment the patient may be ready to go about in a few hours. In a few cases of extreme prostration in weakly persons death may ensue from cardiac failure. The sequelae of heat-stroke are quite interesting and peculiar in some instances. Osier relates the case of a patient who " was subse- quently so sensitive to temperatures in the neighborhood of 75° F. (23.8° C.) (italics mine) that at such times he lived comfortably only in the cellar, and finally sought refuge in Alaska." Chromatopsia, severe headaches, irritability and ugliness of temper, or delirium may occur in some patients as soon as warm weather sets in, and may be due occasionally to chronic meningitis (Wood). Diagnosis. — Bearing in mind the characteristic difi"erences that are outlined above between sunstroke (including the asphyxial and hyper- pyrexial forms) and heat-exhaustion, the diagnosis is not difficult. The history and circumstances attending the seizure are also important in making the diagnosis. From other affections, as acute alcoholism., inen- ingitis, uremia, and cerebral apoplexy, the differentiation is readily made by noting the previous history, mode of attack, presence or absence of thermic fever, state of consciousness, urine, skin, pupils, pulse, respira- tion, and nervo-muscular apparatus. Prognosis. — This is usually favorable in cases of heat-prostration. It is less so in sunstroke, but in all cases it depends on the severity of the stroke, the previous health and habits of the patient, the complica- tions, and the promptness and fjicility of the treatment. The mortality- rate during a prolonged period of excessively hot and humid weather may be very high, ranging from 15 to 50 per cent. In New York City, during the week ending August 15, 1896, out of a total number of 1810 deaths, 648 were reported as due to sunstroke (Lambert).' Treatment. — Prophylaxis. — This is highly imperative in hot, sultry weather, particularly in cities, in which persons must work in the sun or in poorly-ventilated and highly-heated, closed places. Workmen should be taught and warned privately and publicly, as through the medium of the press and Health Board circulars, to take extra pre- cautions during hot weather, to work and sleep in as well-ventilated rooms as possible, and to secure artificial ventilation, if necessary. They should live regular and temperate lives, avoiding alcohol and heavy eating ; oat-meal water should be drunk, light-weight and light- colored clothing should be worn, and the direct rays of the sun should be avoided as much as possible. The condition of the skin should be watched and care taken that sweating continues freely. Shelter or rest should be sought at once if sweating stops. Cool wet cloths or green ' Loc. cil. HE A T-STR OKE. 1235 leaves should be worn inside a light straw hat, and sometimes it may be necessary for employers to shorten the hours of labor during the hot- test part of the day. Treatment of the Attack. — Cases of ordinary heat-prostration seldom require much treatment beyond the removal of the patient to the shade of a comparatively cool place, loosening all constricting clothing, spray- ing with cool water, the use of ammonia- or amyl-nitrite-inhalations, and of the aromatic spirits of ammonia or spiritus glono'ini by the mouth. If the temperature is subnormal and collapse threatens, a hot bath is advisable. Strychnin and digitalis may be used for a day or two to combat the nervo-muscular weakness. Heat-stroke, especially the hyperpyrexial cases, must be promptly treated by the application of the ice-bath (ice floating in a tub of water), temperature about 40° F. (4.4° C), or by rubbing, by the cold pack, or by the needle-spray with iced water. In the asphyxial cases venesection is frequently indicated. Exter- nal stimulation should be applied to the precordium by mustard and to the feet by hot bottles, and hypodermic injections of nitroglycerin, strychnin, atropin, brandy, camphor, or ether are useful. Ice should be rubbed over the head constantly. Care should, however, be taken to see that the temperature is not reduced too far. A temperature of about 102° F. (38.8° C.) should be the signal for cessation of the ice- bath, and for the removal of the patient to a cot, where he is to be rubbed dry and allowed to rest until an exacerbation of fever indicates the reapplication of the cooling measures. Ice-water enemata, with or with- out brandy, are often useful adjuvants. The needle-spray of cold water is an excellent nervous stimulant as well as antipyretic. It is given while the patient lies on a Kibbee or netting cot, or on a cot covered with a rubber sheet so arranged as to drain into a pail or trough. In- ternal antipyretics are seldom well absorbed, and their depressant action is so well known as to discourage their use in place of hydrotherapy. Hutchinson, Coplin, and Bevan recommend highly the use of morphin to control the convulsions of heat-stroke. Artificial respiration in the asphyxial cases, kept up until other measures and stimulants have time to act, may be the means of saving life. After the reduction of the hyperpyrexia the patient should be lightly covered on a cot placed in a cool place. An ice-cap should be applied to his head, and small pieces of cracked ice may be given to allay gas- tric irritability, with calomel to open the bowels if necessary. Albumin- water, skimmed milk, buttermilk, unfermented grape-juice, junket, and the like may be given for several days preparatory to the ingestion of heavier food. If, as sometimes happens, free diaphoresis does not come on after the reduction of most of the fever and the stimulating treatment, a hot bath may be given, and perhaps aided by the hypodermic injec- tion of pilocarpin in urgent cases. Sequelce must be treated on general principles. The increased susceptibility to repeated attacks of insolation (after the first attack) makes it necessary to avoid exposure to heat ever after, and, if possible, to seek a cooler climate during the hot months. PART XI. ANIMAL PARASITIC DISEASES. PSOROSPERMIASIS. Psorosperms belong to the lowest form of protozoa. They are also known as sporozoa, and, because of their parasitic relation to cells, as c9/tozoa. The amoeba coli of amebic dysentery belongs to the protozoa. Blood parasites (hematozoa), as the plasmodium malaria, are likewise closely related to the sporozoa. Various coccidia may occur in man to produce the disease indicated by this heading. The coccidium oviforme of the rabbit is the commonest variety, being found also in rats and mice. It escapes from the livers of the latter animals and passes into the dejecta; it produces an hepatic disease in which there are numerous whitish nodules studding the liver. These range in size from a pinhead to a split pea, and on section dis- close a bile-duct, the dilated portion of which forms the nodule. The ovoid coccidia are found in the epithelial cells of the walls of these biliary expansions. The coccidium perforans and coccidium higeminum are found in the cells. of the intestinal villi instead of in the liver of the hosts mentioned above. Among veterinarians a common form of sickle-shaped organism is known that is found within an ovoid body in the sarcolemma of the pig's muscle — {i. e. the so-called Rainey's tube). In man, hepatic disease similar to that found in the rabbit is pro- duced by the coccidium oviforme. The tumors formed by the coccidia may be palpable, and the liver may be quite tender. Some chilliness and fever, malaise, and stupor passing into coma have been observed. Death was caused on the fourteenth day in a case admitted to St. Thomas's Hospital (Osier). The necropsy showed whitish neoplasms in the peritoneum, omentum, and kidneys. In the intestinal variety of internal psorospermiasis nausea and vomiting, diarrhea, and the typhoid state may be manifested. Involve- ment of the kidneys has caused hematuria and frequency of urination. External or cutaneous psorospermiasis, one form of which was for- merly called keratosis follicuJaris, is characterized by lesions at first of a hard, crusty, papular type, later becoming confluent, and situated on the face, lumbo-abdominal, and inguinal regions. These papillomatous growths contain numerous parasitic sporozoa. In carcinoma, epithelioma, and Paget's disease of the nipple coc- cidia are readily found in and between the pathologic epithelial cells, 1236 DISTOMIASIS. 1237 but whether they have an etiologic bearing upon these malignant afifec- tions is still a matter of uncertainty. Prophylaxis consists in cleanliness and care in preparing such food vegetables as spinach, lettuce, cabbage, and other greens that may pos- sibly be contaminated by the excreta of the lower animals liable to psorosperm-infection. The treatment of psorospermiasis is symptom- atic, though rectal injections of a solution of quinin (1 : 5000 to 1 : 1000) may be tried. DISTOMIASIS. ( Trematodiasis.) Various forms of trematodes, including the distomata, may become parasitic in man. Distoma Hepaticuin (Liver-fluke). — Among the more common va- rieties of trematodes or flukes, is the distoma hepaticum or liver-fluke^ a parasite found in animals (horse, goat, ass, sheep, rabbit) and acci- dentally ingested by man. It is almost 30 millimeters (1.1 inches) in length, and inhabits the biliary passages of the animal, and from them is discharged into the intestinal tract and evacuated with the feces. Under certain conditions of temperature and moisture, a ciliated embryo escapes from the egg, and is ingested by a gasteropod or snail {limncea truncatula), in which it undergoes development into a sporocyst, that in turn gives origin to radice or parent nurses. These give birth to daughter-radise or cercarice, which leave the gasteropod or snail and attach themselves to aquatic plants, where they are in turn eaten by animals. Symptoms. — When present in sufficient numbers in the bile-passages the liver becomes greatly enlarged, with the occurrence of jaundice and ascites that may prove fatal. Other symptoms may also be present; thus pain was prominent in 41 out of 100 cases reported by Kurimato in Japan, and heart-murmurs were present in 42 of those cases. Late in the disease the liver may become nodulated and terminate in atrophy. On inspection in Avell-marked cases, a peculiar barrel-shaped bulging is sometimes seen, extending over the hepatic area, with tense abdom- inal walls over the enlarged liver. This is a pathognomonic symptom of hepatic distoma. An endemic form occurring in Japan has been de- scribed ; it is characterized by marked emaciation, diarrhea, hepatic enlargement, and often by ascites. The prognosis of distoma hepaticum is absolutely fatal and the treat- ment is merely palliative. Among other trematodes may be mentioned (a) distoma lanceolatum (found also in cattle) ; (b) distoma crassum, which is larger in size than the preceding ; (c) distoma sibiricum ; (d) distoma pulmonale- {D. Bin- geri) ; (e) distoma spatulatwn (endemicum) ; (/) amphistomum liominis ; (g) distoma hematobium (Bilharz). Two of these deserve extra, though brief, mention. 1238 ANIMAL PARASITIC DISEASES. Distoma Pulmonale (i>. Ringeri) {BroncMal-fluke ; Parasitic He- mopti/sis). — This parasite is very common in Japan. It finds lodgement primarily in the lung, and its ova sometimes form emboli in the brain, liver, and other tissues, and may also be found in the form of little cysts throughout the body. The S3^mptoms are a cough, a reddish-brown bloody sputum, and the presence of the flukes in the expectoration. The latter are club-shaped, and are about 8-10 mm. [^ in.) long. Distoma Hematobium {Bilharzia hematohia ; Blood-flukes). — This hematode is a narrow worm with anterior abdominal sucking-disks. The male is shorter and thicker than the female ; the former being 4-15 mm. (^— I in.) long ; the latter, about 20 mm. (|^ in.). It prevails mostly in Egypt. Cape Colony, and other parts of Africa, and its en- trance into the human body is now believed to be through the skin of those who bathe frequently in the African rivers, in many of which it abounds. It is not unlikely that, as formerly held, infection may also occur in many cases from drinking the impure water of the rivers. The parasites or their ova are found in the bladder, the pelvis of the kidney, and the veins (especially the portal and mesenteric). The symptoms are hematuria, with some pain during urination. Pus, and some of the ova of the parasites, may also be found in the urine. No serious systemic disturbances occur in bilharziosis. Prophylaxis as regards drinking and bathing in African waters should be exercised. Fouquet aflSrms the value of the extract of male-fern internally in this form of distomiasis. NEMATODES. Helminthologists include in this class the cylindric worms, certain varieties of which are among the most common entozoa that infest the human body and inhabit the intestines. ASCARIASIS. Ascaris I/Umbricoides (i?oi*n(?-?i'orm).— Natural History.— This species resembles the common earth-worm, and is the most frequent in occurrence of all the parasites. It usually appears in children be- tween the ages of three and ten years. The round-worm inhabits the upper portion of the small intestine, and occurs singly or in numbers. Its body is round, fusiform, and marked with fine transverse striae. It has a yellowish or reddish-brown color, and measures in the female from 7 to 14 inches in length (17.5-35 cm.), and from 4 to 8 inches in the male (about 20 cm.), its thickness being about that of an ordinary goose-quill. The cephalic extremity of the worm has three oval papilhie. furnished with fine teeth ; the caudal extremity is straight in the female and curved in the male. Lumbricoid worms develop from ova, which are about .05 to .06 mm. long, elliptic, dark-reddish in color, and have a thick, resisting envelope. There may be sixty million of them in a single female worm, and they sometimes occur in the feces in vast numbers. The development ASCARIASIS. 1239 of the embryo and -^-orm external to tlie body is not accurately known. The eggs obtain entrance into the human intestine most probably through drinking-^vater. and it has been held that abundant mucus, and the pre- dominating starchy and saccharine diet of ^n-hich children so often par- take, offer a fayorable nidus for the deyelopment of the ingested asca- ridian eggs. The round-worm sometimes, though rarely, migrates from the small intestine. It has been yomited up. and it has also crawled into the pha- rynx, mouth, and nares. and has been withdrawn thence by the patient's fino-ers. It has eyen passed into the larynx and trachea, causing fatal asphyxia or pulmonary gangrene. The Eustachian tube and biliary ducts may be inyaded with such serious symptoms as perforation of the mem- branum tympani and hepatic abscess. The ascarides have also been found in the peritoneal cayity, postmortem, with intestinal perforation, due, most likely, to other causes. They may penetrate the pancreatic duct and enter fistulfe connected with the intestine. Symptoms may be absent, and yet the worms be found repeatedly in the stools. Existing symptoms are indefinite, and point simply to an irritatiye condition of the bowel. Serious symptoms may, however, result from the migration of the worm, as into the biliary passages. Eustachian tube, or larynx. Feyer is not a necessary concomitant. Lumbricoid worms may give rise to any or all of the following symp- toms : colicky pains, nausea, vomiting, indigestion, diarrhea (sometimes), restlessness, irritability, anorexia, itching of and picking at the nose, disturbed sleep with grinding of the teeth, salivation , and nervous twitchings. The child's abdomen and face may be swollen. Very ner- vous children may manifest epileptiform convulsions, choreic movements, dilated pupils, vertigo, cephalalgia, mental disturbances, and even con- tractures. Complications. — The development of jaundice will indicate obstruc- tion of the bile-duct, in cases in which the worms have been found in the feces. So also, suffocative symptoms coming on, especially at night, in a child with worms, may be due to a migrating lumbricoid. Perineal abscesses and inflamed hernia that have perforated externally some- times discharge the ascaris lumbricoides. Diagnosis. — This is positively determined only by discovering the worm or ova in the stools. In doubtful cases, judged symptomatically. the administration of a suitable purgative and inspection of the resultant passages will enable the physician to arrive at a diagnosis. The prognosis is good, unless serious complications arise {vide supra), when the case should be guarded accordingly. Treatment. — Prophylaxis. — The water used for drinking-purposes should be obtained from the purest sources. That from small streams, shallow wells, and the like is most likely to contain the ova of the lum- bricoides. and should be avoided. The use of filtered water should be encouraged. Before givins an anthelmintic, it should be borne in mind that no good result can be certainly obtained unless the gastro-intestinal tract be nearly deprived of food for from twelve to thirty-six hours, so that the toxic action of the drug used may be exerted directly upon the un- protected worm. 1240 ANIMAL PARASITIC DISEASES. Santonin is at once the most efficient and the most easily administered remedy. It may be given in doses of gr. J to 1 (0.0162-0.0648) of the crystals to a child, or from gr. ij to iv (0.1296-0.2592) to an adult, in the form of a troche, before breakfast. A little milk or other light nourishment may be allowed, the troches being continued once or twice daily for two or three days. This treatment is to be followed by a brisk purge, preferably gr. j to iij (0.0648-0.1944) of calomel. I have sometimes combined small doses of calomel Avith the santonin in a troche, and with good eifect. Xanthopsia or yellow vision, spasms, and even convulsions, and saffron-colored urine may follow the use of san- tonin in cases of idiosyncrasy or overdose of the drug. Oil of worm- seed (chenopodium) in doses of five to ten drops, in emulsion, capsules, or on sugar, may also be used with benefit. Another favorite remedy with some is the unofficial fluid extract of spigelia and senna, to be given in from 1- to 3-dram (4.0-12.0) doses. Finally, the fluid extract of spi- gelia alone (1 to 2 drams — 4.0-8.0), followed by a brisk purge, may bring away dead worms. Oxyuris Vermicularis {Seat-, Pin-, Thread-, or Mmv-ivorm). — Natural History. — The ascaris verinicularis, as this worm is also called, inhabits the colon and especially the rectum. It is a small worm, as several of the commonly-used terms signify, and frequently it occurs in great numbers, sometimes agglutinated with mucus into feculent balls. It is most common in children, though found not rarely at any period of life. The female oxyuris is whitish in color and about ten or twelve millimeters (one-half inch) long, the male being about three or four millimeters (about one-sixth of an inch) in length. Oxyures develop from ova in about two weeks after the ingestion of the latter. The eggs are irregularly ovoid, about -^^ in. (0.05 mm.) in length, and tena- cious of life. By the time the embryos have reached the cecum, they are sexually mature, and when the female arrives in the rectum, im- mense numbers of eggs are deposited that mature into great numbers of worms, the latter being discharged with the feces. Sometimes the worms crawl out of the anus. Infection with the ova may take place through water and food (green, uncooked vegetables and fruit) that have come in contact with the hands of infected persons. Scratching the anus Avill permit of the reception of oxyuris eggs under the finger-nails (Zenker and Heller), and in careless, ignorant, and uncleanly persons the possibility of such an auto- or re-infection should be recognized and avoided. Symptoms. — Pruritus ani (itching of the anus), sometimes burning pain, and tenesmus, with restlessness and disturbed sleep, are the com- monest symptoms of the presence of this parasite. The itching is always worse at night, and may be paroxysmal. An herpetic or eczem- atous eruption around the anus should arouse suspicion, particularly in children, of the presence of the oxyuris in the rectum, and it ac- counts for the intense itching (Flint). Anorexia and anemia, rectal irritability, and ''nervousness" may be associated. It is believed that the migration of the worms into the vagina of girls may set up pruritus and leukorrhea, and that habits of masturbation may be induced in both girls and boys by the sexual irritation caused by the Avorm. Inspection of the stools will reveal, in positive cases, the whitish, thread-like j^arasites. ASCABIA8IS. 1241 Diagnosis. — The pruritus, indicating rectal trouble, will direct the physician's attention to the anus, where the oxyures may be seen ; if not found, their discovery in the feces or the discovery of the eggs by microscopic examination will suffice. The prognosis is good, and proper treatment is always eflFective. Treatment. — The exhibition of anthelmintics and purgatives, such as recommended for destroying and removing the lumbricoid worm, may be effective against seat-worms also, but mainly in reaching those lodged in the bowel above the rectum. Attacking the oxyures directly, however, by means of enemata is the most useful and rational treatment. The rectum should be well emptied of feces, so that the worms may be exposed to the action of the medicament injected, and for this pur- pose enemata of cold water, either simple or with salt or soap, may be resorted to. Injections containing the decoction of quassia (1 or 2 ounces — 32.0 to 64.0 — of the powder or chips to the pint — half liter — of water) are nearly always curative. Other useful remedies are carbolic acid, turpentine, tannin, vinegar, camphor, potassium sulphid, and the oil of eucalyptus. The injections should be repeated once or twice daily for at least ten days. It sometimes happens that killing the worms as directed above affords only temporary relief The reason for this is obviously to be found in the fact that the oxyuris breeds in the cecum, and that only grown forms descend, reaching the rectum. Rectal irritation may be allayed by injections of laudanum and starch-water (gtt. iij-v to the ounce — 32.0). Anal itching is often amenable to carbolized vaselin, applied at bed-time, or to belladonna ointment, or the following, which has been highly recommended : I^. Hydrarg. chloridi mitis, Bij (2.592) ; Petrolati, 5ss (16.0). M. et ft. ung. Sig. — Apply at bedtime. Ascaris Alata. — This is another name for the ascaris mystax, a species of worm found in the intestines of the dog and cat, and occa- sionally in man. It is a slender worm, with a closely-rolled spiral tail and a wing-like projection on either side of the head. The female is about 6-7 centimeters (2.7 inches), the male about 4 centimeters (1.75 in.) in length. Scarcely ten instances, however, have been recorded in which this parasite has occurred in man. Trichocephalus Dispar {Ascaris tricUura). — Natural History. — This worm measures about four or five centimeters (2 inches) in length, and is characterized by the very slender, hair-like appearance of the anterior two-thirds of its body, in contrast to the thick posterior por- tion, which is more or less straight and blunt-pointed in the female, but rolled into a spiral in the male. Its particular habitat seems to be the cecum, though sometimes it is also found in the colon. It may exist in great numbers. Europeans appear to be infected with the parasite more commonly than Americans. The trichocephalus has been found postmortem in many subjects dying with various diseases, as typhoid fever (Flint), meningitis (Barth), profound anemia (Osier), and beri-beri. Propagation is effected by the microscopic eggs, which are ovoid, hard, nodular, brownish, and about 0.05 mm. (g-^ in.) in length. 1242 ANIMAL PARASITIC DISEASES. Symptoms. — It is not certain that the parasite causes any symptoms, nor even that it aggravates those of an associated disease {vide supra). When occurring in great numbers the possibility of fecal accumulation may be mentioned. The diagnosis may be made by microscopy. The ova may be de- tected in the feces. The prognosis and treatment are not called for. ANKYLOSTOMIASIS . Ankylostomum Duodenale {Dochmius duodenalis). — Natural History. — This parasite belongs to the family of strongylidce of the nematoid worms. It was discovered in Milan, in 1838, by Dubini. The length of the female is from 8 to 18 mm. (^ inch), and of the male from 6 to 10 mm. (^ inch). Its body is thread-like, with a conical- shaped head, and a large, bell-shaped mouth surrounded by a horny capsule, and possessing four hook-like teeth, ventrally situated, and two smaller, vertical teeth on the dorsal side, by which the worm fixes itself to the mucous membrane. A bulbous-like swelling exists at the tail end of the male worm. It inhabits the jejunum and duodenum. The eggs are found in muddy water, and there liberate the embryos. These de- velop into larvffi, which, when taken into the human bowel through drinking-water develop into mature worms. They do not multiply within the intestine. Pathology. — The ankylostomum is nourished by the blood it sucks from the intestinal vessels. It is found jyostmot^te^n, sometimes, in the mucous or even submucous coat, rolled up in a little blood-cavity. Ec- chymoses, containing a central opening through which blood can ooze, are the usual result of the worms action. Chronic catarrhal enteritis is usually associated. Hypertrophic dilatation of the heart is observed. Symptoms. — The chief symptom of the condition is anemia (second- ary). When the number of ankylostoma embryos introduced into the intestine is large, the anemia may develop acutely ; when but a few are introduced, the withdrawal of blood is more gradual, and chronic anemia develops. I think, however, it may be safely affirmed that the anemia is not wholly due to blood-sucking. In some cases the impoverishment of the blood has been so profound as to simulate a pernicious anemia. This parasite has been found to be the cause of the disease known as ''Egyptian chlorosis," first described by Griesinger. Ankylostomiasis is not uncommon in tropical countries (Italy, Brazil). In Italy it has been termed tunnel or mountain anemia; in Belgium it is known as hrickmakers anemia ; again, it occurs among workers in coal-mines — ' miner s cachexia. In this country it is rare, though alleged to have been seen in the Southern States. The importation of infected Italian, Hungarian, and Polish laborers may, at some future time, cause the propagation of the ankylostoma parasite in the United States. The anemia of ankylostomiasis is progressive, and it is notcAvorthy that no organic cause for it can be discovered. There may be in addition, slight gastro-intestinal disorder (anorexia, colicky pains, nausea and vomiting, and constipation alternating with diarrhea). In cases marked by an acute development of anemia considerable general weakness, TBICHINIASIS. 1243 dyspnea and sometimes dropsy may ensue. The areas of the apical cardiac impulse and of cardiac dulness are increased downward and laterally. Various murmurs — hemic — may be heard, and the pulmonic sound may be accentuated (vide Pernicious Anemia, p. 429). Diagnosis. — This is made by finding the eggs or mature worms in the feces. The former are oval-shaped, about 0.05 mm. {-^ inch) in length, and have a much thinner shell than the ova of the round-worm. They do not segment except within the intestine. In any case of pro- nounced anemia in which the cause is obscure the patient's dejections should be carefully examined for the ankylostoma parasite or its eggs. Duration. — The disease may last for months or for several years. Prognosis. — If left untreated, the affection may end fatally. Intense anemia, obstinate diarrhea, and profound nutritive disturbances con- stitute symptoms of grave import. Properly treated, the prognosis is quite favorable. A spontaneous cure may occur in some cases. Treatment. — Prophylactic. — Workmen in mines, tunnels, and brick- yards, and in tropical localities especially, should be warned not to drink the water close at hand without previous boiling and then cooling. Medicinal. — Anthelmintics to kill the ankylostoma and purgatives to remove it from the intestine are indicated as for other intestinal para- sites. The oleoresin of male fern in J- to 1-dram (2.0-4.0) doses, san- tonin, and thymol are very useful for the first-named object. Cathartics or enemata are used to bring away the dead parasites, after which nourishing food, iron, and tonics are to be given. TRICHINIASIS. {Trichinosis.) The parasite that gives rise to this affection is the trichina spiralis. Natural History. — The mature male worm is 0.8 to 1.5 mm. (^ in.) long and the female 2 to 4 mm. (y^-^ in.). The head is pointed and unarmed, and the neck is long and more slender than the body, which has a round blunt end. The worm is viviparous. It inhabits the intes- tines of such animals as the rat, dog, cat, hog, and man. The embryo or muscle trichina is about 0.6 to 1 mm. (^ in.) long, and lies coiled up in a spiral form within an ovoid capsule in the sarcolemma- sheath of muscle-fiber. The life-history begins with the larval state of the trichinje encysted in the muscles. When this flesh is eaten by another animal, or by man, the larvae are liberated during the digestive process. Passing into the intestines, they reach the adult stage in from two to four days, being then sexually mature, and in five to seven days more they produce hundreds of living embryos. The intestinal trichinae become fully grown, and then usually die in from four to five weeks. The female trichina may bring forth several broods of embryos during her life-period in the intestine. The living embryos leave the intestine at once, and invade the muscles through various channels — principally along the connective-tissue routes — so that the symptoms of muscular irritation develop in from seven to ten days after eating the trichinous meat. The embryos attain to maturity (larval form) in about two weeks after entering the muscular tissues. Their presence causes a mechanical irritation that results in the formation of a 1244 ANIMAL PARASITIC DISEASES. Fig. 81.— Tr; - > :r''m the head of the right gasirocnemiu? muscle three weeks after the first symptoms appeared 'Queen obj. |; eye piece No. lli. fibrous cap.5ule in from four to sis weeks. In man it probably becomes encysted at a later period than in the lower animals, as shown by the accompanying illustration, taken from a case under the im- mediate observation of Dr. L. Na- poleon Boston (Fig. 81). Usually but a single worm is found within one capsule, though occasionally three or four are seen. Leuckart found numbers of embryos free in the abdominal cavity of in- fected animals; they have also been found in the mesentery. The encapsulated trichinae may live many years in the muscles. With increasing age the capsules become thicker and may be the seat finally of calcareous infiltration. Pathology. — The diaphragm is most thickly infested with the larval trichina;. Next in order are such trunk-muscles as the intercostals and abdominals, then the muscles of the neck, including the larynx, head, eyes, and extremities. Up to the seventh week of the disease the intes- tinal trichinae may be very numerous, as many as a dozen being found in a drop of intestinal mucus. There may be some intestinal inflammation (catarrh) and the mesenteric glands may also be swollen and appear like those of typhoid fever. In cases that proved fatal during the second month, Cohnheim noted an abundance of fat in the liver, a granular state of the renal epithelium and of the heart-muscle, broncho-pneumonic areas (occasionally), and hypostatic pneumonia (frequently). Microscopically, the muscles show '-the changes characteristic of acute myositis"' (Fitz) after the fifth week. The trichinous cysts in the muscles may be seen with the naked eye as small, grayish-white, opaque, " oat-shaped " specks, longitudinally disposed in the meat-fibers. Sources'of the Trichina. — The trichina was first found in pork — the usual source of ti'ichiniasis in man — by the late Joseph Leidy. It should be noted that some individuals may be dangerously infested with trichinae and yet give no symptomatic evidence of the presence of the parasite. Recent investigations show that the live trichinae may be found in the fatty as well as the fleshy portion of pork. The pig is infested by eating trichinous rats, trichinous pork, or possibly human or porcine ex- crement containing the embryos of propagating intestinal trichinae. The rat may be the original host of the parasites, or it may itself become in- fected by older rodents eating their fellows, or by eating trichinous pork or human or porcine excrement voided during the stage of intestinal infection. As to the frequency of the infection of hogs, it may be said that about 2 per cent, were found to be trichinous, according to Salmon's report (1884), of nearly three hundred thousand examinations of American pork. Other examinations, however, show a variation of infection of from .05 to 6 per cent, of hogs. In Prussia, according to Eulenberg's statistics, the ratio is decidedly less varying — from 1 to 2160 hogs (1876) to 1 to TBIGHINIA SIS. 1245 1817 (1889). According to Osier, " the dissecting-room and postmortem statistics show that from one-half to two per cent, of all bodies contain trichinae." Of course, man, as a rule, becomes infected by eating raw or partially cooked pork containing living muscle-trichinae (larvae). The habit of indulging in raw ham and sausages, so common among the Germans of Prussia (particularly during pic-nics) and in some parts of the United States where German immigrants have settled in large numbers, explains the comparative frequency of this parasitic disease in such localities. Trichiniasis has occurred in epidemic form in North Germany, France, Spain, Russia, the Scandinavian countries, and in several of the north- western United States. SymptOJns. — The fact that the jjostmortem examination often reveals the presence of muscle-trichinae, whereas no history of trichiniasis or of any disease resembling it has been obtainable, shows that one may eat trichinous pork containing a small number of larvae without the develop- ment of any symptoms. It is to be recollected that to the migration of the parasites the principal symptoms of trichinosis are due. In well-marked cases of infection gastro-intestinal disturbances appear on the second or third day after the ingestion of the infected meat. Vom- iting, diarrhea, and colicky pains in the abdomen may be present. The diarrhea sometimes takes on the characteristics of a choleraic attack or may be followed by obstinate constipation. Extreme "muscular weariness" and bodily fatigue often occur for several days before the embryonic parasites can have begun to wander into the muscles. On about the tenth to the fifteenth day, when migra- tion usually commences, chills, followed by a temperature of 101.5° to 104° (38.6° to 40° 0.) and marked myositis, come on. The muscles are stiff, tense, painful on pressure and motion, and somewhat swollen. The flexors of the extremities are particularly sore and often firmly contracted, causing the knees and elbows to be acutely bent. Mastication, deglu- tition, and phonation may be difficult and painful because of the involve- ment of the muscles of the jaws, pharynx, and larynx. Intense and distressing dyspnea is frequent on account of the involvement of the dia- phragm and intestinal muscles. The temperature shows marked remis- sions in most cases, and may even be subnormal. The fever lasts from three to seven weeks. The pulse varies with the temperature. Edema is characteristic in nearly all of the cases. It appears on about the seventh day after the infection, and begins in the face, usually being noted first in the eyelids, and extending thence to the extremities and trunk during the height of the muscular symptoms. It may last for several days, then disappear for several days or a week, and reappear. Ascites even has been observed. Edema of the larynx and bronchial catarrh, the latter rarely leading to broncho-pneumonia, may also super- vene and add to the gravity of the dyspnea. Profuse sweating may last for several weeks. Miliaria, urticaria, acne, furunculosis, herpes, and pruritus may occur as skin-manifestations. Insomnia, headache, a tempo- rary loss of the tendon-reflexes, and dilatation of the pupils (Rupprecht) have been noted among the nervous symptoms. Prolonged cases show a marked degree of emaciation and anemia. Complications, as a typhoid state, hypostatic pneumonia, and pleurisy 1246 ANIMAL PARASITIC DISEASES. may appear. Albumin, with casts, and occasionally red and white cor- puscles are found in the urine. Recovery is effected in mild cases within two Aveeks ; in the severe cases of infection from six weeks to several months may be occupied before convalescence begins. Diagnosis. — The following symptoms are regarded as pathogno- monic : sudden swelling of the face, coming on after the patient has suffered for several days from muscular soreness ; loss of appetite, fever, and profuse sweats (Bohler) : painful, tender, and "rubber-like" hard- ness of the muscles, with difficulty in movement ; semiflexed extremities ; gastro-intestinal catarrh, with a red, dry, coated tongue ; dyspnea, diar- rhea, and edema of the extremities following the subsidence of that first noticed in the face. Friedreich also emphasizes the hoarseness due to invasion of the laryngeal muscles. Meat- and sausage-poisoning may be distinguished from trichiniasis by the more rapid course of the former, and by the dry throat and skin, jaundice, visual disturbances, more marked gastro-enteritis, and the ab- sence of edema and muscular symptoms. Direct examination of the passages and of the muscles may be resorted to. The discovery of the parasites in the pork a portion of which has been eaten by the sick of course establishes the diagnosis. A low-power microscope should be used to examine the intestinal mucus for the trichinae. Light purgation should precede this endeavor. Harpooning such muscles as the biceps for the purpose of removing some muscle-fiber, or directly incising a small portion under Schleich's method of infiltration-anes- thesia, may permit of a positive diagnosis in some cases. Acute rheumatism, cholera, typhoid fever, and acute polymyositis {^pseudo-trichiniasis) may at times resemble trichiniasis. Epidemics of the parasitic disease are more readily diagnosed than an isolated case. Prognosis. — This depends upon the number of parasites ingested with the infected meat or sausage, and upon the number of embryos gen- erated in the intestines by the matured worms. Marked early diarrhea is favorable. The prognosis should be guarded, however, in all cases, as the mortality-rate may range from 5 to 35 per cent. Death, too, often occurs as late as from the fourth to the sixth week. Treatment. — Prophylaxis is of supreme importance, both as to the infection of the hog and the danger of eating infected pork. Care should be exercised in the feeding of swine, and the destruction of rats should be made as complete as possible in and about the styes. Pig-excrement should be removed and burned, and feeding with milk, bran, grain, and vegetables should be forced upon all keepers of swine. Rigid inspection of the meat-supply, as is done in Germany, should be carried out by sanitary officers employed by the government. It is held to be an impracticable measure where immense quantities of meat are handled daily to examine microscopically simply a minute fragment of pork taken from each hog slaughtered. Decidedly the safest and most efficient way to prevent trichinosis is to thoroughly salt, smoke, and cook the pork that is to be used. Roasting should be particularly well done, in order that the heat may effectively reach the central portions of the meat. Putrefaction does not kill the parasites. The treatment of those who have eaten trichinous meat should be by FILABIASIS. 1247 a prompt evacuation of the bowel, especially within the first twenty-four hours, as after the embryo young have been brought forth and have passed into the muscles no known treatment is successful in attacking them. Calomel is one of the best drugs, and active purgation usually follows its use in large doses, succeeded by salines ; rhubarb, senna, sul- phur, aloin, and large doses of oil or glycerin may also be tried. In combination with the purgatives some anthelmintic (male fern, santonin, thymol) should be used. The encysted or larval parasites are not acces- sible to treatment, although picric acid has been recommended. The symptoms to be met are the great muscular pains, insomnia, and weak- ness, which is often severe in protracted cases. Prolonged hot baths, anodyne embrocations, with hypodermics occasionally, may prove useful for the first ; bromids, chloralamid, and the like for the second symptom ; and a concentrated liquid diet, strychnin, peptonoids, and the like for the last. Massage, electricity, and stimulating applications, as chloroform liniment, may be required during convalescence and for some time there- after to combat the muscular weakness, soreness, and stiffness. FILARIASIS. {Filaria Sanguinis Rominis.) There are several varieties of filarise that may be found in human blood. The two principal ones are the filaria sanguinis hominis nocturna and filaria sanguinis ho7ninis diurna. The first is a white, opaline, thread-like worm, tapering toward the ends, which latter, however, are blunt. The male is 83 mm. (3.2 inches) long ; the female 155 mm. (6.1 inches). The second worm is known only in embryonic form, and is distinguished by granulations in the axis of the body. Manson found them in the blood of Congo negroes, but only during the daytime. On the other hand, the nocturnal filaria is found only at night, or, if the host be either by habit, necessity, or choice, a day-sleeper, during this time, showing, then, that there is some condition of the body during quietude that is conducive to the appearance of the filaria in the blood (blood and chyle flow, Granville). This " filarial periodicity " is a curious and strik- ing characteristic of these parasites. The embryos are produced by the female in great numbers, and are so small that they readily pass through the capillaries. According to Man- son, who, in 1877, found the larvse of filaria sanguinis hominis in the stomach of a female mosquito, it is probable that after filling itself with the blood of an infested man during sleep, the mosquito seeks stagnant water, dies, and the larvse are set free. In this way it may happen that man takes in the embryos through the drinking-water. They find a permanent seat in the lymphatics of the human host, mature, and bring forth young, which may again infest the blood by passing through the lymph-ducts into the thoracic duct and general circulation. The geographic distribution of the filaria is limited mainly to the tropics and sub-tropics. Filariasis is most common in Brazil, the West Indies, Mexico, the Southern States, Southern China, India, Egypt, a part of Australia, and the southern Pacific islands, where it is quite endemic. The symptoms of filariasis are in abeyance until some obstruction 1248 AyniAL PARASITIC DISEASES. of the lymph-channels is caused by the parasite. There are several con- ditions or endemic diseases produced. Elephantiasis arabum is believed by Manson to be the effect of these parasites iu a certain proportion of cases at least. In specimens of night-blood from 88 Cochin Chinese he ":is:apc*r"^4 Fig. S2. — The movement of a single tilaria during a series of four successive instantaneous exposures. The length of each exposure was one-fifth of a second, the entire series occupying les.« than five seconds. The magnification is to eight hundred diameters, with a Zeiss one-twelfth homoge- neous immersion lens (F. P. Henry). Fig. 83. — Filaria alive in the blood. Instantaneous photomi- crograph. Four hundred diam- eters magnification. Four milli- meters Zeiss apochromatic (F. P. Henry). found filarife in 21 : 14 specimen.^; came from patients with elephantiasis, and only 1 showed filarias. This latter fact, he explains, is to be expected, since, in order to give rise to elephantiasis (due to an infarction of the lymphatic glands connected with the diseased areas), the adult filariae must lie on the distal side of the glands, which makes it impossible for the young filariae to pass into the general circulation. " Therefore the person least likely, in a filarial district, to have filariae in his blood is one who is the subject of elephantiasis."^ Hematocliyluria and Chyluria. — The patient passes a white, opaque, milky urine, occasionally bloody, with a clotty sediment. This may be intermittent, and normal urine may be passed for many weeks before chyluria or hematochyluria reappears. There may be at the same time a slight degree of polyuria. Under the microscope, fat granules and white and red corpuscles are seen. The lively, wriggling embryo filarise may also be discovered in the urine, as well as in the blood at night. There is a dilatation of the lymph-vessels in the kidneys alongside of the tubules, and in the abdominal lymph-plexuses. Sometimes a little vesical irritation and straining during urination may be caused by the endeavor to pass chylous blood-clots. The thoracic duct above the diaphragm has been found impervious (Stephen Mackenzie). 1 British Med. Jour., June 2, 1894. DBACONTIASIS. 1249 Lymph-scrotum and lymph-vulva have been caused by the filarise. The parts are greatly swollen, thickened, and contain distended lymphatics filled with a turbid and either milk-white, salmon-colored, or blood-red coagulable liquid that is discharged upon puncturing the varices. The filaria is not always found in the exuded lymph. The inguinal and femoral regions are often enlarged and doughy. An erysipelatous inflam- mation of the parts is not infrequent in these cases, and may be ushered in by a chill and high fever, lasting a day or two, and ending with a pro- fuse sweat. The filarise have also been found in a case of ascites (Winckel), in one of hemoptysis (Yamane, Japan), and, by the same observer, they were found in the feces (chylous diarrhea). Treatment. — Prophylaxis in regard to the drinking-water is essen- tial in order to avoid filariasis. Filtering, boiling, and storing the water in mosquito-proof receptacles is sufficient. Thymol in from 1- to 5-grain (0.0648-0.324) doses, given for from two to eight weeks, has caused the disappearance of the larval filarise in several cases. Methylene-blue appears also to have produced a cure in a case of chyluria reported by Flint, although Laveran and Henry believe that it is of little value. The latter states that he has " given this drug in larger doses than were used in the case reported by Flint, and for a much longer period, with- out the slightest efi"ect upon the parasite."^ The adult filaria seems to be beyond the reach of any known medication that will not prove dangerous, either directly or indirectly, to its human host. DRACONTIASIS. ( Guinea-ioorm Disease.) The parasite is the filaria or dracunculus medinensis or persarum, common in the tropics of Asia, Africa, and America. It is only recently that the male guinea-worm has been found. It is usually solitary, and measures from 50 to 100 cm. (20 to 40 in.) in length and about 2 mm. {■^ in.) in diameter. It is cylindric, whitish, with blunt papillated head, and a sharp, curved tail. The body is nearly filled by the uterus, which contains innumerable embryos. The live young dracunculus escapes from the intestines of an infested man, ox, horse, dog, or jackal, enters the body of a cyclops or small cray-fish, and there becomes a fully-devel- oped larva. It is then taken into the stomach and intestines of man through the contaminated drinking-water. The female enters the intes- tines by way of the mesentery, and the male worm, after fulfilling its sexual functions there, probably dies, while the female brings forth its young, which pass into the connective tissues of its human host. The worm has an inexplicable affinity for the subcutaneous and intermuscular tissues of the feet and legs, where it attains full development. Symptoms. — Wherever the parasite is situated, it may often be felt coiled up under the skin, which at that point becomes red, sore, and fluc- tuating like an abscess. When opened, either surgically or naturally by the worm, the head appears through the aperture. The favorite spot for perforation is the dorsum of the foot, though sometimes it extrudes from 1 3Ied. News, May 2, 1896. 79 1250 ANIMAL PARASITIC DISEASES. the legs, occasionally from the thighs, and very rarely from the thorax and abdomen. Treatment. — Prophylaxis in regard to the drinking-water and as to bathing where the intermediary host of the dracunculus — the cyclops — has its habitat is essential for safety. The active treatment embraces the surgical measures necessary to re- move the worm entire and to promote the healing of the irritated tissues. The burrow should be opened, and the worm gradually coiled around a quill or a smooth, cylindric piece of wood until it can be withdrawn with- out being torn and allowing any embryos to escape into the tissues. Roth claims that after incision the application of compresses of carbolic acid (1 to 15) over the wound causes the worm to be removed in two or three days. Native Indian physicians commend highly the local application of the leaves of the " amarpattee " plant. Asafetida and sulphur have been recommended internally, but without any definite result. OTHER PILARIS. Among other filarige that have been found in man are the following : The filaria immitis, which causes hematuria and has been found in the por- tal vein, Avhilst the ova were discovered in the ureteral and vesical walls ; filaria labialis, found in a lip pustule ; filaria lentis, found in a cataract ; filaria trachealis and hronchialis, seen in the trachea, bronchioles, and lungs ; filaria hominis oris, observed by Leidy in the mouth of a child ; filaria loa, noticed in the tropics among negroes, its habitat being beneath the conjunctiva. OTHER AND UNCOMMON NEMATODES. Eustrongylus Gigas. — This parasite is exceedingly rare in man, but has been found in many of the carnivora and in some herbivora. It is supposed that fish act as the intermediate host for the larv?e. The worm is enormous in size, the female being from 25 to 100 cm. (10 to 40 in.) in length and from 5 to 12 mm. (^ to ^ in.) long. It is a red, cylindric parasite with blunt-pointed ends. Its most common seat is the kidney, which it may destroy, causing hematuria and, perhaps, the presence of the eustrongylus ova. Strongylus paradoxus has been found in the respiratory organs of the pig and in the dejecta of a pork-dealer. Anguillula stercoralis or intestinalis occurs in the stools of certain tropical endemic diarrheas. The parasites are oviparous, and the eggs may be taken through the drinking-water. They have been found in the biliary and pancreatic ducts, as well as in various parts of the intestines. Boiling the water as a prophylactic measure and the administration of thymol or male-fern are to be recommended. Echinorhyncus gigas belongs to the Acanthocephala (thorn-headed worms) and infests the intestines of the pig. The larval host is the cockchafer or floral beetle grub. In the only case reported, that of a boy (Lambl), a small echinorhyncus was found in the intestines. Echinorhyncus moniliformis occurs in rats, and one case, that of a Sicilian, has been reported by Calandruccio, in which the ova were found ECHINOCOCGUS DISEASE. 1251 in the feces. The larval host is probably the Blaps micronata. The ethereal extract of male-fern causes the expulsion of the parasite. CESTODES. ECHINOCOCGUS DISEASE. [Hydatid or Bladder-worm Disease.) The taenia echinococcus is also called taenia nana by Van Beneden, but should not be confounded with the tenia nana of v. Siebold, a brief de- scription of which follows this article. It is the smallest tape-worm of our domestic animals, and lives between the villi in the small intestine, especially in the larger breeds of dogs, as the mastiff and Newfoundland. It has a length of from 4 to 9 mm. (|- to ^ in.), and consists of only three or four sections, the last one of which is mature. The rostellum project- ing from the small head has thirty or forty booklets arranged in a double row. Hundreds and sometimes thousands of eggs are contained in the mature segment. The intermediary hosts for the larvae are rarely man, the horse, and the sheep, and more often the hog and ox. I^ife History. — The ova, embryos, or the proglottides even, of the adult tenia are voided by the dog, and in various ways, to be pointed out later, are ingested by man. The dog first becomes infected by eating the bladders or echinococcus cysts of some animal that harbors the larval form of the tenia, and the matured teniae appear in from eight to ten weeks. The liberated six-hooked embryos burrow through the intestinal wall or enter the portal vein ; they then pass into the solid viscera, as the liver, into the peritoneal cavity, the muscles, lungs, brain, etc. There they develop into the larval form and cause the formation of hydatid or echinococcus cysts. During the latter process the booklets disappear. In the development of echinococcus cysts, about four weeks after the ingestion of the bladder-worm eggs, small nodules appear, about 1 mm. (2^ in.) in size. In about five months the cyst-walls consist of two layers, an external layer and an inner, granular, parenchymatous layer (or endocyst), containing a clear liquid. As the reaction to the irritation caused by the parasite and its cyst increases, a fibrous investment forms around them. At this time, also, small daughter-cysts, or vesicular buds, form the minor granular layer of the mother-cyst, and contain the heads of the larvae. They are soon .set free, and may themselves give rise to other or granddaughter-cysts in a similar way. These really become the breeding capsules of little cellular outgrowths that form the scolices or heads of future teniae. They show the four sucking disks and a circle of booklets. Each scolex, Avhen taken into the intestine of the dog, de- velops into an adult bladder-worm or taenia echinococcus. This endogenous mode of cystic growth is common in man {E. hydatidosus) ; but in some of the lower animals, and rarely in man, the daughter- and grand- daughter-cysts may develop between the two layers of the primary or mother-cyst, and then extrude (exogenous variety ; E. granulosus). A third variety is the multilocular echinococcus (E. alveolaris, Buhl), 1252 ANIMAL PARASITIC DISEASES. aflfecting principally the liver. A large, hard tumor is seen that on sec- tion shows a firm connective-tissue framework surrounding alveoli that average a small pea in size. These alveoli contain small echinococcus cysts with thick, laminated walls. They may contain scolices or hooklets, and sometimes they are quite sterile. The echinococci may be situated in the lymph-channels and bile-ducts (Zenker). The pure hydatid fluid is colorless, odorless, limpid, neutral in reaction, and has a specific gravity of 1005 to 1012. About 96 to 98 per cent, is water, and sodium chlorid, carbonate, and sulphate, traces of sugar (dextrose), and uric acid are found among the constituents. Among the changes that an echinococcus cyst may undergo the com- monest is that of the death of the echinococci, as from diminished nour- ishment due to intense proliferation of daughter- and granddaughter- cysts. The contents become thickened, putty-like, or granular, and even calcified. Remnants of these obsolete cysts, such as the chitinous sub- stance of the old and outer wall-layer and hooklets, may be found. Traumatism or chemical irritation may also cause the death of the echinococcus and obliteration of the cysts. Sometimes rupture of the cyst occurs, with serious consequences to the patient ; on the perito- neum daughter-cysts or free scolices may be disseminated and grow. Or perforation into the respiratory, digestive, or urinary tracts and dis- charge of daughter-cysts and hydatid fluid may take place. Lastly, sup- puration and the formation of large hepatic abscesses may ensue, eitheir- spontaneously or on account of septic instruments used for tapping the cysts. Ktiology. — Carelessness in the feeding and the keeping of dogs is the primary source of hydatid disease, and the preparing of food where dogs are allowed to roam about, to be petted, and so on, accounts for the majority of cases. Females are more often affected than males, and chil- dren and young adults seem to be oftener aflfected than those older m years. As regards the geographic distribution., echinococcus disease prevails most extensively in Iceland, where man and dog live closely together. In Australia, also, many persons are affected. It is not so common in Europe, Asia, or Africa, and in America it is rare. Organs Affected. — The tenia echinococcus has an undoubted predi- lection for the liver. Next in order of frequency are the lungs, intes- tines, pei-haps the urinary organs, brain, and spinal cord. The spleen, bones, muscles, the heart, and blood-vessels are involved with uncertain frequency. Symptoms. — Hydatids of the Liver. — Unless the cystic tumors com- press the portal area or the biliary passages, or invade the neighboring viscera, subjective symptoms may be entirely wanting. Not infrequently echinococcus sacs, partly calcified, have been found postmortem, not having produced any symptoms during life. Gradual but progressive loss of flesh and strength with the presence of a fluctuating tumor may be the only symptoms present until late in the disease. If the cysts attain a large size, a sensation of dragging, and of pain even, is often present ; as a rule, however, pain is absent throughout the course of the disease. If the tumor displaces the diaphragm upward and compresses the lung, cough and dyspnea result. In some cases the sac has ruptured EOHINOCOCCUS DISEASE. 1253 into the bronchi, and given rise to cough and to expectoration of the fluid and vesicles. If the portal veins and bile-duct are compressed, splenic enlargement from passive congestion, ascites, and jaundice will occur, these symptoms being more common when the cysts are multilocular. Rupture may occur into the intestines (colon), into the pleura or pericardium, causing pyothorax or pyo-pericardium, or into the inferior vena cava, causing fatal pulmonary embolism. Fever is usually absent throughout, unless the contents of the sac become converted into an abscess ; then rigors or chills, fever (hectic in type), and sweatings occur, with jaundice (more or less intense) and rapid emaciation. Not infrequently the cyst-wall becomes partly calcified and the con- tents are reabsorbed, with an entire absence of symptoms, the patient dying in after years of some intercurrent disease. When rupture occurs, unless the contents be evacuated through the respiratory or alimentary tract or externally, symptoms of collapse develop and are followed by death. The physical signs give on inspection fulness or bulging in the right hypochondriac region, especially if the cyst be single, of large size, and situated anteriorly. Palpation confirms inspection and shows a fluctuating mass or masses. A trembling impulse is felt sometimes on deep palpation, aided by light percussion over the opposite side of the cyst, constituting the so-called " hydatid thrill." This sign cannot always be elicited, but when present is pathognomonic of the disease. The remainder of the liver shows uni- form enlargement. The spleen is often palpably increased in size from passive congestion. Percussion reveals, in addition to the hydatid fremitus, an increased area of dulness to the left or posteriorly, depending on the location and extent of the growths. If the left lobe be involved, the line of flatness may extend across the sternum to the left hypochondriac region. If the cysts are multiple and on the antero-inferior surface, the stomach may be displaced toward the left and dulness may extend across the epigastrium ; if posteriorly, the pleural cavity may be encroached upon, causing an increased area of flatness upward in the postero-axillary line. Frerichs claims the line of dulness posteriorly in hydatid disease to be a curved one, whose convexity is upward. Auscultation gives, according to Santoni and others, a short sharp booming sound when the tumor is percussed, that may be likened to one produced by striking a membrane stretched over a metallic frame. Diagtiosis. — In the entire absence of subjective symptoms and of characteristic physical signs, the diagnosis is impossible. If, however, the cyst be of sufficient size to give fluctuation and the liver be irregu- larly enlarged, with an absence of fever, pain, and marked emaciation, the disease may be strongly suspected. The only certain demonstration of the condition is the discovery of the characteristic booklets in the as- pirated or discharging contents of the cyst. Among the conditions that may be misdiagnosed for hydatid disease are — (a) Dilatation of the gall- bladder, {h) hydronephrosis, (c) right-sided pleurisy with effusion, [d) syphilis of the liver, (e) carcinoma, (/) abscess, and {g) cirrhosis. 1254 ANUIAL PARASITIC DISEASES. Hydatid Cvst. Previous history negative, except the com- panionship of dogs. Pain and jaundice usually absent. Enlargement in any direction, depending upon the location of the cysts. Hydatid thrill may be present. Less so. Hydatid Cyst. The history is negative (vide supra). Urinalysis is negative. The tumor is most prominent over the hepatic area, and is associated with enlargement of the liver. The duration is indefinite and uremia rare. Hydatid Cyst. The onset is slow ; pain and fever are absent. The presence of a fluctuating mass in the hepatic area, 7iot chaiujing with the po- sition of the patient. Hydatid fremitus is present, but no bulging of the inter- costal spaces. Aspiration reveals a clear yellow liquid of low specific gravity, containing no albumin, but chlorids and booklets. The disease invariably runs a chronic course. Dilatation of the Gall-bladder. A previous history of having passed biliary calculi is often present. Attacks of biliaiy colic followed by jaun- dice either are present or enter into the previous history. Enlargement is always in one direction — downward and posteriorly. "Hydatid fremitus" never present. The tumor is somewhat movable. Hydronephrosis. There is a history of renal calculi or of vesical inflammation. Urinalysis reveals evidences of renal disease. The tumor is most prominent in the flank and iliac fossa. If extending to the right hypochondriac region, it does not move with the liver. The duration is short ; a termination in uremia is common. Pleurisy with Effusion. The onset is sudden, and violent pain is present, with fever and dyspnea. The presence of eS"usion, beginning at the Vjase of the chest and gradually extending upward — changing loith the position of the patient and accompanied by bulging of the intercostal spaces. Aspiration gives a cloudy, turbid liquid, containing albumin and flakes of lymph with high specific gravity. The disease generally runs an acute course. For a differential diagnosis from (c?), (e), (/), and {g) I would refer the reader to the discussion of the several diseases [vide Diseases of the Liver). Echinococcus of the Respiratory Organs. — The lung has been the seat of the larvae quite frequently, and instances have been noted especially in North Germany and Australia. The right lower lobe has been the seat of predilection, though sometimes the pleura is the primary source of trouble. There are pain in the chest, cough, dypsnea, perhaps arching of the overhanging thoracic region, signs of a pleural effusion, a tym- panitic note above the prominence, hemoptysis, and the pathognomonic expectoration of hydatid disease. The general condition may not be seri- ously affected. Perforation into the pleural sac by pulmonary echino- cocci may be followed by empyema, and, later, by perforation of the chest wall. The heart may be dislocated. Compression of the lung may pro- duce gangrene. The diagnosis, in the absence of the characteristic sputum, is to be made from phthisis and a pleural effusion. Their location at the base of the chest may serve to differentiate hydatid cysts from phthisis, as well as the absence of marked emaciation. The characteristic curved upper EOHINOCOCCUS DISEASE. 1255 boundary of dulness in pleural effusion and the change of the boundary upon changing the patient's position will serve to distinguish this affec- tion. Puncture of any bulging area will determine the character of the liquid. Pleural echinococci sometimes cause great compression of the lung and a barrelling of the chest on one or both sides. The pain may be quite sharp, and the respiratory murmur either distant or altogether absent. Echinococcus of the Mediastinum. — Hare has collected 6 cases of hydatid disease among 520 cases of mediastinal tumors. Ecliiiiococcus of the Heart. — Since most of the cases have shown in- volvement principally of the right side of the heart, the instances of sud- den death that have been reported may be readily understood. EcMnococcus of the brain and spinal cord should not be confounded with cystic degeneration of the choroid plexuses. The symptoms of cere- bral hydatids are those of tumor, peristent and intense cephalalgia, vom- iting, psychical disturbances, convulsions, amblyopia, and " choked disk," and sometimes paralysis. Hydatid disease may develop inside the dura mater, or it may penetrate from without and destroy the vertebrae before they compress the cord to a great degree. The symptoms are those of a compression myelitis. Echinococcus of the Spleen. — About 40 cases of involvement of the spleen have been described. The organ may become greatly enlarged and be mistaken for that due to malaria, leukemia, etc. The hydatid thrill may be detected. Echinococcus of the Kidneys. — More than 100 cases have been ob- served, mostly in Germany and France. The cyst may be as large as in hydronephrosis. Many of the cysts are of the exogenous form of growth. As a rule, one kidney only is affected, and generally the left one. Ab- dominal and thoracic compression symptoms may be caused, and bulging is often present in the lumbar region in marked cases. This may be punctured as an aid in the diagnosis. Rupture into the pelvis of the kidney and the discharge of the smaller cysts may give rise to renal colic and to the discharge of the cysts with the urine. More rarely, rupture of a suppurating cyst may take place in the loin. Echinococcus of the peritoneum is rare as a primary condition. Echinococci have also been located in the bladder, prostate, testicle, ovary, uterus, great omentum, mesentery, arteries, lymphatics, thyroid gland, muscles, bones, joints, parotid gland, orbit, and mamma. A multilocular echinococcus cyst may give rise to a very large, fluc- tuating, bossellated tumor below the liver; this may simulate colloid cancer, either of the liver or the gall-bladder. Icterus, marked and obstinate, with or without ascites, an enlarged spleen, and a long course without decided loss of flesh, are indicative of this form of hydatid. Fatal hemorrhage may supervene. A peculiar complication of echinococcus cysts is the occasional development of urticaria. It has been noted especially shortly after the puncture of a cyst, and this is somewhat diagnostic Avhen it appears. The prognosis is generally grave both as to life and cure, although some cases of hydatid disease of the liver have lasted for more than ten years. The character of the changes in the cysts and their mode of termi- nation influence the prognosis. Thus, the occurrence of suppuration 1256 ANIMAL PARASITIC DISEASES. is to be dreaded. Spontaneous cures have been noted in a few in- stances. Treatment. — As in most of the other parasitic diseases, prevention is more or less effectual, and a cure is difficult or impossible. Infection of the dog should be avoided by preventing its gaining access to possible sources of hydatid disease, as the raw flesh of animals, especially in the form of meat-scraps around slaughter-houses. In order that human beings may not be affected, dogs should not be carelessly handled or allowed to be where they may come in contact with food and drink in any way, whether meat or eggs, vegetables, fruits, or cereals. Cleanli- ness in keeping dogs and in the proper preparation of food are essential in regions Avhere hydatid disease is prevalent. Medicines cannot reach the parasites in man, situated as they are in larval form encysted in the various tissues and organs of the body. Whenever the cyst becomes large, accessible, and the cause of trouble- some symptoms, surgical measures may be resorted to. Among these are. simple tapping, tapping with aspiration, and with the subsequent injection of various substances (as iodin and zinc-chlorid electrolysis), and incision with drainage. Excision of the liver cysts has been practised by Raggi, Pozzi, Tansini, and others, but its practical value is still undetermined. T^NIJE OB TAPE- WORMS. Natural History. — Tape-worms are found in the intestine of man, and are the matured or completely developed larvse or cysticerci from the muscles and solid viscera of animals. Different varieties of cysticerci develop from the ova of the respective varieties of tenige. These tape- worm eggs, after having passed out of the bowel, may be taken into the systems of various animals by various modes, entering the circulation, it may be, and becoming fixed within the solid tissues, especially the muscles. In about two or three months pea-sized cysts develop, and from the cyst-walls there gradually forms a new tenia-head, called a scolex, or nurse. The Avorm-cysts, popularly termed "measles," con- stitute the cysticerci. Remaining in the tissues, they die and become calcified in from three to six years (Striimpell). But, if taken into the stomach by the eating of raw or partially-cooked meat, a tape-worm de- velops from the scolex. The maturation of the segments of the tape- worm commences several months after the fixation of the scolex in the intestine. In the natural life-cycle of a tape-worm the usual order of lodo-ement may be reversed. Thus man instead of a lower animal may become the host of the tenia eggs, which in turn may find their way into the solid viscera and muscles to develop into cysticerci. Again, this same order may in some way be brought about by "auto-infection." The tape-worm, as its name indicates, has a ribbon-like form ; although it has a number of segments and joints, giving it a link-belt appearance. When matured, these segments, or proglottides, develop male and female generative organs. Varieties. — Taenia Solium {Pork Tajje-icorm). — This worm is seen much less frequently here than in Europe. It develops in the small intestine after the ingestion of raw or underdone "measly" pork. This worm does not necessarily exist singly, as its name would indicate, TAPE-WORMS. 1257 although such is usually the case. It ranges from 2 to 4 meters (6 to 13 feet) in length. The head is rounded, pin-head in size, and is succeeded by a thread-like neck and by gradually shortening and -widen- ing segments. Four suckers and a projecting circle of twenty-six long and short booklets arm the head of the tenia. There may be as many as 800 segments. The mature ones become detached continuously, and are passed ^vith the feces, several, as a rule, occurring together, and not singly, as in the case of tsenia saginata. They are about 1 centimeter (|- in.) in length and from 6 to 8 millimeters (^--g- in.) in breadth, and about 1 meter (39.36 in.) from the head they are "approximately quad- rilateral" in shape. These proglottides are bisexual. The female mat- rix occupies the middle of each proglottis, and is provided with from eight to fourteen irregular, tree-like branches on each side. The male generative organs are small vesicles in the anterior portion of the seg- ment. The sexual opening is situated on one side, near the middle. The ovarian or uterine apparatus of a mature segment contains myriads of thick-shelled eggs, each one of which has an embryo with six booklets. Taenia Mediocanellata (Saginata). — The beef tape-worm is some- times called the "unarmed tape-worm," since the head possesses suck- ing disks, but no booklets. It is more common in this country and even in some of the European nations, as England. Longer than the tenia solium, being 4 to 6 meters (12 to 20 feet) in length, its segments are also thicker and larger, measuring from 16 to 18 mm. (|- in.) long, and from 8 to 10 mm. (^ in.) broad. The head of the worm as well as the ripe ovum is also slightly larger and proportionately thicker. The ova- rian branches are more numerous (eighteen to thirty in number) and di- vide more dichotomously than those of tenia solium. Proglottides are also found in the stools, where they sometimes exhibit a crawling motion that has caused them to be mistaken for individual parasites. Cysti- cercus saginata has never been observed in man. Bothriocephalus latus (^Fish tajje-ivoryn, Tcenia lata) occurs most com- monly in Eussia, Switzerland, Holland, and the German Baltic prov- inces. It is the longest cestode, measuring from 6 to 10 meters (20 to 30 feet). The head is club-shaped, unarmed, and has two lateral longi- tudinal grooves as suckers. The segments may be distinguished from those of the preceding varieties named by their marked breadth and shortness, also by the centrally situated, tortuous ovarian rosette, and the sexual orifice near the center of the abdominal surface of each pro- glottis. The ova are larger than those of the pork and beef tape-worms, though thinner-shelled and with a sort of lid at one end. They develop only in fresh water. From them is formed an embryo with vibrating cilia and six booklets. Pike and other fish swallow these embryos, which develop into cysticerci in the muscles, peritoneum, and solid vis- cera. The eating of measly fish, raw or partially cooked, thus favors the development of this tape-worm in the human intestine. Symptoms. — Contrary to what has been supposed in days gone by, there are no absolutely diagnostic symptoms of the presence of tape-worm that can be relied upon. Indeed, the existence of a tape-worm in the bowel may not be suspected even because of the total absence of indica- tive, subjective sensations. On the other hand, teniae may cause consid- erable local distress and impairment of the general health. Because of 1258 ANIMAL PARASITIC DISEASES. this fact a knowledge of the existence of tape-worm in certain neurotic subjects leads to an inordinate description of symptoms that exist mainly in the workings of a morbid imagination. Alimentary symptoms of tape-worm ma^^ be as follows : anorexia alter- nating with a voracious appetite, constipation alternating with diarrhea, colicky pains in the abdomen, indigestion, nausea, and vomiting, and sometimes salivation. Q-eneral symptoms of the teniae may be added, as lassitude, inappe- tence, mental uneasiness, w^orry and irritability, depression of spirits, some physical prostration, and even emaciation. Various reflex symptomSi such as pruritus of the nose and anus, vertigo, migrain, tinnitus aurium, palpitation, visual disturbances (even temporary amaurosis), dilatation of the pupils, choreic movements, and epileptiform convulsions have been attributed to these parasites. But, on careful inquiry, adequate causes for some of these symptoms may be found in other associated morbid conditions. Diagnosis. — This is always to be made by the discovery of tenia segments or ova in the underclothing or stools. The doubtful presence of suspected tape-worm may be cleared by the administration of a suitable purgative, which will usually suffice to bring away portions of the worm in the dejections. I would here add a special warning lest mucous casts or shreds or vegetable structures (as of onion) be mistaken for tape-worm. The diagnosis of the variety of the tape-worm may also be made by a careful scrutiny of the segments. Those of the tenia saginata are larger and fatter than, and their generative apparatus is unlike that, of tenia solium (vide supra). Hypochondriasis can be excluded by repeated examinations of the stools, especially after the exhibition of cathartics, and by the uniform failure to detect portions of tape-worm or tenia eggs. The prognosis is favorable. Indeed, teniae may exist at all ages and for years without any danger to the patient. Treatment. — Prophyla.i-is. — The way to avoid acquiring a tape- worm is to use none but well-cooked meats ; this applies to beef and pork in particular. The use of pure drinking-water is of no little im- portance also. The proglottides of the tenia should always be burned, and not thrown where they may be taken into the bodies of other ani- mals, as the cow or hog, and then be allowed to propagate. Govern- mental inspection of the meat-supply in abattoirs should be rigidly carried out in all parts of the country. Curative. — Before administering the chosen anthelmintic, the patient needs to undergo a "preparatory treatment." This has for its object the starvation of the parasite, so as to weaken, if possible, its hold upon the intestinal mucosa. This is specially necessary in the case of tenia solium, in which the cephalic booklets are obstinately and firmly fixed to the membrane, and since a cure cannot be said to have been effected unless the head be dislodged with the dejecta. For about two days prior to giving the remedy the patient should be restricted in diet to milk, light soups, a little white bread, and the like. Meanwhile, the bowels should be purged gently once or twice, after a simple enema, to clear away accumulated fecal masses that might prevent the easy discharge of the worm. TAPE-WORMS. 1259 In the evening preceding the day on which the drug is to be exhibited, a saline cathartic should be given to empty the bowel of fecal matter as completely as possible. The following morning no breakfast should be allowed, and before noon the selected anthelmintic should then be ad- ministered. Some authors assert that if the worm does not come away in a few hours, and an intense sense of pressure is felt in the abdomen, a brisk purge is indicated. To make assurance doubly sure, and if the patient be not too weak, it might be well to order a cathartic as routine practice, within a few hours at the latest. There are several very efficacious anthelmintic drugs to choose from. Prominent among them is male fern. Given to an adult in doses of ^ to 1 dram (2.0-4.0) of the ethereal extract, and followed in several hours by a calomel and a saline purge, it usually succeeds in bringing away the tenia. Another valuable remedy is pelletierin, the active principle of pomegranate, dose J to 2 grains (0.0324-0.1296) in capsules ; or, a de- coction of the pomegranate bark may be used, in combination with male fern, as in the Leipsic formula (Strlimpell) : ^. Granati radicis corticis, §iv-v (128.0-160.0) ; Aquae, Oij (1 liter). Mix and macerate for twenty-four hours, and boil until reduced to f §v (148.0). Add : Oleoresinse aspidii, 3j (4.0). Sig. To be taken in three or four doses, at short intervals. Pepo in emulsion or in a sugary paste (about two ounces — 64.0 — and deprived of the envelopes) is at once a useful and harmless remedy. Another effective vermifuge is kousso (Brayera anthelmintica). An infusion of half an ounce (16.0) of the flowers to one pint of water and mucilage of acacia is made, a wineglassful of which may be taken every half hour. The Germans recommend sometimes the agreeable, though more expensive, Rosenthal's " kousso tablets." Enough of these to make 15 grains (0.972) may be taken within one hour, with cafe noir or lemonade. Koussin (the active principle) in doses of 30 to 40 grains (1.94—2.592) has also been recommended, but should not be given to pregnant women, as abortion may be produced. Among other remedies of value as vermifuges may be mentioned kamala (1 to 3 drams — 4.0— 12.0 — of the powder and hairs, in wine or water), oil of turpentine (i to 2 ounces — 16,0-64.0 — in emulsion or milk), and thymol. The combined use of such drastics as croton oil renders the action of the anthelmintic drug more certain at times. Although the head of the tenia may not be detected in the stools along with the body of the Avorm (and such is usually the case), a cure usually follows nevertheless, since, on account of its smallness, it may easily escape notice, and also from the fact that the head often dies and thus loses its hold upon the membrane, being carried away with the feces. On the other hand, if after the lapse of several months from the removal of a tape-worm, segments again appear in the stools, it may be inferred that the head was not dislodged or that another worm has developed. In cases where the tenia seems to redevelop with remarkable frequency and 1260 ANIMAL PARASITIC DISEASES. obstinacy it may happen that the head and neck are well protected beneath one of the valvulse conniventes. After the removal of the tape-worm — a weakening procedure, as a rule — the condition calls for supportive measures. The diet should not be too heavy for a time, but nutritious and easily digestible. T^NIA NANA. This is the smallest tape-worm in man (v. Siebold). It varies from 8 to 20 mm. (|^-f in.) in length and from 0.5 to 0.7 mm. {-^^^ in.) in width. The head has four suckers, a rostellum, and booklets. The seg- ments are yellowish, short, and broad. It is believed by some observers that, occurring in children, as it commonly does, this parasite is the cause of epilejytifoi'iJi convulsions and enuresis nocturna. Thousands of ova may be found within a cubic centimeter of fecal matter. T.^NIA CUCUMERINA. (Elliptica ; Canina.) A small reddish tape-worm found frequently in the intestines of the dog. It is 10 to 40 cm. (4-16 in.) in length. The larvae or cysticerci develop in the louse or flea of the dog or cat. The parasite is more com- mon in children than in adults, owing to the intimate relation of the former with the last-named pet animals. T^NIA FLAVOPUNCTATA. [Taenia Diminuta : Tcenia Leptocephala.) Taenia diminuta is a very small cestode, 20 to 60 mm. (f- 2^ in.) in length, with a small club-shaped head and nearly a thousand segments. The cysticerci inhabit such insects as the asopia famialis (caterpillar and cocoon) ; the anisolahis annuli (belonging to the orthoptera) ; and the coleoptera axis spinosa and scaurus striatus. Man has been infected a number of times, probably by taking food containing these infested insects. Taenia Madagascariensis and Tcenia serrata are other forms rarely found in man. PARASITIC ARACHNIDA. Pentastoma Tenioides. — This parasite in its adult form is an inhabitant of the nasal fossre of the dog or horse, though it may also occur in man both in this and in the larval form. The ova are ejected during sneezing, and are then ingested by man. The larvae are found in the liver, lungs, and kidneys. Sarcoptes (Aearus Scahiei). — This insect produces the skin afifection known as " the itch," or scabies., an affection more common in Europe than in America, where it constitutes only about 4 or 5 per cent, of all OTHER PARASITIC INSECTS. 1261 cases of skin disease. It is most pi-evalent among tlie poor and the un- clean. The female is visible to the naked eye, and is about 0.5 mm. (J^ in.) in length; the male is about 0.25 mm. (y^ in.). Both are nearly as broad as they are long. The parasite penetrates the skin and lives in a burrow or cuniculus that it makes for itself. The female lives in the end of the burrow, which may contain a number of ova, and appears as a minute, brownish-black, dotted, sinuous line, situated chiefly in the cutaneous folds, where the skin is mostly delicate, as between the fingers. Secondary skin lesions, due to scratching, are common. Sulphur ointment, well rubbed in after hot bathing, is usually quite efiBcacious. Sarcoptes scabiei hominis is a variety of the preceding that infests other animals (cat, dog, cow, horse, wolf, goat, camel, etc.). Occasionally it may gain an entrance into man's skin, but dies simultaneously in the human host, although many invasions may occur. Leptus Autumnalis (Harvest Bug). — The most common of several va- rieties is a mite of a reddish color, having six legs armed with claws and sharp mandibles. It arises among low bushes and thus appears about the ankles and legs. It partially penetrates the skin, boring only far enough with its short, thick head to procure nourishment. Artificial dermatitis may be produced by the irritation of scratching. Mercury, sulphur, and naphthol ointments suffice to destroy the parasite. Demodex Foliculorum [Comedo Mite). — This minute parasite may be expressed from swollen sebaceous follicles of the nose, cheek, and other parts of the face. It has a worm-like body with very short legs, and is only about 0.2 to 0.4 mm. {-^ in.) in length. It is not known to produce acne, as was formerly supposed. OTHER PARASITIC INSECTS. PEDICULOSIS. {PhtJiiriasis.) Lice or pediculi live on and attack the skin. Three forms are found on man : pediculus capitis, pediculus corporis, and pedieidus pubis. The pediculus capitis is whitish or grayish in color, about 1 mm. (^ in.) long (male), and has six legs under the front part of the body. The oviparous female is nearly twice as long as the male, and lays from fifty to eighty eggs on the hairs within a week. These ova, or "nits," ma- ture in from three to eight days. Itching is the most prominent symp- tom, and an eczematous eruption above and behind the ears and in the neck is often associated. "Plica polonica " was a phrase once used to designate the matted condition of the hair in extremely dirty, crusty, and long-neglected cases of head-lice. Pediculus Vestimentorum {Corporis). — This louse inhabits more often the clothing than the body itself. It is larger than the head louse, and, like the latter, moves slowly. The nits are found with difficulty on the 1262 ANIMAL PARASITIC DISEASES. fibers of the underclothing. It sucks blood through a proboscis inserted into the sweat pores, and after withdrawing leaves a minute hemorrhagic speck. Irritation of the skin is produced, and in old cases, as in filthy tramps (the great unwashed class), the skin becomes scaly and quite pig- mented (vagabond's disease). The efforts at scratching are almost frantic, and after a cure is effected parallel white lines, the remains of scratch- marks, followed by atrophic changes, may be visible, as in a case that I reported.^ Pediculus or Phthiriasis Pubis {Crab-louse). — This parasite is not limited to the pubis, but attacks also the hairy region in the axilla, on the chest, and may even reach the beard and eyebrows. It clings firmly to one or two hairs close to the skin. Its six legs with strong claws are placed closely together at the anterior part of the ovoid body. Treatment. — The hair should be cut short where the head-lice and nits are abundant. Saturating the hair and scalp with kerosene oil for twenty-four hours usually kills the parasites. Body-lice may be destroyed by scalding the underclothing and hot-ironing carefully about the seams. A hot soap-and-water bath is sufficient for the body, and sedative and antiseptic ointments may be useful adjuvants. Mercurial and beta- naphthol unguents usually suffice in treating for pediculus pubis. Prof. J. V. Shoemaker ^ affirms that naphthol is a remedy that seems to meet the indications presented by the three forms of the disease ; he prepares it as follows : I^. Beta-naphtol, 3) ("l-O); Cologne water, f§iv-vi (120.0-178.0).— M. Cimex Lectularius or Bed-bug. — This too well-known parasite is flat, brownish-red in color, and from 2 to 5 mm. (y^"-^ in.) in length. It in- fests beds and public vehicles, emitting a disagreeable odor. It is a blood-sucker, and causes considerable itching, local irritation, and urti- caria even in some persons, while others are unmindful of their attacks. Sulphur fumigation and mercuric chlorid applications to the harboring places of the bed-bugs are effectual destructive agents. Saturated sodium bicarbonate solution will relieve the burnino; and itching. Pulex Irritans [Common Flea). — This "ubiquitous" parasite is from 2 to 4 mm. (yj -^ in.) in length, black or (when filled with blood) brown- ish-red in color, having six legs, the hind ones of which are relatively very large and powerful, enabling it to jump many times its own height. A flea's bite causes a sharp sting, and leaves a slightly raised red spot. Treatment is the same as for the preceding insect. Pulex Penetrans {''■Jigger''). — This parasite, also called "sand-flea," is indigenous to the West Indies, South America, and the Southern States. The impregnated female penetrates the skin, and especially that of the feet, for purposes of ovulation. iVs the distention with the eggs occurs, swelling, pain, and even ulceration may appear. The sand-flea is a small, egg-shaped insect, about half the size of an ordinary flea, brownish in color, and exceedingly resistant to crushing force. Prophy- laxis in regard to foot-wear is necessary. Essential and antiseptic oils may also be put on the feet or stockings. ^ International Clinics, vol. iii. third series, p. 76. ^ A Practiced Treatise on Diseases of the S/cin, p. 849. OTHER PARASITIC INSECTS. 1263 Ixodes {Wood-tick). — There are several varieties of tick- or ■wood- louse that may attack the human skin, among which ixodes alhipictus is supposed to be the most common. Ixodes rieinus and ixodes bovis are found on horses and cattle. They are blood-suckers, adhering to the skin very firmly, and wheals may be produced by them. A drop of tur- pentine, or of some such essential oil as anise or rosemary, will cause them to loosen their hold. Dermanyssus Avium at Gallinae. — These bird- and fowl-insects are small and grayish- white in color, and may attack the human skin and cause eczematous eruptions, owing to the scratching induced by the irritation. Culicidae [Mosquitoes and Grnats). — The blood-sucking mosquito [culex auxifer\ so well known, may also transfer to human beings the filaria sanguinis hominis and perhaps the plasmodium malarige. The gnat {culex jpifiens) is very troublesome during certain seasons, particularly along water-courses and in wooded districts. Its bite is quick, sharp, and stinging. The Idrudo (leech) is a parasite that sometimes attaches itself to bathers. In the tropics it has been known to cause severe bites and inflammation. The bites and stings of bees, wasps, spiders, and ants have been known to cause considerable inflammation, edema, and blood-poisoning. CEstridae {Bot-jiies). — These may become parasitic in man in the larval form. Species of the hydoxerma and dermatohia, that infest the skin of the horse, ox, goat, etc., have also been observed among the Central and South American Indians. They burrow beneath the skin of the abdomen, scrotum, and other regions, Muscidae {Common Flies). — Common flies affect the skin of man by depositing eggs in wounds. The ova hatch within twenty-four hours sometimes, and the dipterous larvse may swarm to make the so-called "living" wound or sore {myiasis vulnerum). The larv?e or maggots do not penetrate the tissues, however. The principal flies that infest wounds are the flesh-fly {sareojjhila car7iaria), the blow-fly {calliphora vomitoria)., the screw-worm fly {compsomyia macellaria)^ and the ordinary house-fly {musca domestica). Internal myiasis may also be caused by swallowing the ova of these flies. The larvae may thus be vomited or defecated. Epidemic urticaria is often caused by the migration of the caterpillar {cuetJiocampa). Among other parasites that attack man and inhabit par- ticular regions are the following : The simulium reptans, or creeping gnat of Sweden ; the seroot-jiy {zimh) of Abyssinia ; the ixodes carapato, a virulent bed-bug in Brazil; the hcematopota pluvialis (Clegg) of the West Highlands. INDEX Abscess, atheromatous, 678 hepatic, 878 of brain, 1113 of liver, 878 complications and sequelae, 880 diagnosis, 881 etiology, 878 pathology, 878 physical signs, 880 prognosis and treatment, 883 symptoms, 879 of lungs, 534 etiology, 534 pathology, 534 prognosis, 233 symptoms and diagnosis, 433 treatment, 535 of spinal cord, 1079 perinephritic, 1000 retropharyngeal, 724 Acarus scabiei, 1260 Acetonuria, 952 Achalme's bacillus, 203 Acidity of gastric contents, 736 Acid, lactic, in gastric contents, 737 Acromegaly, 1179 Acroparesthesia, 1192 Actinomycosis, 350 bacteriology, 350 course and prognosis, 352 cutaneous, 351 intestinal, 351 method of detecting actinomyces, 352 modes of infection, 351 oral, 351 pulmonary, 351 Acute articular rheumatism, 202 ascending paralysis, 1065 cause, 1066 definition, 1065 diagnosis, 1066 etiology, 1066 pathology, 1065 prognosis and treatment, 1066 reflexes in, 1066 symptoms, 1066 Bright's disease, 974 catarrhal gastritis, 749 laryngitis, 473 chorea, 1144 cystitis, 1006 delirium, 1135 fatty degeneration of the new-born, 418 febrile jaundice, 367. (See Weil's Dis- ease.) gastro-intestinal catarrh, 800 hemorrhagic encephalitis, 1115 myelitis, 1073 nephritis, 974 pancreatitis, 905 80 Acute perihepatitis, 875 phthisis, 282 poliencephalitis, 1115 rhinitis, 467 spinal meningitis, 1068 suppurative gastritis, 753 yellow atrophy, 883 Addisou's disease, 451 blood in, 453 definition, 451 diagnosis, 454 etiology, 452 extract of suprarenal capsules in treatment, 455 pathogenesis, 452 pathology, 451 prognosis, 454 skin in, 453 symptoms, 454 treatment, 454 urine in, 454 Adenia, 444. (See Pseudo-leukemia.) Afebrile typhoid, 32 Ainhum, 1190 Albumin, tests for, 943 AlbuminSiria, 942 causes, 942 functional, 943 senile, 940 Alcoholism, 1208 chronic, 1210 Alimentary or lipogenic glycosuria, 382 tract, tuberculosis of, 304 AUorrhythmia, 669 Amblyopia, toxic, 1039 Amoeba coli. (See Dysentery.) dysenterise, 100 Amyloid degeneration of heart, 659 kidney, definition, 966 diagnosis, 968 etiology, 967 pathology, 966 prognosis and treatment, 968 symptoms, 967 urine in, 967 Anemia, 419 blood in simple, 420 definition, 419 diagnosis, 417 etiology, 416 idiopathic, 426 infantum pseudo-leuksemica, 449 pathology, 449 symptoms, 449 of simple, 419 primary or essential, 420 prognosis, 417 progressive pernicious, 426 secondary, 433 simple or benign, 420 1265 1266 INDEX. Anemia, splenic, 450 symptoms, 416 treatment, 417 Aneurysm, 682 arterio-venous, 694 axial, 682 cardiac, 660 congenital, 694 definition, 682 differential diagnosis, 689 dissecting, 682 false, 682 fusiform, 682 miliary, 682 of abdominal aorta, 692 of celiac axis, 693 of hepatic artery, 693 of pulmonary artery, 693 of splenic artery, 693 of the heart, 660 of thoracic aorta, 683 pathology and etiology, 682 peripheral, 682 arteries in, 687 physical signs, 686 prognosis, 690 pulse in, 687 sacculated, 682 sphygmographic tracing in, 687 symptoms, 683 tracheal tugging in, 688 treatment, 690 varieties, 682 Angina Ludov^ici, 709 maligna, 179 pectoris, 671 diagnosis from pseudo-angina, 672 etiology, 672 pathology, 672 prognosis and treatment, 673 symptoms, 672 vasomotoria, 672 Angioneurotic edema, 485 Anhydremia, 419. (See Anemia.) Animal parasitic diseases, 1237 Ankylostomum duodeuale, 1242 Anorexia, 787 Anterior poliomyelitis, definition, 1077 etiology, 1077 prognosis and treatment, 1078 reflexes in, 1078 symptoms, 1078 Anthracosis, 535. (See Pneumonokoniosis.) Anthrax, 352 bacillus, 352 diagnosis, 354 edema, 354 external, 353 immunity in, 353 internal, 354 manner of infection, 353 pathology, 352 prognosis, 355 treatment, 355 Antipneumococcic serum, 156 Antistreptococcic serum, 177 Antitetanic serum, 362 Aortic incompetency or insufficiency, 599 regurgitation, 599 blood-count in, 602 Corrigan or water-hammer pulse in, 603 murmur in, 604 Aortic regurgitation, pulse-tracing in, 604 Quincke's capillary pulse in, 603 stenosis, 605 murmur in, 607 Aphasia, 1120 motor, 1120 sensory, 1122 Aphthongia, 1061 Aphthous fever, 372. (See Foot-and-mouth Disease.) stomatitis, 696 definition, 696 diagnosis, 697 prognosis and treatment, 697 symptoms, 697 Apoplexy, cerebral, 1115 ingravescent, 1117 serous, 1117 Appendicitis, 812 anatomical aspect, 813 bacteriology, 817 chronic, 824 clinical history, 817 consequences of perforation, 815 definition, 812 diagnosis, 821 from acute intestinal obstruction, 823 from acute tubercular peritonitis, 823 from extra-uterine pregnancy, 823 from indigestion, 822 from perinephritic abscess, 822 from renal colic, 822 from typhoid fever, 823 local measures in treatment, 827 pathology of catarrhal, 813 of interstitial, 814 of ulcerative, 814 phj'sical signs, 820 recurrent or relapsing, 825 surgical aspect in treatment of, 826 temperature-chart, 821 treatment, 827 Apraxia, 1121 Arsenicism, 1219 Arterial sclerosis, 678 clinical history, 680 definition, 678 diagnosis, 681 etiology, 679 pathology, 678 prognosis and treatment, 682 Arteries, aneurysm of, 682 atheroma of, 678. (See Arterial Sclerosis.) diseases of, 677 Arthritic muscular atrophy, 1203 Arthritis deformans, 387 acute form, 391 bacteriology of, 389 causes, 388 diagnosis, 391 pathology, 388 symptoms of chronic form, 389 treatment, 391 varieties, 390 gonorrheal, 213 Arthropathies in locomotor ataxia, 1084 Ascaris alata, 1241 lumbricoides, 1238 Ascites, 926 adiposus, 926 character of fluid in, 929 INDEX. 1267 Ascites, definition, 926 diagnosis from chronic peritonitis, 929 from ovarian cyst, 928 etiology, 926 fluid in, 926 pathology, 926 physical signs, 927 prognosis, 929 symptoms, 929 treatment, 929 Asiatic cholera, 109 Astasia-abasia, 1181 Asthma, 493 bronchial, 493 cardiac, 657 clinical history, 494 course and prognosis, 496 Curschmann's spirals in, 495 definition, 493 diagnosis, 496 duration of attack, 495 etiology, 493 hay-, 471 pathology, 493 reflex causes of bronchial, 493 renal, 964 treatment, 496 Ataxic paraplegia, 1089 Atelectasis, pulmonary, 521 Atheroma, 778 Athetosis, 1150 Atrophy, acute yellow, 883 definition, 883 diagnosis, 885 etiology, 883 liver in, 883 pathology, 883 physical signs, 884 prognosis, 885 symptoms and physical signs, 884 treatment, 885 urine in, 884 Autumnal catarrh, 471 Bacillus, Achalme's, 203 comma. 111 icteroides, 120 of anthrax, 352 of diphtheria, 181 diagnostic value of, 187 manner of staining, 181 of Eberth, 22 of glanders, 348 of hydrophobia, 356 of influenza, 158 of leprosy, 346 of syphilis, 327 of tetanus, 359 of the plague, 169 of tuberculosis, 263 distribution of, 264 of typhoid fever, 22 of typhus, 68 of yellow fever, 120 pestis bubonicse, 169 tussis convulsivse, 253 Bacterium coli commune. 111 of cerebro-spinal meningitis, 125 Barrel-shaped chest of emphysema, 530 Basedow's disease, 458. (See Exophthalmic Goiter.) Baths in scarlet fever, 243 Baths in typhoid fever, 55 Beaded ribs in rickets, 405 Bed-bug, 1262 Bed-sores in typhoid fever, 66 Beef tape-worm, 1256 Bell's palsy, 1050 Beri-beri, 1031 (See Endemic Neuritis.) Bernhardt' s disturbance of sensation, 1193 Bile-ducts, carcinoma of, 861 stenosis, 862 Black death, 169. -(See Bubonic Plague.) vomit, 121 Bladder, diseases of, 1006 hemorrhage of, 1011 neoplasms of, 1011 neuroses of, 1012 Bleeders' disease, 415. (See Hemophilia.) Blood, diseases of, 416 in ansemia infantum pseudo-leuksemica, 449 in chlorosis, 424 in leukemia, 440 in progressive pernicious anemia, 430 in pseudo-leukemia, 447 in purpura, 414 in scurvy, 408 in secondary anemia, 433 in simple anemia, 419 in typhoid, 22, 40 Boiled-ham appearance, 904 Bothriocephalus latus, 1257 Brachycardia, 667 associated with neurosis, 668 diagnosis, 671 etiology, 670 pathology and etiology, 667 physical signs, 671 prognosis, 671 symptoms, 670 treatment, 671 Brain, abscess of, 1113 and meninges, diseases of, 1104 anemia of, 1108 disturbances of circulation of, 1107 edema of, 1108 emboli and thrombosis, 1109 hyperemia of, 1107 iniiammation of, 1113 sclerosis of, 1130 softening of, 1109-1111 tuberculosis of, 315 vascular degeneration of, 1112 Break-bone fever, 167. (See Dengue. ) Breast-pang, 671 Bronchial asthma, 493 diagnosis, 493 pathology and etiology, 492 physical signs, 492 prognosis and treatment, 493 symptoms, 492 stenosis, 493 Bronchiectasis, 489 diagnosis from tuberculosis, 491 etiology, 490 histology, 490 physical signs, 491 prognosis, 491 symptoms, 490 treatment, 491 Bronchitis, acute, 481 capillary, 514 catarrhal, 480 physical signs, 484 1268 INDEX. Bronchitis, chronic, 485 clinical varieties, 486 diagnosis from pulmonary tuberculosis, 486 from pneumonia, 483 fibrinous, 498 plastic, 498 prognosis, 498 treatment, 498 Bronchocele, 456. (See Goiter.) Broncho-pneumonia, 514 atelectasis in, 514 blood in, 515 cerebral type, 517 definition, 514 diagnosis from lobar pneumonia, 518 duration, 517 etiology, 515 general, 518 morbid anatomy, 515 pathology, 514 physical signs, 516 prognosis, 519 sputa in, 516 treatment, 520 tubercular, 518 Bronchorrhea, 486 Brown atrophy of heart, 659 Brown-Sequard's spinal paralysis, 1080 Bruit de diable, 423 Bubonic plague, 169 Buhl's disease, 418. (See Acute Fatty Degen- eration of the New-bor7i.) Bulbar paralysis, 1094 Cachexia in cancer of stomach, 774 malarial, 91 pachydermique, 462. (See Myxedema.) saturnine, 1217 syphilitic, 332 Caisson disease, 1182 Calculi, biliary, 853. (See Cholelithiasis.) pancreatic, 913 renal, 968. (See Nephrolithiasis.) Camp-fever, 67. (See Typhtts Fever.) Capillary bronchitis, 514. (See Broncho- pneumonia.) Carcinoma of esojihagus, 726 of intestines, 835 of liver, 895 of lungs, 538 of pancreas, 910 of stomach, 771 Cardiac aneurysm, 660 dilatation, 645 diseases, 585 hypertrophy, 638 murmurs, hemic, in acute chorea, 1144 in chlorosis, 423 in pernicious anemia, 429 in aortic regurgitation, 599 in aortic stenosis, 605 in mitral regurgitation, 607 in mitral stenosis, 611 in pulmonary regurgitation, 621 in pulmonary stenosis, 622 in tricuspid regurgitation, 617 in tricuspid stenosis, 620 thrombosis, 636 Cardialgia, 785 Catarrhal bronchitis, 480 laryngitis, acute, 473 chronic, 475 Celiac disease, 804 Cephalodynia, 364. (See Muscular Eheuma' tism. ) Cerebral hemorrhage, 1115 palsies of childhood, 1133 Cerebro-spinal fever, or meningitis, 124 meningitis, abortive form, 129 complications, 129 cutaneous symptoms, 128 differential diagnosis, 130 duration and prognosis, 131 fulminaut or apoplectic form, 130 history, 124 immunity in, 131 incubation, 126 intermittent form, 129 local remedies in, 1.32 lumbar puncture in, 130 micro-organism of, 125 mild or rudimentary form, 129 modes of conveyance, 126 mortality, 131 ' nervous symptoms, 127 pathology, 124 predisposing causes, 126 sequelffi, 131 symptoms, 126 treatment, 131 typhoid form, 129 Cestodes, 1251 Chalicosis, 535. (See Pneumonokonidsis.) Charcot's disease, 1095 Chicken-pox, 231. (See ]'aricella.) Chills and fever, 79. (See Malaria.) Chloroma, 451 Chlorosis, 421 blood in, 424 complexion in, 422 heart-murmurs in, 423 malaise in, 422 pica in, 422 rubra, 422 Choked disk, 1040 Cholelithiasis, 853 acute obstruction in, 854 chronic obstruction in, 856 composition and appearance of biliary calculi, 853 definition, 853 differential diagnosis, 855 etiology, 853 prognosis, 855 rupture of the duct from, 855 symptoms, 854 Cholera Asiatica, 109 algid stage, 114 bacillus of, 111 causes, 111 clinical types, 115 complications, 115 contagiousness, 112 diet in, 116 differential diagnosis, 115 enteroclysis in treatment, 118 epidemic, 109 mortality of, 115 history, 109 hypodermoclysis in treatment, 117 immunity in, 113 incubation period, 113 intravenous injections in treatment, 118 lavage in treatment, 117 INDEX. 1269 Cholera Asiatica, modes of infection, 112 preventive inoculations in, 116 prognosis, 115 prophylaxis in, 116 serous diarrhea in, 113 sicca, 113 stage of reaction, 114 symptoms, 113 . temperature in, 114 treatment of attack, 117 urine in, 114 visceral lesions, 109 infantum, 800, 802 morbus, 806 nostras, 806 Choluria, 948 Chorea, acute, 1144 chronic progressive, 1147 electrica, 1149 fibrillary, 1150 major, 1154 rhythmic, 1148 Choreiform disorders, 1148 Chronic arsenical poisoning, 1220 cystitis, 1009 hydrocephalus, 1128 interstitial nephritis, 985 laryngitis, 475 lead-poisoning, 1217 mercurial poisoning, 1221 myelitis, 1075 parenchymatous nephritis, 981 pericarditis, 584 progressive chorea, 1147 tuberculosis, 286 Chyluria, 947 Cimex lectularius, or bed-bug, 1262 Cirrhosis, atrophic, 888, 889 biliary, 888, 891 Glissonian, 889 hypertrophic, 888, 889, 891 Laennec's, 888 of liver, 887 of lung, 512 Colic, renal, 968 Colitis, 796 simple ulcerative, 811 Collapse of the lungs, 521. (See Pulmonary Atelectasis.) Colon, dilatation of, 842 Comma bacillus. 111. (See Cholera.) Congestion of lungs, 500 Constipation, 838-846 hygienic treatment, 840 Convulsions, infantile, 1159 Corradi's method of treating aneurysm, 690 Cow-pox, 229. (See Vaccinia.) Cranial nerves, diseases of, 1037 Croup, diphtheritic, 179 membranous, 185. (See Laryyigeal Diph- theria.) Croupous or fibrinous pneumonia, 132. (See Lobar Pneumonia.) Culicidiffi, 1263 Cystic kidnev, 1002 Cystitis, 1006 catarrhal, 1006 chronic, 1009 mycotic, 1008 septic, 1006 toxic, 1007 traumatic, 1007 Degenerations of the heart, 656 amyloid, 659 brown atrophy, 659 calcareous, 6.59 fatty, 656 fatty overgrowth, 658 hyaline, 6.59 Delirium, acute, 1135 tremens, 1211 Dementia, alcoholic, 1211 Demodex folliculorum, 1261 Dengue, causes, 167 complications, 168 diflferential diagnosis from yellow fever, 168 symptoms, 167 treatment, 168 Dermanyssus avium et gallinse, 1263 Diabetes insipidus, 385 treatment, 887 mellitus, 374 acetone in, 378 acute, 377 blood in, 376 blood-test in, 382 causes, 377 chronic, 377 coma in, 379 cutaneous symptoms, 379 diagnosis, 382 diet in, 382 hygienic treatment, 384 infantile, 381 medicinal treatment, 384 microbic theory of, 375 mortality, 382 nervous symptoms, 379 pancreatic, 381 pathogenesis, 374 pathology, 375 Pavy's view of, 375 prognosis, 382 sexual symptoms, 381 special etiology, 377 sugar in, 378 symptoms, 378 test for acetones, 378 treatment, 382 uric acid and urea in, 378 urine in, 378 Diabetic coma, 379 Diarrhoea alba, 804 nervous, 845 of children, 800 Dilatation of heart, 645 of stomach, 744 Diphtheria, 179 albuminuria in, 186 antitoxin treatment, 192 bacillus, 181 blood in, 180 causes of death in, 189 complications, 186 diagnosis, 187 external applications in, 192 hygienic treatment, 190 immunity in, 183 incubation of, 183 intubation in, 192 laryngeal, 185 local treatment, 191 malignant, 184 1270 INDEX. Diphtheria, modes of infection, 182 mortality, 188 nasal, 185 paralysis in, 186 pathology, 179 of pseudo-membrane, 179 pharyngeal, 183 predisposing factors, 183 prognosis, 188 prophylaxis against, 189 pseudo-diphtheria, 179 sequelae, 186 serum-therapy in, 192 skin-rashes in, 186 tonsillar, 183 toxins, 182 tracheotomy in, 192 treatment, 189 use of cultures in diagnosis of, 187 Diphtheritic dysentery, 103 Disease, Addison's, 451 caisson, 1182 celiac, 804 Charcot's, 1095 of the coronary arteries, 655 Diseases, combined forms of cardiac, 622 of arteries, 677 of auditory nerve, 1051 of bladder, 1006 of bi-ain and its meninges, 1104 of bronchial plexus, 1062 of cervical plexus, 1062 of circulatory system, 575 of cranial nerves, 1037 of dura mater, 1104 of esophagus, 724 of fifth nerve, 1047 of glosso-pharyngeal nerve, 1054 of hypoglossal nerve, 1060 of intestines, 788 methods of diagnosis, 788 of kidneys, 933 of liver, 847 of lumbar and sacral plexuses, 1064 of mediastinum, 571 of meninges, 1067 of motor nerves of eyeball, 1043 of muscles, 1196 of nervous system, 1017 of pancreas, 905 of peripheral nerves, 1028 of peritoneum, 914 of pharynx, 720 of pia mater, 1105 of pneumogastric nerve, 1054 of portal vein, 867 of salivary glands, 709 of seventh nerve, 1048 of spinal accessory nerve, 1058 of spinal nerves, 1062 of spleen, 901 of stomach, 735 methods of diagnosis, 735 of the blood, 419 of the bronchi, 480 of the ductless glands, 451 of the heart, 588 of the larynx, 473 of the lungs, 501 of the nose, 467 of the pleura, 541 of the respiratory sj'stem, 467 of the suprarenal capsules, 451 Diseases of the thyroid gland, 455 of the tonsils, 711 of the urinary system, 933 of unknown pathology, 1137 Dislocated kidney, 933 Distomiasis, 1238 Dorsodynia, 364. (See Muscular Rheumatism.) Dracontiasis, 1249 Ductless glands, diseases of, 418 Duodenal ulcer, 808 Duodenitis, 795 Dura mater, diseases of, 1104 Dysentery, 97 amoeba coli in, 100 amebic or tropical form, 100 catarrhal form, 99 causes, 98 chronic catarrhal, 107 intestinal irrigation in, 108 complications, 102 dietetic treatment, 108 diphtheritic, prophylactic treatment of, 105 sequelse, 105 hepatic abscess in, 101 history of, 98 intestinal ulceration in, 101 Dyspepsia, atonic, 785 chronic catarrhal, 754 nervous, 779 Dystrophia musculorum progressiva, 1201 Ear, care of, in scarlet fever, 244 complications of, in scarlet fever, 239 condition of, in svphilis, 332 Eberth's bacillus, 22 ' Ebstein's method in obesity, 1228 Eburnation of cartilages, 388 Echirococcus disease, 1251 endogenous, 1251 exogenous, 1251 fluid, 1252 multilocular, 1251 Echinorhyncus gigas, 1250 moniliformis, 1250 Echokinesis, 1153 Echolalia, 1153 Eclampsia infantilis, 1159 Ectopia cordis, 675 Edema, angio-neurotic, 1184 of brain, 1108 of larynx, 480 of lungs, 502 Ehrlich's reaction in typhoid fever, 43 Elastic tissue in tubercular sputum, 292 Electrical reaction in facial palsy, 1050 Electrolysis in aneurysm, 690 Electrothermogen, 212 Elephantiasis, 1248 arabum, 1248 Emaciation in acute tuberculosis, 276 in anorexia nervosa, 1170 in carcinoma of esophagus, 727 of stomach, 774 in chronic tuberculosis, 299 Embolism in aneurysm, 683 in chorea, 1144 in typhoid fever, 39 of cerebral arteries, diagnosis of, 1119 Embrocardia. 670 Emphysema, 524 compensating, 525 complications, 530 INDEX. 1271 Emphysema, cough in, 527 diagnosis from pneumothorax, 529 dyspnea in, 527 hypertrophic, 525 cyanosis in, 527 etiology, 526 hereditary character of, 527 pathology, 526 physical signs, 528 • interlobular, 524 natiire of, 525 senile, 531 vesicular, 524 Emprosthotonos in tetanus, 360 Empyema, 558 diagnosis from pleurisy with effusion, 560 differential diagnosis, 560 method of James in treatment, 560 micro-organisms in, 558 necessitatis, 560, 689 of pericardium, 583. (See Purulent Peri- carditis.) paracentesis in, 561 peptonuria in, 559 pulsating, 560 rupture of air-cells in, 559 Encephalitis, acute hemorrhagic, 1115 chronic diffuse. 1114 focal, 1113 optic neuritis in, 1114 Encephalopathy, lead, 1217 Endocarditis, 588 cerebral variety of ulcerative, 594 chronic interstitial, 596 diagnosis of ulcerative, from typhoid fever, 495 etiology of simple acute, 589 of ulcerative or malignant, 593 malignant or infectious form, 592 micro-organisms in etiology of, 590 recurrent malignant, 594 simple acute, 488 syphilitic, 339 tuberculous, 289 ulcerative, 592 mural, 592 valvular, 592 varieties, 588 Enteralgia, 843 Enteric fever, 17. fSee Typhoid Fever.) Enteritis, catarrhal, 792 croupous or diphtheritic, 805 membranous, 842 phlegmonous, 805 ulcerative, 811 Enteroclysis, 117 Enteroliths as a cause of appendicitis, 816 Enteroptosis, 791 Enterospasm, 845 Enuresis, 1014 Environment in phthisis, 318 in tuberculosis, 266 Ephemeral fever, 369. (See Febricida.) Epidemic catarrhal fever, 158. (See Injlu- ensa.) hemoglobinuria, 418 stomatitis, 372. (See Foot-and-mouth Dis- ease.) Epilepsy, 1137 diagnosis from hvsteria, 1141 etiology, 1138 grand or haut mal, 1139 Epilepsy in plumbism, 1219 Jacksonian, 1140 in brain-tumor, 1125 nocturnal, 1140 paroxysmal period, 1140 pathology, 1137 petit mal, 1139 post-epileptic phenomena, 1140 prognosis, 1141 symptoms, 1139 treatment, 1141 Epistaxis, 472 in hemophilia, 416 in scorbutus, 409 in typhoid fever, 27 Erysipelas, 172 bacteriology, 172 causes, 172 complications and varieties, 175 diagnosis from acute eczema, 176 from chronic erythematous eczema, 176 from eczema nodosum, 176 from erythema, 176 from urticaria, 176 duration, 176 facial, 174 gangrsenosum, 174 incubation, 173 local treatment, 178 method of conveyance, 173 migrans, 174 mortality, 176 ■'nephro-," 175 occurring in typhoid fever, 44 pathology, 172 phlegmonous, 175 '' pneumo-," 175 prognosis, 176 pustulosum, 174 relapsing, 175 sequelse, 175 symptoms, 173 treatment, 176 vesiculosum, 174 Erythromelalgia, 1191 Esophagismus, 729 Esophagitis, acute, 724 chronic, 726 Esophagus, carcinoma of, 726 dilatation of, 730 diseases of, 724 diverticulum of, 731 neuroses of, 729 paralysis of. 729 rupture of, 728 stricture of, 7.32 ulcer of, 726 Estridag, 1263 Ether-pneumonia, 149 treatment, 157 Exophthalmic goiter, 458 acute, 459 cardiac, physical signs in, 459 chronic, 459 etiology, 459 muscular tremors in, 460 treatment, 461 Experimental typhoid, 23 Eyes in cerebro-spinal meningitis, 128 in hemiplegia, 1117 in intracranial growths, 1125, 1126 in syphilis, 332 1272 INDEX. Eyes, oculo-motor paralysis of, in brain- tumor, 1126 Face in apoplexy, 1116 in Bell's palsy, 1050 in bulbo-paralysis, 1095 in disease of seventh nerve, 1048 in epilepsy, 1139 in hemiplegia, 1117 in progressive muscular dystrophy, 1202 in syphilis, 332 in torticollis, 1059 progressive hemiatrophy of, 1187 Facial expression in chronic tonsillitis, 718 in paralysis agitans, 1155 nerve, 1048 spasm or paralysis, 1047 Facies in cholera. 114 in jaundice, 850 leontina in leprosy, 345 Factitious purpura, 414 Fallopian tubes, tuberculosis of, 314 False croup, 477, (See Spasmodic Laryn- gitis.) Farcy, 348. (See Glanders.) Fat-embolism iu diabetes, 376 Fat-necrosis, 915 Fatty degeneration in acute vellow atvophv, 883 in cirrhosis of liver, 888 in idiopathic anemia, 427 of heart, 652 of kidneys in diabetes. 376 in phosphorus-poisoning, 886 of liver, 874 in phosphorus-poisoning, 886 infiltration of liver, 873 kidney, 981 overgrowths of heart, differential diag- nosis, 654 Febricula, 369 Febris flava, 119. (See Yellow Fever.) recurrens. 73. (See Eelapsing Fever.) Fecal concretions as a cause of appendicitis, 816 impaction, 829 vomiting, 831 Fehling's test for sugar, 950 Fermentation-test for sugar, 951 Fetal heart-rhythm. 670 Fetus, endocarditis in, 599 Fever and ague, 79. (See Malaria.) cerebro-spinal, 124 dengue, 167 gastric. 750 glandular, 372 hysteric, 1171 in abscess of liver, 879 in acute pneumonic phthisis, 283 in appendicitis, 817 iu cholera, 115 in chronic obstruction of bile-passages, 856 in chronic tuberculosis, 290 in general miliary tuberculosis, 276 in Hodgkin's disease, 447 in influenza. 158 in intermittent fever. 86 in meningitic tuberculosis, 279 in pneumonia, 516 in pyelitis, 995 in pyemia. 200 in pylephlebitis, suppurative, 869 Fever in relapsing fever, 75 in remittent fever, 90 in scarlet fever, 236 in secondary syjihilis, 329 in septicemia. 197 in small-pox, 223 iu sun-stroke, 1232 in tuberculosis of lymph-glands, 274 in typhoid fever. 29 jail-, 67. (See Typhus Fever.) lung. 132 malarial, 79 Malta, 368 Mediterranean, 368 miliary, 371 mountain-, 67 pernicious malarial, 89 relapsing, 73 ship-, 67. (See Typhus Fever.) splenic, 352 spotted, 124 typhoid, 17 typhus, 67 yellow, 119 Fibrinous bronchitis, 498 . pleurisy, 544 Fibroid induration of lung, 512 of pancreas in diabetes, 375 Fifth nerve, diseases of, 1047 paralysis of, 1047 trophic changes in paralysis of, 1047 Filaria bronchialis, 1250 hominis oris, 1250 immitis, 1250 labial is oris, 1250 leutis, 1250 loa, 1250 sanguinis hominis, 1248 distribution of, 1248 tracheal is. 1250 Filariasis. 1248 Fire, St. Anthony's, 172. (See Erysipelas.) Flatulence in hysteria. 1170 Flint's murmur in heart disease, 605 Floating kidney, 933 Florid phthisis, 282. (See Acute Phthisis.) Fluke, blood-, 1238 bronchial, 1238 liver-, 1237 varieties of, 1237 Folie brightique, 964 Follicular stomatitis, 696 Food-infection and ptomain-poisoning, 1223 Foot-and-mouth disease. 372 Foot-drop. 1029 Foreign bodies in intestinal obstruction, 830 Fourth nerve. 1045 paralvsis of, 1045 Fremitus, hydatid, 1253 tactile, iu chronic tuberculosis, 296 in pneumonia, 518 French measles, 248. (See Rubella.) Friction-rub in acute peritonitis, 917 Friction-sound in pleurisy, 543 iu sero-fibrinous pericarditis, 580 Friedreich's disease, 1086 sign iu adherent pericardium, 585 Frontal convolution, speech-center in, 1025 Gait, ataxic, 1031 in beri-beri, 1032 iu differential diagnosis of locomotor ataxia, 1084 INDEX. 127^ Gait in pseudo-hypertrophic muscular paral- ysis, 1200 in pseudo-tabes, 1031 In spastic paraplegia, 1088, 1089 Gall-bladder, distention or dropsy of, 857 empyema of, 858 fistulous communications of, 859 phlegmonous inflammation of, 858 Galloping consumption, 282. (See Acute Phthisis.) Gallop-rhythm in fatty degeneration of heart, 657 Gall-stones, 853. (See Calculi, Biliary.) remote eflFects of, 858 treatment for removal of, 860 Galvano-puncture in aneurysm, 691 Ganglion, basal rumors in or about, 1125 Gangrene, expectoration in, 533 in diabetes, 379 in ergotism, 1224 in lobar pneumonia, 150 in Eaynaud's disease, 1186 in typhoid fever, 40 in typhus fever, 71 of lungs, 531 Gangrenous pancreatitis, 908 stomatitis, 703 Gastralgia, 785 Gastrectasis, 744 Gastric contents, examination of, 736 crisis, 1083 fever, 749 juice, hyperacidity of, 782 subacidity, 783 ulcer, 763 clinical forms, 767 complications of, 767 diagnosis from gastralgia, 768 difierential diagnosis, 768 hematemesis in, 766 Gastritis. (See Stomach.) acute catarrhal, 649 suppurative, 753 chronic catarrhal, 754 diphtheritic, 753 toxic, 752 Gastrodynia, 785 Gastro-enteritis, 800 Gastroptosis, 743. (See Malposition of Stom- ach.) Gastroxynsis, 783 Gelbfieber. (See Yellow Fever.) General lymphadenoma, 444. (See Pseudo- leukemia.) miliary tuberculosis, 275 paresis, 1131 of insane, 1131 diagnosis from cerebral syphilis, 1132 stage of mania in, 1132 tic, 1152. (See Tic.) Genito-urinary system, tuberculosis of, 312 German measles, 248. (See Rubella.) Giant cells in tuberculosis, 261 Gigantoblasts in progressive pernicious anemia, 430 Gin-drinkers' liver, 887. (See Cirrhosis.) Glanders, 348 acute, 348 bacillus mallei, 348 chronic, 349 diagnosis, 349 immunity in, 348 Glanders, lesions of, 348 modes of infection, 348 period of incubation, 348 prognosis and treatment, 350 Glandular fever, 372 definition, 372 diagnosis, 373 etiology, 373 history, 373 pathology, 373 prognosis, 373 symptoms, 373 treatment, 373 Glioma of brain, 1124 Globus hystericus, 1167 Glomerulo-nephritis, 974 Glossitis, 706 desiccans, 708 Glosso-labio-laryngeal paralysis, 1094 Glosso-pharyngeal nerve, 1054 diseases of, 1054 Glossy skin in arthritis deformans, 390 Glottis, edema of, in small-pox, 221 in typhoid fever, 38 Glycosuria, 949 alimentary, 382 salts for, 950 Gmelin's test for bile, 948 Goiter, 456 exophthalmic, 458 physical cardiac signs of exophthalmic, 459 simple, 456 symptoms of exophthalmic, 457 thymus gland in treatment of simple, 458 treatment of exophthalmic, 461 Gonorrheal arthritis, 213 endocarditis in, 214 pathology of, 213 Gout, 392 causes, 394 dietetic treatment, 399 difierential diagnosis, 398 irregular, 396 morbid anatomy, 393 nervous manifestations in, 397 pathogenesis, 392 prophylactic treatment, 398 retrocedent, 395 rheumatic, 387 symptoms of acute, 395 of chronic, 396 treatment, 398 urine in, 397 Graefe's signs, 459 Grain-poisoning, 1222 Grand mal, 1139 Granular kidney, 985 Graves' disease, 458. (See Exophthalmic Goiter.) Green sickness, 421. (See Chlorosis.) Grippe, la, 158 Ground-soil, Pettenkofer's theory of, 24 Guaiacum-test for blood, 939 Gummata in acquired syphilis, 330 in congenital syphilis, 332 of arteries, 335, 339 of brain and spinal cord, 333 of heart, 338 of liver, 335 of lung, 337 of pharynx, 336 of rectum, 337 1274 INDEX. Gummata of testicles, 340 of tongue, 336 structure of, 327 Gums, blue line in lead-poisoning, 1217 Gustatory nerve, 1048 Habit-chokea, 718 Habit-spasm, 1152 Hair in typhoid fever, 33 Hallucinations iu hysteria, 1168 Handwriting in general paresis, 1131 Harrison's groove iu rickets, 405 Hay-asthma. 471. (See Autumnal Catarrh.) Hay-fever, 471. (See Autumnal Catarrh.) Headache iu intracranial growths, 1125 in syphilis. 334 iu typhoid fever, 41 in uremia, 963 sick, 1 142. ( See Migra in e. ) Heart, amyloid degeneration of, 659 aneurysm of, 560 arrhythmia of, 669 brown atrophy of, 659 calcareous degeneration of, 659 canter-rhythm in dilatation of, 648 congenital aftections of, 674 degenerations of, 656 dilatation of, 645 displacement of, in pleurisy, 548 fatty, 656 floating, 663 hyaline degeneration of, 659 hypertrophy of, 638 in pneumothorax, 567 irregular, 669 minor atfections of, 662 misplacement of, 663 new growths of, 662 organic, murmui-s of, 599. (See Cardiac Murmur.^.} palpitation of, 663 parasites of, 662 rapid, 665 rupture of, 661 shape of, in hypertrophy, 638 slow, 667 thrombosis of, 636 tuberculosis of, 315 Heart -failure in diphtheria, 187 in lobar pneumonia, treatment, 154 Heat-apoplexy, 1232 Heat-exhaustion, 1230 Heat-stroke, 1230 temperature in, 1234 treatment, 1234 Heberden's nodules, 390. (See Arthritis De- formans.) Heller's test, 944 Hematemesis, 778 diagnosis from hemoptysis, 779 in acute yellow atrophy, 884 in cirrho.sis of liver. 890 in hysteria, 1170 in leukocythemia, 440 Hematobium distoma, 1238 Hematomyelia, 1072 Hematorrachis. 1072 Hematozoa of malaria, 82 Hematuria, 938 in acute cystitis. 1007 in acute nephritis, 977 in acute vellow atrophy, 884 in blood-iSukes, 1238 Hematuria iu chronic tuberculosis, 300 in chyluria, 948 in malaria. 89, 92 in nephrolithiasis, 971 in renal calculus, 971 in scorbutus, 409 in tuberculosis of kidney, 313 Hemeralopia, 1039 Hemianopia in brain-tumors, 1126 Hemic murmur iu chlorosis, 429 Hemicrania, 1142. (See Migraine.) Hemiplegia. 1117 anesthesia in, 1117 atrophy in, 1118 crossed. 1117 diagnosis, 1118 in brain-tumors, 1126 in chronic nephritis, 990 in hysteria, 1168 of childhood, 1133 reflexes in, 1117 spastica cerebralis. 1134 Hemoglobin in anemia, 424 Hemoglobinuria, 940 diagnosis, 941 etiology, 940 in Eaynaud"s disease, 1186 paroxysmal, 941 treatment, 941 Hemolysis, causes of, 940 in toxic hemoglobinuria, 940 Hemopericardium, 587 Hemophilia, 415 Hemoptysis, 504 etiology, 505 in acute pneumonic phthisis, 29 iu emphysema, 530 in gangrene of lung, 533 iu hysteria, 1170 in mitral incompetency, 609 in mitral stenosis, 514 in onset of phthisis, 290 in scorbutus, 409 in tuberculosis, 293 parasitic, 1234 pathology, 505 symptoms, 506 treatment, 508 vicarious, 506 Hemorrhage, broncho-pulmonary, 504 cerebral, 1115 extra-meningeal, 1069 in acute yellow atrophy, 884 in anemia. 429 in cirrhosis of liver, 890 in hemophilia, 416 in infantile scorbutus, 411 in intussusception, 8.33 in leukocythemia. 440 in malaria, 91 in purpura. 413 in scarlet fever, 842 in scorbutus, 409 in tuberculosis of kidney, 313 in typhoid fever, 34 in yellow fever, 119 into spinal cord, 1072 into spinal meninges, 1069 intra-meningeal, 1069 pulmonary. 293 retinal, in chronic nephritis, 990 vesical, 1011 Hemorrhagic diathesis, 415 INDEX. 1275 Hemorrhagic diseases of the new-born, 418 nephritis, 982 in variola, 221 pleurisy, 552 purpura, 412 scarlet fever, 238 Hemorrhoids in cirrhosis of liver, 890 Hepatic abscess, 878 blood-vessels, diseases of, 870 colic, 854 infiltrations and degenerations, 871 Hepatitis, diffuse syphilitic, 334 interstitial, 887 suppurative, 878 Hepatization, gray, 134 red, 133 white, of fetus, -338 Hepatogenous jaundice, 852 Hereditary ataxia, 1086 muscular paralysis, 1204 Heredity in tuberculosis, 268, 269 Herpes in cerebro-spinal meningitis, 128 in febricula, 370 in malaria, 87 in neuralgia, 1035 in pneumonia, 143 Hirudo, 1263 Hodgkin's disease, 444. (See Pseudo-leuhe- mia.) Huntingdon's chorea, 1147 Hutchinson's teeth, 632 triad, 332 Hyaline casts in urine, 983, 989 Hydatid disease, 1251 thrill, 1253 Hydrarthrosis, 214 Hydrocephalus, chronic, 1128 Hydrochloric acid, test for, in gastric juice, 736 ITydromyelia, 1097 Hydronephrosis, 997 intermittent, 999 Hydropericardium, 586 in nephritis, 977 Hydrophobia, 356 bacteriology, 356 diagnosis, 358 incubation, 356 morbid anatomy, 355 paralytic stage, 357 preventive inoculation in, 358 prodromal symptoms, 356 stage of excitement, 356 temperature in, 357 treatment by attenuated virus, 359 virus of, 356 Hydrops articulorum intermittens, 1185 peritonsei, 926 Hydrothorax, 569 in nephritis, 977 Hypernephroma, 1003 Hyperorexia, 788 Hyperpyrexia in heat-stroke, 1233 in hysteria, 1171 in rheumatic fever, 207 in scarlet fever, 238 in tetanus, 360 Hypertrophy of the heart, 638 Hypnotism in hysteria, 1173 Hypochondria in neurasthenia, 1175 Hypoglossal nerve, 1060 paralysis of, 1061 spasm of, 1061 Hypostatic congestion in typhoid fever, 38 of lung, 501 Hysteria, 1164 anesthesia in, 1169 ataxia in, 1169 cataleptic form of, 1168 contractures in, 1168, 1169 convulsions in, 1167 dyspnea in, 1170 fever in, 1171 gymnastic form of, 1167 latent or interconvulsant stage of, 1169 nervous system in, 1169 paralysis in, 1168 prodromal stage of, 1166 pseudo-angina in, 1171 psychic symptoms, 1170 stage of delirium, 1168 tachycardia in, 1171 traumatic, 1165 urinary symptoms, 1171 Hystero-epilepsy, 1167 Icterus, 848. {Se& Jaundice.) neonatorum, 864 Idioglossia, 1121 Idiopathic anemia, 426. (See Progressive Per- nicious Anemia.) Ileo-colitis, 801. Ileus, 828. (See Intestinal Obstruction.) Imbecility in cerebral palsies of childhood, 1134 Imitation in chorea, 1153 Incontinence of urine in locomotor ataxia, 1083 Indicanuria, 945 Infantile convulsions, 1159 Infarction, intestinal, 808 Infectious diseases, 17 Iniiuenza, 158 antagonism of, 160 bacillus of, 159 broncho-pneumonia in, 162 causes, 159 clinical types, 161 complications, 161 diagnosis, 163 from cerebro-spinal meningitis, 163 from pneumonia, 163 from typhoid fever, 163 duration, 164 heart-failure in, 162 history, 158 immunity in, 160 lobar pneumonia in, 161 manner of invasion, 159 modes of conveyance, 159 mortality, 164 nervous system in, 162 pathology, 159 pleurisy in, 162 prognosis, 164 prophylaxis, in, 164 sequelee, 164 symptoms, 160 treatment, 165 Injection of salines in cholera. 117 Inoculation, preventive, in hydrophobia, 358 in small-pox, 229 protective, in yellow fever, 123 tuberculosis produced by, 267 Inoculations, prophylactic, in typhoid fever, 53 1276 INDEX. Insular sclerosis, 1091 Intercurrent relapse, 51 Intermittent fever, 84 Intestinal catarrh, 792 hemorrhage in typhoid fever, 34 infarction, 808 obstruction, 828 perforation in typhoid fever, 34, 35 tumors, 830 ulcers, 808 Intestine, carcinoma of, 835 diminished sensibility of, 844 neuralgia of, 843 neuroses of, 842 spasm of, 845 Intestines, diseases of, 788 Intoxications, 1208 Intracranial growths, 1124 Intussusception, 828 Invagination, 828 Iridoplegia, 1044 Iritis in syphilis, 332 Irregular heart- and pulse-beat, 669 Ixodes, 1263 Jacksonian epilepsy, 1137 Jail-fever, 67. (See Typhus Fever.) Japan, bronchial fluke in, 1238 endemic neuritis in, 1032 Jaundice, 848 acute febrile, 367 catarrhal, 849 emotional, 853 forms of, 852 hepatogenous, 848 in acute yellow atrophy, 883 in atrophic cirrhosis of liver, 890 in biliary calculi, 854 in carcinoma of liver, 896 in epidemic form, 849 in hypertrophic cirrhosis of liver, 891 in impacted calculi, 882 in pneumonia, 147 in the new-born, 848 in typhoid fever, 33 in Weil's disease, 367 in yellow fever, 122 malignant, 883 toxic, 849 xanthelasma in, 850 Joints in gout, 392-396 in rheumatism, 203 in small-pox, 221 in syphilis, 339 Jumpers, 1154 Keratitis in inherited syphilis, 332 in small-pox, 222 Keratosis follicularis, 1236 Kidney, amyloid, 966 carcinoma and sarcoma of, 1004 circulatory disorders of, 937 cirrhosis of, 985 congenital cystic, 1002 contracted, 985 cyanotic induration of, 937 cystic, 1002 diseases of, 933 dislocated, 933 echinococcus of, 1255 floating, 933, 934 gouty, 985 granular, 985 Kidney, ardaceous, 966 large white, 981 movable, 936 new growths of, 1003 removal of, in carcinoma, 1005 rhabdomyoma, 1003 senile, 991 syphilis of, 339 tuberculosis of, 312 wandering, 933 waxy, 966 Kidneys, active hyperemia" of, 937 embolic infarctions of, 938 jn diphtheria, 181 mobility of, 933 passive hyperemia of, 937 stone in, 968 Kindhusten, 251. (See Wkooping-congh.) Knee-jerk, loss of, in ataxia, 1081 in diphtheria. 186 in diseases of lumbar plexus, 1064 Koplik's sign in measles, 247 Lactic acid, test for, 738 Lagophthalmos, 1043 La grippe, 158. (See Influensa.) Landry's paralysis, 1065 Lardaceous degeneration of kidney, 966 infiltration of liver, 871 Larvffi of flies, 1263 Laryngeal crises, 1055, 1083 nerves, 1055 Laryngismus stridulus, 477. (See Spasmodic Laryngitis.) Laryngitis, acute catarrhal, 473 chronic, 475 membranous, 475-478 spasmodic, 477 Larynx, adductor paralysis of, 1056 anesthesia of, 1057 diseases of, 473, 1055 edema of, 474-480 hyperesthesia of, 1057 nerves of, 10.54, 1055 paralysis of, 1055 complete, 1056 of abductors, 1056 spasm of, 1055 tumors of, 479 unilateral abductor paralvsis of, 1056 Latah, 1154 Lateral sclerosis, amvoti-ophic, 1095 primary, 1087, 1088 Lateritous sediment, 954 Lathyrismus, 1225 Lathyrus cicera, 1225 clymenum, 1225 sativus, 1225 Lavage in chronic gastric catarrh, 762 in dilatation of stomach, 748 in gastric ulcer, 770 Lead arthralgia, 1218 colic, 1218 encephalopathy, 1218 in urine, test i"or, 1218 palsj- or paralysis, 1218 Lead-poisoning, 1216 blue-line on gums, 1217 cerebral symptoms, 1218 cramps of, 1218 Lead-workers, gout in, 394 Lepra alba, 346 cells, 345 INDEX. 1277 Leprosy, 345 anesthetic form, 346 bacillus of, 346 diagnosis, 347 etiology, 346 history, 345 modes of infection, 346 pathology, 345 prognosis, 347 serum-diagnosis of, 347 treatment, 347 trophic alterations in, 347 tubercular form, 346 Leptomeningitis, 1068, 1105 acute, 1068 as a sequel to acute febrile diseases, 1105 chronic, 1069 non-tubercular form, 1105 tache cerebrale in, 1106 tubercular form, 1068, 1105 Leptus autumnalis, 1261 Lesions of cauda equina and conus termi- nalis, 1103 Leucin, 956 in leukemia, 437 in urine, test for, 956 Leucinuria, 956 Leukemia, 437. (See LeiiJcocythemia.) blood in, 441 bone-marrow in, 438 complications of, 443 etiology, 439 liver in, 438 lymphatic, 437-442 glands in 441 microbic origin of, 439 pathology of, 437 pseudo-, 444 spleen in, 441 splenic-myelogenous, 437 symptoms, 440 Leukemic blood, abnormal substances in, 437 peritonitis, 440 Leukocythemia, 437 pseudo-, 444 pseudo-anemia infantum, 449 Leukocytosis, 436 pathological, 436 physiological, 436 Leukoplakia oris, 708 Leyden's crystals, 493. (See Asthma.) Lichen in jaundice, 850 Lienteric diarrhea, 797 Lingual psoriasis, 708 Lips, tuberculosis of, 304 Lipuria, 958 Lithemia, 400 Lithic-acid diathesis, 953 Lithuria, 953 Liver, abscess of, 878 active congestion of, 865 acute yellow atrophy of, 883 affections of blood-vessels of, 870 altered shape of, 847 amyloid infiltration of, 871 anemia of, 865 anomalies in shape and position of, 847 atrophy of, 871 carcinoma of, 895 circulatory affections of, 865 cirrhosis of, 887 atrophic, 863 hypertrophic, 863 Liver, diagram of, in cirrhosis, 893 diseases of, 847 dulness of, in acute peritonitis, 917 fatty degeneration of, 874 infiltration of, 873 gummata of, 335 hydatids of, 1252 hyperemia of, 865 hypertrophy of, 871 in phosphorus-poisoning, 885 new growths of, 900 perihepatitis, 875 psorospermiasis in, 1236 syphilis of, 334 toxic symptoms in acute yellow atrophy of, 884 tuberculosis of, 311 waxy, 871 Lobar pneumonia, 132. (See Pneumonia.) Localization, cerebral, 1026 spinal, 1023 Lockjaw, 358. (See Tetanus.) Locomotor ataxia, 1081 Argyll-Eobertson pupil in, 1082 course, 1084 diagnosis from ataxic paraplegia, 1084 from cerebellar disease, 1085 from peripheral neuritis, 1084 etiology, 1082 gait in, 1083 gastric crisis in, 1083 pathology, 1081 polyesthesia in, 1083 prognosis, 1085 symptoms, 1082 treatment, 1085 trophic changes in, 1083 Long thoracic nerve, 1062 Ludwig's angina, 709 Lumbago, 363. (See Muscular Rheumatism.) Lumbar puncture, 1069, 1106 in cerebro-spinal meningitis, 130 Lumpy -jaw, 350. (See Actinomycosis.) Lung, actinomycosis of, 351 carcinoma of, 538 echinococcus of, 1254 gangrene of, circumscribed, 532 diffuse, 531 embolic, 531 hemorrhagic infarction of, 505 hydatid cyst of, 540 neoplasms of cobalt-miners, 540 sarcoma of, 539 splenization of, 502 Lung-fever, 132 Lungs, abscess of, 534 embolic, 534 symptoms of, 535 active hyperemia of, 500 apoplexy of, 510 brown induration of, 501 cirrhosis of, 512 congestion of, 500 edema of, 502 embolism of, 510 emphysema of, 524 fibroid induration of, 512 gangrene of, 531 etiology, 532 pathology, 531 symptoms, 533 hemorrhage of, 504 1278 INDEX. Lungs, hemorrhagic infarct of, 510 new growths of, 538 passive hyperemia of, 501 syphilis of, 337 tuberculosis of, 277 Lymphadenitis, 571 tuberculous, 571 Lymphadenoma, general, 444 Lymphatics, distended, 1249 Lymph-glands, suppuration of, 571 tuberculosis of, 271 Lymphoma, multiple malignant, 444 Lympho-sarcoma, malignant, 444 Lymph-scrotum, 1249 Lymph-vaccine, 230 Lymph-vulva, 1249 Lyssophobia, 357 Macrocytes, 424 Macrocytosis, 419 Maidismus, 1224 " Main en griffe " in diseases of muscles, 1198 Malacia, 788 Malarial cachexia, 91 fever, 79 ameba causing estivo-autumnal fever, 83 causing quartan fever, 83 causing tertian intermittent fever, 83 chart in, 81 ciliaj or flagella in, 84 complications, 92 cutaneous symptoms, 87 diagnosis, 93 etiology, 80 examination of blood for parasite of, 94 hematozoa of, 82 hematuria and hemoglobinuria in, 92 hot stage of intermittent, 85 immunity in, 84 incubation in, 84 intermittent, 83 temperature-chart in, 85 life-cycle of parasite. 83, 84 localities of, 79 masked intermittent, 91 mild form, 87 mode of infection in, 84 mosquitoes and, 84 occurring with typhoid fever, 44 parasite of, 82 paroxysms in intermittent, 84 pathology of, 79 pernicious, intermittent form, 87 algid form, 88 comatose form, 89 congestive chills in, 88 hematuric form, 89 Plasmodium of, 82 prognosis, 94 prophylaxis in pernicious intermit- tent", 96 quartan, 86 quotidian, 86 remittent form, 89 seasons favoring, 81 spleen in, 80, 87 splenic enlargement in, 87 sub-varieties, 79 sweating stage of intermittent, 86 telluric conditions, 80 Malarial fever, tertian, 86 treatment of intermittent form, 95 urine in, 87 Malignant edema, 353 lympho-sarcoma, 444. (See Pseudo-leu- kemia.) pustule, 352. (See Anthrax.) Malta fever, 368 Mammary glands in hysteria, 1170 tuberculosis of, 315 Mania-a-potu, 1210 Mania, acute delirious, 1135 Bell's, 1135 melancholic stage of, in general paresis. 1132 typho-, 1135 Marriage in hemophilia, 417 in syphilis, 342 Marrow in bones in leukocythemia, 437 in pernicious anemia, 427 in small-pox, 216 Masticatory spasm, 1047 McBurney's point, 817 Measles, 245 bacteriology of, 245 catarrhal stages, 246 causes, 245 complications, 246 contagiousness of, 245 dequamation in, 246 diagnosis, 247 from German, 250 epidemics of, 245 eruption of, 246 German, 249 immunity in, 245 incubation of, 246 mortality, 247 pathology, 245 symptoms, 246 temperature in, 246 treatment, 248 of German, 290 Meat in animal parasitic disease, 1258 tuberculous infection by. 267 Meat-poisoning, 1223, 1246 Meckel's diverticulum, 828 Median nerve, diseases of, 1063 Mediastinal hemorrhage, .574 Mediastinum, abscess of, 572 carcinoma of, 572 diseases of, 571 dysphagia in diseases of, 573 inflammation of, 571 sarcoma of, 572 tumors of. ,572 Mediterranean fever, 368 Medulla, tumors of, 1127 Megalocytosis, 419. (See Anemia.) Megalogastria, 747 Melano-sarcoma of liver, 900 Melanotic carcinoma, diagnosis in Addison's disease, 454 Melanuria, 958 Melasma suprarenale, 454 Melena in typhoid fever, 31 Meniere's disease, 1053 Meningeal apoplexy, 1069 Meninges, diseases of, 1065 Meningitis, acute spinal, 1068 cerebro-.spinal, 129 in encephalitis, 1113 in erysipelas, 175 INDEX. 1279 Meuingitis in gout, 397 in hydrocephalus, 1129 tuberculous, 278, 1106 Meningococcus intracellularis, 126 Meningo-encephalitis, tuberculous, 315 Meralgia paresthetica, 1193 Mercurial tremor, 1221 Mercurialism, 1220, 1221 stomatitis and salivation in, 1221 Merycism, 784 Mesenteric artery, occlusion of, 808 glands in typhoid fever, 19 tuberculosis of, 273 Mesenterica, tabes, 273, 310 Mesentery, hemorrhage into, 905 Mesocolon, hemorrhage into, 905 Metallic rales, 567 tinkling, 297, 567 Metastatic abscesses, 199 Meteorism in typhoid fever, 64 Micrococci in measles, 245 Micrococcus in dengue, 167 lanceolatus, 135 meliteusis in Malta fever, 369 Microcytes, 424 Microcytosis, 419 Micro-organisms in chorea, 1144 in rheumatic fever, 203 Middle cerebral artery, embolism and throm- bosis of, 1110 ear, disease of, in measles, 247 in scarlet fever, 239 Migraine, 1142 ophthalmique, 1044 Miliary abscesses in typhoid fever, 20 fever, 371 tubercles, 28H in typhoid fever, 38 tuberculosis, general, 275 Milk in scarlet fever, 235 in tuberculosis, 266 in typhoid fever, 26 poisoning by, 1222 Milk-curds, 702 Milk-sickness, 370 Mimic spasm, 1048 Mind-blindness, 1042 Mind-deafness, 1122 Miners' cachexia, 1242 lung, 535 neoplasms of lung, 540 nystagmus, 1043 Mitchell, Weir, rest-cure in hysteria, 1173 Mitral incompetency, 607 regurgitation or insufficiency, 607 diagnosis from functional mur- murs, 612 mechanism of, 608 murmur in, 610 stenosis, 613 chlorosis and, 613 chorea and, 613 murmur in, 616 pathology and etiology, 613 physical signs in, 615 presystolic murmur in, 616 rheumatism in, 613 sphygmogram of, 615 symptoms of, 614 Moist rales, 297 Monoplegia facialis, 1050 hysteric, 1168 Morbus Addisonii, 454 Morbus C0X8B senilis, 390. (See Arthritis De- formans.) maculosus neonatorum, 418 Morphea, 1190 Morphinism, 1215 Mortality in cerebro-spinal meningitis, 131 in pneumonia, 152 in small-pox, 225 in typhus fever, 72 in whooping-cough, 255 in yellow fever, 122 Morvan's disease, 1098 Mosquitoes, 1263 and malarial fever, 84 relation of, to fllaria disease, 1247 Motor centers, 1021, 1022 impulses, course of, 1026 nerves of eyeball, diseases of, 1043 ocuJi, lesions of, 1043 paralysis of, 1043 spasm of, 1043 phenomena in neurasthenia, 1175 system, lesions of, 1027 Mountain anemia, 1242 fever, 67 sickness, 67 Mouth, diseases of, 694 Mouth-breathing, 717 Movable kidney, 933 diagnosis, 935 dilatation of stomach in, 934 symptoms, 934 treatment, 936 Movement, limitation of, in eye-muscles, 1045 Muco-pus, occlusion of bronchioles, 483 Mucous membranes, lesions of, in syphilis, 337 Mulberry calculi, 969 Multiple malignant lymphoma, 444. (See Pseudo-leukemia. ) neuritis, 1029 sclerosis, 1091 Mumps, 258. (See Parotitis.) Murmur, Flint's, 605 in aneurysm, 687 in congenital heart disease, 676 in endocarditis, 590 in rachitis, 405 in subclavian artery in phthisis, 295 in valvular disease, 604, 607, 610, 616, 619, 621, 622 Murmurs, hemic, 423-429 myocardial, 651 Musea domestica, 1263 Muscaria amanita, 1225 Muscidse, 1263 Muscle, diseases of, 1196 Muscle-trichinse, 1245 Muscles, electric reaction of, Erb's sign, 1157 of eye, paralysis of, 1045 Muscular atrophy, 1204 arthritic, 1203 progressive neural, 1197 progressive, 1202 facio-scapulo-humeral type, 1202 infantile type, 1202 spinal, 1196 pseudo-hypertrophic, 1199 contractures, hysteric, 1168, 1169 cramp in dilatation of stomach, 746 hypertrophy, 1204 paralysis, hereditary, 1203 rheumatism, 362 1280 INDEX. Muscular sense iu Brown-Sequard's spinal paralysis, 1080 wasting, hysteric, 1169 weariness in trichiniasis, 1243 Muscularis progressiva, dystrophia, 1202 Musculo-spiral nerve, paralysis of, 1063 Mushroom-poisoning, 1225 Music-faculty, loss of, in aphasia, 1224 Musical murmur, 611 Mussel-poisoning, 1223 Myalgia, 362. (See Muscular Rheumatism.) cervical is, 363 lumbalis, 363 Mycosa stomatitis, 701 Mycosis, intestinal, 354 Mycotic diarrhea, 800 Mydriasis, 1044 Myelin-droplets of Virchow, 480 Myelitis, acute. 1073 chronic, 1075 diagnosis, 1075 diaphragmatic breathing iu, 1074 diffuse, 1073 disseminated, 1074 girdle-feeling in, 1074 reflexes in, 1074, 1076 transverse, 1073 Myelocytes, 442 Myelogenic leukemia, 437 Myiasis, internal, 1263 vulnerum, 1263 Myocarditis, 650 acute, 650 circumscribed, 6.50 diffuse interstitial, 650 parenchymatous, 650 angina pectoris in, 653 cardiac arrhythmia in, 653 chronic or filDrous, 651 in rheumatism, 203, 206 in syphilis, 339 segmentaire, 21 Myocardium, diseases of, 650 lesion of, due to diseases of the coronary artery, 655 Myosis, 1043 spinal, 1045 Myositis, infectious, 1195 progressive ossifying, 1196 Myotonia congenita, 1204 Myotonic contraction, 1205 Mytilotoxin, 1223 Myxedema, 462 associated with cretinism, 465 operative, 465 pathogenesis, 462 treatment of, by thvroid-feeding, 464 true, 462 varieties, 462 Myxoma in intracranial growths, 1125 Nails in typhoid fever, 33 Nasal catarrh, acute, 467 chronic, 468 diphtheria, 185 Necrosis, anemic, 655 in tubercle, 262 Necrotic tonsillitis, 714 Nematodes, 1239 uncommon, 1250 Neoplasms of bladder, 1011 Nephrectomy, 936 Nephritides, the, 959 Nephritis, acute parenchymatous, 974 cardiac hypertrophy in chronic inter- stitial, 989 chronic interstitial, 985 parenchymatous, 981 complicating the infectious fevers, 978 complications, 990 definition, 974 diagnosis, 978 diet in treatment, 980 dropsy in, 961 edema in, 977 etiology, 976 glomeruli in, 975 hemorrhagic, 975 hygiene and diet in treatment of acute, 979 interstitial changes in acute, 975 large white kidney in chronic, 981 lympliomatous, of Wagner, 43 of pregnancy, 978 pale, granular kidney of chronic, 982 pathology, 974 prognosis, 979 suppurative, 993 symptoms, 976 treatment, 979 tube-casts in, 959, 977 tubular changes in acute, 974 in chronic interstitial, 986 uremia in, 962, 978 urine in, 977, 983, 988 Nephrolithiasis, 968 Nephroptosis, 933 Nephrorrhaphy, 936 Nephro-typhoid, 43 Nerves, auditory, 1051 brachial plexus, 1062 cervical plexus, 1062 fifth, 1047 fourth, 1045 glosso-pharygneal, 1054 hypoglossal, 1060 lumbar and sacral plexuses, 1064 of eyeball (motor), diseases of, 1043 peripheral, diseases of, 1028 pneumogastric, 1054 seventh, 1048 sixth, 1045 spinal accessory, 1058 diseases of, 1062 third, 1043 Nervous dyspepsia, 779 system, diseases of, 1017 function of cerebrum, 1025 general and topical, diagnosis of, 1026 histology of, 1017 lesions of, 1026 localization of functions of segments of spinal cord, 1023 tumors of, 1032 Nettlerash. (See Urticaria.) Neural progressive muscular atrophv, 1197 Neuralgia, 1033 cervico-brachial, 1035 cervico-occipital, 1035 femoral or crural, 1035 infra-maxillary, 1034 intercostal, 10.35 lumbo-abdominal, 1035 mastodynia, 1035 obturator, 1036 INDEX. 1281 Neuralgia of genitalia and rectum, 1036 of the head, 1034 ophthalmic, 1034 phrenic, 1035 supra-maxillary, 1034 visceral, 1036 Neurasthenia, 1174 diagnosis from hysteria, 1176 etiology, 1174 lithemic, 1176 motor phenomena, 1175 psychic symptoms in, 1175 rest-cure in, 1178 sensory disturbances in, 1175 symptomatic, 1174 Neuritis, 1028 alcoholic, 1029 arsenical, 1030 diffuse, 1028 focal, 1028 in diphtheria, 186 interstitial, 1028 lipomatous, 1028 malarial, 1030 multiple, 1029 reflexes in 1030 optic, 1040 recurring multiple, 1030 rheumatic, 1028 spontaneous or idiopathic, 1030 Neurogliar hyperplasia, 1130 tissue, 1124 Neuromata, 1032 Neurons, 1013 Neuroses, occupation-, 1161 of bladder, 1012 of intestine, 842 disturbances of motility, 845 secretory disturbances, 842 sensory disturbances, 843 of micturition, 1014 of stomach, 779. (See Stomach.) of the heart, 663 Neutrophiles, 442 Night-blindness, 1039 in scurvy, 409 Night-sweats in phthisis, 299 Nipple, Paget's disease of, 1236 Nits, 1261 Nodosities, Heberden's, 390 Noma, 703. (See Gangrenous Stomatitis.) pudendse, 714 Normoblasts, 430 Nose, diseases of, 476 Nose-bleed, 472. (See Epistaxis.) in typhoid fever, 27, 38 Nutmeg-liver, 887 (See Cirrhosis of Liver. Nyctalopia, 1039 Nystagmus, bilateral, 1087 in insular sclerosis, 1092 paralytic, 1045 Obesity, 1226 treatment, 1229 Oertel's, 1229 Obstruction, intestinal, 828 acute, and varieties, 828 chronic, and varieties, 829 Occupation-neuroses, 1161 Oculo-motor palsy, 1043 Oligemia, 419. (See Anemia.) Oligochromemia, 419. (See Anemia.) Oligocythemia, 419. (See Anemia.) 81 Oliver's sign, 689 Omentum, new growths in, 930, 931 tuberculosis of, 309 Omodynia, 364. (See Muscular Rheumatism,.) Onomatomania, 1153 Onychia in arthritis deformans, 390 syphilitic, 331 Ophthalmic migraine of Charcot, 1044 Ophthalmoplegia, 1046 Opium-inebriety, 1214. (See Morphinism.) Opiumism, 1214 Opium-poisoning, differential diagnosis from uremia, 966 Oppolzer's sign, .578 Optic atrophy, 1041 nerve and tract, diseases of, 1038 neuritis, 1040 in abscess of brain, 1114 in Bright's disease, 984 in tuberculous meningitis, 281 in tumor, 1125 Optic-nerve atrophy in locomotor ataxia, 1083 Orchitis in parotitis, 259 interstitial, in syphilis, 340 in tuberculosis, 313 in typhoid fever, 43 Oriental plague, 169 Osteitis deformans, 1181 Osteo-arthropathy, hypertrophic pulmonary, of Marie, il81 Osteo-myelitis, acute, diagnosis from rheu- matism, 209 Otitis media in scarlatina, 239 Ovaries, tuberculosis of, 314 Oxaluria, 954 Oxyuris vermicularis, 1243 Oysters, poisoning by, 1223 typhoid bacilli conveyed by, 26 Ozena, bacillus mucosis as a cause of, 469 Pachymeningitis, 1067 externa and interna, 1104 heemorrhagica, extra-dural, 1104 internal hemorrhagic, 1104 Palate, paralysis of, in diphtheria, 186 tuberculosis of, 305 Palpitation of heart, 663 Palsies, cerebral, of childhood, 1133 Palsy, lead, 1030 Paludism. (See Malarial Fever.) Pancreas, calculi of, 913 carcinoma of, 910 cyst of, 912 diseases of, 905 hemorrhage of, 909 lesions of, in diabetes, 375 Pancreatic cyst, 912 Pancreatitis, acute, 905 chronic, 908 fat-necrosis in, 905 gangrenous, 908 hemorrhagic, 905 suppurative, 907 Paralysis, acute ascending (Landry's palsy), 1065 after diphtheria, 186 agitans, 1155 alcoholic, 1029 Bell's, 1050 bulbar, acute, 1094 chronic, 1094 crossed, 1117 1282 INDEX. Paralysis, crutch-, 1063 divers', 1182 geueral, of iusane, 1131 hysteric, 1168 in cerebro-spinal meningitis, 1128 infantile, 1133 in lateral sclerosis. 10.^8 in locomotor ataxia, 1083 in progressive muscular atrophy, 1198 of brachial plexus, 1062 of circumflex nerve, 1063 of diaphragm, 1062 of facial nerve, 1050 of fifth nerve, 1047 of fourth nerve, 1045 of hypoglossal nerve, 1060 of larynx, 1055 of median nerve, 1063 of musculo-spiral nerve, 1063 of oculo-motor nerve, 1043 of olfactory nerve, 1037 of recurrent laryngeal nerve, 1055 of sixth nerve. 1045 of third nerve, 1043 of ulnar nerve, 1064 of vocal cords, 1055 of paroxysmal family, 1163 periodic, 1163 pseudo-hvpertrophic muscular, 1199 radial, 1064 sleep-. 1063 Paralytic thorax. 203 Paramyoclonus multiplex, 1148 Paraphasia, 1226 Paraplegia, ataxic, 10S9 congenital. 1089 from ergotism, 1224 from tumors of the cord, 1101 hysteric. 1168 in tabes. 1083 intermittent, 1691 pellagra. 1225 reflex, 1091 spastic. 1089 syphilitic, 334 Parasites, animal, diseases due to, 1236 of heart, 662 Parasitic arachnida, 1260 gastritis, 750 Parkinson's disease, 1257 Parosmia, 1037 Paroxysmal family paralysis, 1163 Parotitis, 259 complications and sequelae, 259 contagiousness of, 258 duration, 259 epidemic, 258 etiology of, 258 facial paralysis in, 260 immunity iu, 259 in lobar pneumonia, 147 in typhoid fever, 37 pathology. 258 symptomatic, 710 symptoms, 259 treatment, 260 Paroxysmal hemoglobinuria, 941 Parrot's ulcers, 701 Pediculosis, 1261 Pediculus capitis, 1261 corporis, 1261 pubis, 1262 Peliomata typhosa ( taches bleuatres), 33 Peliosis rheumatica, 413. (See Arthritic Pur- pura.) Pemphigus neonatorum, 331 Pentastoma tanioides, 1260 Peptones in the urine, tests for, 945 Perforation of bowel in dysentery, 102 in typhoid fever, 35 Pericarditis, 575 acute plastic or fibrinous, 575 adhesive, 584 callosa, 585 chronic, 584 diagnosis from acute pleurisy, 582 from cardiac dilatation, 582 hemorrhagic, 584 hyperpyrexia in, 581 in rheumatism, 206 pulsus paradoxus in sero-fibrinous, 579 purulent. 583 sero-fibrinous, 578 tuberculo-mediastinal, 577 varieties of, 575 Pericardium, diseases of, 575 dropsy of, 565 tuberculo.sis of, 308 Perichondritis, larvngeal, iu tvphoid fever, 38 Perihepatitis, acute, 875 chronic, 877 Perinephritic abscess, 899 Peripancreatitis, 905 Perisplenitis, 902 Peristaltic unrest, 784, 1170 Peritoneum, carcinoma of, 930 diseases of, 914 new growths in, 930 tuberculosis of, 309 Peritonitis, acute, 914 adhesive, 924 cancerous, 924 chronic, 923 hemorrhagic, 923 tuberculous, 923 circumscribed, 918 hysteric, 920 in typhoid fever, 35 leukemic, 440 localized or partial, 918 proliferative, 923 saline treatment of, 922 symptoms of general, 916 Perityphlitis, 813 Perlicher, 703 Pernicious anaemia, 426 malaria, 87 Pertussis, 251. (See Whooping-cough.) Pestis major, 170 minor, 170 sideraus. 170 Petit mal, 1139 Peyer's patches in typhoid fever, 17 Pfeifier serum-reaction, 113 Phagocytosis in erysipelas, 172 in tuberculosis, 262 Pharyngitis, acute, 720 chronic, 722 herpetic, 720 membranous, 721 Pharyngocele, 731. (See Esophageal Divertic- ulum.) Pharynx, acute infectious phlegmon of, 723 diseases of, 720 inflammatory edema of, 724 INDEX. 1283 Pharynx, tuberculosis of, 305 Phosphaturia, 955 Phosphorus-poisouiug, liver iu, 885 Phreuic nerve, diseases of, 1062 Phthiriasis, 1261 Phthisis, acute broncho-pneumonic, in chil- dren, 285 acute pneumonic, 282 chronic ulcerative, 285 course of acute pneumonic, 284 diagnosis of acute pneumonic, 284 fibroid, 302 pathology of acute pneumonic, 282 stone-cutters', 536 subacute cases, 284 symptoms of acute pneumonic, 283 Pia mater, diseases of, 1105 Pica, 422 Pigeon-breast in rickets, 405 Pigmentation of skin, 454. (See Addison's Disease.) Pin-worms, 1240 Pituitary body in acromegalia, 1179 Pityriasis versicolor, 301 Plague, bacillus of, 169 bubonic, 169 clinical history of, 170 diagnosis, 171 etiology, 169 prognosis, 171 treatment, 171 Plague-pneumonia, 170 Plasmodium malarite. (See Malaria.) Pleura, diseases of, 541 new gi'owths in, 570 Pleurisy, 541 acute plastic, 541 aspiration in, 557 Baccelli's sign in, 559 bacteriology of, 541 chronic, 562 diagnosis from lobar pneumonia, 553 diaphragmatic, 551 diet in, 556 egophony in, 549 encysted, 551 hemorrhagic, 552 iu scarlet fever, 239 interlobar, 551 pulsating, 660 diagnosis from aneurysm, 689 purulent, 558. (See Empyema.) sero-fibriuous, 544 Skoda's resonance in, 549 tuberculous, 550 varieties of acute sero-fibrinous, 550 with effusion, 544. (See Sero-fibrinous Pleurisy.) Pleurodynia, 363. (See Muscular Rheumatism.) Plica polonica, 1261 Plumbism, 1217 prevention of, 1219 Pneumatinuria, 958 Pueumogastric nerve, branches of, 1055-1057 diseases of, 1054 Pneumonia, abortive treatment of, 155 abscess of the lung in, 134 anti-pneumococcic serum in, 156 bacteriology in, 135 blood in, 142 catarrhal, 514 causes, 135 cerebral symptoms, 143 Pneumonia, chronic interstitial, 150, 510 circulatory symptoms, 142 complications of, 145 crisis in, 142 cutaneous symptoms of, 143 delayed resolution in, 149 diagnosis, 150 from acute pneumonic phthisis, 150 from meningitis, 152 from typhoid pneumonia, 152 diet in, 154 differential diagnosis, 150 duration, 149 endocarditis in, 146 epidemic, 148 epidemic influence in, 136 ether-, 149 gangrene of the lung in, 134 gray hepatization in, 134 heart-clots in, 147 hydrotherapy in, 155 hypostatic, 502 immunity from, 138 in children, 148 in diabetes, 381 inhalation-, 516 in influenza, 163 in the aged, 148 jaundice in, 147 latent, 148 lobar, 132 local measures in, 157 meningitis in, 147 micro-organism of, 135 migratory, 148 mode of infection, 135 modes of death in, 153 mortality of, 152 neuritis in, 148 pathology, 133 pericarditis in, 146 physical signs, 144 pleurisy in, 145 preventive inoculations in, 138 prodromal symptoms, 138 prognosis, 152 purulent infiltration of the lung in, 134 red hepatization in, 133 relapses in, 149 resolution in, 134 secondary, 157 special symptoms, 139 sputum in, 140 stage of engorgement in, 133 symptoms, 138 syphilitic, 337 temperature-chart of lobar, 141 terminations, 142 treatment, 154 typhoid, 148 urine in, 144 venesection in, 155 Pueumonokoniosis, 535 Pneumopericardium, 587 Pneumorrhagia, 510 Pneumothorax, 564 bell-tympany in, 567 diagnosis from large pleural cavity, 569 from large pulmonary cavity, 568 dyspnea in 565 etiology, 564 Hippocratic succussion in, 567 metallic tinkling in, 567 1284 INDEX. Piieumotoxin, 138 PneumotTphoid. 38 Podagra, 392. (See Goi/f.) Poikilocytosis, 419. (Seo Anemia.) Poisoniug by milk and meat, 1222, 1223 Polioeucephalitis. acute, 1114 of Strumpell, 1133 Poliomyelitis, acute, 1079 anterior, 1077 chronic, 1079 subacute, 1079 Polysarcia adiposa, 1225. (See Obesity.) Polyuria, 3S5. (See Diabetes Insipidus.) Pons, tumors of, 1127 Porencephalia of Hesche, 1125 Portal vein, stenosis of, 870 suppurative pylephlebitis, 868 thrombosis and embolism of, 868 Post-epileptic phenomena. 1140 Post-hemiplegic chorea. 1151 Post-typhoid elevations of temperature, 32 Pott's disease in compression of cord, 1099 Presystolic murmur, 605, 616 Priapism in leukemia, 440 Proctitis, 797 Profeta's law, 32S Progressive hemiatrophy of the face, 1187 ossifying myositis, 1196 pernicious anemia. 426 arsenic and bone-marrow in treatment of, 432 blood in, 430 diagnosis. 430 lesions of. 427 spinal muscular atrophy, 1196 Prostate, tuberculosis of, 313 Protozoa. 1236. (See Psorospermiasis.) Pseudo-angina pectoris, 673 Pseudo-apoplectic attacks in fatty heart, 657 Pseudo-bulbar paralysis, 1095 Pseudo-cyesis. 1168 Pseudo-diphtheria. 179 Pseudo hydrophobia. 357 Pseudo-hvpertrophic muscular paralvsis. ■ 1200 Pseudo-leukemia, 444 blood in, 445 spleen in, 445 varieties, 445 Pseudo-sclerosis. 1094 Psorospermiasis, 1237 Ptosis. 1044 Ptyalism, 709 Pulex ii-ritans. 1262 penetrans, 1262 Pulmonary apoplexy, 510 atelectasis, 581 diagnosis from pleuritic eflfusion, 523 physical signs, 522 edema, 503 embolism, 510 hemorrhage, 504 etiology, 505 treatment, 508 varieties not due to phthisis, 507 incompetency, 621 regurgitation, 621 stenosis, 622 Pulse, capillary, Quincke's, 603 Corrigan's, 603 Pulse-tracings, 604, 606, 615 Pulsus alterans, 669 paradoxus. 579 Pulsus quadrigeminns, 670 trigeminus, 670 Puncture, lumbar, 1069, 1105 Pupil, Argyll-Eobertson, 1083 Purpura, 412 arthritic, 413 factitious, 414 fulminans, 414 baemorrhagica, 414 Henoch's, 414 idiopathic, 412 pemphigoid, 413 prognosis, 415 secondary, 412 simplex, 412 treatment, 415 Pustule, malignant, 352. (See Anthrax. Pyelitis, 993 calculous, 994 infectious, 994 obstructive. 994 pathology, 993 pyuria in, 995 Pvelouephritis, 993. Pyemia, 199 abscesses in, 199 bacteriology, 199 diagnosis from septicemia, 202 pathology, 199 paths of infection of the body in. 200 spontaneous, 200 temperature in, 201 treatment, 202 ulcerative endocarditis in, 201 Pylephlebitis in appendicitis, 815 in dysentery, 102 Pyonephrosis, 993 Pyo-pneumothorax, 564 subphrenicus, 875. titis.) Pyuria, 946, 995 in cystitis, 1008 (See Pyelitis.) (See Pneumothorax.) (See Acute Perihepa- QUARTAX PAEASITE.S, 83 Quinine as a specific in malaria, 94 hydrobromate hypodermically in ma- laria, 95 Quinsy, 713. (See Tonsillitis.) Quotidian intermittent fever, 83 Eabies, 355. (See Hydrophobia.) preventive inoculation in, 357 Rachitic rosary, 405 Rachitis, 402 Radial paralysis, 1063. (See Musculo-spiral Paralysis.) Rag-pickers' disease, 354 Railroad spine, 1166 Rainey's tube, 1236 Ray-fungus, 350. (See Actinomyces.) Raynaud's disease. 1185 clinical grades, 1186 diagnosis of, 1186 hysteric. 1185 paroxysmal hemoglobinuria in, 1186 Reaction of degeneration in anterior polio- myelitis, 1078 in chronic myelitis, 1076 in neuritis, 1029 in progressive muscular atrophy. 1096. (See Myelopathic.) Recrudescence of fever in typhoid fever, 32 Rectum, syphilis of, 337 INDEX. 1285 Eectum, tuberculosis of, 306 Eecurrent laryngeal nerve, paralysis of, 1056 Eecurring multiple neuritis, 1030 Eed softening of brain, 1109 Eeduplication of heart-sounds, 670 Eeichmann's disease, 783 Eelapse in typhoid fever, 51 Eelapsing fever, 73 causes, 74 clinical varieties, 76 history, 73 pathology, 73 spirillum of, 74 Eemittent fever, 89 Een mobilis, 933 Eenal colic, 968 tuberculosis, 312 Eespiratory system, diseases of, 467 Eest-cure in hysteria, 1178 Eetina, diseases of, 1038 Eetinitis, albuminuric, 1038 leukemic, 440 pigmentary, 1039 syphilitic, 1039 Eetroperitoueal sarcomata, 932 Eetropharyngeal abscess, 724 Ehabdomyoma of kidney, 1004 Ehagades, 331 Eheumatic fever, 202 gout, 387. {^ee Arthritis Deformans.) myositis, 364 nodules, subcutaneous, 207 peliosis, 411 Eheumatism, acute articular, 202 bacteriology, 203 blood in, 203 chronic articular, 366 complications, 206 diagnosis, 209 differential, 209 duration, 205 endocarditis and pericarditis in, 206 gonorrheal, 209 immunity in, 204 in children, 209 joints in, 205 local measures in, 213 monarticular, 205 muscular, 363 treatment, 365 pathology, 203 subacute, 213 symptoms, 204 temperature in, 207 treatment, 211 Eheumatoid arthritis, 387. (See Arthritis Deformans.) Ehinitis, acute, 467 atrophica, 468 chronic, 468 hypertrophica, 468 simplex, 467 syphilitica, 331 Eibs, resection of, in empyema, 561 Eice-water stools, 113 Eickets, 402. (See Rachitis.) etiology, 403 " fat-rickets," 406 Harrison's groove in, 405 prophvlaxis, 406 Eock-fever, 368. (See Malta Fever.) Eomberg's sign, 1083 Eoot-nerve symptoms in compression-para- plegia, 1099 "Eose-cold,-' 471 Eose-spots, 32 Eotheln, 248. (See Rubella.) Eound worms, 1234 Eubella, 248 Eubeola notha, 248. (See Rubella.) Eumination, 784 Eupture of heart, 661 of spleen, 905 Sacchaeomyces albicans, 701 Sacral plexus, diseases of, 1064 Salaam convulsions in hysteria. 1168 Salad, chicken, poisoning by, 1223 Saline infusion in typhoid fever, 65 injections, intravenous, in diabetic coma, 385 subcutaneous, in cholera, 118 in lobar pneumonia, 155 Salivary glands, diseases of, 709 Salivation, 705 in bulbar paralysis, 1095 Saltatoric spasm, 1154. (See Spasm.) Sanatorium treatment of tuberculosis, 322 Sand-flea, 1262 Sanitaria, home, 322 Sapremia, 195. ( See Septicemia.) Saranac sanitarium, 322 Sarcina ventriculi, 745 Sarcoma, mediastinal, 572 melanotic, 900 of bladder, 1011 of brain. 1124 of kidney, 1004 of liver, 900 of lung, 539 of pleura, 570 Sarcoptes scabiei hominis, 1261 Sardonic grin, 360 Saturnine encephalopathy, 1219 neuritis, 1030 Saturnism, 1216 Sausage-poisoning, 1223 Scarlatina, 234. (See Scarlet Fever.) Scarlatinal svnovitis, 239 Scarlet fever, 234 anginose form, 238 atactic form, 238 causes, 235 complications, 239 desquamation in, 239 diagnosis, 241 eruption in, 2.36 "goose-skin " in, 236 hemorrhagic, 238 immunity in, 236 incubation-period, 236 infection in, 235 invasion of, 236 joint-affections in, 239 lesions in, 234 malignant, 238 micro-organisms in, 234 mild form, 238 modes of conveyance in, 235 nephritis in, 239 otitis in, 239 prognosis, 242 prophylaxis against nephritis, 244 pulse in, 237 • pyemia in, 239 1286 INDEX. Scarlet fever sine eruptione, 238 synovitis in, 239 temperature in, 237 tongue in, 237 tonsils in, 23G treatment, 242 urine in, 237 Schlammfieber, 367 Schonlein's disease. (See Rheumatic Peli- osis. ) "Schweinfurth's" green, 1219 Sciatic nerve, 10G4 Sciatica, 1036 Scleroderma ditfusuni, 1189 Sclerosis, amyotrophic lateral, 1095 arterial, 678 caused by ei'gotism — "ergot tabes," 1224 caused by syphilis, 333. (See also Loco- motor Ataxia.) combined system, 1090 lateral, 1087 multiple or disseminated, 1091 of brain, 11.30 of pulmonary artery, 679 of veins, 679 posterior, 1081 Sclerotic changes in chronic gastritis, 755 Scolices of echinococcus, 1251 Scorbutus, 407 diagnosis, 410 dietetic treatment, 410 infantile, 411 Scriveners' palsy, 1161. (See Writers' Cramp.) Scrofula, 271. (See Tuberculosis of Lymph- glands.) Scrotal appendicitis, 815 Scurvy, 407. {See Scorbuttis.) Seasonal relations of erysipelas, 172 of malaria, 81 of pneumonia, 137 of rheumatism, 204 Secondary fever-curve in small-pox, 220 spastic paralysis, 1089 emphysema, 531 kidney, 991 "Sepsis intestinalis," 196 Septicemia, 195 bacteriology, 195 coagulation-necrosis in, 195 diagnosis from sapremia, 198 modes of infection and introduction of the poison into the system, 196 pathology, 195 ptomains in, 195 symptoms, 197 treatment, 198 true, 198 typhoid, 27 Septicopyemia, 202 Serous membranes, tuberculosis of, 307 Serum, antipneumococcic, 156 antistreptococcic, 177 Serum-diagnosis of typhoid fever, 46 of yellow fever, 122 Serum-reaction, Pfeiffer's, 113 Sewer-gas, relation of, to typhoid fever, 26 Shaking palsy, 1154. (See^Paralysis Agitans.) Shell-fish, poisoning by, 1223. Ship fever. (See Typhus Fever.) Sick headache, 1142. (See Migraine.) Siderosis, 537. (See Ptienmonokoniosis.) Simple continued fever, 369. (See Febricula.) Sinus-thrombosis, 1110 in chlorosis, 423, 1110 secondary to ear-disease, 1110 Sixth nerve, j>aralysis of, 1045 Skoda's resonance in lobar pneumonia, 145 in sero-fibrinous effusion, 549 Skull in external hydrocephalus, 1128 in internal hydrocephalus, 1128, 1129 in rickets, 403 natiform, in congenital syphilis, 331 Small-pox, 215 abortive form, 223 bacteriology, 217 causes, 217 complications, 219 confluent form, 222 contagion of, 217 diagnosis, 223 eruption of, 219 hemorrhagic form, 222 immunity in, 217 incubation of, 218 initial rashes in, 218 mortality and prognosis, 225 prophylaxis in, 225 secondary lesions in, 216 special modes of treatment, 228 symptoms, 2.19 treatment, 225 Snake-virus, purpura caused bv, 412 SnuflJes, 331 Soil, influence of. in cholera. 111 in malaria, 79 in tuberculosis, 270 in typhoid fever, 24 Southern California in tuberculosis,'^21 Southern Georgia, .321, 322 Southern Italy and France, 322 Spasm, habit-, 1152 in ergotism, 1224 in hydrophobia, 3.56 in hysteria, 1167, 1168, 1169 mimic, 1048 of the intestine, 845 retro-colic, 1059 saltatoric, 1154 tonic, in tetanus, 360 Spasmodic laryngitis, 477 Spastic paraplegia, 1087 congenital, 1089 family tendency in, 1088 Speech, 1120. (See Aphasia.) in general ])aralysis of insane, 1131 in hereditary ataxia, 1086 loss of, in bulbar paralysis, 1094 scanning, in multiple sclerosis, 1092 Spina bifida in lesions of cauda equina, 1103 Spinal accessory nerve, paralysis of, 1060 compression, 1098 cord, abscess of, 1079 comjjression of, 1098 discas.s of, 1065 disturbance of circulation in, 1070 hemorrhage into, 1072 localization of functions of, 1023 syphilis of, 3.34 tuberculosis of, 315 tumors of, 1100 unilateral lesion of, 10.50 membranes, hemorrhage into, 1069 meningitis, acute, 1068 nerves, diseases of, 1062 neurasthenia, 1176 INDEX. 1287 Spirals, Curschmann's, 495 Spirillum of relapsing fever, 74 Splanchnoptosis, 792 Splashing sounds in dilatation of stomach, 746 Spleen, amyloid degeneration of, 904 diseases of, 901 * dislocation of, 901 echinococcus of, 1255 floating, 901 hyperemia of, 901 in anthrax, 353 in cirrhosis of livei', 891 in malaria, 80, 91 in pseudo-leukemia, 447 in rickets, 406 in typhoid fever, 20, 28 in typhus fever, 70 morbid growths of, 904 rupture of, 905 sago, 904 Splenic anemia, 450 fever, 352. (See Anthrax.) Splenitis, 901 Spondylitis deformans, 390. (See Arthritis Deformans.) Sporadic cretinism, 462. (See Myxedema.) Spotted fever, 124. (See Cerebrospinal Men- ingitis. ) Spurious relapse in typhoid fever, 51 Sputa, amceba coli, 103, 881 in abscess of lung, 535 in acute bronchitis, 482 in asthma, 495 in bronchiectasis, 490 in cancer of lung, 538 in chronic bronchitis, 486 in chronic pulmonary tuberculosis, 290 in edema of lung, 503 in fetid bronchitis, 486 in gangrene of lung, 533 in lobar pneumonia, 140 St. Anthony's fire. (See Erysipelas.) St. Vitus's dance, 1144. (See Chorea.) Status eclampticus, 1160 epilepticus, 1140 Stellwag's sign, 459 Stenocardia, 671. (See Angina Pectoris.) Stenosis, bronchial, 493 of aortic orifice, 605 of mitral orifice, 613 pulmonary, 622 tricuspid, 620 Stomach, auscultation of, 742 carcinoma of, 771 chemical examination of contents, 736 dilatation of, 744 diminished peristalsis of, 784 diseases of, 735 hemorrhage of, 778 hyperacidity of, 782 hyperesthesia of, 787 increased peristalsis of, 784 inflammatory diseases of, 749 malposition of, 743 neuroses of, 779 of motility of, 784 of secretion of, 782 of sensation of, 785 palpation of, 741 percussion of, 742 physical or external examination of, 740 test for absorptive power of, 740 Stomach, test-meals used in diagnosis, 736 tests for motor function of, 739 ulcer of, 763 Stomatitis, 695 aphthous, 696 gangrenous, 703 La Perleche, 703 membranous, 698 mercurial, 705 parasitic, 701 ulcerative, 799 Strabismus, 1045 Strangulation of bowel, 828 " Strawberry tongue " in scarlet fever, 237 Stricture of esophagus, 732 Strictures and tumors of bowel, 830 cicatricial, of bowel, 830 congenital, of bowel, 830 Strongyloides intestinalis, 1250 Strumitis, 455. (See Thyroiditis.) Styrians, arsenical habit in, 1220 Subphrenic abscess, 568. (See Actite Peri- hepatitis.) Succussion, Hippocratic, 567, 568 Sudoral form of typhoid fever, 33 Sugar in the urine, 374. (See Diabetes Mel- litus.) Sun-stroke, 1230. (See Heat-stroke.) Suppurative pneumonitis, 534. (See Abscess of Lungs.) pylephlebitis, 868 Surgical kidney, 994 Swamp-fever. (See Malaria.) Sweating sickness, 371. (See Miliary Fever.) Sydenham's chorea, 1144. (See Actite Chorea.) Symptom-complex of Brown-Sequard, 1101 Syncope, local, in Raynaud's disease, 1186 Synovitis, gonorrheal, 213 Syphilis, 326 amyloid degeneration in, 330 bacteriology of, 327 brain tumor in, 334 Colles' law in, 328 contagion of, 328 difierential diagnosis of, 341 eruption of, 329 general diagnosis, 340 gummata in, 330 hsemorrhagica neonatorum, 418 hereditary, 328 Hutchinson teeth in, 332 hypodermic treatment, 343 incubation of, 329 inunctions in, 343 late symptoms of hereditary, 333 malignant, 330 modes of infection, 328 morbid anatomy, 327 of alimentary tract, 336 of arteries, 339 of brain and cord, 333 of circulatory system, 338 of joints, 339 of kidneys, 339 of liver, 334 of lungs, 337 of spleen, 338 of testicles, 340 primary sore of, 329 stage, 329 secondary stage, 329 tertiary stage, 330 treatment of acquired, 343 1288 INDEX. Syphilis, treatment of hereditary, 342 visceral, 333 Syphilitic cachexia, 329 fever, 329 paralysis, 334. (See Dementia Paralytica.) Syringomyelia, 1097 hydi"omyelia in, 1097 Tabes, diabetic, 380 dorsalis, 1081. (See Locomotor Ataxia.) mesenterica, 310 Tache bleuatres, 33 Tachycardia, 665 neurotic, 666 symptomatic, 666 Tactile fremitus in emphysema, 529 in passive hyperemia, 501 in pleural effusion, 548 in pneumothorax, 566 in pulmonary tuberculosis, 294 Taenia cucumerina, 1260 echinococcus, 1251 flavopunctata, 1260 mediocanellata, 1257 nana, 1260 solium, 1256 Tseuiae or tape-worm, 1256 Teeth, Hutchinson's, 332 Temperature-sense, loss of, in svringomvelia, 1097 Tertian intermittent fever, ameba causing, 82 Testes, syphilis of, 340 tuberculosis of, 313 Tetanus, 358 acute, 359 antitoxin of, 362 bacillus of, 359 cephalic, 360 chronic, 360 diagnosis, 360 duration, 361 idiopathic, 359 immunity in, 359 incubation, 359 modes of infection, 359 morbid anatomy, 359 mortality, 361 traumatic, 359 treatment, 361 Tetanv, 1156 Thermic fever, 1231 Third nerve, diseases of, 1043 paralysis of, l543 relapsing and recurring paralysis of, 1044 Thiroloix Achalmii, 203 Thomsen's disease, 1205 Thoracic aorta, aneursym of, 683 dropsy, 569. (See Uydrothorax.) duct, rupture of tuberculous focus into, 275 Thorax in emphysema, 528 in pulmonary tuberculosis, 283 in rachitis, 405 Thread-worm, 1240 Throat, acute infectious jihlegmon of, 723 Thrombi in veins in typhoid fever, 39 Thrombosis, cardiac, 636 Thrush, 701. (See Parasitic Stomatitis.) Thymus gland, diseases of, 574 Thyroid extract, use of, 461, 464, 465 gland, diseases of, 455 in cretinism, 465 Thyroid gland in exophthalmic goiter, 458 in goiter, 456 in mvxedema, 462 Thryoidin, 462 Thryoiditis, 455 Thyro-proteid, 462 Tic convulsif, 1049 douloureux, 1034 general, 1152 Tobacco as a cause of arrhythmia, 670 of tremor, 1155 Tongue, acute inflammation of, 706 atrophy of, 1061 chronic inflammation of, 707 diseases of, 706 fissure of, 708 in bulbar paralysis, 1095 paralysis of, 1061 spasm of, 1061 ulcers of, in syphilis, 329 Tonsillitis, acute catarrhal, 712 acute parenchymatous, 713 chronic, 717 follicular, 712 necrotic, 714 Tonsils, disease of, 711 Toothache in actinomycosis, 351 Tophi in gout, 393 Torticollis, 363. (See Muscular Ehenmatisjn.) Tracheo-bronchitis, 480 Traube's semilunar space, 549 Tremor, hereditary, 1156 hystei-ic, 1156 in exophthalmic goiter, 460 in multiple sclerosis, 1156 in paralysis agitans, 1155 senile, 11.56 simple, 1156 smokers', 1156 toxic, 1156 Trichina spiralis, 1243 sources of infection with, 1244 Trichinosis, 1243 diagnosis, 1246 symptoms, 1245 treatment, 1246 Trichocephalus dispar, 1242 Tricuspid incompetency or regurgitation, 617 regurgitation, murmur in, 619 venous congestion in, 619 stenosis, 620 Trigeminus, 1047. (See Fifth Nerve.) Trismus, 358. (See Tetanus.) Trousseau's sign in tetany, 1157 Tuberculosis, 260 acute, 274 cerebral or meningeal form, 278 general miliary form, 275 pulmonary form, 277 typhoid form, 275 amyloid degeneration in, 289 antiseptic treatment of, 319 associated diseases and complications, 316 inflammatorv processes in, 263 bacillus of, 263 biology of bacillus, 264 cavities in chronic, 287 changes occurring in a tubercle, 262 chemical products elaborated by bacillus, 264 chronic, 285 climatic treatment of, 321 INDEX. 1289 Tuberculosis, clinical types of tuberculous meningitis, 281 contagious theory of, 266 diagnosis, 281 of acute, 276 of chronic, 301 diet in, 323 differential diagnosis, 302 direct hereditary transmission, 268 disseminated, 288 distribution of the bacilli in, 264 of tubercular lesions in, 261 dyspnea in, 293 elastic iibers in, 292 elementary tubercle, 261 etiology, 263 of chronic, 285 Flick's studies in, 266 general pathology of tubercular lesions, 261 prognosis, 316 symptoms, 297 tuberculous adenitis, 274 geographical distribution of, 260 hemoptysis in chronic, 293 histology of tuberculous meningitis, 280 historic note of, 261 infection by inoculation, 267 by swallowing, 266 inhalation of the bacilli, 265 inoculations in, 264 interstitial pneumonia in, 288 intestinal, 305 isolation in, 318 local causes, 270 symptoms of chronic, 290 mensuration in, 294 method of staining bacilli, 291 modes of infection, 265 morbid anatomy of chronic, 285 night-sweats in, 299 of alimentary tract, 305 of arteries and veins, 316 of brain, 315 of bronchial glands, 273 of endocardium, 289 of Fallopian tubes, ovaries, and uterus, 314 of genito-urinary system, 312 of heart, 315 of intestinal tract, 289 of kidneys, 312 of larynx, 289 of lip, 304 of liver, 311 of lymph-glands, 271 of mammary glands, 315 of mesenteric glands, 273 of pericardium, 308 of peritoneum, 309 of pleura, 288 of serous membranes, 307 of spinal cord, 315 onset of chronic, 289 pathology of tuberculous meningitis, 278 physical signs in stage of consolidation, 293 of cavity, 296 predisposing causes, 268 prognosis of tuberculous meningitis, 282 prophylaxis, 317 sanatorium treatment of, 322 serum-diagnosis in, 302 Tuberculosis, serum-therapy of, 324 sources of the bacilli, 264 special remedies in, 324 special symptoms of chronic, 299 sputum in, 290 stages in development of tubercle, 261 symptoms of tuberculous meningitis, 280 temperature in chronic, 298 treatment, 319 of leading symptoms, 324 tuberculin in, 320 Tumors, intracranial, 1124 of larynx, 479 of nerves, 1032. (See Neuromata.) of spinal coi-d, 1100 Tunnel-anemia, 1242 Tussis convulsiva, 251. (See Whooping-cough.) Twists and knots in the bowels, 829 Tylosis linguse, 708. (See Lingual Psoriasis.) Tympanites in acute peritonitis 917 in appendicitis, 820 in intestinal obstruction, 831, 832 in typhoid fever, 34 Typhoid fever, 17 abnormal course of fever, 31 bacteriology of, 22 bed-sores in, 33 blood-changes in, 40 chart showing effect of cold baths in, opposite p. 55 clinical history, 27 varieties, 44 complicated by infectious diseases, 44 constipation in, 34 contraindications to cold baths in, 60 delirium in, 41 diabetes in, 43 diagnosis, 46 diarrhea in, 34 diazo-reaction in, 43 diet in, 54 differential diagnosis, 47 disinfection in, 52 Ehrlich's reaction in, 43 epistaxis in, 38 etiology, 22 experimental, 23 fastigium or second stage, 28 gastric symptoms in, 36 guaiacol in treatment of, 61 headache in, 62 history, 17 hydrotherapy of, 55 hypostatic congestion of lungs in, 38 immunity to, 25 in children, 46 incubation of, 27 insanity in, 42 insomina in, 63 internal antipyretics in, 61 intestinal antiseptics in, 61 hemorrhages in, 35 in the aged, 46 isolation of patients, 53 jaundice in, 33 leukocytosis in, 36 liver in, 20 lobar pneumonia in, 38 lobular pneumonia in, 37 lungs in, 21 management of convalescence in, 66 1290 INDEX. Typhoid fever, methods of conveyance of the poison into the human body, 25 modes of infection, 25 mouth and tonsils in, 37 muscular system in, 22, 44 nephritis in, 43 nervous symptoms in, 41 neuralgia in, 42 ocular complications in, 42 osseous system in, 44 oysters and, 26 pathology, 18 perforation in, 35 pericarditis in, 39 perichondritis in, 38 period of Wunderlich, 29 peritonitis in, 35 Peyer's patches in, 18 pleuro-typhoid, 45 post-typhoid elevations of tempera- ture in, 32 predisposing causes, 24 prognosis, 49 prophylactic inoculations in, 53 prophylaxis in, 52 pseudo-membranous inflammation in, 44 pulse in, 39 pyelitis in, 43 recurrence of, 52 relapses in, 51 rose-colored spots in, 32 saline infusion in, 65 serum -diagnosis of, 46 serum-therapy in, 46, 62 skin-rashes in, 33 spleen in, 36 stage of decline, 28 of development, 27 stimulants in, 55 stools in, 34 substitutes for the cold bath in, 60 subsultus tendiuum in, 42 sweating in, 33 temperature-charts in, 30 thrombosis in, 39, 40 tonsillo-typhoid, 37 treatment, 52 of bed-sores, 66 of hemorrhages, 65 of individual symptoms, 62 of lobar pneumonia. (See Sec- ondary Pneumonia.) of tympanites, 64 tympanites in, 34 typho-toxin of, 23 urine in, 42 walking-form, 45 Widal's reaction in, 47, 48 septicemia, 27 Typho-toxin, 23 Typhus fever, 67 causes, 68 contagiousness of, 69 course and duration, 71 diagnosis, 72 eruption in, 70 history, 67 pathology, 68 symptoms, 69, 71 temperature in, 70 treatment, 72 Isevissimus, 44. (See Typhoid Fever.) Ulcer, duodenal, 808 follicular, 811 gastric, 763 intestinal, 808 in typhoid fever, 18 of bowel in dysentery, 99, 101, 104, 107 of esophagus, 726 solitary, 812 stercoral, 811 Ulcerative endocarditis. (See Endocarditis.) stomatitis, 699 Ulcero-membranous tonsillitis, 711 Ulcers, aphthous, 697 Ulnar nerve, diseases of, 21, 1064 Uremia, 962 acute, 963 chronic, 963 diagnosis from cerebellar hemorrhage and alcoholic narcosis, 965 in chronic nephritis, 988 pathology and etiology, 962 symptoms, 963 Ureter, blocking of, 969 tuberculosis of, 313 Urethritis in lithemia, 401 Uric-acid calculi, 969 diathesis, 400. (See Lithemia.) Urinary system, diseases of, 933 Urine, acetone, diacetic and oxybutyric acids in, 952 albumin in, 942 alkaptone in, 959 bacteria in, 959 bile-pigment in, 948 blood in, 938 chlorides in, 958 chyle in, 947 cystin in, 9.56 fat in, 958 fibrinous cast in, 9.55 gas-formation in, 958 glucose in, 949 hematoporphyrin in, 958 hemoglobin in, 940 in acute cystitis, 1007 in Bright's disease, 977, 983, 988 in chronic parenchymatous nephritis, 98S in diabetes insipidus, 386 in diabetes mellitus, 378 in diphtheria, 186 in jaundice, 849 in pneumonia, 144 in scarlet fever, 240 in typhoid fever, 42 incontinence of, 1014 indican in, 945 inosite in, 959 lactose in, 959 leucin and tyrosin in, 956 oxalates in excess in, 954 peptone and albumose in, 945 phosphates in excess in, 955 pus in, 946 retention of, 1016 special pathologic states of, 938 suppression of, in acute intestinal ob- struction, 831 in acute nephritis, 977 urea in, 957 uric acid in excess in, 953 urobilin in, 949 Urobilinuria, 949 Urticaria epidemica, 1263 INDEX. 1291 Urticaria, giant, 1184 in acute articular rheumatism, 207 in chronic gastritis, 758 in pneumonia, 143 in typhoid fever, 33 Uterus, tuberculosis of, 314 Uvula, edema of, in diphtheria, 184 Vaccination, 229 complications, 231 danger of conveying syphilis when hu- manized virus is used, 230 history, 229 lymph used in, 230 operation, 230 period of life for, 231 site, 230 symptoms, 231 time for re vaccination", 231 Vaccine virus, 230 Vaccinia, 229 " Vagabonds' disease," 454 Valvular (cardiac) diseases, complications of, 623 duration, 624 prophylaxis in, 626 treatment, 627 venesection in, 631 disease of the heart, chronic, 596 tuberculosis, 316 Varicella, 231 cause, 231 diagnosis, 233 from variola, 224 eruption in, 232 gangrsenosa, 232 immunity in, 232 incubation, 232 treatment, 233 with sero-purulent vesicles, 232. Variola, 215. (See Small-pox.) Varioloid, 223 Vasomotor and trophic disorders, 1184 disturbance in chronic pleurisy, 563 in exophthalmic goiter, 458 in migraine, 1142 in myelitis, 1075 in neuralgia, 1034 in tumors of the spinal cord, 1101 Veal pie, poisoning by, 1223 Veins, arterio-venous' aneurysm, 694 cerebral, thrombosis in, 1111 diastolic collapse of, 585 Vena cava inferior, compression of, by an- eurysm, 684 Venesection in chronic valvular disease, 631 in emphysema, 531 in pneumonia, 155 Venous cerebral hemorrhage, 1116 pulse in aortic incompetency, 603 in neurasthenia, 1176 in tuberculosis, 299 Ventricles of brain, enlargement of, 1129 tapping of, 1130 Ventricular hemorrhage, 1115 Vertebrse, injuries and caries of, 1099 Vertigo, auditory, 1053. (See Meniere's Dis- ease.) gastric, 758 in arterio-sclerosis, 681 in cerebellar disease, 1125 Vesical catarrh in typhoid fever, 43 hemorrhage, 1011 Vesical irrigation, 1010 medication, 1010 Vesiculse seminales, tuberculosis of, 313 Voice, change of, in mouth-breathers, 718. (See Speech.) Volitional tremor, 1092 Volvulus, 829 Vomica, 287. (See Cavities in Chronic Tuber- culosis.) Vomit, black, 122 coffee-ground, 773 stercoraceous, 831 Wall-paper a source of arsenical poison- ing, 1219 War of the Eebellion, statistics of dysen- tery in, 98 Washing out the stomach, method of, 736 Water, infection by, in cholera, 112 in dysentery, 101 in typhoid fever, 25 Water-hammer pulse, 603 Weber, syndrome of, 281 Weil's disease, 367 Weir Mitchell's disease, 1191 Werlhoff's disease, 414 Wernicke's "aphasia of conduction," 1121 Westphal's symptom, 1045 Wet pack, 60 " White flux " of India, 804 White softening, cerebral, 1109 Whooping-cough, 251 bacteriology, 253 catarrhal stage, 254 complications and sequelae, 255 contagiousness, 251 diagnosis, 256 etiology, 251 incubation, 254 mortality, 255 nature and bacteriology, 203 paroxysmal stage, 254 pathology, 251 prognosis, 255 symptoms, 254 treatment, 257 Widal reaction in typhoid fever, 47 in yellow fever, 122 Winckel's disease, 418. (See Epidemic Hemo- globinuria.) Winged scapulae, 294, 528 Wiutrich's sign, 297 Wood-tick, 1263 Wool-sorters' disease, 352. (See Anthrax.) Word-blindness, 1123 Word-deafness, 1122 Wormian bones, 1129 Worms, 1238. (See Nematoda.) Wound-diphtheria, 185 Wrist-drop, 1063 in plumbism, 1218 Writers' cramp, 1161 Wry-neck, 1058. (See Torticollis.) Wunderlich, "ambiguous period" of, 29 Xanthelasma, 850 Xanthin, 965 Xanthopsia, 850, 1240 Xerostoma, 710 Yellow Fever, 119 bacteriologv, 120 blood in, i'io 1292 INDEX. Yellow fever, causes, 120 duration, 122 epidemics of, 119 grave symptoms in, 122 hemorrhages in, 121 history, 119 incubation. 120 in vasiou -stage, 121 mortality, 122 pathology, 119 prophylaxis in, 123 protective inoculation in, 123 1 Yellow fever, remission stage, 121 secondary fever or collapse in, 121 serum-diagnosis of, 122 serum-therapeutics of, 124 temperature in, 120 treatment, 123 varieties, 122 vomit in, 121 softening, cerebral, 1109 vision, 1240 Yeo's diet-list, 1229 CATALOGUE OF THE MEDICAL PUBLICATIONS OF W. B. SAUNDERS, No. 925 WALNUT STREET, PHILADELPHIA. Arranged Alphabetically and Classified under Subjects. 'T'HE books advertised in tliis Catalogue as being sold by subscription are usually to be obtained from, traveling solicitors, but they wlU be sent direct from tbe office of pub- lication (charges of shipment prepaid) upon receipt of the prices given. All the other books advertised are commonly for sale by booksellers in all parts of the United States ; but any book will be sent by the publisher to any address, carriage prepaid, on receipt of the published price* Money may be sent at the risk of the publisher in either of the following ways : A post-office money order, an express money order, a bank check, and in a registered letter. Money sent in any other way is at the risk of the sender. See pages 30, 31, for a List of Contents classified according to subjects. LATEST PUBLICATIONS. American Text-Book of Genito-Urinary and Skin Diseases. Page 4, American Text-Book of Diseases of Children — Rev. Edition* Page 3. American Text-Book of Gynecology — Revised Edition. See page 4. American Year-Book of Medicine and Surgery. See page 6. Anders' Practice of Medicine — Revised Edition. See page 6. Vierordt's Medical Diagnosis — Fourth (Revised) Edition. See page 28. Van Valzah and Nisbet's Diseases of the Stomach. See page 28. Church and Peterson's Nervous and Mental Diseases. See page 9. Da Costa's Surgery — Revised and Enlarged Edition. See page 10. Saunders' Medical Hand-Atlases. See page 2. Keen's Surgical Complications of Typhoid Fever. See page J5. Griffith on The Baby — Revised Edition. See page 12. Butler's Materia Medica and Therapeutics — Revised Edition. Page 8. De Schweinitz' Diseases of the Eye — Revised Edition. See page 10. Chapin's Compendium of Insanity. See page 8. Senn's Genito-Urinary Tuberculosis. See page 25. Penrose's Diseases of Women. See page 18. McFarland's Pathogenic Bacteria — Revised Edition. See page 17. Macdonald's Surgical Diagnosis. See page 16. Moore's Orthopedic Surgery. See page 17. Mallory and "Wright's Pathological Technique. See page 16. Saunders' Medical Hand-Atlases. The series of books included under this title are authorized translations into English of the world-famous Lehmann Medicinische Hand=atlanten. Tor scientific accuracy, pictorial beauty, compactness, and cheapness these books surpass any similar volumes ever published. Each volume contains from 50 to 100 Colored Plates, besides numerous other illustrations in the text. These colored plates have been executed by the most skilful German lithographers, in some cases twenty or more impressions being required to obtain the desired result. There is a full and appropriate description of each plate (printed, for convenience, opposite the plate) , together with a condensed outline of the subject to which the book is devoted. The same careful and competent editorial supervision will be secured in the English edition as in the originals. The translations will be directed and edited by the leading American specialists in the different subjects. The great advantage of natural pictorial representation is indisputable. For lasting and practical knowledge, one accurate illustration is better than several pages of dry description. These Atlases offer a ready and satisfactory substitute for clinical observation, avail- able only to the residents of large medical centers ; and with such persons the requisite variety is seen only after long years of routine hospital service. By reason of their projected universal translation and reproduction, affording inter- national distribution, the publishers have been enabled to secure for these Atlases the best artistic and professional talent, to produce them in the most elegant style, and yet to offer them at a price heretofore unapproached in cheapness. The success of the under- taking is demonstrated by the fact that volumes have already appeared in German, English, French, Italian, Russian, Spanish, Danish, Swedish, and Hungarian. WTiile appreciating the value of such colored plates, the profession has heretofore been practically debarred from purchasing similar works because of their extremely high price, made necessarj- by the limited sale and the enormous expense of production. The very low price of these Atlases will place them within the reach of even the novice in practice. NOW READY. Atlas of Internal Medicine and Clinical Diagnosis. By Dr. Chr. Jakob, of Erlangen. Edited bj-AuGL-STLS A. EsHNER, M.D.. Pi ofessof of CHtiical Medicine in the Philadelphia Polvclinic ; At- tending Physician to the Philadelphia Hospital. 68 colored plates, and 64 illustrations in the text. Cloth, $3.00 net. Atlas of Legal Medicine. By Dr. E. R. von Hofmaxn, of Vienna. Edited by Frederick Peter- son, M.D., Clinical Professor of Mental Diseases, Woman's Medical College, New York; Chiel of Clinic Nervous Dept., College of Physicians and Surgeons, New York. 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AN AMERICAN TEXT=BOOK OF DISEASES OF THE EYE, EAR, NOSE, AND THROAT. By 58 Prominent Specialists. Edited by G. E. de Schweinitz, M.D., Professor of Ophthalmology in the Jefferson Medical College, Phila- delphia ; and B. Alexander Randall, M.D., Professor of Diseases of the Ear in the University of Pennsylvania and in the Philadelphia Polyclinic, Ready soon. Illastrated Catalogue. of the ** American Text-Books*' sent free tipon applicatioiu 4 Medical Publications of W. B. Saunders. AN AMERICAN TEXT=BOOK OF GENITO=URINARY AND SKIN DISEASES. By 47 Eminent Specialists and Teachers. Edited by L. Bolton Bangs, M.D., Late Professor of Genito-Urinary and Venereal Diseases, New York Post-Graduate Medical School and Hospital ; and W, A. Hardaway, M.D., Professor of Diseases of the Skin, Missouri Medical College. Imperial octavo volume of 1229 pages, with 300 en- gravings and 20 full-page colored plates. Cloth, $7.00 net; Sheep or Half Morocco, $8.00 net. Sold by Subscription. 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Prices per volume : Cloth, $5.00 net ; Sheep or Half Morocco, ^6.00 net. Sold by Subscription. " I am quite sure it will commend itself both to practitioners and students of medicine, and become one of our most popular text-books." — Alfred Loomis, M.D., LL.D., Pro- fessor of Pathology and Practice of Medicine, University of the City of New York. " We reviewed the first volume of this work, and said : ' It is undoubtedly one of the best text-books on the practice of medicine which we possess.' A consideration of the second and last volume leads us to modify that verdict and to say that the completed work is in our opinion the best of its kind it has ever been our fortune to see. " — New York Medical Journal. Illustrated Catalogue of the *^ American Text-Books*^ sent free upon application. 6 Medical Publications of W. B. Saunders. AN AMERICAN YEAR-BOOK OF MEDICINE AND SURGERY. A Yearly Digest of Scientific Progress and Authoritative Opinion in all branches of Medicine and Surgery, drawn from journals, monographs, and text-books of the leading American and Foreign authors and investigators. Collected and arranged, with critical editorial com- ments, by eminent American specialists and teachers, under the general editorial charge of George M. Gould, M.D. One handsome imperial octavo volume of about 1200 pages. Uniform in style, size, and general make-up with the "American Text-Book" Series. Cloth, $6.50 net; Half ISIorocco, $7.50 net. SM by Subscription. " It is difficult to know which to admire most — the research and industry of the distin- guished band of experts whom Dr. Gould has enlisted in the service of the Year- Book, or the wealth and abundance of the contributions to every department of science that have been deemed worthy of analysis. . . . It is much more than a mere compilation of abstracts, for, as each section is entrusted to experienced and able contributors, the reader has the advantage of certain critical commentaries and expositions . . . proceeding from writers fully qualified to perform these tasks. . . . It is emphatically a book which should find a place in every medical library, and is in several respects more useful than the famous ' Jahrbiicher ' of Germany." — London Lancet. ANDERS' PRACTICE OF MEDICINE. Second Edition. A Text=Book of the Practice of Medicine. By Ja.mes M. Anders, M.D., Ph.D., LL.D., Professor of the Practice of Medicine and of Clinical Medicine, Medico-Chirurgical College, Philadelphia. In one handsome octavo volume of 1287 pages, fully illustrated. Cloth, $5.50 net; Sheep or Half Morocco, $6.50 net. " It is an excellent book, — concise, comprehensive, thorough, and up to date. It is a credit to you ; but, more than that, it is a credit to the profession of Philadelphia — to us." James C. Wilson, Professor of the Practice of Medicine and Clinical Medicine, Jefferson Medical College, Philadelphia. " I consider Dr. Anders' book not only the best late work on Medical Practice, but by far the best that has ever been published. It is concise, systematic, thorough, and fully up to date in everything. I consider it a great credit to both the author and the publisher." — A. C. COWPERTHWAITE, President of the Illinois Homeopathic Medical Association. ASHTON'S OBSTETRICS. Fourth Edition, Revised. Essentials of Obstetrics. By W. Easterly Ashton, M.D., Pro- fessor of Gynecology in the Medico-Chirurgical College, Philadelphia. Crown octavo, 252 pages; 75 illustrations. Cloth, $1.00; interleaved for notes, $1.25. [See Saunders' Questiofi- Comfends, page 21.] " Embodies the whole subject in a nut-shell. We cordially recommend it to our read- ers." — Chicago Medical Times. BALL'S BACTERIOLOGY. Third Edition, Revised. Essentials of Bacteriology ; a Concise and Systematic Introduction to the Study of Micro-organisms. By M. V. Ball, M.D., Bacteriol- ogist to St. Agnes' Hospital, Philadelphia, etc. Crown octavo, 218 pages; 82 illustrations, some in colors, and 5 plates. Cloth, $1.00; interleaved for notes, $1.25. [See Saunders'' Question- Compends, page 21.] " The student or practitioner can readily obtain a knowledge of the subject from a perusal of this book. The illustrations are clear and satisfactory." — Medical /Record, New York. Medical Publications of W, B. Saunders. 7 BASTIN'S BOTANY. Laboratory Exercises in Botany. By Edson S. Bastin, M.A., late Professor of Materia Medica and Botany, Philadelphia College of Pharmacy. Octavo volume of 536 pages, with 87 plates. Cloth, $2.50. "It is unquestionably the best text-book on the subject that has yet appeared. The work is eminently a practical one. We regard the issuance of this book as an important event in the history of pharmaceutical teaching in this country, and predict for it an unquali- fied success." — Alumni Report to the Philadelphia College of Pharmacy. "There is no work like it in the pharmaceutical or botanical literature of this country, and we predict for it a wide circulation." — American Jotirnal of Pharmacy, BECK'S SURGICAL ASEPSIS. A Manual of Surgical Asepsis. By Carl Beck, M.D., Surgeon to St. Mark's Hospital and the New York German Poliklinik, etc. 306 pages; 65 text-illustrations, and 1 2 full-page plates. Cloth, ^1.25 net. " An excellent exposition of the ' very latest ' in the treatment of wounds as practised by leading German and American surgeons." — Birmingham (Eng.) Medical Review. "This little volume can be recommended to any who are desirous of learning the details of asepsis in surgery, for it will serve as a trustworthy guide." — London Lancet. BOISLINIERE'S OBSTETRIC ACCIDENTS, EMERGENCIES, AND OPERATIONS. Obstetric Accidents, Emergencies, and Operations. By L. Ch. BoisLiNiERE, M.D., late Emeritus Professor of Obstetrics, St. Louis Medical College. 381 pages, handsomely illustrated. Cloth, ^2.00 net. " It is clearly and concisely written, and is evidently the work of a teacher and practi- tioner of large experience." — British Medical Journal. " A manual so useful to the student or the general practitioner has not been brought to our notice in a long time. The field embraced in the title is covered in a terse, interesting way." — Yale Medical Jotirnal. BROCKWAY'S MEDICAL PHYSICS. Second Edition, Revised. Essentials of Medical Physics. By Fred J. Brockway, M.D,, Assistant Demonstrator of Anatomy in the College of Physicians and Surgeons, New York. Crown octavo, 330 pages ; 155 fine illustrations. Cloth, ^i.oo net; interleaved for notes, $1.25 net. [See Saunders' Question- Compends, page 21.] " The student who is well versed in these pages will certainly prove qualified to com- prehend with ease and pleasure the great majority of questions involving physical principles likely to be met with in his medical studies." — American Practitioner and News. "We know of no manual that affords the medical student a better or more concise exposition of physics, and the book may be commended as a most satisfactory presentation of those essentials that are requisite in a course in medicine." — iVew York Medical Jotirnal. " It contains all that one need know on the subject, is well written, and is copiously illustrated." — Aledical Record, New York. BURR ON NERVOUS DISEASES. A Manual of Nervous Diseases. By Charles W. Burr, M.D., Clinical Professor of Nervous Diseases, Medico-Chirurgical College, Philadelphia ; Pathologist to the Orthopedic Hospital and Infirmary for Nervous Diseases; Visiting Physician to St. Joseph's Hospital, etc. I71 Preparation. 8 Medical Publications of W. B. Saunders. BUTLER'S MATERIA MEDICA, THERAPEUTICS, AND PHAR- MACOLOQY. Second Edition, Revised. A Text=Book of Materia Medica, Therapeutics, and Pharma- cology. By George F. Butler, Ph.G., M.D., Professor of Materia Medica and of Clinical Medicine in the College of Physicians and Surgeons, Chicago ; Professor of Materia Medica and Therapeutics, Northwestern University, Woman's INIedical School, etc. Octavo, 860 pages, illustrated. Cloth, ;g4.oo net; Sheep, $5.00 net. •' Taken as a whole, the book may fairly be considered as one of the most satisfactory of any single-volume works on materia medica in the market," — Journal of the American Medical Associatio7i. "The work is executed in a clear, concise, and practical manner, and should meet with a hearty endorsement from the students of our up-to-date colleges. The book will be found a valuable work of reference for the practitioner." — American Medico-Surgical Bulletin. CASSELBERRY ON THE NOSE AND THROAT. Diseases of the Nose and Throat. By W. E. Casselberrv, Pro- fessor of Laryngology and Rhinology in the Northwestern University Medical School, Chicago. In Preparation. CERNA ON THE NEWER REMEDIES. Second Edition, Revised. Notes on the Newer Remedies, their Therapeutic Applications and Modes of Administration. By David Cerna, M.D., Ph.D., formerly Demonstrator of and Lecturer on Experimental Therapeutics in the University of Pennsylvania ; Demonstrator of Physiology in the Medical Department of the University of Texas. Rewritten and greatly enlarged. Post-octavo, 253 pages. Cloth, ^1.25. " The appearance of this new edition of Dr. Cema's very valuable work shows that it is properly appreciated. The book ought to be in the possession of every practising physi- cian." — XclU York ^Ic'dical Journal. CHAPIN ON INSANITY. A Compendium of Insanity. By John B. Chapin, M.D., LL.D., Physician-in-Chief, Pennsylvania Hospital for the Insane ; late Physi- cian-Superintendent of the Willard State Hospital, New York ; Hon- orary Member of the Medico-Psychological Society of Great Britain, of the Society of Mental Medicine of Belgium. 1 2mo, 234 pages, illustrated. Cloth, $1.25 net. The author has given, in a condensed and concise form, a compendium of Diseases of the Mind, for the convenient use and aid of physicians and students. The work will also prove valuable to members of the legal profession and to those who, in their relations to the insane and to those supposed to be insane, often desire to acquire some practical knowledge of insanity presented in a form that may be understood by the non-professional reader. CHAPMAN'S MEDICAL JURISPRUDENCE AND TOXICOLOGY. Second Edition, Revised. Medical Jurisprudence and Toxicology. By Henry C. Chapman, M.D., Professor of Institutes of Medicine and Medical Jurisprudence in the Jefferson Medical College of Philadelphia. 254 pages, with 55 illustrations and 3 full-page plates in colors. Cloth, $1.50 net. "The best book of its class for the undergraduate that we know of." — N^ew York Medical Times. Medical Publications of W. B. Saunders. 9 CHURCH AND PETERSON'S NERVOUS AND MENTAL DISEASES. Nervous and Mental Diseases. By Archibald Church, M.D., Professor of Mental Diseases and Medical Jurisprudence in the North- western University Medical School, Chicago ; and Frederick Peter- son, M.D., Clinical Professor of Mental Diseases in the Woman's Medical College, New York ; Chief of Clinic, Nervous Department, College of Physicians and Surgeons, New York. In Press. CLARKSON'S HISTOLOGY. A Text=Book of Histology, Descriptive and Practical. By Arthur Clarkson, M.B., CM. Edin., formerly Demonstrator of Physiology in the Owen's College, Manchester; late Demonstrator of Physiology in Yorkshire College, Leeds. Large octavo, 554 pages; 22 engravings in the text, and 174 beautifully colored original illustra- tions. Cloth, strongly bound, ^6.00 net. " The work must be considered a valuable addition to the list of available text-books, and is to be highly recommended." — New York Medical Journal. ' ' This is one of the best works for students we have ever noticed. We predict that the book will attain a well-deserved popularity among our students." — Chicago Medical Recorder. "The volume is a most valua.ble addition to the armamentarium of the teacher." — Brooklyn Medical Jou?-nal. CLIMATOLOGY. Transactions of the Eighth Annual Meeting of the American Climatological Association, held in Washington, September 22-25, 1 89 1. Forming a handsome octavo volume of 276 pages, uniform with remainder of series. (A limited quantity only.) Cloth, $1.50. COHEN AND ESHNER'S DIAGNOSIS. Essentials of Diagnosis. By Solomon Solis-Cohen,' i\LD., Pro- fessor of Clinical Medicine and Applied Therapeutics in the Philadel- phia Polyclinic ; and Augustus A. Eshner, M.D., Professor of Clinical Medicine in the Philadelphia Polyclinic. Post-octavo, 382 pages; 55 illustrations. Cloth, §1.50 net. [See Saunders' Questioii-Cojupends, page 21.] " We can heartily commend the book to all those who contemplate purchasing a 'com- pend.' It is modern and complete, and will give more satisfaction than many other works which are perhaps too prolix as well as behind the times." — Medical Review, St. Louis. CORWIN'S PHYSICAL DIAGNOSIS. Essentials of Physical Diagnosis of the Thorax. By Arthur M. Corwin, A.M., M.D., Demonstrator of Physical Diagnosis in Rush Medical College, Chicago ; Attending Physician to Central Free Dis- pensary, Department of Rhinology, Laryngology, and Diseases of the Chest, Chicago. 200 pages, illustrated. Cloth, flexible covers, $1.25 net. " It is excellent. The student who shall use it as his guide to the careful study of physical exploration upon normal and abnormal subjects can scarcely fail to acquire a good working knowledge of the subject." — Philadelphia Polyclinic. "A most excellent little work. It brightens the memor}' of the differential diagnostic signs, and it arranges orderly and in sequence the various objective phenomena to logical solution of a careful diagnosis." — Journal of Net-vous and Me7ital Diseases. 10 Medical Publications of W. B. Saunders. CRAQIN'S QYN/ECOLOQY. Fourth Edition, Revised. Essentials of Gynaecology. By Edwin B. Cragin, M.D., Attend- ing Gynaecologist, Roosevelt Hospital, Out-Patients' Department, New York, etc. Crown octavo, 200 pages; 62 fine illustrations. Cloth, ;^i.oo; interleaved for notes, $1.25. [See Saufiders' Questio?i-Compe7ids, page 21.] "A handy volume, and a distinct improvement on students' compends in general. No author who was not himself a practical gynecologist could have consulted the student's needs so thoroughly as Dr. Cragin has done." — Medical Record, New York. CROOKSHANK'S BACTERIOLOGY. Fourth Edition, Revised. A Text=Book of Bacteriology. By Edgar M. Crookshank, M.B., Professor of Comparative Pathology and Bacteriology, King's College, London. Octavo volume of 700 pages, with 273 engravings and 22 original colored plates. Cloth, $6.50 net; Half Morocco, 57.50 net. " To the student who wishes to obtain a good resume of what has been done in bacteri- ology, or who wishes an accurate account of the various methods of research, the book may be recommended with confidence that he will find there what he requires." — London Lancet. Da COSTA'S SURGERY. Second Ed., Revised and Greatly Enlarged. Modern Surgery, General and Operative. By John Chalmers DaCosta, M.D., Clinical Professor of Surgery, Jefferson Medical College, Philadelphia ; Surgeon to the Philadelphia Hospital, etc. Handsome octavo volume of 900 pages, profusely illustrated. Cloth, $4.00 net; Half Morocco, ^5.00 net. "We know of no small work on surgery in the English language which so well fulfils the requirements of the modern student." — Medico-Chirtirgical Journal, Bristol, England. DE SCHWEINITZ ON DISEASES OF THE EYE. Second Edition, Revised. Diseases of the Eye. A Handbook of Ophthalmic Practice. By G. E. DE ScHWEiNiTZ, M.D., Professor of Ophthalmology in the Jefferson Medical College, Philadelphia, etc. Handsome royal octavo volume of 700 pages, with 256 fine illustrations and 2 chromo-litho- graphic plates. Cloth, $4.00 net ; Sheep or Half Morocco, $5-oo net. " A clearly written, comprehensive manual. One which we can commend to students as a reliable text-book, written with an evident knowledge of the wants of those entering upon the study of this special branch of medical science." — Bintish Medical Journal. " A work that will meet the requirements not only of the specialist, but of the general practitioner in a rare degree. I am satisfied that unusual success awaits it." — William Pepper, M.D., Professor of the Theory and Practice of Medicine and Clinical Medicine, University of Pennsylvania. DORLAND'S OBSTETRICS. A Manual of Obstetrics. By W. A. Newman Borland, M.D., Assistant Demonstrator of Obstetrics, University of Pennsylvania; Instructor in Gynecology in the Philadelphia Polyclinic. 760 pages; 163 illustrations in the text, and 6 full-page plates. Cloth, $2.50 net. " By far the best book on this subject that has ever come to our notice." — American Medical Review. " It has rarely been our duty to review a book which has given us more pleasure in its perusal and more satisfaction in its criticism. It is a veritable encyclopedia of knowledge, a gold mine of practical, concise thoughts." — American Aledico-Surgical Bulletin. Medical Publications of W. B. Saunders. 11 FROTH INGHAM'S GUIDE FOR THE BACTERIOLOGIST. Laboratory Guide for the Bacteriologist. By Langdon Froth- iNGHAM, M.D.V., Assistant in Bacteriology and Veterinary Science, Sheffield Scientific School, Yale University. Illustrated. Cloth, 75 cts. " It is a convenient and useful little work, and will more than repay the outlay neces- sary for its purchase in the saving of time which would otherwise be consumed in looking up the various points of technique so clearly and concisely laid down in its pages." — Ameri- can Medico- Sn7-gical Bulletin. GARRIGUES' DISEASES OF WOMEN. Second Edition, Revised. Diseases of Women. By Henry J. Garrigues, A.M., M.D., Pro- fessor of Gynecology in the New York School of Clinical Medicine ; Gynecologist to St. Mark's Hospital and to the German Dispensary, New York City, etc. Handsome octavo volume of 728 pages, illus- trated by 335 engravings and colored plates. Cloth, $4.00 net; Sheep or Half Morocco, ^5.00 net. ' ' One of the best text-books for students and practitioners which has been published in the English language ; it is condensed, clear, and comprehensive. The profound learning and great clinical experience of the distinguished author find expression in this book in a most attractive and instructive form. Young practitioners to whom experienced consultants may not be available will find in this book invaluable counsel and help." — Thad. A. Reamy, M.D., LL.D., Professor of Clinical Gynecology, Medical College of Ohio. GLEASON'S DISEASES OF THE EAR. Second Edition, Revised. Essentials of Diseases of the Ear. By E. B. Gleason, S.B., M.D., Clinical Professor of Otology, Medico-Chirurgical College, Philadelphia ; Surgeon-in-Charge of the Nose, Throat, and Ear Depart- ment of the Northern Dispensary, Philadelphia. 208 pages, with 114 illustrations. Cloth, $1.00; interleaved for notes, ^1.25. [See Saunders' Question- Comp ends, page 21.] " It is just the book to put into the hands of a student, and cannot fail to give him a useful introduction to ear-affections ; while the style of question and answer which is adopted throughout the book is, we believe, the best method of impressing facts permanently on the mind. " — Liverpool Medico- Chii'ujgical Journal. GOULD AND PYLE'S CURIOSITIES OF MEDICINE. Anomalies and Curiosities of Medicine. By George M. Gould, M.D., and Walter L. Pyle, M.D. An encyclopedic collection of rare and extraordinary cases and of the most striking instances of abnormality in all branches of Medicine and Surgery, derived from an exhaustive research of medical literature from its origin to the present day, abstracted, classified, annotated, and indexed. Handsome im- perial octavo volume of 968 pages, with 295 engravings in the text, and 12 full-page plates. Cloth, $6.00 net; Half Morocco, ^7.00 net. Sold by Subscription. " One of the most valuable contributions ever made to medical literature. It is, so far as we know, absolutely unique, and every page is as fascinating as a novel. Not alone for the medical profession has this volume value : it will serve as a book of reference for all who are interested in general scientific, sociologic, or medico-legal topics." — Brooklyn Medical Journal. "This is certainly a most remarkable and interesting volume. It stands alone among medical literature, an anomaly on anomalies, in that there is nothing like it elsewhere in medical literature. It is a book full of revelations from its first to its last page, and cannot but interest and sometimes almost horrify its readers." — American Medico- Surgical Bulletin. 12 Medical Publications of W. B. Saunders. GRIFFIN'S MATERIA MEDICA AND THERAPEUTICS. Manual of Materia Medica and Therapeutics. By Henry A. Griffin, A.B., IM.D., Assistant Physician to the Roosevelt Hospital, Out-Patient Department, New York City. In Preparatio7i. GRIFFITH ON THE BABY. Second Edition, Revised. The Care of the Baby. By J. P. Crozer Griffith, M.D., Clini- cal Professor of Diseases of Children, University of Pennsylvania ; Physician to the Children's Hospital, Philadelphia, etc. i2mo, 404 pages, with 67 illustrations in the text, and 5 plates. Cloth, $1.50. " The best book for the use of the young mother with which we are acquainted. . . . There are verj' few general practitioners who could not read the book through with advan- tage. ' ' — Archives of Pediatrics. "The whole book is characterized by rare good sense, and is evidently written by a master hand. It can be read with benefit not only by mothers but by medical students and by any practitioners who have not had large opportunities for obser\'ing children." — Ameri- can Journal of Obstetrics. GRIFFITH'S WEIGHT CHART. Infant's Weight Chart. Designed by J. P. Crozer Griffith, M. D. , Clinical Professor of Diseases of Children in the University of Penn- sylvania, etc. 25 charts in each pad. Per pad, 50 cents net. A convenient blank for keeping a record of the child' s weight during the first two years of life. Printed on each chart is a curve representing the average weight of a healthy infant, so that any deviation from the normal can readily be detected. GROSS, SAMUEL D., AUTOBIOGRAPHY OF. Autobiography of Samuel D. Gross, M.D., Emeritus Professor of Surgery in the Jefferson Medical College, Philadelphia, with Remi- niscences of His Times and Contemporaries. Edited by his Sons, Samuel W. Gross, M.D., LL.D., late Professor of Principles of Sur- gery and of Clinical Surgery in the Jefferson Medical College, and A. Haller Gross, A.M., of the Philadelphia Bar. Preceded by a Memoir of Dr. Gross, by the late Austin Flint, M.D., LL.D. In two handsome volumes, each containing over 400 pages, demy octavo, extra cloth, gilt tops, with fine Frontispiece engraved on steel. Price per volume, §2.50 net. " Dr. Gross was perhaps the most eminent exponent of medical science that America has yet produced. His Autobiography, related as it is with a fulness and completeness seldom to be found in such works, is an interesting and valuable book. He comments on many things, especially, of course, on medical men and medical practice, in a very interest- ing way.'" — 77/1? Spectator, London, England. HAMPTON'S NURSING. Nursing : Its Principles and Practice. By Isabel Adams Hamp- ton, Graduate of the New York Training School for Nurses attached to Bellevue Hospital ; Superintendent of Nurses, and Principal of the Training School for Nurses, Johns Hopkins Hospital, Baltimore, Md. i2mo, 484 pages, profusely illustrated. Cloth, $2.00 net. " Seldom have we perused a book upon the subject that has given us so much pleasure as the one before us. We would strongly urge upon the members of our own profession the need of a book like this, for it will enable each of us to become a training school in him- self. ' ' — Ontario Medical Journal. Medical Publications of W. B. Saunders. 13 HARE'S PHYSIOLOGY. Third Edition, Revised. Essentials of Physiology. By H. A. Hare, M.D., Professor of Therapeutics and Materia Medica in tiie Jefferson Medical College of Philadelphia; Physician to the Jefferson Medical College Hospital. Containing a series of handsome illustrations from the celebrated " Icones Nervorum Capitis" of Arnold. Crown octavo, 239 pages. Cloth, ^i.oo net; interleaved for notes, $1.25 net. [See Saunders' Question- Compefids, page 21.] "The best condensation of physiological knowledge we have yet seen." — Medical Record, New York. HART'S DIET IN SICKNESS AND IN HEALTH. Diet in Sickness and in Health. By Mrs. Ernest Hart, formerly Student of the Faculty of Medicine of Paris and of the London School of Medicine for Women ; with an Introduction by Sir Henry Thompson, F.R.C.S., M.D., London. 220 pages ; illustrated. Cloth, ^1.50. " We recommend it cordially to the attention of all practitioners ; both to them and to their patients it may be of the greatest service." — New York Medical Journal. HAYNES' ANATOMY. • A Manual of Anatomy. By Irving S. Haynes, M.D., Adjunct Professor of Anatomy and Demonstrator of Anatomy, Medical Depart- ment of the New York University, etc. 680 pages, illustrated with 42 diagrams in the text, and 134 full-page half-tone illustrations from original photographs of the author's dissections. Cloth, ^2.50 net. " This book is the work of a practical instructor — one who knows by experience the requirements of the average student, and is able to meet these requirements in a very satis-- factory way. The book is one that can be commended." — Medical Record, New York. HEISLER'S EMBRYOLOGY. A Text=Book of Embryology. By John C. Heisler, M.D., Pro- fessor of Anatomy in the Medico-Chirurgical College, Philadelphia. In Preparation. HIRST'S OBSTETRICS. A Text=Book of Obstetrics. By Barton Cooke Hirst, M.D., Professor of Obstetrics in the University of Pennsylvania. In Press. HYDE AND MONTGOMERY ON SYPHILIS AND THE VENEREAL DISEASES. Syphilis and the Venereal Diseases. By James Nevins Hyde, M.D., Professor of Skin and Venereal Diseases, and Frank H. Mont- gomery, M.D., Lecturer on Dermatology and Genito-U^rinary Diseases in Rush Medical College, Chicago, 111. 618 pages, profusely illustrated. Cloth, $2.50 net. " We can commend this manual to the student as a help to him in his study of venereal diseases. ' ' — Liverpool Medico- Chiriirgical Journal. "The best student's manual which has appeared on the subject." — St. Louis Medical tnd Surgical Journal. 14 Medical Publications of W. B. Saunders. JACKSON AND QLEASON'S DISEASES OF THE EYE, NOSE, AND THROAT. Second Edition, Revised. Essentials of Refraction and Diseases of the Eye. By Edward Jackson, A.M., M.D., Professor of Diseases of the Eye in the Phila- delphia Polyclinic and College for Graduates in Medicine; and — Essentials of Diseases of the Nose and Throat. By E. Bald- win Gleason, M.U., Surgeon-in-Charge of the Nose, Throat, and Ear Department of the Northern Dispensary of Philadelphia. Two volumes in one. Crown octavo, 290 pages; 124 illustrations. Cloth, $1.00; interleaved for notes, $1.25. [See Saunders' Question- Co7iipends, page 21.] " Of great value to the beginner in these branches. The authors are both capable men, and know what a student most needs." — Medical Record, New York. KEATINQ'S DICTIONARY. Second Edition, Revised. A New Pronouncing Dictionary of Medicine, with Phonetic Pronunciation, Accentuation, Etymology, etc. By John M. Keating, M.D., LL.D., Fellow of the College of Physicians of Phila- delphia ; Vice-President of the American Paediatric Society ; Editor "Cyclopaedia of the Diseases of Children," etc.; and Henry Hamilton, Author of '-'A New Translation of Virgil's ^neid into English Rhyme," etc.; with the collaboration of J. Chalmers Da- Costa, M.D., and Frederick A. Packard, M.D. With an Appendix containing Tables of Bacilli, Micrococci, Leucomaines, Ptomaines; Drugs and Materials used in Antiseptic Surgery ; Poisons and their Antidotes; Weights and Measures; Thermometric Scales; New Official and Unofficial Drugs, etc. One volume of over 800 pages. Prices, with Denison's Patent Ready-Reference Index: Cloth, $5.00 net; Sheep or Half Morocco, $6.00 net; Half Russia, $6.50 net. Without Patent Index: Cloth, $4.00 net; Sheep or Half Morocco, $5.00 net. " I am much pleased with Keating's Dictionary, and shall take pleasure in recommend- ing it to my classes." — Henry M. Lyman, M.D., Professor of the Principles and Practice of Medicine, Ptcsh Medical College, Chicago, III. " I am convinced that it will be a very valuable adjunct to my study-table, convenient in size and sufficiently full for ordinary use." — C. A. Lindsley, M.D., Professor of the Theory and Practice of Medicine, Medical Dept. Yale University. KEATINQ'S LIFE INSURANCE. Mow to Examine for Life Insurance. By John M. Keating, M.D., Fellow of the College of Physicians of Philadelphia; Vice- President of the American Paediatric Society ; Ex-President of the Association of Life Insurance ISIedical Directors. Royal octavo, 211 pages ; with two large half-tone illustrations, and a plate prepared by Dr. McClellan from special dissections ; also, numerous other illustra- tions. Cloth, $2.00 net. " This is by far the most useful book which has yet appeared on insurance examination, a subject of growing interest and importance. Not the least valuable portion of the volume is Part II, which consists of instructions issued to their examining physicians by twenty-four representative companies of this country. If for these alone, the book should be at the right hand of every physician interested in this special branch of medical science. ' ' — The Medical News. Medical Publications of W. B. Saunders. 15 KEEN ON THE SURGERY OF TYPHOID FEVER. The Surgical Complications and Sequels of Typhoid Fever. By Wm. W. Keen, M.D., LL.D., Professor of the Principles of Sur- gery and of Clinical Surgery, Jefferson Medical College, Philadelphia; Corresponding Member of the Societe de Chirurgie, Paris ; Honorary Member of the Societe Beige de Chirurgie, etc. Octavo volume of 386 pages, illustrated. Cloth, $3.00 net. This monograph is the only one in any language covering the entire subject of the Surgical Complications and Sequels of Typhoid Fever. It will prove to be of importance and interest not only to the general surgeon and physician, but also to many specialists — laryn- gologists, gynecologists, pathologists, and bacteriologists. KEEN'S OPERATION BLANK. Second Edition, Revised Form. An Operation Blank, with Lists of Instruments, etc. Required in Various Operations. Prepared by W. W. Keen, M.D., LL.D., Professor of ttae Principles of Surgery in Jefferson Medical College, Philadelphia. Price per pad, containing blanks for fifty operations, 50 cents net. KYLE ON THE NOSE AND THROAT. Diseases of the Nose and Throat. By D. Braden Kyle, M.D., Clinical Professor of Laryngology and Rhinology, Jefferson Medical College, Philadelphia; Consulting Laryngologist, Rhinologist, and Otologist, St. Agnes' Hospital ; Bacteriologist to the Philadelphia Orthopedic Hospital. In Preparation. LAINE'S TEMPERATURE CHART. Temperature Chart. Prepared by D. T. Laine, M.D. Size 8 x 13^ inches. A conveniently arranged Chart for recording Temperature, with columns for daily amounts of Urinary and Fecal Excretions, Food, Remarks, etc. On the back of each chart is given in full the method of Brand in the treatment of Typhoid Fever. Price, per pad of 25 charts, 50 cents net. " To the busy practitioner this chart will be found of great value in fever cases, and especially for cases of typhoid." — Indian Lancet, Calcutta. LOCKWOOD'S practice of MEDICINE. A Manual of the Practice of Medicine. By George Roe Lock- wood, M.D., Professor of Practice in the Woman's Medical College of the New York Infirmary, etc. 935 pages, with 75 illustrations in the text, and 22 full-page plates. Cloth, $2.50 net. " Gives in a most concise manner the points essential to treatment usually enumerated in the most elaborate works." — Massachusetts Medical Journal. LONG'S SYLLABUS OF GYNECOLOGY. A Syllabus of Gynecology, arranged in Conformity with " An American Text=Book of Gynecology." By J. W. Long, M.D., Professor of Diseases of Women and Children, Medical College of Virginia, etc. Cloth, interleaved, ^i.oo net. " The book is certainly an admirable resume of what every gynecological student and practitioner should know, and will prove of value not only to those who have the ' American Text-Book of Gynecology,' but to others as well." — Brooklyn Medical Journal. 16 Medical Publications of W. B. Saunders. MACDONALD'S SURGICAL DIAGNOSIS \ND TREATMENT, Surgical Diagnosis and Treatment. By J. W. Macdonald, M.D. Edin., L.R. C.S., Edin., Professor of the Practice of Surgery and of Clinical Surgery in Hamline University ; Visiting Surgeon to St. Barnabas' Hospital, Minneapolis, etc. Handsome octavo volume of 800 pages, profusely illustrated. Cloth, $5.00 net; Half Morocco, $6.00 net. " A thorough and complete work on surgical diagnosis and treatment, free from pad- ding, full of valuable material, and in accord with the surgical teaching of the day." — The Medical Netvs, New York. "The work is brimful of just the kind of practical information that is useful alike to students and practitioners. It is a pleasure to commend the book because of its intrinsic value to the medical practitioner." — Citiciniiati Lancet-Clinic. MALLORY AND WRIGHT'S PATHOLOGICAL TECHNIQUE. Pathological Technique. A Practical Manual for Laboratory Work in Pathology, Bacteriology, and Morbid Anatomy, with chapters on Post-Mortem Technique and the Performance of Autopsies. By Frank B. Mallory, A.M., M.D., Assistant Professor of Pathology, Harvard University Medical School, Boston; and James H. Wright, A.M., M.D., Instructor in Pathology, Harvard University Medical School, Boston. Octavo volume of 396 pages, handsomely illustrated. Cloth, $2.50 net. " I have been looking forward to the publication of this book, and I am glad to say that I find it to be a most useful laboratory and post-mortem guide, full of practical information, and well up to date." — William H. Welch, Professor of Pathology, Johns Hopkins Uni- versity, Baltimore, Md. MARTIN'S MINOR SURGERY, BANDAGING, AND VENEREAL DISEASES. Second Edition, Revised. Essentials of Minor Surgery, Bandaging, and Venereal Diseases. By Edward Martin, A.M., M.D., Clinical Professor of Genito-Urinary Diseases, University of Pennsylvania, etc. Crown octavo, 166 pages, with 78 illustrations. Cloth, $1.00 ; interleaved for notes, $1.25. [See Saunders'' Questiofi-Compends, page 21.] "A very practical and systematic study of the subjects, and shows the author's famil- iarity with the needs of students." — Therapeutic Gazette. MARTIN'S SURGERY. Sixth Edition, Revised. Essentials of Surgery. Containing also Venereal Diseases, Surgi- cal Landmarks, Minor and Operative Surgery, and a complete de- scription, with illustrations, of the Handkerchief -and Roller Bandages. By Edward Martin, A.M., M.D., Clinical Professor of Genito- Urinary Diseases, University of Pennsylvania, etc. Crown octavo, 338 pages, illustrated. With an Appendix containing full directions for the preparation of the materials used in Antiseptic Surgery, etc. Cloth, ^i.oo; interleaved for notes, ^1.25. [See Saunders' Question- Compends, page 21.] " Contains all necessary essentials of modern surgery in a comparatively small space. Its style is interesting, and its illustrations are admirable." — Medical and Surgical Reporter. Medical Publications of W. B. launders. 17 IVlcFARLAND'5 PATHOGENIC BACTERIA. Second Edition, Re= vised and Greatly Enlarged. Text=Book upon the Pathogenic Bacteria. By Joseph McFar- LAND, M. D., Professor of Pathology and Bacteriology in the Medico- Chirurgical College of Philadelphia, etc. Octavo volume of 497 pages, finely illustrated. Cloth, $2.50 net. " Dr. McFarland has treated the subject in a systematic manner, and has succeeded in presenting in a concise and readable form the essentials of bacteriology up to date. Alto- gether, the book is a satisfactory one, and I shall take pleasure in recommending it to the students of Trinity College." — H. B. Anderson, M.D. , Professor of Pathology and Bac- teriology, Trinity Medical College, Torotito. MEIGS ON FEEDING IN INFANCY. Feeding in Early Infancy. By Arthur V. Meigs, M.D. Bound in limp cloth, flush edges, 25 cents net. "This pamphlet is worth many times over its price to the physician. The author's experiments and conclusions are original, and have been the means of doing much good." — Medical Bulletin. MOORE'S ORTHOPEDIC SURGERY. A Manual of Orthopedic Surgery. By James E. Moore, M.D., Professor of Orthopedics and Adjunct Professor of Clinical Surgery, University of Minnesota, College of Medicine and Surgery. Octavo volume of 356 pages, handsomely illustrated. Cloth, $2.50 net. A practical book based upon the author's experience, in which special stress is laid upon early diagnosis, and treatment such as can be carried out by the general practitioner. The teachings of the author are in accordance with his belief that true conservatism is to be found in the middle course between the surgeon who operates too frequently and the orthopedist who seldom operates. MORRIS'S MATERIA MEDICA AND THERAPEUTICS. Fifth Edition, Revised. Essentials of Materia Medica, Therapeutics, and Prescription= Writing. By Henry Morris, M.D., late Demonstrator of Thera- peutics, Jefferson Medical College, Philadelphia; Fellow of the College of Physicians, Philadelphia, etc. Crown octavo, 288 pages. Cloth, ;^i.oo; interleaved for notes, ^1.25. [See Saunders^ QuestioJi-Compends, page 21.] " This work, already excellent in the old edition, has been largely improved by revi- sion. ' ' — Atnerican Practitioner and News. MORRIS, WOLFF, AND POWELL'S PRACTICE OF MEDICINE Third Edition, Revised. Essentials of the Practice of Medicine. By Henry Morris, M.D., late Demonstrator of Therapeutics, Jefferson Medical College, Phila- delphia ; with an Appendix on the Clinical and Microscopic Examina- tion of Urine, by Lawrence Wolff, M. D. , Demonstrator of Chemistry, Jefferson Medical College, Philadelphia. Enlarged by some 300 essen- tial formulae collected and arranged by William M. Powell, M.D. Post-octavo, 488 pages. Cloth, $2.00. [See Saunders' Question- Conipends, page 21.] " The teaching is sound, the presentation graphic ; matter full as can be desired, and style attractive." — American P?-actitiotur and A^ews. 18 Medical Publications of W. B, Saunders. MORTEN'S NURSE'S DICTIONARY. Nurse's Dictionary of Medical Terms and Nursing Treat- ment. Containing Definitions of the Principal Medical and Nursing Terms and Abbreviations ; of the Instruments, Drugs, Diseases, Acci- dents, Treatments, Operations, Foods, Appliances, etc. encountered in the ward or in the sick-room. By Honnor Morten, author of "How to Become a Nurse," etc. i6mo, 140 pages. Cloth, $1.00. " A handy, compact little volume, containing a large amount of general information, all of which is arranged in dictionary or encyclopedic form, thus facilitating quick reference. It is certainly of value to those for whose use it is published." — Chicago Clinical Review. NANCREDE'S ANATOMY. Fifth Edition. Essentials of Anatomy, including the Anatomy of the Viscera. By Charles B. Nancrede, M.D., Professor of Surgery and of Clini- cal Surgery in the University of Michigan, Ann Arbor. Crown octavo, 388 pages; 180 illustrations. With an Appendix containing over 60 illustrations of the osteology of the human body. Based upon Gray s Anatony. Cloth, $1.00; interleaved for notes, $1.25. [See Saunders' Question- Comperids, page 21.] " For self-quizzing and keeping fresh in mind the knowledge of anatomy gained at school, it would not be easy to speak of it in terms too favorable." — American Practitioner. NANCREDE'S .ANATOMY AND DISSECTION. Fourth Edition. Essentials of Anatomy and Manual of Practical Dissection. By Charles B. Nancrede, M.D., Professor of Surgery and of Clinical Surgery, University of Michigan, Ann Arbor. Post-octavo ; 500 pages, with full-page lithographic plates in colors, and nearly 200 illustrations. Extra Cloth (or Oilcloth for the dissection-room), $2.00 net. " It may in many respects be considered an epitome of Gray's popular work on general anatomy, at the same time having some distinguishing characteristics of its own to commend it. The plates are of more than ordinary excellence, and are of especial value to students in their work in the dissecting room." — Journal of the American Medical Association. NORRIS'S SYLLABUS OF OBSTETRICS. Third Edition, Revised. Syllabus of Obstetrical Lectures in the Medical Department of the University of Pennsylvania. By Richard C. Norris, A.M., M.D. , Demonstrator of Obstetrics, University of Pennsylvania. Crown octavo, 222 pages. Cloth, interleaved for notes, $2.00 net. "This work is so far superior to others on the same subject that we take pleasure in calling attention briefly to its excellent features. It covers the subject thoroughly, and will prove invaluable both to the student and the practitioner." — Medical Record, New York. PENROSE'S DISEASES OF WOMEN. Second Edition, Revised. A Text=Book of Diseases of Women. By Charles B. Penrose, M.D., Ph.D., Professor of Gynecology in the University of Pennsyl- vania; Surgeon to the Gynecean Hospital, Philadelphia. Octavo volume of 529 pages, handsomely illustrated. Cloth, $3.50 net. "I shall value very highly the copy of Penrose's 'Diseases of Women' received. I have already recommended it to my class as THE BEST book." — Howard A. Kelly. Professor of Gynecology and Obstetrics, Johns Hopkins University, Baltimore, Aid. " The book is to be commended without reserve, not only to the student but to the general practitioner who wishes to have the latest and best modes of treatment explained with absolute clearness." — Therapeutic Gazette. Medical Publications of W. B, Saunders. 19 POWELL'S DISEASES OF CHILDREN. Second Edition. Essentials of Diseases of Children. By William M. Powell, M.D., Attending Physician to the Mercer House for Invalid Women at Atlantic City, N. J. ; late Physician to the Clinic for the Diseases of Children in the Hospital of the University of Pennsylvania. Crown octavo, 222 pages. Cloth, ^i.oo; interleaved for notes, ^1.25. [See Saunders' Question- Compends, page 21.] "Contains the gist of all the best works in the department to which it relates."— American Practitioner and News. PRINQLE'S SKIN DISEASES AND SYPHILITIC AFFECTIONS. Pictorial Atlas of Skin Diseases and Syphilitic Affections (American Edition). Translation from the French. Edited by J. J. Pringle, M.B., F.R.C.P., Assistant Physician to the Middlesex Hospital, London. Photo-lithochromes from the famous models in the Museum of the Saint-Louis Hospital, Paris, with explanatory wood- cuts and text. In 12 Parts. Price per Part, ^3.00. Complete in one volume, Half Morocco binding, ^40.00 net. "I strongly recommend this Atlas. The plates are exceedingly well executed, and will be of great value to all studying dermatology." — Stephen Mackenzie, M.D. ' ' The introduction of explanatory wood-cuts in the text is a novel and most important feature which greatly furthers the easier understanding of the excellent plates, than which nothing, we venture to say, has been seen better in point of correctness, beauty, and general merit." — New York Medical Journal. PYE'S BANDAGING. Elementary Bandaging and Surgical Dressing. With Direc- tions concerning the Immediate Treatment of Cases of Emergency. For the use of Dressers and Nurses. By Walter Pye, F.P-.C.S., late Surgeon to St. Mary's Hospital, London. Small 121110, with over 80 illustrations. Cloth, flexible covers, 75 cents net. " The directions are clear and the illustrations are good." — London Lancet. ' ' The author writes well, the diagrams are clear, and the book itself is small and port- able, although the paper and type ai'e good." — British Medical Journal. RAYMOND'S PHYSIOLOGY. A Manual of Physiology. By Joseph H. Raymond, A.M., M.D., Professor of Physiology and Hygiene and Lecturer on Gynecology in the Long Island College Hospital ; Director of Physiology in the Hoagland Laboratory, etc. 382 pages, with 102 illustrations in the text, and 4 full-page colored plates. Cloth, ^1.25 net. " Extremely well gotten up, and the illustrations have been selected with care. The text is fully abreast with modern physiology." — British Medical Jotirnal. RONTGEN RAYS. Archives of the Rontgen Ray (Formerly Archives of Clinical Skiagraphy). Edited by Sydney Rowland, M.A., M.R.C.S., and W. S. Hedley, M.D., M.R.C.S. A series of collotype illustrations, with descriptive text, illustrating the applications of the new photo- graphy to Medicine and Surgery. Price per Part, $1.00. Now ready: Vol. I., Parts I. to IV.; Vol. II., Parts I., II. •AUNDERS' Question Arranged in Question and Answer Form. T^HE MOST COMPLETE AND BEST r^OA7rPTHM"nQ ILLUSTRATED SERIES OF v^L^lVLr lilNiJo coMPENDS ever issued. Now the Standard Authorities in Medical Literature .... with Students and Practitioners in every City of the United States and Canada. O- OVER 165,000 COPIES SOLD. THE REASON WHY. They are the advance guard of "Student's Helps" — that DO HELP. They are the leaders in their special line, well and authoritatively written by able men, who, as teachers in the large colleges, know exactly what is wanted by a student preparing for his examinations. The judgment exercised in the selection of authors is fully demonstrated by their professional standing. Chosen from the ranks of Demonstrators, Quiz-masters, and Assistants, most of them have become Professors and Lecturers in their respective colleges. Each book is of convenient size (5x7 inches) , containing on an average 250 pages, profusely illustrated, and elegantly printed in clear, readable type, on fine paper. The entire series, numbering twenty-three volumes, has been kept thoroughly revised and enlarged when necessary, many of the books being in their fifth and sixth editions. TO SUM UP. Although there are numerous other Quizzes, Manuals, Aids, etc. in the market, none of them approach the "Blue Series of Question Compends;" and the claim is made for the following points of excellence : 1. Professional distinction and reputation of authors. 2. Conciseness, clearness, and soundness of treatment. 3. Quality of illustrations, paper, printing, and binding. Any cf these Compends will be mailed on receipt of price (see next page for List). baunders^ Question-Compend Series* Price, Cloth, $1.00 per copy, except when otherwise noted. "Where the work of preparing students' manuals is to end we cannot say but the baunders Series, in our opinion, bears off the palm at present." —JVew Tork Medical Record. 1. ESSENTIALS OF PHYSIOLOGY. By H. A. Hare, M.D. Third edition, revised and enlarged, (^i.oo net.) 2. ESSENTIALS OF SURQERY. By Edward Martin, M.D. Sixth edition, revised, with an Appendix on Antiseptic Surgery. 3. ESSENTIALS OF ANATOMY. By Charles B. Nancrede, M.D. Fifth edition, with an Appendix. 4. ESSENTIALS OF MEDICAL CHEMISTRY, ORGANIC AND INORGANIC. By Lawrence Wolff, M.D. Fourth edition, revised, with an Appendix. 5. ESSENTIALS OF OBSTETRICS. By W. Easterly Ashton, M.D. Fourth edition, revised and enlarged. 6. ESSENTIALS OF PATHOLOGY AND MORBID ANATOMY. By C. E. Armand Semple, M.D. 7. ESSENTIALS OF MATERIA MEDICA, THERAPEUTICS, AND PRE- SCRIPTION=WRITING. By Henry Morris, M.D. Fifth edition, .revised. 8. 9. ESSENTIALS OF PRACTICE OF MEDICINE. By Henry Morris, M.D. An Appendix on Urine Examination. By Lawrence Wolff, M.D. Third edition, enlarged by some 300 Essential Formulse, selected from eminent authorities, by Wm. M. Powell, M.D. (Double number, ^2.00.) 10. ESSENTIALS OF GYNECOLOGY. By Edwin B. Cragin, M.D. Fourth edition, revised. 11. ESSENTIALS OF DISEASES OF THE SKIN. By Henry W. Stelwagon, M.D. Third edition, revised and enlarged. ($1.00 net.) 12. ESSENTIALS OF MINOR SURGERY, BANDAGING, AND VENEREAL DISEASES. By Edward Martin, M.D. Second ed., revised and enlarged. 13. ESSENTIALS OF LEGAL MEDICINE, TOXICOLOGY, AND HYGIENE. By C. E. Armand Semple, M.D. 14. ESSENTIALS OF DISEASES OF THE EYE, NOSE, AND THROAT. By Edward Jackson, M.D., and E. B. Gleason, M.D. Second ed., revised. 15. ESSENTIALS OF DISEASES OF CHILDREN. By William M. Powell, M.D. Second edition. 16. ESSENTIALS OF EXAMINATION OF URINE. By Lawrence Wolff, M.D. Colored " VoGEL Scale." (75 cents.) 17. ESSENTIALS OF DIAGNOSIS. By S. Solis Cohen, M.D., and A. A. Eshner, M.D. ($1.50 net.) 18. ESSENTIALS OF PRACTICE OF PHARMACY. By Lucius E. Sayre. Second edition, revised and enlarged. 20. ESSENTIALS OF BACTERIOLOGY. By M. V. Ball, M.D. Third edition, revised. 21. ESSENTIALS OF NERVOUS DISEASES AND INSANITY. By John C. Shaw, M.D. Third edition, revised. 22. ESSENTIALS OF MEDICAL PHYSICS. By Fred J. Brockw.a.y, M.D. Second edition, revised. ($1.00 net.) 23. ESSENTIALS OF MEDICAL ELECTRICITY. By David D. Stewart, M.D., and Edward S. Lawrance, M.D. 24. ESSENTIALS OF DISEASES OF THE EAR. By E. B. Gleason, M.D. Second edition, revised and greatly enlarged. Pamphlet containing specimen pages, etc. sent free upon application. Saunders' New Series of Manuals for Students and Practitioners. ■" I 'riAT there exists a need for thoroughly reliable hand-books on the leading branches of Medicine and Surgery is a fact amply demonstrated by the favor with which the SAUNDERS NE'W SERIES OF MANUALS have been received by medical students and practitioners and by the Medical Press, These manuals are not merely condensations from present literature, but are ably written by well-known authors and practitioners, most of them being teachers in representative American colleges. Each volume is concisely and authoritatively written and exhaustive in detail, without being encumbered with the introduction of "cases," which so largely expand the ordinary text-book. These manuals will therefore form an admirable collection of advanced lectures, useful alike to the medical student and the practitioner: to the latter, too busy to search through page after page of elaborate treatises for what he wants to know, they will prove of inestimable value ; to the former they will afford safe guides to the essential points of study. The SAUNDERS NEW SERIES OF MANUALS are conceded to be superior to any similar books now on the market. No other manuals afford so much infor- mation in such a concise and available form. A liberal expenditure has enabled the publisher to render the mechanical portion of the work worthy of the high literary standard attained by these books. Any of these Manuals will be mailed on receipt of price (see next page for List). Saunders^ New Series of Manuals* VOLUMES PUBLISHED. PHYSIOLOGY. By Joseph Howard Raymond, A.M., M.D., Professor of Physiology and Hygiene and Lecturer on Gynecology in the Long Island College Hospital ; Director of Physiology in the Hoagland Laboratory, etc. Illustrated. Cloth, ^1.25 net. SURGERY, General and Operative. By John Chalmers DaCosta, M.D., Clini- cal Professor of Surgery, Jefferson Medical College, Philadelphia; Surgeon to the Philadelphia Hospital, etc. Second edition, thoroughly revised and greatly enlarged. Octavo, 900 pages, profusely illustrated. Cloth, $4.00 net ; Half Morocco, ^5.00 net. DOSE=BOOK AND MANUAL OF PRESCRIPTI0N=WR1T1NG. By E. Q. Thornton, M.D., Demonstrator of Therapeutics, Jefferson Medical College, Phila- delphia. Illustrated. Cloth, ^1.25 net. SURGICAL ASEPSIS. By Carl Beck, M.D., Surgeon to St. Mark's Hospital and to the New York German Poliklinik, etc. Illustrated. Cloth, ^1.25 net. MEDICAL JURISPRUDENCE. By Henry C. Chapman, M.D. Professor of Insti- tutes of Medicine and Medical Jurisprudence in the Jefferson Medical College of Phila- delphia. Illustrated. Cloth, |i. 50 net. SYPHILIS AND THE VENEREAL DISEASES. By James Nevins Hyde,.M.D., Professor of Skin and Venereal Diseases, and Frank H. Montgomery, M. D., Lecturer on Dermatology and Genito-Urinary Diseases in Rush Medical College, Chicago. Profusely illustrated. (Double number.) Cloth, ^2.50 net. PRACTICE OF MEDICINE. By George Roe Lockwood, M.D., Professor of Practice in the Woman's Medical College of the New York Infirmary; Instructor in Physical Diagnosis in the Medical Department of Columbia College, etc. Illustrated. (Double number.) Cloth, ^2.50 net. MANUAL OF ANATOMY. By Irving S. Haynes, M.D., Adjunct Professor^ of Anatomy and Demonstrator of Anatomy, Medical Department of the New York University, etc. Beautifully illustrated. (Double Number.) Cloth, $2.50 net. MANUAL OF OBSTETRICS. By W. A. Newman Dorland, M.D., Assistant Demonstrator of Obstetrics, University of Pennsylvania ; Chief of Gynecological Dis- pensary, Pennsylvania Hospital, etc. Profusely illustrated. (Double number.) Cloth, ^2.50 net. DISEASES OF WOMEN. By J. Bland Sutton, F.R.C.S., Assistant Surgeon to Middlesex Hospital and Surgeon to Chelsea Hospital, London; and Arthur E. Giles, M.D., B.Sc. Lond., F.R.C.S. Edin., Assistant Surgeon to Chelsea Hospital, London. Handsomely illustrated. (Double number.) Cloth, ^2.50 net. VOLUMES IN PREPARATION. NOSE AND THROAT. By D. Braden Kyle, M.D., Clinical Professor of Laryn- gology and Rhinology, Jefferson Medical College, Philadelphia ; Consulting Laryngolo- gist, Rhinologist, and Otologist, St. Agnes' Hospital ; Bacteriologist to the Philadel- phia Orthopedic Hospital and Infirmary for Nervous Diseases, etc. NERVOUS DISEASES. By Charles W. Burr, M.D., Clinical Professor of Nervous Diseases, Medico-Chirurgical College, Philadelphia ; Pathologist to the Orthopedic Hospital and Infirmary for Nervous Diseases ; Visiting Physician to the St. Joseph Hospital, etc. *** There will be published in the same series, at short intervals, carefully-prepared works on various subjects by prominent specialists. Pamphlet containing specimen pages, etc. sent free upon application. 24 Medical Publications of W. B. Saunders. SAUNDBY'S RENAL AND URINARY DISEASES. Lectures on Renal and Urinary Diseases. By Robert Saundby, M.D. Edin., Fellow of the Royal College of Physicians, London, and of the Royal Medico-Chirurgical Society ; Physician to the General Hospital ; Consulting Physician to the Eye Hospital and to the Hos- pital for Diseases of Women; Professor of Medicine in Mason College, Birmingham, etc. Octavo volume of 434 pages, with numerous illus- trations and 4 colored plates. Cloth, ^2.50 net. " The volume makes a favorable impression at once. The style is clear and succinct. We cannot find any part of the subject in which the views expressed are not carefully thought out and fortified by evidence drawn from the most recent sources. The book may be cordially recommended." — B7-itish Medical Journal. SAUNDERS' POCKET MEDICAL FORMULARY. Fourth Edition, Revised. By William M. Powell, M.D., Attending Physician to the Mercer House for Invalid Women at Atlantic City, N. J. Containing 1800 formulae selected from the best-known authorities. With an Appen- dix containing Posological Table, Formulae and Doses for Hypo- dermic Medication, Poisons and their Antidotes, Diameters of the Female Pelvis and Foetal Head, Obstetrical Table, Diet List for Various Diseases, Materials and Drugs used in Antiseptic Surgery, Treatment of Asphyxia from Drowning, Surgical Remembrancer, Tables of Incompatibles, Eruptive Fevers, Weights and Measures, etc. Hand- somely bound in flexible morocco, with side index, wallet, and flap. ^1.75 net. "This little book, that can be conveniently carried in the pocket, contains an immense amount of material. It is very useful, and, as the name of the author of each prescription is given, is unusually reliable." — Medical Hecord, New York. SAUNDERS' POCKET MEDICAL LEXICON. Fourth Edition. Revised. A Dictionary of Terms and Words used in Medicine and Surgery. By John M. Keating, M.D., Fellow of the College of Physicians of Philadelphia; Editor of the "Cyclopaedia of Diseases of Children," etc.; Author of the "New Pronouncing Dictionary of Medicine;" and Henry Hamilton, Author of "A New Translation of Virgil's yEneid into English Verse;" Co-Author of the "New Pronouncing Dictionary of Medicine." 32mo, 280 pages. Cloth, 75 cents; Leather Tucks, $1.00. "Remarkably accurate in terminology, accentuation, and definition." — Journal of the American Medical Associatio7t. SAYRE'S PHARMACY. Second Edition, Revised. Essentials of the Practice of Pharmacy. By Lucius E. Sayre, M.D,, Professor of Pharmacy and Materia Medica in the University of Kansas. Crown octavo, 200 pages. Cloth, $1.00; interleaved for notes, $1.25. [See Saunders'' Question- Compends, page 21.] " The topics are treated in a simple, practical manner, and the work forms a very useful student's manual." — Boston Medical and Surgical Jou7-nal. Medical Publications of W. B. Saunders. 25 SEMPLE'S LEGAL MEDICINE, TOXICOLOGY, AND HYGIENE. Essentials of Legal Medicine, Toxicology, and Hygiene. By C. E. Armand Semple, B. A., M. B. Cantab., M.R.C. P. Lond., Physician to the Northeastern Hospital for Children, Hackney, etc. Crown octavo, 2 1 2 pages ; 130 illustrations. Cloth, ^i. 00; interleaved for notes, $1.25. [See Saunders' Qicestio7i-Compe7ids, page 21.] " No general practitioner or student can afford to be without this valuable work. The subjects are dealt with by a masterly hand." — London Hospital Gazette. SEMPLE'S PATHOLOGY AND MORBID ANATOMY. Essentials of Pathology and Morbid Anatomy. By C. E. Armand Semple, B.A., M.B. Cantab., M.R.C. P. Lond., Physician to the Northeastern Hospital for Children, Hackney, etc. Crown octavo, 174 pages; illustrated. Cloth, ^i. 00; interleaved for notes, ^1.25. [See Saunders' Question- Compends , page 21.] " Should take its place among the standard volumes on the bookshelf of both student and practitioner." — London Hospital Gazette. SENN'S GENITO=URINARY TUBERCULOSIS. Tuberculosis of the Genito=Urinary Organs, Male and Female. By Nicholas Senn, M.D., Ph.D., LL.D., Professor of the Practice of Surgery and of Clinical Surgery, Rush Medical College, Chicago. Handsome octavo volume of 320 pages, illustrated. Cloth, ^3.00 net. " An important book upon an important subject, and written by a man of mature judg- ment and wide experience. The author has given us an instructive book upon one of the most important subjects of the day." — Clinical Reporter. " A work which adds another to the many obligations the profession owes the talented author." — Chicago Medical Recot'der. SENN'S SYLLABUS OF SURGERY. A Syllabus of Lectures on the Practice of Surgery, arranged in conformity with " An American Text=Book of Surgery." By Nicholas Senn, M.D., Ph.D., Professor of the Practice of Surgery and of Clinical Surgery in Rush Medical College, Chicago. Cloth, ^2.00. '* This syllabus will be found of service by the teacher as well as the student, the work being superbly done. There is no praise too high for it. No surgeon should be without it." — New York Medical Times. SENN'S TUMORS. Pathology and Surgical Treatment of Tumors. By N. Senn, M.D., Ph.D., LL.D., Professor of Surgery and of Clinical Surgery, Rush Medical College ; Professor of Surgery, Chicago Polyclinic ; Attending Surgeon to Presbyterian Hospital; Surgeon-in-Chief, St. Joseph's Hospital, Chicago. Octavo volume of 710 pages, with 515 engravings, including full-page colored plates. Cloth, |6.oo net; Half Morocco, ^7.00 net. " The most exhaustive of any recent book in English on this subject. It is well illus- trated, and will doubtless remain as the principal monograph on the subject in our language for some years. The book is handsomely illustrated and printed, and the author has given a notable and lasting contribution to smgtry.'''— Journal of the Americati Medical Associatioti. 26 Medical Publications of W. B. Saunders. SHAW'S NERVOUS DISEASES AND INSANITY. Third Edition, Revised. Essentials of Nervous Diseases and Insanity. By John C. Shaw, M.D., Clinical Professor of Diseases of the Mind and Nervous System, Long Island College Hospital Medical School ; Consulting Neurologist to St. Catherine's Hospital and to the Long Island College Hospital. Crown octavo, i86 pages; 48 original illustrations. Cloth, $1.00 ; interleaved for notes, $1.25. [See Saimders' Question- Compends, page 21.] "Clearly and intelligently written." — Boston Medical and Surgical Journal. "There is a mass of valuable material crowded into this small compass." — American Medico- Su7-gical Bulletin. STARR'S DIETS FOR INFANTS AND CHILDREN. Diets for Infants and Children in Health and in Disease. By Louis Starr, M.D., Editor of "An American Text-Book of the Diseases of Children." 230 blanks (pocket-book size), perforated and neatly bound in flexible morocco. $1.25 net. The first series of blanks are prepared for the first seven months of infant life ; each blank indicates the ingredients, but not the quantities, of the food, the latter directions being left for the physician. After the seventh month, modifications being less necessary, the diet lists are printed in full. Formulae for the preparation of diluents and foods are appended. STELW AGON'S DISEASES OF THE SKIN. Third Edition, Revised. Essentials of Diseases of the Skin. By Henry W. Stelwagon, M.D., Clinical Professor of Dermatology in the Jefferson Medical College, Philadelphia; Dermatologist to the Philadelphia Hospital; Physician to the Skin Department of the Howard Hospital, etc. Crown octavo, 270 pages; 86 illustrations. Cloth, ^i. 00 net; inter- leaved for notes, $1.25 net. [See Saunders'' Question- Compends, page 21.] " The best student's manual on skin diseases we have yet seen." — Titnes and Register. STENGEL'S PATHOLOGY. A Manual of Pathology. By Alfred Stengel, M.D., Physician to the Philadelphia Hospital ; Professor of Clinical Medicine in the Woman's Medical College ; Physician to the Children's Hospital ; late Pathologist to the German Hospital, Philadelphia, etc. In Press. STEVENS' MATERIA MEDICA AND THERAPEUTICS. Second Edition, Revised. A Manual of Materia Medica and Therapeutics. By A. A. Stevens, A.M., M.D., Lecturer on Terminology and Instructor in Physical Diagnosis in the University of Pennsylvania; Demonstrator of Pathology in the Woman's Medical College of Philadelphia. Post- octavo, 445 pages. Cloth, $2.25. "The author has faithfully presented modern therapeutics in a comprehensive work, and, while intended particularly for the use of students, it will be found a reliable guide and sufficiently comprehensive for the physician in practice." — University Medical Magazine. Medical Publications of W. B. Saunders. 27 STEVENS' PRACTICE OF MEDICINE. Fourth Edition, Revised. A Manual of the Practice of Medicine. By A. A. Stevens, A.M., M.D., Lecturer on Terminology and Instructor in Physical Diagnosis in the University of Pennsylvania ; Demonstrator of Pathology in the Woman's Medical College of Philadelphia. Specially intended for students preparing for graduation and hospital examinations. Post- octavo, 511 pages; illustrated. Flexible leather, $2.50. " The frequency with which new editions of this manual are demanded bespeaks its popularity. It is an excellent condensation of the essentials of medical practice for the student, and maybe found also an excellent reminder for the busy physician." — Buffalo Medical Jou7'nal. STEWART'S PHYSIOLOGY. A Manual of Physiology, with Practical Exercises. For Students and Practitioners. By G. N. Stewart, M.A., M.D., D.Sc, lately Examiner in Physiology, University of Aberdeen, and of the New Museums, Cambridge University ; Professor of Physiology in the Western Reserve University, Cleveland, Ohio. Octavo volume of 800 pages; 278 illustrations in the text, and 5 colored plates. Cloth, ^3.50 net. " It will make its way by sheer force of merit, and amply deserves to do so. It is one of the very best English text-books on the subject." — London Lancet. "Of the many text-books of physiology published, we do not know of one that so nearly comes up to the ideal as does Prof. Stewart's volume." — British Medical Journal. STEWART AND LAWRANCE'S MEDICAL ELECTRICITY. Essentials of Medical Electricity. By D. D. Stewart, M.D., Demonstrator of Diseases of the Nervous System and Chief of the Neurological Clinic in the Jefferson Medical College ; and E. S. Lawrance, M.D., Chief of the Electrical Clinic and Assistant Demon- strator of Diseases of the Nervous System in the Jefferson Medical College, etc. Crown octavo, 158 pages; 65 illustrations. Cloth, ^i.oo ; interleaved for notes, ^1.25. [See Saunders' Question- Compends, page 21.] " Throughout the whole brief space at their command the authors show a discriminating knowledge of their subject." — Medical News. STONEY'S NURSING. Second Edition, Revised. Practical Points in Nursing. For Nurses in Private Practice. By Emily A. M. Stoney, Graduate of the Training-School for Nurses, Lawrence, Mass.; late Superintendent of the Training-School for Nurses, Carney Hospital, South Boston, Mass. 456 pages, illustrated with 73 engravings in the text, and 8 colored and half-tone plates. Cloth, $1.75 net. " There are few books intended for non-professional readers which can be so cordially endorsed by a medical journal as can this one." — Therapeutic Gazette. " This is a well-written, eminently practical volume, which covers the entire range of private nursing as distinguished from hospital nursing, and instructs the nurse how best to meet the various emergencies which may arise, and how to prepare everything ordinarily needed in the illness of her patient." — American Journal of Obstetrics and Diseases of Women and Children. " It is a work that the physician can place in the hands of his private nurses with the assurance of benefit." — Ohio Medical Journal. 28 Medical Publications of W. B. Saunders. SUTTON AND GILES' DISEASES OF WOMEN. Diseases of Women. By J. Bland Sutton, F.R.C.S., Assistant Surgeon to Middlesex Hospital, and Surgeon to Chelsea Hospital, London; and Arthur E. Giles, M.D., B.Sc. Lond., F.R.C.S. Edin., Assistant Surgeon to Chelsea Hospital, London. 436 pages, hand- somely illustrated. Cloth, $2.50 net. ' ' The book is very well prepared, and is certain to be well received by the medical public. ' ' — British Medical Journal . "The text has been carefully prepared. Nothing essential has been omitted, and its teachings are those recommended by the leading authorities of the day." — Journal of tht American Medical Association. THOMAS'S DIET LISTS AND SICK=ROOM DIETARY. Diet Lists and Sick=Room Dietary. By Jerome B. Thomas, M.D., Visiting Physician to the Home for Friendless Women and Children and to the Newsboys' Home ; Assistant Visiting Physician to the Kings County Hospital. Cloth, $1.50. Send for sample sheet. " The idea is good, and the lists are copious." — London Lancet. "Its practical usefulness places it among the requirements of every practitioner." — Chicago Medical Recorder. THORNTON'S DOSE=BOOK AND PRESCRIPTION=WRITINQ. • Dose=Book and Manual of Prescription=Writing. By E. Q. Thornton, M.D., Demonstrator of Therapeutics, Jefferson Medical College, Philadelphia. 334 pages, illustrated. Cloth, $1.25 net. "Full of practical suggestions; will take its place in the front rank of works of this sort." — Medical Record, New York. VAN VALZAH AND NISBET'S DISEASES OF THE STOMACH. Diseases of the Stomach. By William W. Van Valzah, M.D. , Professor of General Medicine and Diseases of the Digestive System and the Blood, New York Polyclinic; and J. Douglas Nisbet, M.D., Adjunct Professor of General Medicine and Diseases of the Digestive System and the Blood, New York Polyclinic. Octavo volume of 674 pages, illustrated. Cloth, ^3.50 net. VIERORDT'S MEDICAL DIAGNOSIS. Fourth Edition, Revised. Medical Diagnosis. By Dr. Oswald Vierordt, Professor of Medi- cine at the University of Heidelberg. Translated, with additions, from the fifth enlarged German edition, with the author's permission, by Francis H. Stuart, A. M., M, D. Handsome royal octavo volume of 600 pages; 194 fine wood-cuts in text, many of them in colors. Cloth, $4.00 net; Sheep or Half Morocco, 55.00 net; Half Russia, $5.50 net. " A treasury of practical information which will be found of daily use to every busy practitioner who will consult it." — C. A. LiNDSLEY, M.D., Professor of the Theory and Practice of Medicine, Yale University. " Rarely is a book published with which a reviewer can find so little fault as with the volume before us. Each particular item in the consideration of an organ or apparatus, which is necessary to determine a diagnosis of any disease of that organ, is mentioned; nothing seems forgotten. The chapters on diseases of the circulatory and digestive apparatus and nervous system are especially full and valuable. The reviewer would repeat that the book is one of the best — probably the best — which has fallen into his hands." — University Medical Magazine. Medical Publications of W. B. Saunders, 29 WARREN'S SURGICAL PATHOLOGY AND THERAPEUTICS. Surgical Pathology and Therapeutics. By John Collins Warren, M.D., LL.D., Professor of Surgery, Medical Department Harvard University; Surgeon to the Massachusetts General Hospital, etc. Handsome octavo volume of 832 pages; 136 relief and lithographic illustrations, 33 of which are printed in colors, and all of which were drawn by William J. Kaula from original specimens. Cloth, $6.00 net; Half Morocco, ^7.00 net. "There is the work of Dr. Warren, which I think is the most creditable book on Surgical Pathology, and the most beautiful medical illustration of the bookmaker's art, that has ever been issued from the American press." — Dr. Roswell Park, t/t the Hai'vard Gradttate Magazine. " The handsomest specimen of bookmaking that has ever been issued from the American medical press." — Ainerican Journal of the Medical Sciences. " A most striking and very excellent feature of this book is its illustrations. Without exception, from the point of accuracy and artistic merit, they are the best ever seen in a work of this kind. Many of those representing microscopic pictures are so perfect in their coloring and detail as almost to give the beholder the impression that he is looking down the barrel of a microscope at a well-mounted section." — Annals of Surgery. WEST'S NURSING. An American Text=Book of Nursing. By American Teachers. Edited by Roberta M. West, late Superintendent of Nurses in the Hospital of the University of Pennsylvania. In Preparatio7i. WOLFF ON EXAMINATION OF URINE. Essentials of Examination of Urine. By Lawrence Wolff, M.D., Demonstrator of Chemistry, Jefferson Medical College, Philadelphia, etc. Colored (Vogel) urine scale and numerous illustrations. Crown octavo. Cloth, 75 cents. [See Saunders' Question- Co7fipends, page 21.] " A very good work of its kind— very well suited to its purpose." — Times and Register. WOLFF'S MEDICAL CHEMISTRY. Fourth Edition, Revised. Essentials of Medical Chemistry, Organic and Inorganic. Containing also Questions on Medical Physics, Chemical Physiology, Analytical Processes, Urinalysis, and Toxicology. By Lawrence Wolff, M.D., Demonstrator of Chemistry, Jefferson Medical College, Philadelphia, etc. Crown octavo, 218 pages. Cloth, ^i.oo; inter- leaved for notes, ^1.25. [See Saunders' Question- Compends, page 21.] "The scope of this work is certainly equal to that of the best course of lectures on Medical Chemistry." — Pharmaceutical Era. CLASSIFIED LIST Medical Publications W. B, SAUNDERS, 925 Walnut Street, Philadelphia. ANATOMY, EMBRYOLOGY, HISTOLOGY. Clarkson — A Text-Book of Histology, 9 Haynes — A Manual of Anatomy, . . . 13 Heisler — A Text- Book of Embryology, 13 Nancrede — Essentials of Anatomy, . . 18 Nancrede — Essentials of Anatomy and Manual of Practical Dissection, ... 18 Semple — Essentials of Pathology and Morbid Anatomy, 25 BACTERIOLOGY. Ball — Essentials of Bacteriology, ... 6 Crookshank — A Text-Book of Bacteri- ology, ID Frothingham — Laboratory Guide, . . 11 Mallory and Wright — Pathological Technique, 16 McFarland — Pathogenic Bacteria, . . 17 CHARTS, DIET-LISTS, ETC. Griffith — Infant's Weight Chart, ... 12 Hart — Diet in Sickness and in Health, . 13 Keen — Operation Blank, 15 Laine — Temperature Chart, 15 Meigs — Feeding in Early Infancy, . . 17 Starr — Diets for Infants and Children, . 26 Thomas — Diet-Lists and Sick-Room Dietary, 28 CHEMISTRY AND PHYSICS. Brockway — Essentials of Medical Phys- ics, 7 Wolff — Essentials of Medical Chemistry, 29 CHILDREN. An American Text-Book of Diseases of Children, . 3 Griffith — Care of the Baby, 12 Griffith — Infant's Weight Chart, ... 12 Meigs — Feeding in Early Infancy, . . 17 Powell — Essentials of Dis. of Children, 19 Starr — Diets for Infants and Children, . 26 DIAGNOSIS. Cohen and Eshner — Essentials of Di- agnosis 9 Corwin — Physical Diagnosis, .... 9 Macdonald — Surgical Diagnosis and Treatment, 16 Vierordt — Medical Diagnosis, .... 28 DICTIONARIES. Keating — Pronouncing Dictionary, . . 14 Morten — Nurse's Dictionar)', .... 18 Saunders' Pocket Medical Lexicon, , 24 EYE, EAR, NOSE, AND THROAT. An American Text- Book of Diseases of the Eye, Ear, Nose, and Throat, . 3 Casselberry — Dis. of Nose and Throat, 8 De Schweinitz — Diseases of the Eye, . lO Gleason — Essentials of Dis. of the Ear, 1 1 Jackson and Gleason — Essentials of Diseases of the Eye, Nose, and Throat, 14 Kyle — Diseases of the Nose and Throat, 15 QENITO=URINARY. An American Text-Book of Genito- urinary and Skin Diseases, 4 Hyde and Montgomery — Syphilis and the Venereal Diseases 13 Martin — Essentials of Minor Surgery, Bandaging, and Venereal Diseases, . 16 Saundby — Renal and Urinary Diseases, 24 Senn — Genito-Urinary Tuberculosis, . 25 GYNECOLOGY. American Text- Book of Gynecologj', 4 Cragin — Essentials of Gynecology, . . 10 Garrigues — Diseases of Women, ... 11 Long — Syllabus of Gynecolog}', ... 15 Penrose — Diseases of Women, . ... 18 Sutton and Giles — Diseases of Women, 28 MATERIA MEDICA, PHARMACOL- OGY, AND THERAPEUTICS. An American Text-Book of Applied Therapeutics, 3 Butler — Text-Book of Materia Medica, Therapeutics and Pharmacology, ... 8 Cerna — Notes on the Newer Remedies, 8 Griffin — Materia Med. and Therapeutics, 12 Morris — Essentials of Materia Medica and Therapeutics, 17 Saunders' Pocket Medical Formulary, 24 Sayre — Essentials of Pharmacy, ... 24 Stevens — Essentials of Materia Medica and Therapeutics, ... 26 Thornton — Dose-Book and Manual of Prescription-Writing, 28 Warren — Surgical Pathology and Ther- apeutics, 29 MEDICAL JURISPRUDENCE AND TOXICOLOGY. An American Text-Book of Legal Medicine and Toxicology, 4 Chapman — Medical Jurisprudence and Toxicology, 8 Semple — Essentials of Legal Medicine, Toxicology, and Hygiene, 25 Medical Pablications of W. B. Saunders, 31 NERVOUS AND MENTAL DISEASES, ETC. Burr — Nervous Diseases, 7 Chapin — Compendium of Insanity, . . 8 Church and Peterson — Nervous and Mental Diseases, 9 Shaw — Essentials of Nervous Diseases and Insanity, 26 NURSING. An American Text-Book of Nursing, 29 Griffith— The Care of the Baby, ... 12 Hampton — Nursing, 12 Hart — Diet in Sickness and in Health, 13 Meigs — Feeding in Early Infancy, . . 17 Morten — Nurse's Dictionary, .... 18 Stoney — Practical Points in Nursing, . 27 OBSTETRICS. An American Text-Book of Obstetrics, 4 Ashton — Essentials of Obstetrics, ... 6 Boisliniere — Obstetric Accidents, Emer- gencies, and Operations, 7 Borland — Manual of Obstetrics, . . . lo Hirst — Text-Book of Obstetrics, ... 13 Norris — Syllabus of Obstetrics, .... 18 PATHOLOGY. An American Text-Book of Pathology, 5 Mallory and Wright — Pathological Technique, 16 Semple — Essentials of Pathology and Morbid Anatomy, 25 Senn — Pathology and Surgical Treat- ment of Tumors, 25 Stengel — Manual of Pathology, ... 26 Warren — Surgical Pathology and Thera- peutics, 29 PHYSIOLOGY. An American Text-Book of Physi- ology, 5 Hare — Essentials of Physiology, ... 13 Raymond — Manual of Physiology, . . 19 Stewart — Manual of Physiology, ... 27 PRACTICE OF MEDICINE. An American Text-Book of the The- ory and Practice of Medicine, .... 5 An American Year-Book of Medicine and Surgery, 6 Anders — Text-Book of the Practice of Medicine, 6 Lockwood — Manual of the Practice of Medicine, IS Morris — Essentials of the Practice of Medicine, 17 Rowland and Hedley — Archives of the Roentgen Ray, 19 Stevens — Manual of the Practice of Medicine, 27 SKIN AND VENEREAL. An American Text-Book of Genito- urinary and Skin Diseases, 3 Hyde and Montgomery — Syphilis and the Venereal Diseases, 13 Martin — Essentials of Minor Surgery, Bandaging, and Venereal Diseases, . 16 Pringle — Pictorial Atlas of Skin Dis- eases and Syphilitic Affections, ... 19 Stelwagon — Essentials of Diseases of the Skin, 26 SURGERY. An American Text-Book of Surgery, 5 An American Year-Book of Medicine and Surgery, 6 Beck — Manual of Surgical Asepsis, . . 7 DaCosta — Manual of Surgery, . . . . lo Keen — Operation Blank, 15 Keen — The Surgical Complications and Sequels of Typhoid Fever, 15 Macdonald — Surgical Diagnosis and Treatment, 16 Martin — Essentials of Minor Surgery, Bandaging, and Venereal Diseases, . 16 Martin — Essentials of Surgery^ .... 16 Moore — Orthopedic Surgery, 17 Pye — Elementary Bandaging and Surgi- cal Dressing, 19 Rowland and Hedley — Archives of the Roentgen Ray, 19 Senn — Genito-Urinary Tuberculosis, . 25 Senn— Syllabus of Surgery, 25 Senn — Pathology and Surgical Treat- ment of Tumors, 25 Warren — Surgical Pathology and Ther- apeutics, 29 URINE AND URINARY DISEASES. Saundby — Renal and Urinary Diseases, 24 Wolff — Essentials of Examination of Urine, 29 MISCELLANEOUS. Bastin — Laboratory Exercises in Bot- any, 7 Gould and Pyle — Anomalies and Curi- osities of Medicine, II Keating — How to Examine for Life Insurance, 14 Keen — Surgical Complications and Se- quels of Typhoid Fever, 15 Rowland and Hedley — Archives of the Roentgen Ray, 19 Saunders' Medical Hand-Atlases, . . 2 Saunders' New Series of Manuals, 22, 23 Saunders' Pocket Medical Formulary, . 24 Saunders' Question-Compends, . . 20, 21 Senn — Pathology and Surgical Treat- ment of Tumors, ■ ^5 Stewart and Lawrance — Essentials of Medical Electricity, 27 Thornton — Dose-Book and Manual of Prescription-\Yriting, 28 Van Valzah and Nisbet— Diseases of the Stomach, 28 In Preparation for Early Publication. AN AMERICAN TEXT=BOOK OF DISEASES OF THE EYE, EAR, NOSE, AND THROAT. Edited by G. E. DE SCHWEINITZ, M.D. , Professor of Ophthalmology in the Jeffer- son Medical College, Philadelphia; and B. Alexander Randall, M.D., Professor' of Diseases of the Ear in the University of Pennsylvania and in the Philadelphia Polyclinic. AN AMERICAN TEXT=BOOK OF PATHOLOGY. Edited by John Guiteras, M.D., Professor of General Pathology and of Morbid Anatomy in the University of Pennsylvania; and David Riesman, M.D., Demon- strator of Pathological Histology in the University of Pennsylvania. AN AMERICAN TEXT=BOOK OF LEGAL MEDICINE AND TOXICOLOGY. Edited by Frederick Peterson, M.D., Clinical Professor of Mental Diseases in the Woman's Medical College, New York ; Chief of Clinic, Nervous Department, College of Physicians and Surgeons, New York ; and Walter S. Haines, M.D., Professor of Chemistry, Pharmacy, and Toxicology in Rush Medical College, Chicago, Illinois. STENGEL'S PATHOLOGY. A Manual of Pathology. By Alfred Stengel, M. D., Physician to the Philadelphia Hospital ; Professor of Clinical Medicine in the Woman's Medical College ; Physician to the Children's Hospital ; late Pathologist to the German Hospital, Philadelphia, etc. CHURCH AND PETERSON'S NERVOUS AND MENTAL DISEASES. Nervous and Mental Diseases. By Archibald Church, M.D., Professor of Mental Diseases and Medical Jurisprudence in the Northwestern University Medical School, Chicago ; and Frederick Peterson, M.D. , Clinical Professor of Mental Diseases in the Woman's Medical College, New York ; Chief of Clinic, Nervous Department, College of Physicians and Surgeons, New York. HEISLER'S EMBRYOLOGY. A Text=Book of Embryology. By John C. Heisler, M.D., Professor oi Anatomy in the Medico-Chirurgical College, Philadelphia. KYLE ON THE NOSE AND THROAT. Diseases of the Nose and Throat. By D. Braden Kyle, M. D., Clinical Pro- fessor of Laryngology and Rhinology, Jefferson Medical College, Philadelphia; Con- sulting Laryngologist, Rhinologist, and Otologist, St. Agnes' Hospital; Bacteriologist to the Philadelphia Orthopedic Hospital and Infirmary for Nervous Diseases, etc. HIRST'S OBSTETRICS. A Text=Book of Obstetrics. By Barton Cooke Hirst, M.D., Professor of Obstetrics in the University of Pennsylvania. WEST'S NURSING. An American Text-Book of Nursing. By American Teachers. Edited by Roberta M. West, Late Superintendent of Nurses in the Hospital of the University of Pennsylvania. r r^ •