HX641 19262 RC46 .B28 A treatise on the pr Qlolmnhia llmtierBttg in tl|f (Ett^ at H^m fork (!l0Upg? of pifgalrianH anb ^ttrgwita / A TREATISE PRACTICE OF MEDICmE, TI8E OF STUDENTS AND PRACTITIONERS. BY ROBERTS BARTHOLOW, M. A., M. D., LL. D., Professor of Materia Medica and General Therapeutics in the Jefferson Medical College of Philadelphia; formerly Professor of the Theory and Practice of Medicine and of Clinical Medicine in the Medical College of Ohio; Fellow of the College of Physicians of Philadelphia; Member of the American Philosophical Society; Honorary Member of the Medical and Chirurgical Faculty of Maryland, of the Ohio State Medical Society, of the Cincinnati Academy of Medicine, of the New York Neurological Society; President of the American Neurological Association, etc. ISTEW YORK: D. APPLETON AND COMPANY, 1, 3, AND 5 BOND STREET. 1880. COPYRIGHT BT D. APPLETON AND COMPANY. THIS WORK, THE FIEST PRODUCT OF MY LABOR IN PHILADELPHIA, WITH AFFECTIONATE REGARD, TO THE PRESIDENT, TRUSTEES, AND FACULTY OF JEFFERSON COLLEGE. P E E F A C E . In undertaking the preparation of a treatise on the Practice of Medicine, I had the intention to write a companion volume to my work on Materia Medica and Therapeutics. When announced, the book was so far advanced that its completion was confidently anti- cipated within the year. Unfortunately, the condensation of mate- rial found necessary, when the work had reached that stage where its proportions could be judged with some accuracy, involved much additional labor. This was the more regrettable, as the incessant demands of a large private practice and the onerous duties of an exacting professorial position permitted little of that uninterrupted leism-e which is essential for successful literary composition. Slow progress was inevitable under these circmnstances, and hence it was not until my removal to Philadelphia last year that I could devote some hours each day to my arduous task. I trust that this explana- tion of the delay in the appearance of the treatise will be satisfac- tory to my readers, especially to the large number who have hon- ored me by subscribing for the work long in advance of its publi- cation. As my treatise on Materia Medica and Therapeutics embraced those topics of importance to the physician, and omitted matters of rather extraneous interest, so in the preparation of this volume my purpose was to include the subjects embraced under the title of " Practice of Medicine," omitting those topics of general pathology, etiology, etc., with which the works on Practice usually open, and yi PREPACE. whicli, thougli siifSciently valuable in themselYes, are too often passed over hastily, or not read at all, in tlie desire to reacli tlie practical subjects. I have therefore omitted the topics in question from their position as an introduction to special pathology, and have, although at the disadvantage of some repetition, incoi-porated them in their proper relation with individual diseases. That I should, under all the circumstances above stated, have undertaken such a task as the preparation of this treatise, for which, it may be suggested, there was no special need, and, if the need ex- isted, there was no claim on me to supply it, may be accounted for by the fact that, when the work was begun, I was Professor of the TheoiT and Practice of Medicine and of Clinical Medicine in the Medical College of Ohio, and was ui'ged, not only by the students and practitioners who attended my lectures, but also by many read- ers of my therapeutical treatise, to prepare a volume on Practice, which should have the practical characteristics, the definiteness of statement, the conciseness, and. at the same time, the fullness of the work on Materia Medica and Therapeutics. I was the more inclined to accede to these wishes because of a natural desire to ap- pear as an author on subjects to which I had devoted all the years of my professional life, and under the most varied conditions. Serving as an officer of the medical stafE of the ITnited States Army in Kansas, Utah, Colorado, Xew Mexico, Minnesota, and during the war of the rebellion at "Washington, Xashville, Chattanooga, Balti- more, etc., followed by an extensive practice (private and hospital) of sixteen years at Cincinnati, I may justly claim to have enjoyed large opportunities for the clinical study of the diseases of the Xorth American Continent. "With one or two unimportant excep- tions, I have had personal charge of the maladies treated of in this work, and have made them the subject of clinical demonstration and jpost-mortern investigation, either privately or in public lectures. In the treatment of the various topics, I have attempted to give to each just that amount of consideration to which its importance entitles it, within the limitations imposed by the size of the work. A just harmony and proportion can be secured only by condensing some subjects and displaying others, ^o space has been given to merely historical disquisitions, or to the discussion of controverted PREFACE. y{{ points. Also, to utilize all available sj^ace, chapters have been dis- j)ensed with, and the intervals between the sections have been ab- breviated as much as possible. ^Notwithstanding my utmost efforts at condensation, the work has grown beyond the contemplated size ; but I would fain hope that no part of it could be sacrificed without impairing the value of the whole. Much of the matter embraced in a work of this kind is the common property of the medical profession, and hence I have not quoted many authorities. I have rather avoided references when their mention would have been mere pedantry, and would have occupied valuable space. IS^evertheless, when I was distinctly in- debted for some fact or opinion, I have given the reference to the authority. Sometimes, when the authority is well known, the name is merely inclosed in parentheses. It is a comparatively easy task, especially with the aids now at our disposal, to give an ex- tended bibliography, but the space occupied would have swollen this work to encyclopedic proportions, without adding to its real utility. When an author only expresses the opinions of his author- ities, he avoids the appearance of dogmatism, which must be the tone of a work giving utterance to individual opinions ; but I could hardly do otherwise than draw my clinical material — the descrip- tions of diseases — from my own observations at the bedside. Also, a large experience in the treatment of disease could not fail to develop some positive convictions as to the real value of remedies. The reader will find that I have no sympathy with the therapeu- tical nihilism of the day, and that my convictions find expression in the recommendation of plans of treatment. In a work of this kind, intended for the guidance of young practitioners and students, some dogmatism, although offensive to the highest taste, may be pardoned, in view of the practical advantages of experienced leader- ship. Indeed, there is no department of the subject in which it seemed to me so necessary to express positive opinions. The influ- ence of some of our most prominent medical thinkers has been opposed to the value of medicines in the treatment of disease. The modern school of pathologists, absorbed in the contemplation of the ravages of diseases, are either oblivious of the curative powers of remedies, or openly ridicule the pretensions of thera- ■y^jjj PREFACE. peutists. I have, therefore, in the therapeutical sections, especially endeavored to set forth true principles, and have taught the utility of drugs when rightly administered, but have none the less tried to indicate the limits of their utility, for he who is unmindful of the injury done by ill-directed or reckless medication is as unsafe a guide as the most pronounced therapeutical nihilist. The pathological doctrines inculcated in the work are derived from the highest sources. The few illustrations of morbid changes introduced were obtained from the admirable atlas of Thierfelder. As my information on this subject was derived from those best qualified to instruct, I have not hesitated to express with some decision the present state of knowledge in resj^ect to the pathology of the various diseases, desiring in this, as in other departments of my subject, to give some positive views. I may be criticised with the observation that, in the progress of discovery, the doctrines at present received unreservedly may be entirely overthrown, and very different views be substituted. It will be time enough, how- ever, when the change comes, to adapt our opinions to the new order of pathological doctrines. Having thus explained my intentions in producing the work, I submit it to the judgment of the medical profession, with the assurance that, whether favorable or unfavorable, the decision will be just. Roberts Baetholow. 1509 Walnut Street, Philadelphia, September, 1880. TABLE OF COI^TEj^TS. SPECIAL PATHOLOGY AND THERAPEUTICS. Diseases of the Digestite System Stomatitis Aphthous Muguet Glossitis Superficial . Deep Gangrene of the Mouth . Noma Catarrh of Xaso-pharyngcal Mucous Catarrh of Lower Pharynx Retro-pharyngeal Abscess Diseases of the CEsophagcs CEsophagitis Dysphagia Stenosis of the (Esophagus Dilatations of the (Esophagus Diseases of the Stomach Acute Gastritis Toxic Gastritis . Phlegmonous Gastritis Chronic Gastric Catarrh Atonic Dyspepsia Gastralgia Ulcer of the Stomach Carcinoma of the Stomach Hfematemesis Dilatation of the Stomach Diseases or the Intestine Catarrh of the Intestine Cholera Morbus Infantum Duodenitis . Ileitis Ileo-colitis . Membrane ?ASE 1 5 5 1 1 9 11 12 13 13 14 15 16 \1 18 21 20 23 29 30 33 41 49 53 55 55 57 60 64 67 67 COXTENTS. Tvplilitis .... Inflammation of the Appendix Yermiformis Perityphlitis .... Proctitis — Catarrh of the Rectum . Croupous Enteritis Dysentery .... Ulcers of the Intestines Cancer of the Intestines Intestinal Haemorrhage Enteralgia . . . , Obstruction of the Intestines . Intestinal Parasites Cestoda Taenia Solium . Tcenia Saginata Eothriocephalus Latus Xematoda . Ascaris Lumbricoidcs Osyurus Yermicularis Trichocephalus Diseases of the Peritoneum Peritonitis .... Ascites Diseases of the Pancreas . Pancreatitis Cancer of the Pancreas Cysts of the Pancreas . Calculi .... Diseases of the Liter . Congestion of the Liver Interstitial Hepatitis Sclerosis .... Abscess of the Liver . Acute Yellow Atrophy Amyloid Liver . Carcinoma of the Liver Echinococcus of the Liver Aneurism of the Hepatic Artery . Thrombosis of the Portal Yein Suppurative Pylephlebitis . Catarrh of the Bile-Ducts Occlusion of the Biliary Passages . Biliary Calculi . Diseases of the Spleen Acute Splenitis Enlargement of the Spleen Misplaced Spleen Amyloid Degeneration of the Spleen Echinococcus of the Spleen Diseases of the Blood-forming Organ- Leucocythemia . Melansemia . . PAGE 69 . 14 74 Yo 79 82 91 96 99 100 102 113 114 114 116 119 120 120 123 124 125 125 132 136 137 138 140 140 140 140 145 145 151 161 165 169 172 178 178 179 180 184 185 189 189 191 192 193 193 194 194 200 CONTENTS. XI page Haemophilia ... = .,. 201 Scorbutus . . . 205 Purpura ....... 210 Ana?mia ........ . 213 Chlorosis ....... 219 Progressive Pernicious Anaemia ..... . 222 Thrombosis and Embolism . . . . . 224 Diseases of the Heart ...... . 228 Pericarditis ....... 228 Adhesions of the Pericardium ..... . 238 Hydropericardium ...... 240 Myocarditis ....... . 242 Fatty Degeneration ...... 245 Rupture of the Heart ...... . 248 Hypertrophy and Dilatation ..... 248 Plastic Endocarditis . . . . 256 Ulcerative Endocarditis ..... 260 Diseases of the Valves and of the Orifices . 264 Affections of the Aortic Valves and Orifice 269 Affections of the Mitral Valves and Orifice . 272 Affections of the Tricuspid Valves and Orifice. 275 Affections of the Pulmonary Valves and Orifice . 277 Heart-Clots ....... 283 Palpitation of the Heart ...... . 285 Diseases of the Blood-Vessels . . : . 287 Arteritis ........ . 287 Aneurism of the Aorta ..... 291 Diseases of the Respiratory Organs .... . 304 Pleuritis ....... 304 Hydi'othbrax ....... .318 Pneumothorax . . . 320 Hydropneumothorax ...... . 320 Pneumonia ....... 325 Embolic Pneumonia ...... . 341 Catarrhal Pneumonia ...... 343 Phthisis Pulmonalis ...... . 350 Caseous ....... 350 Tubercular ....... . 355 Fibroid .... ... 363 Hasmoptysis . . . ' , . 373 Hyperaemia and (Edema ..... 379 Atelectasis ........ . 383 Gangrene ....... 394 Carcinoma ........ . 398 Echinococci ....... 400 Acute Bronchitis ....... . 402 Chronic Bronchitis 407 Croupous Bronchitis ...... . 411 Stenosis of Trachea and Bronchi . . , „ 415 Asthma ........ .416 Diseases of the Larynx ..... 422 Acute Laryngitis . . . , . 422 Xll CONTENTS. PAGE Chronic Laryngitis ...... 424 (Edema of the Glottis ...... . 426 Laryngismus Stridulus ..... 429 Croupous Laryngitis (True Croup) .... . 431 Coryza . . . . . • . 437 Epistaxis ........ . 439 Diseases of the Kidney ..... 441 Congestion of the Kidneys, active . . 441 Congestion of the Kidneys, passive .... 442 Acute Parenchymatous Nephritis ..... . 443 Acute Parenchymatous Nephritis of Pregnancy 448 Chronic Parenchymatous Nephritis .... . 450 Interstitial Nephritis ...... 454 Amyloid Kidney ....... . 461 Pyehtis and Pyelonephritis 466 Eenal Calculi ....... . 469 Hydronephrosis ...... 476 Carcinoma of the Kidney ...... . 478 Tuberculosis of the Kidney ..... 481 Echinococcus of the Kidney ..... . 482 Movable Kidney ...... 485 Perinephritis . . . . . ... . 487 Diseases of the Nervous System .... 489 Cerebral Hypersemia . . . . . . . 489 Ansemia ....... 493 Occlusion of the Cerebral Vessels ..... . 496 Obliteration of the Capillaries .... 501 Occlusion of the Sinuses ..... . 502 Cerebral Hsemorrhage ...... 604 Meningeal ....... . 511 Pachymeningitis ...... 512 Externa ....... . 512 Interna ....... 512 Acute Hydrocephalus ...... . 515 Chronic Hydrocephalus . . . ' . 517 Congenital Hydrocephalus ...... . 518 Tubercular Meningitis ...... 520 Acute Meningitis . . . . . 524 Chronic Meningitis ...... 527 Abscess of the Brain . . . . . 528 Intra-cranial Tumors ...... 532 Aphasia ........ . 538 Diseases of the Medulla Oblongata .... 541 Haemorrhage in the Medulla ..... . 541 Occlusion of the Vessels of the Medulla 543 Acute Inflammation of the Medulla (Acute Bulbar Paralysis) . 543 Chronic Inflammation of the Medulla (Chronic Progressive Bulbar ] 'aralysis) . 544 Diseases of the Spinal Meninges and Cord . 548 Hypersemia of the Spinal Cord .... 548 Spinal Meningeal Hasmorrhage . 550 Pachymeningitis Spinalis ..... 552 Spinal Meningitis ....... . 553 CONTENTS. xm Acute Myelitis . . • • Chronic Myelitis Posterior Spinal Sclerosis (Progressive Locomotor Ataxia) Lateral Spinal Sclerosis (Spastic Spinal Paralysis' Infantile Paralysis Progressive Muscular Atrophy Pseudo-Hypertrophic Multiple Sclerosis of the Brain and Cord Dementia Paralytica . Syphilis of the Nervous System Cerebral Syphilis . Spinal Syphilis Of the Nerves Ckrebro-spinal Neuroses Epilepsy .... Hysteria .... Catalepsy .... Paralysis Agitans . Chorea ..... Writer's Cramp Tetanus .... Diseases of the Peripheral Nerves Neuritis .... Atrophy of the Nerves Neuralgia .... Tic-Douloureux Cervico-occipital . Cervico-brachial Intercostal Lumbo-abdominal Sciatica .... Convulsive Tic (Histrionic Spasm) . Torticollis (Wry Neck) Spasm of the Diaphragm (Singultus) Paralysis of the Ocular Muscles Facial Paralysis Vaso-motor and Trophic Neuroses Hemicrania (Migraine) Angina Pectoris Exophthalmic Goitre (Graves's Disease) GENERAL OR CONSTITUTIONAL DISEASES. Eruptive Fevers Variola . Confluens Hsemorrhagica Varioloid . Vaccinia and Vaccination Varicella Rubeola (Measles) Roseola (Roetheln) Scarlatina — Scarlet Fever PAGE 557 561 564 571 573 576 580 581 585 590 590 593 595 595 595 603 611 612 615 618 620 624 624 626 626 626 630 630 630 630 631 635 636 638 639 640 642 642 644 646 649 649 657 658 659 662 665 666 672 673 XiY CONTENTS. PAGE Diagnosis of the Eruptive Fevers . . . . . 683 Erysipelas . . 684 Fevkks . . . . . . . . 689 Typhoid Fever ....... 689 Typhus ....... . 705 Kelapsing Fever . . . . '710 Yellow Fever ...... . 715 Dengue. ....... 724 Miasmatic Diseases ...... . 727 Cholera . . . . . . 727 Diphtheria ....... . 736 Cerebro-spinal Meningitis ... . ' . 751 Influenza (Epidemic Catarrh) .... . 761 Hay-Fever (Summer Catarrh) . . . . . 764 Whooping-Cough (Pertussis) .... . 768 Parotiditis (Mumps) ...... 771 Malarial Diseases ...... . 774 Intermittent and Remittent Fevers . , . . 774 Disorders of Nutrition ..... . 790 Scrofula ....... 790 Acute Miliary Tuberculosis . , . . 795 Eickets ...,., 798 Lymphadenoma ,,..., . 804 Acute Rheumatism ....,, 809 Chronic Rheumatism . , . . , . 817 Gout (Podagra) . , . 819 Arthritis Deformans . ^ , . 825 Diabetes Mellitus ' . . 828 Diabetes Insipidus „<,... . 837 Animal Poisons ....... 839 Hydrophobia ...... . 839 Parasites ....... 848 Trichinae and Trichinosis .... . 843 LIST OF ILLUSTEATIOI^S. FIG. 1. 2. 3. 4. 5. 6. 7. 10. 11. 12. 13. 14. 15. 16. 11. 18. 19. 20. 21. 22. 23. 24. 25. 26. 27. 28. 29. 80. 31. .32. 33. 34. 35. PAGE Torsion of the Intestine ....... 103 Constriction of the Intestine by a Band of False Membrane . . . 103 Teenia Solium ........ 115 Scolex of Taenia ......... 115 Bothriocephalus Latus . . . . . . . 115 Bothriocephalus Latus, Egg of . . . . . . .115 Bothriocephalus Latus, Scolex of . . , . . . 116 Ascaris Lumbricoides . . . . . . = .120 Tricocephalus Dispar ........ 123 Oxyurus Vermicularis . . . . c . . .123 Area of Hepatic Dullness in Cancer of the Liver . , . . 171 Scolex of Taenia Echinococcus ....... 174 Taenia Echinococcus of the Pig ...... 174 Taenia Echinococcus of the Dog . . . . . . .174 Enlargement of the Liver by Hydatids ..... 175 Relation of the Valves and Orifices of the Heart to the Ribs, Sternum, and Exterior ....... To face 228 Effusion into the Sac of the Pericardium ..... 233 Sphygraographic Tracing in Hypertrophy of the Heart . . . 251 Sphygmographic Tracing in Aortic Stenosis ..... 269 Sphygmographic Tracing in Aortic Insufiiciency .... 270 Sphygmographic Tracing in Mitral Stenosis . . . - , 273 Sphygmographic Tracing in Mitral Insufficiency . , . . 274 Pleurisy with Effusion ...-..-. 311 Hydropneumothorax . . , . . ■ 322 Fibrous Tissue in Sputa ........ 330 Temperature Range in Pneumonia (Crisis) ..... 333 Temperature Range in Pneumonia (Lysis) ..... 334 Caseous Pneumonia ........ 352 Temperature Range in Caseous Pneumonia . . . . .354 Miliary Tuberculosis . . . . . . . 356 Fragment of Lung-Tissue and Sputa ...... 361 Cavities ; one pai'tly filled, one empty ..... 365 Casts in Acute Parenchymatous Nephritis ..... 446 Epithelium from Convoluted Tubes ...... 446 Casts in Chronic Parenchymatous Nephritis . . . . .451 Casts becoming fatty . . . . . . . 451 XVI ILLUSTRATIONS. Fra. PAGE 36. Hyaline Casts . . . . . . . . . 464 37. Various Forms in Pj'elitis . . ... . . . 468 38. Various Forms in Urinary Deposits .... . . . 472 No. 1. Uric Acid. 2. Urate of Soda. 3. Cystine. 4. Oxalate of Lime. 5. Dumb-bell Oxalate of Lime. 39. Epithelium of the Kidney . . . . . 476 No. 1. Of the Ureter. 2. Of the Urethra. 40. Temperature in Discrete Variola ...... 654 41. Temperature in Coherent Variola ...... 655 42. Temperature in Confluent Variola ...... 658 43. Temperature in Uncomplicated Measles ..... 668 44. Temperature in Measles with Catarrhal Pneumonia .... 670 45. Temperature in Typhoid Fever . . , . . . 697 46. Temperature in Acute Miliary Tuberculosis ..... 796 SPECIAL PATHOLOGY AND THERAPEUTICS, DISEASES OE THE DIGESTIVE SYSTEM. STOMATITIS. Definition. — Stomatitis is an inflammation of the buccal mucous membrane. There are various forms of the disease, determined by the seat and character of the lesion — for example : simple, follicular or aphthous, ulcerative, mercurial, and parasitic. Causes. — Simple stomatitis may be a part of a catarrhal process which involves the mouth, the oesophagus, and the stomach ; but more frequently it is caused by local irritants, such as condiments, tobacco, too hot and too cold liquids, etc. The follicular or aphthous form occurs at all ages, but is more common in early life. Children having feeble constitutions depressed by bad hygienic influences are especially liable. Often dependent on gastro-intestinal disorders, it is a frequent complication of prolonged diarrhcea, and more certainly so when the stools have an acid reaction. The ulcerative form is due to all those causes, also, which depress the vital forces — to fatigue, to excesses of all kinds, to bad hygiene, to damp and dark habitations, to improper and insuflicient food, and to various cachexise. Mercurial stomatitis is produced by the systemic action of mercury, in what form or mode soever the metal may be introduced into the organism. It should be remembered that in infancy the mercurial action does not manifest itself in stomatitis, but in an equally injurious toxic action of another form. Symptoms. — It is almost invariably true of inflammation of a mu- cous membrane, that the first effect of the process is to arrest secretion of its glandular appendages. The membrane becomes rough and swollen, and of a vivid red color ; and the glands, especially those at the base of the tongue, by an increase of their contents, enlarge and become prominent ; but the dryness, in a few hours, is succeeded by increased secretion. The fluid now poured out from the surface of the 1 2 DISEASES OF THE DIGESTIVE SYSTEM. mucous membrane consists of a transparent solution — serum — holding in suspension numberless young cells, cast-off epitbelium undergoing fatty metamorphosis, and minute organisms, bacteria, etc., derived from the external air. The exuded fluid tends to accumulate at cer- tain points in the cheeks and on the gums, and on the floor of the mouth. In some places, especially at the mouths of the follicles, superficial erosions are produced by the falling off of the epithelium. The mouth feels dry and hot at the outset. Considerable pain is experienced at every movement of the lips, tongue, and soft palate, or when hot and cold liquids or irritating solids are introduced into the mouth. Taste is much perverted, or is entirely wanting. The secre- tion poured out in the mouth excites a subjective taste of foulness, and this is represented, objectively, by an odor of putrefaction, especially when there are carious teeth. The characteristic of the aphthous form of stomatitis is a fibrinous exudation occurring first in the follicles. The exudation has a gray- ish or yellowish-white tint, round or oval in shape, and varying in size from the head of a pin to a bean. Subsequently, additions laterally of fibrin bring the isolated deposits in contact, and thus larger patches are formed. The exudation softens in two or three days, the mucous membrane disintegrates, and small ulcers are formed, which cicatrize in a week or two. As a similar process takes place in the skin, in variola, the same terms are used to describe the variations in the aph- thous patches ; thus they are said to be discrete, coherent, confluent, etc. In infancy the aphthous exudation is arranged somewhat sym- metrically, on the vail of the palate, and at the junction of the vail with the bony vault ; in adults, the exudation occurring in the follicles assumes a vesicular and pustular character, and attacks the lips, the cheeks, and the point of the tongue. Considerable suffering attends aphthous stomatitis ; the mouth is dry with the initial hyperaemia ; but, in a short time, a transparent and viscid secretion streams from the mouth ; the ulcers, painful at all times, are exquisitely so when acids, sweets, and sapid substances are ingested, and by the mere movements of the jaws in mastication. The breath is fetid ; the sublingual, submaxillary, and parotid glands become swollen and sensitive to pressure. The system at large sym- pathizes with the local disturbance ; and, in children especially, there is more or less fever ; disturbances of the digestive organs ensue ; the urine becomes scanty and high-colored. It occasionally happens that systemic infection takes place, with all the evidences of the most pro- found adynamia — the so-called typhoid state. Gangrene of the mu- cous membrane may then set in, or, commencing in the mouth, may induce an adynamic state. More frequently, aphthae occur in the mouth as a complication in typhoid or puerperal fever, when gangrene of the mucous membrane may follow. STOMATITIS. 3 Muguet is a term applied by the French to designate a form of exu- dative stomatitis, the special characteristic of which is the occurrence of minute parasitic organisms. The local morbid process is the same as in the other forms of stomatitis : hypersemia, arrest of, followed by greatly increased secretion ; production of new cells and easting off of the epithelium, but without exudation of fibrin. The bviccal secre- tion is usually acid, a condition which favors the growth of parasitic organisms. Atmospheric germs are deposited, and a process of acid fermentation goes on with a correlative growth of microscopic organ- isms. Whitish masses, looking like curds, are to be seen on the pal- ate, cheeks, tongue, and lips. These masses may remain separate and discrete, or enlarge, cohere, and cover the whole mucous surface. They may also extend into the air-passages, but more frequently into and through the intestinal canal. The extension into the latter organs is not by growth along contiguous surfaces, but by deglutition. In the fauces these curd-like masses interfere with deglutition, in the larynx with respiration. The membrane-like exudation of muguet is not truly a membrane, but is a collection of epithelial and mucous corpuscles matted to a mass by the vegetation of oidium albicans. The systemic disturbance produced by it depends on the extent of the patches : if small in size and discrete, there may be no fever and only restlessness due to the soreness of the mouth ; if confluent, there may be considerable fever. When patches develop in the intestinal canal after the vegetations are swallowed, very decided gastro-intestinal symptoms may be pro- duced. There will be more or less diarrhoea, or the stomach may be- come excessively irritable, food being rejected as soon as swallowed. The suspension of or serious interruption in the process of alimenta- tion causes an extreme degree of angeraia and impairment of the vital forces with cerebral symptoms, comprehended under the term hydren- cephaloid, or spurious hydrocephalus. These cerebral symptoms are frequently confounded with the opposite state — cerebral congestion. Diagnosis, — The ulcerative form of stomatitis is to be distinguished from syphilitic mucous patches. The distinction rests on the history, the form and duration of the patches, and the presence of concomitant symptoms. In syphilis the ulcers are less sharply defined and contain ashy-gray sloughs closely attached ; they are slow to heal, and appear and disappear ; they are accompanied by other syphilitic lesions, and preceded by a characteristic symptomatology. The aphthous form of stomatitis, muguet, may be confounded with diphtheria. The differentiation is arrived at by attention to the fol- lowing points : In diphtheria the exudation usually begins as a delicate pellicle on the tonsils or vail of the palate ; in muguet as a curd-like or pultaceous mass, on the lips, gums, or cheeks — the former extending forward, the latter backward. The exudation of diphtheria thickens 4 DISEASES OF THE DIGESTIVE SYSTEM.. and widens as it develops, and extends into the Eustachian tube, nares, larynx, and to wounded surfaces ; that of muguet is rarely co- herent, and extends into the fauces and oesophagus. The exudation of muguet is made up of cast-off epithelium, mucous corpuscles, and the vegetation of oidium albicans ; that of diphtheria, of a true fibrinous material within and upon the epithelium, and an immense quantity of bacteria, which also extend into the neighboring vessels and lymphat- ics. The odor, the swelling of the cervical lymphatics, the general systemic infection, and the profound adynamia, together with the pe- culiar sequelae of diphtheria, separate this malady readily from aph- thous stomatitis. Treatment.— Attention to diet is of the first importance. Acid substances, sweets, and condiments, excite smarting and distress in the process of mastication. In adults ulcerative stomatitis is often due to errors of diet, and such subjects soon learn that acid fruits and vegeta- bles, and those capable of acid indigestion in the stomach, will produce a plentiful crop of painful ulcers in the mouth. Obviously, in such cases, the offending articles should be omitted from the diet. The starchy and saccharine substances, owing to their facility for undergo- ing the acid fermentation, may be equally objectionable. In infants, to avoid the evil effects of acid indigestion, some sodic bicarbonate, or lime-water, is added to the milk. In ulcerative stomatitis, local appli- cations are highly serviceable. The surface of each ulcer should be cleansed, and a little pure carbolic acid applied. This produces a little momentary smarting, but great relief follows. A crystal of sul- phate of copper, or nitrate-of -silver stick, may be used to touch the surface of the ulcers — to set up a new action in the diseased part. If the local disease be due to gastric disorder, besides regulation of the diet, remedies to allay gastric irritability are necessary : for example, bismuth, oxide of silver, Fowler's solution of arsenic, hydrocyanic acid, etc. In some cases remarkably good results follow the admin- istration of potassium chlorate in large doses — for adults fifteen grains every four hours, and for children proportionally. In aphthous stoma- titis the same principles of treatment obtain ; but some attention must be given to the peculiar local conditions. As the extension of the patches is determined, to a large extent, by the growth of the oidium albicans, remedies destructive of minute organisms ought to be em- ployed — as salicylic acid, dissolved by aid of sodium biborate ; quinia sulphate, in solutions of varying strength according to the age of the subject; carbolic and boracic acid solutions, etc. The internal admin- istration of quinia and salicylic acid, to arrest the spread of the vegeta- tions swallowed, is highly important. A combination of bismuth and carbolic acid is very effective to relieve the extreme imtability of the stomach. Potassium chlorate is equally effective in this as in the ulcerative form. To be successful, it is necessary to administer large • GLOSSITIS. 5 doses. Mercurials should never be given in any form, for the destruc- tive ulcerations and the gangrene, which now and then occur, will be attributed to their action. Mercurial stomatitis will require the same general plan of treat- ment as the other forms of the disease, with the exception that elimi- nation of the poison must be promoted by the administration of the iodide of potassium. GLOSSITIS. Definition. — Glossitis is a term signifying inflammation of the tongue. It may occur in the mucous membrane, when it is designated supei-ficial, or in the body of the organ, when it is styled deep-seated or profound. The two differ as widely as distinct diseases in respect to external characters and gravity. Causes and Morbid Anatomy. — The superficial variety may be due to traumatism — as the contact of hot liquids, steam, and other local injuries. It may constitute a part of a morbid process involving the •mucous membrane of the mouth. The deep-seated variety may arise under similar conditions, but is more frequently a secondary malady occurring in the course of certain infectious diseases — as erysipelas, typhoid, pyaemia, acute rheumatism, variola, etc. The anatomical alterations occurring in superficial glossitis consist in swelling and redness, with desquamation of the epithelium of the mucous membrane. This change is found on the borders and on the dorsal face of the tongue, giving to these parts a red and raw appear- ance. Another variety of glossitis, entitled the papilliform, is limited to the large basal papillae of the tongue, which are much swollen in consequence of a hyperaemia of these bodies and an accumulation of their contents. This form of glossitis is usually caused by the irrita- tion of tobacco-smoke, or is syphilitic in origin. In superficial glossitis the taste is impaired or lost, and considerable pain is experienced when sapid substances, sweets, and acids are taken in the mouth. The flow of saliva is increased, especially on the occur- rence of pain and smarting from the mastication of sapid substances. When the papillae are involved alone, there will be present heat and smarting in the act of mastication and deglutition, especially when the substances ingested are of a sapid character, or are too hot. In the deep-seated form of glossitis, the whole tongue is usually involved. The mucous membrane is swollen, deeply injected, soft- ened, and disintegrated, deprived of its epithelium, and detached by a fibrinous exudation. The muscular elements are separated by an in- terstitial exudation ; they soften, disintegrate, and the striae sometimes disappear in a species of granular degeneration. The interstitial con- nective tissue is also involved, and hyperplasia may take place, lead- ing to induration, usually in patches, but the cellular elements may 6 DISEASES OF THE DIGESTIVE SYSTEM. • undergo multiplication, and, with the migrated white corpuscles, form centers or tracts of suppuration. In favorable cases resolution may occur, and the healthy state be restored. As very frequently the whole tongue is involved, considerable swelling may ensue and life may be put in imminent jeopardy in a few hours. There is a chronic form of glossitis, interstitial in its seat and chronic in its character, which consists in a hyperplasia of the connective tissue, and conse- quent encroachment on the muscular, which may suffer 'atrophic changes and disappear. When an inflammation involves the whole tongue, the organ may enlarge enormously, become too large, indeed, for the mouth, and pro- trude, the teeth marking deep indentations. Similar swelling occurring posteriorly, the enlarged organ presses painfully against the hard pal- ate, pushes the soft palate into the fauces, and the epiglottis against the larynx, thus causing gi-eat difficulty in, or preventing entirely, masti- cation and deglutition. The voice is at first muf&ed and indistinct, but subsequently is suppressed. Very great pain is experienced ; a tough and rather acrid saliva flows from the mouth incessantly ; the lymphat-- ics of the neck are swollen, often immensely so, and tender to the touch, and the face is puffy and cyanosed, partly in consequence of the swelling of the cervical glands preventing the return of blood through the jugulars, and partly because the swollen tongue interferes with the entrance of air to the larynx. So rapid is the progress of the swelling that, in twenty-four to thirty-six hours, death may occur from suffoca- tion, or a gradually increasing stupor announce the onset of carbonic- acid poisoning. A condition of imminent danger may suddenly cease, and comparative comfort be restored by the discharge of pus, conva- lescence soon setting in. When resolution occurs, the swelling gradu- ally subsides from the maximum, the general state improves corre- spondingly, and health is ultimately restored in its entirety. Rarely does gangrene ensue, with sloughing and subsequently contraction and impaired mobility of the tongue. During the existence of the severe local symptoms, especially when they occur in the course of the infectious maladies, the general state of the patient indicates the gravity of the disorder. The fever rises and is intense, the restlessness and anxiety are great, or there may be delirium of the low, muttering kind when carbonic-acid poisoning comes on. Chills and high fever, the temperature rising to 104°, 105°, or 106° Fahr., and sweats, will indicate the occurrence of suppuration. Increased difficulty of breathing may be due to an extension of the suppuration downward, the matter dissecting from the base of the tongue under the aryteno-epiglottidean folds. Course and Duration. — In the most acute cases life may be put in jeopardy by the swelling which prevents the access of air, in so short a time as twenty-four hours. The occurrence of glossitis in the GAXGREXE OF TEE MOUTH. 7 course of an infectious malady, which has ah-eady taxed the powers of life to the utmost, will soon determine a fatal result. Sudden death may ensue from oedema of the glottis, from rupture of an abscess into important parts, or from paralysis of the heart. The disease may continue several weeks, resolution slowly taking place ; or, an abscess discharging favorably, speedy recovery will ensue ; or more or less sloughing and loss of substance may occur, a tedious convalescence follow, and the tongue remain impaired in its functions. Diagnosis. — Glossitis can hardly be confounded with any other affection. Gumma of the tongue may cause sufficient swelling to ap- pear like the first stage of glossitis, but the previous history and the subsequent course of the latter will leave no room for doubt. Treatment. — The superficial form of glossitis requires the same remedies as stomatitis, or it may be safely permitted to pursue its natural course, a suitable regimen being enforced. The deep-seated form requires more energetic handling. When there is much sthenic reaction, the subject being vigorous, leeches should be applied under the angles of the jaws, or free scarifications of the tongue should be practiced. Water, as hot as can be borne, should be held in the mouth as long and as frequently as possible ; or ice may be as freely used, if grateful or more beneficial to the patient. Deep incisions may be necessary, if swelling threatens the life by asphyxia, or to evacuate matter. Tracheotomy may be required in an extreme case. If swal- lowing be prevented by the swelling, a flexible tube can be passed into the oesophagus through the nares, and nutritive liquids be thus con- veyed into the stomach. Support by suitable aliment is required from the beginning, and the use of alcoholic stimulants must be resorted to as soon as the powers of life flag. At the beginning, if there be much reaction, the arterial sedatives — aconite, digitalis, veratrum viride — may be employed ; but usually, quinia is more efficient as an apyretic, and to check the formation of pus. At the outset, fifteen to twenty grains of quinia and half a grain of morphia should be given to an adult, and subsequently from three to five grains of quinia and one eighth of morphia, every four hours. If swallowing become difficult, the remedies can be administered in solution by enema, the morphia being suspended if there be any indications of stupor from carbonic- acid poisoning. GANGRENE OF THE MOUTH— NOMA. Causes. — Gangrene is a result in some cases of stomatitis ; but these are not, properly speaking, cases of noma, which is a special dis- ease and occurs as an independent affection. It is a disease of early life — from three to five — and attacks the child of squalid poverty, or those living under the most unfavorable hygienic conditions. It is 8 DISEASES OF THE DIGESTIVE SYSTEM. sometimes an accident of the incautious use of mercurials in unhealthy- subjects. Morbid Anatomy and Symptoms. — The inner face of the cheeks, more usually of the left side, is the favorite site of the gangrenous process. At first a deep-violet or purple spot appears, surmounted by a vesicle full of bloody serum. Softening and destruction of the tis- sues take place, producing a quantity of sanies and detritus. Large exca- vations are thus formed, which widen as the destruction proceeds. A horrid stench is emitted from the decomposing mass. The jaws are eroded, the teeth loosened, and the lips invaded. Thromboses close the veins, but the arteries "remain permeable ; the nerves are stained black, but are not otherwise altered in structure. If a cure is effected, very great deformities may result in the process of cicatrization, and the functions of the parts be seriously impaired. Usually this disease begins silently and is painless, and hence escapes detection until the appearance of a grayish-black mass attracts attention to the mouth. When fairly inaugurated, the disease extends so rapidly that distinctive symptoms are produced. A pronounced odor of animal decomposition is exhaled with the breath ; the lips and cheeks become swollen and cedematous ; the sublingual and submaxillary glands enlarge ; sanies and bloody saliva, mixed with the gangrenous and decomposing materials cast off from the sloughing ulcer within, are constantly flowing from the mouth. Marbling of the dirty, wax-colored skin with purplish, vein-like lines, and a central dark spot of commenc- ing decomposition, indicate the outward extension of the gangrene to the cheek. As already indicated, during the first few days of the disease only local symptoms are present ; but then auto-infection ensues by reason of the absorption of the gangrenous materials, and an adynamic state is produced. Then the appetite is lost, nausea and vomiting occur, and a fetid diarrhoea supervenes. The strength fails rapidly, the pulse becomes small and weak, and low-muttering or merely nocturnal de- lirium comes on. Conrse, Duration, and Termination.— The course and duration of the malady vary with the age, the vigor of constitution, and the hy- giene. The gangrenous eschar on the cheek usually forms within the first week, and death may occur by exhaustion at the end of the second week ; or the patient may be cut off by an intercurrent malady, nota- bly pneumonia, at an earlier period. Pursuing its ordinary course, without complications, death may result from septicaemia in two weeks. When recovery takes place, the convalescence will be rapid or tedious, according to the amount of tissue to be repaired, and, even after the arrest of the gangrene, the powers of life may be exhausted by the extensive and protracted suppuration. The mortality is great, and ranges from sixty to seventy per cent. PEARYNGITIS. 9 Diagnosis. — Noma is to be distinguished from malignant ulcer, and from ulcerous stomatitis. Malignant ulcer begins on the lip ; noma on the mucous membrane within. The former is an ulcer covered with an ash-gray slough ; the latter is a mass of blackish, gangrenous, decomposing tissues. The ulcero-membranous stomatitis consists of a number of small, round ulcers, at various points, that do not become gangrenous, and heal readily on appropriate treatment. Treatment. — Support to the powers of life is the main point, and this includes not only aliment but air-space. Alcoholic stimulants must be used early and freely. Quinine in full doses, and opium cau- tiously, should be given with the view to arrest the spread of the gan- grene, and to prevent septicaemic infection. If administered at an early period, belladonna seems to possess the power to prevent the spread of the gangrene. It is very important to destroy the first sloughing tissue by active caustics, as Vienna paste, chromic acid, zinc chloride, muriatic acid, etc. The caustic must be so applied as to destroy a small extent of surrounding healthy tissue. CATARRHAL INFLAMMATION OF THE NASO-PHARYNGEAL MUCOUS MEMBRANE. Definition. — The upper pharynx, into which the posterior nares enter, is the seat of this inflammation. It may be acute or chronic. Causes. — Inflammation of the naso-pharyngeal space is usually a part of an inflammation involving the posterior nares and the lower pharynx. The most prolific cause is taking cold. Next to this is the use of cigarettes, especially if the smoke is inhaled and ejected by the nares ; and then comes alcoholic excess, but little less important. Diphtheria, the eruptive fevers, and inflammatory aifections of the air-passages, are accompanied by this affection. Pathological Anatomy. — An intense hyperaemia — a vivid redness — is the first change, but in chronic cases the color of the membrane is reddish-brown. As a result of the congestion, haemorrhagic extrava- sations may occur. The mucous membrane is swollen, infiltrated, and projecting from the general surface are numerous enlarged follicles. The increase in size of the follicles is due largely to the increase and accumulation of their cellular contents. The pharyngeal tonsils are enlarged from the swelling of the mucous membrane, and the orifices of the Eustachian tubes are changed in form by the same cause, or even obstructed. A quantity of glairy, tenacious mucus is poured out, and coats the surface of the membrane. In chronic qases, the mucous membrane is much altered by the enlarged and tortuous veins, by haemorrhagic extravasation, and by the hypertrophic enlargements of the follicles. In very old cases the mucous membrane undergoes atrophy. There is also increased secretion ; the mucus is mixed with 10 DISEASES OF THE DIGESTIVE SYSTEM. pus, and not unfrequently with blood, and a thick string of muco-pus can often be seen projecting down into the lower pharynx, behind the soft palate. Erosions of the epithelium also take place, and super- ficial ulcers form. Symptoms. — There is at first, in acute cases, an unpleasant, stuffy, and dry feeling in the naso-pharyngeaL space, followed in a short time by increase of secretion falling into the pharynx or discharging by the anterior nares. There may be some headache and pains in the upper jaws. Breathing through the nose is difiicult. The voice is thick and nasal. The symptoms of an acute attack subside in a few days, the secretion changing to a yellow muco-pus from the transparent, glairy mucus which first appeared, breathing through the nose becoming natural, and the voice assuming its normal tone. In the chronic form, the symptoms succeed to the acute or develop slowly from the causes continuously acting. The posterior nares are more or less obstructed, constantly to a slight extent by the swelling of the mucous membrane, and occasionally \erf much by accumula- tion of mucus. Breathing through the nose may be sometimes pre- vented. The voice is more or less thick and nasal. Pain in the ear may be felt, and dullness of hearing is a common symptom from ob- struction of the Eustachian tube. The mucus, hanging down into the lower pharynx, excites frequent attempts to swallow, and causes a feeling of the presence of a foreign body. A disagreeable habit of hawking is induced in this way. In very chronic cases with atrophy of the mucous membrane, secretion ceases, and the membrane has a dry and glazed appearance. Course, Duration, and Termination. — The course of the acute form is short, and the termination is in health, or in the chronic form. The chronic form is very slow, and is usually regarded of importance only when a thick band of mucus hangs into the lower pharjmx, and ex- cites efforts to clear the throat. As a not infrequent cause of deafness it comes under the observation of the aural surgeon. Although cu- rable under appropriate management, the treatment is very protracted. As success in the treatment requires abstention from the two preva- lent habits of smoking and drinking spirituous liquors, success will depend on the conduct of the patient very largely. Left to itself, the duration is indefinite. Treatment. — The first step in the treatment is to free the mucous membrane from the viscid discharge. This is best accomplished by washing out the cavity with the post-nasal syringe, employing a solu- tion of common salt or carbonate of sodium (3 j — | iv). The syringe is passed behind the vail of the palate, the fluid discharged, when, the patient leaning forward, it escapes into a vessel placed to receive it. So much damage to the ear has resulted from the incautious use of the nasal douche, that the author advises the curved post-nasal syringe for CATARRHAL INFLAMMATION OF THE LOWER PHARYNX. H the purpose just indicated. Keeping the mucous membrane free from the unhealthy mucus is an important point. The agents used to bring about a cure of the chronic inflammation are very numerous. Strong applications are injurious. Those most frequently employed are the salts of zinc, copper, and silver. One grain of sulphate of zinc to four ounces of water is strong enough. The author finds that dry appli- cations — powders used by the method of insufflation — are greatly supe- rior in efficacy to all other modes of treatment. A mixture of tannin and iodoform is the best formula ( 3 j of tannin — gr, x of iodoform). A minute quantity of this is put into the chamber of the insufflator and blown into the naso-pharyngeal space. This instrument must have a long tube, and be suitably curved, so that it can be passed be- hind the palate. The salts of zinc, copper, and silver, iodoform, calo- mel, bismuth, may be used in the same way. Next to tannin and iodoform, insufflations of bismuth are most useful. When the former produce much irritation, the author uses bismuth in the interim of the applications. CATARRHAL INFLAMMATION OF THE LOWER PHARYNX. Pathogeny and Symptoms. — This may be acute or chronic. Both forms arise under precisely the same conditions as the corresponding maladies of the naso-pharyngeal space. The changes in the acute form consist of redness, swelling of the mucous membrane, enlargement of the follicles from accumulation of their contents, and increased secre- tion, coming on after a very brief dry stage. These anatomical condi- tions are not limited to the pharynx. In the chronic form, the changes are more decided. The mucous membrane is of a deep reddish-brown, or, in very old cases, grayish. The vessels of the mucous membrane are enlarged and tortuous. The follicles are enlarged and prominent, and have a grayish or reddish-gray color ; there may be considerable development in places of the squamous epithelium, and ulcers, rather shallow than deep, form in various situations. The symptoms are by no means pronounced. Dryness, a sense of heat and irritation, a feel- ing as if something were adherent to the mucous membi'ane, much hawking and clearing the throat, are the chief sensations. On inspec- tion of the fauces the mucous membrane is seen to be of a deep, red- dish-brown color, thick, coated with a tenacious mucus, and roughened by enlarged follicles. In very old cases the posterior wall of the phar- ynx is smooth, thin, and glazed, and has adherent to it dry masses of mucus, colored by dust. Treatment. — The principles and the methods of practice advised for the naso-pharyngeal space are equally applicable here. 12 DISEASES OF THE DIGESTIVE SYSTEM. RETRO-PHARYNGEAL ABSCESS. Definition. — By this term is meant an accumulation of pus in the submucous connective tissue, posterior to the pharyngeal wall. An abscess may form in the mucous membrane itself — this is entitled pharyngeal abscess. Causes. — Diseases of the cervical vertebra, of the atlas and axis, and caries, are the principal causes. Large collections are formed in the same situation, from suppuration in the bronchial glands, and in the deep cervical lymphatics — the pus dissecting up under the mucous membrane, and pointing in the pharynx. Again, an abscess may be the result of an inflammation of the loose connective tissue, under the pharyngeal mucous membrane, a disease not infrequent in children before the tenth year. Symptoms. — The abscess produced by an acute inflammation of the connective tissue is very acute in its course. It begins with chill, high fever, sleeplessness, intense restlessness, and in very young children there may be convulsions. When the abscess results from caries of the vertebrae, its march is slower, and the symptoms of pharyngeal obstruction are the first to call attention to this part. Pain in moving the head is felt, and hence it assumes a fixed position, the cervical muscles being rigid. Then difliculty of swallowing and dyspnoea come on. If digital exploration is then made by passing the index-finger gently over the base of the tongue, a hard, brawny, possibly fluctuating swelling may be detected in the pharynx. The neck will also be much swollen externally, and fluctuation may ultimately be felt under the angle of the jaw. Suppuration is often announced by the occurrence of a chill, and the fever will then assume an intermittent or remittent type, and profuse sweats will occur. The abscess, if not interfered with by art, will discharge spontaneously into the lower pharynx, or exter- nally, or form fistulous communication with the cavity. The author has seen one case in an adult, which extended from the basilar process to the root of the lungs. When spontaneous opening of the abscess takes place, suffocation may be caused by escape of the matter into the larynx. Death may also be caused by the size of the collection, the larynx being occluded, or by secondary disease of the air-passages, or by thrombosis of the transverse sinus, or jugular vein, or even of the carotid artery. Course, Duration, and Termination.— There are great differences, ac- cording to the origin of the abscess, in the course pursued. Those due to caries of the vertebra are slow in development, but fatal in result. The phlegmonous abscess is acute, pursues its course in from five to twenty days or longer, and the danger is determined by the size of the collection, and the direction taken by the pus if not spontaneously evacuated. If not large, the abscess will discharge and heal without (ESOPHAGITIS. 13 danger to life. The large submucous abscess will almost always prove fatal by exhaustion. Treatment. — Pus should be evacuated at the earliest moment. The powers of life must be sustained by proper aliment and the free use of stimulants. The formation and spread of pus must be limited by the administration of quinia, as far as such a result is possible. DISEASES OE THE (ESOPHAGUS CATARRH OF THE CESOPHAGUS.— CESOPHAGITIS. Causes. — Acute oesophagitis exists only as a part of a morbid pro- cess involving the mouth, fauces, and stomach. Typical examples are afforded by the action of irritant poisons and corrosive substances. The chronic variety is produced by the causes which give rise to the chronic stomatitis. The acute and chronic forms differ so little that they may be considered together. The change in the mucous mem- brane consists in more or less hypersemia, especially about the follicles ; at first an arrest of secretion, followed by an abundant pouring out of mucus, which in the chronic form is always in excess. Consider- able hypertrophic thickening of the mucous membrane occurs in the chronic malady, and in some situations takes on the form of papillary or polypoid-like outgrowths. Coincident thickening of the muscular layer also occurs. Erosions of the mucous membrane, at first super- ficial, are produced by disintegration and separation of the epithelium, and ulcers are then formed, which may extend to the deeper layers. The greatest diameter of these ulcers is parallel to the long axis of the tube. Ulcers also result from the impaction of foreign bodies ; from corrosive liquids ; from tubercular deposition, etc. The catarrhal form may be confined to the follicles, when it is called follicular oesophagitis. The follicles are swollen and prominent, partly in con- sequence of an abnormal accumulation of their contents, and partly in consequence of an hypertrophy and contraction of the adjacent con- nective tissue. The diseased follicles appear as firm nodules, some- what conical in shape, projecting above the general surface, and irreg- ularly distributed along the tube. A fibrous or croupous oesophagitis also exists, not as an independent affection, but consisting of an exten- sion downward of an exudation, croupous or diphtheritic, or occurs as a complication in typhus, scarlet fever, small-pox, etc. There is, also, 14 DISEASES OF THE DIGESTIVE SYSTEM. a phlegmonous or purulent inflammation of the oesophagus, which comes on by extension of purulent infiltration of neighboring parts, as in perichondritis of the larynx, by the action of corrosive substances, by lodgment of foreign bodies, etc. Symptoms. — In either acute or chronic form, oesophagitis produces but few symptoms. Pain in swallowing is usually present in the acute form, and may be developed in the chronic cases by the ingestion of hot or rough foods. Pain may be caused by pressure on the tube from without, and by the passage of an oesophageal bougie — a procedure by which we may designate the seat of ulceration, or lesser kinds of irri- tation, even. When there is severe local disease at any point, as an ulcer, for example, food swallowed descends to that point, excites a sensation of heat and pain, and is then regurgitated by a sudden reflex spasm of the tube. Sometimes mucus or muco-purulent matter will be found adherent to the particles of food. Chronic catarrh is espe- cially characterized by the production of much glairy and tenacious mucus, which rises into the pharynx, causing the sensation of the presence of a foreign body. The attempt to clear the throat of this often excites gagging. These symptoms are, not unfrequently, con- founded with those due to corresponding diseases of the throat, espe- cially chronic and follicular catarrh. Course and Duration. — Simple acute catarrh terminates in a few days. When produced by corrosive liquids, the process of cicatriza- tion will occupy several weeks, and subsequent contractions and stric- tures may so interfere with nutrition as to cause death by marasmus after many months. The chronic, and especially the follicular, variety may continue unchanged for years. Treatment. — The management of the various forms of oesophagitis is the same as the corresponding affections of the mucous membrane of the mouth. The topical applications must necessarily be restricted to the agent swallowed. DYSPHAGIA. Dysphagia, or difficulty of swallowing, is a symptom of disease, but not a disease itself. It is frequently hysterical, when it is accom- panied by other hysterical manifestations, as the globus hystericus, laughing and crying, etc. It may be hypochondriacal, when the pa- tients present the deep dejection, the indifference, and other symptoms of that state. It may be due to stricture, succeeding to injury by steam, corrosive liquids, injuries of various kinds, cicatricial tissue, malignant disease, etc. It may also be due to paralysis of the palate, a sequel of diphtheria. It will be more appropriately considered when these topics are discussed. STENOSIS OF THE (ESOPHAGUS. 15 STENOSIS OF THE CESOPHAGUS. Causes. — The term stenosis signifies narrowing of the oesophagus, produced in various ways. It may be congenital or acquired : the lat- ter only will be considered here. As regards acquired stenoses, they may be produced by causes acting from without, by compression ; within, by obstruction. As respects those acting from without, we find the lumen of the oesophagus narrowed by tumors, the enlarged thyroid, aneurisms, caseous lymphatics, etc. Obstructions from the in- terior are caused by foreign bodies lodged, which usually produce acute symptoms, but sometimes remain, lodged in pockets or diverticula, for months or years. Parasitic growths gradually developing may cause stenosis. Fibroid polypi, club-shaped or lobulated, slowly ob- struct the canal, and hence cause the symptoms of obstruction very slowly. Strictures are formed by the contraction of cicatrices, or by carcinoma. Cancerous stenoses are more frequent than all the others combined. Their usual seat is the lower third of the canal, and they may involve the whole periphery and a considerable part longitudi- nally. Symptoms. — Increasing difficulty in the passage of food, which the patient recognizes at a certain point, is usually the first symptom ex- perienced. Swallowing is successful, but the patient feels a sense of obstruction below, requiring at first repeated attempts at swallowing to overcome ; then repeated sips of water, with more swallowing to dislodge the bolus ; and, when the obstruction reaches a certain point, regurgitation occurs, not in consequence of an inverted peristalsis, but the mechanical effect of partial compression of a tube containing liquid contents. The position of the obstruction is pretty accurately indi- cated by the sensations of the patient and by the time when regurgi- tation takes place. In acute stenosis — from burns, scalds, and corro- sives — and in chronic carcinoma, when complete obstruction occurs, food is regurgitated as soon as swallowed. The physical signs of stenosis are important. On mspection in thin persons, the movement of the bolus may be seen descending to the point of stoppage if high enough up, or the return movement may be discerned. Enlarged lym- phatics may be visible at the root of the neck, and the abdomen, especially the hypochondria, may be flattened and retracted, indicat- ing starvation. On auscultation the normal oesophageal sound pro- duced by the passage of foods may be heard suddenly arrested at the point of obstruction and passing upward on regurgitation, or various adventitious sounds may be audible, as gurgling, sucking, spluttering, etc., at the point of narrowing. An important symptom is spasm of the glottis, produced by pressure of a growth, especially cancerous, on the recurrent laryngeal nerve. A peculiar cough, sudden paroxysms of difficult breathing, and a toneless voice, are thus caused. Difficulty 16 DISEASES OF THE DIGESTIVE SYSTEM. of breathing may also be due to pressure on the trachea simultaneously with the oesophageal pressure. The most tormenting hunger and thirst arise in the progress of the case, and increase with the increasing dif- ficulty of getting aliment in the stomach ; the body emaciates to an extraordinary extent ; the mind is incessantly occupied with thoughts of savory viands, and, in the delirium with which the scene closes, the hapless patient is engaged with the most sumptuous repasts. Diagnosis. — The spasmodic stenosis of the hysterical and hypochon- driacal is accompanied by the usual symptoms of these states, and the condition of the patient as to nutrition is not in harmony with the gravity of the local phenomena. Acute stenosis is preceded by the history of injury by scalding or burning, or by the ingestion of corro- sive liquids. The question of cancer is to be considered with refer- ence to the age, which is, almost always after forty-five, and the de- velopment of the disease is marked by a gradually increasing difiiculty of swallowing, by marasmus, and the cancerous cachexia. External compression may be produced by enlarged lymphatics, by an hypertro- phied thyroid, by mediastinal and cervical tumors; but these can easily be differentiated from all kinds of internal obstruction. An aneurism of the arch of the aorta, by compression of the oesophagus and of the recurrent laryngeal nerve, will cause symptoms not unlike those due to cancer of this tube ; but there will be present»the signs of aneurism. Diagnosis will in all cases be greatly facilitated by the oesophageal bougie ; but this instrument must be used with caution when the canal is much injured, lest perforation be produced by its passage. Prognosis. — The termination is fatal in a large proportion of cases of stenosis ; but excellent results may, sometimes, be obtained by the patient and persistent use of the means of dilatation in cases of steno- sis by cicatrices. Treatment. — So far as medical management is concerned, it is de- termined by the causes of the obstruction, and it is not our province to discuss surgical expedients. DILATATIONS OF THE OESOPHAGUS. Causes. — Dilatation, or ektasia, is a uniform enlargement of the oesophagus, the whole cylinder usually being involved. A diverticu- lum is a protrusion from the walls laterally, forming a sac of greater or less extent. Ektasia may be caused by fatty degeneration of the muscular layer, which yields in the act of contracting on the bolus as it descends to the stomach. With increasing dilatation, there is in- creasing weakness of the muscular . layer and consequent dysphagia. Vomiting and regurgitation presently occur ; after a while the nutri- tion fails, and the objective symptoms are similar to those of stenosis, the ultimate result being equally unfortunate. Diverticula may be DILATATIONS OF THE (ESOPHAGUS. lY caused by the lodgment of foreign bodies leading to the formation of pouch-like protrusions. Pressure diverticula are usually situated at or about the junction of the pharynx with the oesophagus, and in the median line, posteriorly, for here the longitudinal muscular fibers are wanting and the pressure is greatest. When fully formed, they are deep pockets, or sacs, of varying length, and may be several inches deep. The first step in their formation is the lodgment of a foreign body ; then yielding of the muscular layer of the tube, due to fatty degeneration of the muscular elements ; increasing pressure from de- posits of food and drink ; the final result being a sac extending down- ward and behind the oesophagus. The mechanical effect of a sac in this situation is to push the tube before it and compress it, so that ulti- mately the food and drink drop into the sac instead of passing into the stomach, thus causing the symptoms of stenosis. The symptoms, however, develop more slowly than in even the most chronic cases of stenosis. Diverticula occur in the great majority of instances after forty, whence it happens that they are often confounded with cancer ; there is no cachexia, and the symptoms continue for years. A bulg- ing, variable in size, may often be observed above the level of the cri- coid cartilage ; this marks the position of the diverticulum within. The food accumulating here may, by the contraction of the cervical muscles or by the fingers of the patient, be dislodged and is then regurgitated. The sound enters the sac, but is not tightly embraced by it, as is a stricture, and moves about freely in the cavity. Traction diverticula are found low down, opposite the bifurcation of the trachea, and are caused by various inflammatory conditions leading to adhesion with the oesophagus. The traction thus caused induces the formation of diverticula. DISEASES OF THE STOMACH. FORMS AND VARIETIES. The diseases of the stomach are named according to their charac- ter and anatomical seat. Inflammation of the stomach is called gas- tritis, and may occur in the mucous membrane, or in the submucous connective tissue. The mucous variety is known as gastric catarrh, and then consists of two forms — acute and chronic ; the submucous variety is designated phlegmonous or interstitial gastritis, and may also occur in two forms — acute and chronic ; the latter is sometimes 2 18 DISEASES OF THE DIGESTIVE SYSTEM. called cirrhosis of the stomach. There is also a form of gastritis caused by the ingestion of corrosive and irritant poisons — toxic gastri- tis. Under the term embarras gastrique the French authors describe a light foi"m of gastric catarrh, due to the use of various kinds of indi- gestible aliment. Severe cases of gastric catarrh, in which, in addition to the ordinary symptoms of indigestion, there is present fever, lasting about a week, have been called gastric fever. Chronic gastric catarrh is only another name for dyspepsia. ACUTE GASTRITIS- Causes. — The stomach is much affected by atmospherical changes. An illustration of this is afforded in the summer and autumnal attacks of bilious and gastric fevers, so called, induced as they are by the very considerable vicissitudes of temperature, the hot days and cool nights of the autumn. Gastric catarrh occurs at all ages after infancy, and is more frequent in men than in women. The most common causes are errors of diet, insufficient mastication of food, swallowing too hot or too cold liquids, excessive eating, abuse of ices, condiments, and sauces, etc. ; and especially of alcoholic drinks. Various external influ- ences and moral causes affect the digestive functions, as occupation, exercise, sedentary habits, grief, etc. Pathological Anatomy, — In the simplest cases, the lesions may be so slight as to escape detection ; in mild but fully developed cases the changes are about as follows : The mucosa is the seat of a delicate in- jection occurring in isolated spots, arborescent or generalized to the whole membrane. Usually at or near the cardiac orifice, the injection or hyperaemia is most pronounced. The mucous membrane may be intensely engorged, and covered with a grayish, semi-transparent, and tenacious mucus (Orth, page 287). It should not be forgotten that enormous congestion of the stomach may exist in cases of mitral ob- struction and regurgitation. The similarity of this to true catarrhal states is rendered the more confusing, because of the quantity of glairy and tenacious mucus found attached to the mucous membrane so firmly as to be washed off with difficulty (Wilks and Moxon, page 380). The mucous glands are prominent, and are increased in size above the nor- mal, in consequence of the overgrowth of their contained cells and the hypertrophy of the adjacent connective tissue. In chronic cases, the glands have shrunk (atrophy), or have become cystic, in some situ- ations, because of the pressure produced by the contracting connec- tive tissue. Sometimes the mucous membrane is softened and easily stripped off ; then again, it is indurated and much thickened, in conse- quence of interstitial inflammation. Much confusion has arisen in regard to the term " mammillated," which consists in the formation of numerous small, conical eminences, by the contraction of the sub- ACUTE GASTRITIS. I9 mucous connective tissue, or of the muscular layer, similar to cutis an- serina. This appearance can not be regarded as morbid, unless asso- ciated with other anatomical changes. Ecchymoses are found, and also dark, brownish patches, the result of subsequent changes in the effused blood. Erosions also occur here and there of various sizes, but not often of considerable size, and just about them the mucous membrane is softened. An (Edematous appearance of the mucous membrane is caused by an infiltration by serum and sero-albumen of the submucous connective tissue. The proper secretion of the gastric glands is much affected by these anatomical alterations. The true gastric juice is no longer secreted, or its production is much lessened, and it is replaced by an alkaline fluid having no power of digestion. Symptoms. — The initial morbid changes, doubtless, precede the oc- currence of objective symptoms. At first, diminution of appetite, labored digestion, nocturnal restlessness, inability to undergo fatigue, supra-orbital headache increased by light, by noises, and by move- ments of the head, and sometimes accompanied by vertigo, are the symptoms experienced. In some instances, the vertigo is extreme ; the patient may fall unconscious for a few seconds, and the vertigi- nous attacks may be confounded with symptoms of the same kind due to cerebral lesions. Pain is felt at the epigastrium, spontaneous or developed by pressure. The epigastric pain may have a boring char- acter, as if passing through the body straight to the spinal column, or under the angle of the scapulae. Pain is frequently felt in the left hypochondrium, two inches under the left nipple, or in the immediate vicinage of the apex-beat. The tongue is enlarged, marked laterally by the indentations of the teeth, and is covered over its whole extent with a whitish or a yellowish-white coating. The taste is perverted, indifferent, bitter, or putrid. Especially on rising in the morning is the mouth pasty, sticky, and filled with a bitter-tasting mucus. The appetite is totally lost (anorexia), and the thought of food-taking, especially the appearance of food, excites a sensation of disgust ; but considerable thirst is experienced, and drinks, particularly those of an acid character, are eagerly sought after. Nausea is present in varying intensity, and there is usually vomiting, at first consisting of the ali- mentary substances, then viscid mucus acid and bitter, and finally bilious matters. Bilious vomiting is commonly supposed to indicate special disturbance in the hepatic function, but it really means that by the act of vomiting the gall-bladder is mechanically compressed, and its contents forced through the duodenum into the stomach. The amount of vomiting is usually determined by the amount of food pre- viously taken. If the result of an indigestion, the vomiting is copi- ous ; but, under other circumstances, it may occur only occasionally, aud then be slight. The sufferings of the patient are always aggra- vated by errors of diet, and vomiting is certainly provoked by eating 20 DISEASES OF THE DIGESTIVE SYSTEM. indigestible food. A foul odor of the breath, eructations of fetid gas, are due to a failure of digestion, and the occurrence of decompositions, the character of which, and the resulting products, being due to the kind of food undergoing this process. Saccharine and starchy foods become converted into carbonic and acetic acids ; the fatty result in setting free irritating fat acids, and the substances containing sul- phur and phosphorus give forth the highly fetid compounds of hydro- gen — sulphuretted and phosphuretted hydrogen gases. Acidity and heartburn (pyrosis) are thus caused, and tympanitic distention of the stomach results from the setting free of a great quantity of carbonic- acid gas. The intestinal functions may or may not be disturbed. Usu- ally there is present slight constipation ; yet, if the attack is brought on by the use of indigestible aliment, more or less diarrhoea may occur, and it may be conservative. Mild cases of acute gastric catarrh may not excite the least disturbance in the heat-function, but in young and susceptible subjects there may be some feverishness, the movement being of a remittent type, the maximum temperature rarely exceeding 103° Fahr. When the stomach disturbance is extreme, and the fever persists for several days, the cases are sometimes entitled gastric fever, or they are confounded with remittent fever, especially in malarious regions. Course and Duration. — The duration of acute catarrh of the stom- ach is four days to a week. A sudden and rapid cure is sometimes effected by a spontaneous or a forced evacuation, by vomiting, by purging, or by a urinary discharge. The beginning of convalescence is sometimes announced by an eruption of herpes, or by a profuse sweat. Diagnosis. — Acute gastric catarrh with fever may be confounded with remittent and typhoid fever of the first week, but all doubts will disappear as these maladies develop. Vertigo a stomacho laeso (Trous- seau) is to be distinguished from similar symptoms due to cerebral hyperaemia. The distinction rests on the age of the sixbject, the pres- ence or absence of degenerative changes in the vessels, and of the arcus senilis, the history of stomachal troubles, the fugitive character of the symptoms, and the prompt disappearance of the stomach-disease when efficient treatment is instituted. Treatment. — Simple cases of acute catarrh of the stomach need only abstinence and quiet. K the stomach is much embarrassed, and excesses of the table have been recently committed, or some specially irritating articles of diet have been consumed, free emesis is the most effective treatment. The salts of the metals belonging to the class of emetics are too irritating for this purpose. If vomiting have occurred, it may be encouraged by swallowing large draughts of warm water, which will act as a sedative if the stomach is empty. Weak alkaline mineral waters — as Congress, Hathorn, and Yichy of the Saratoga Springs, TOXIC GASTRITIS. 21 and the French Vichy — should be drunk freely. Unhealthy and undi- gested aliment, which has reached the intestines, should be dislodged by saline laxatives. When there is much biliousness — so called — ' manifested by a heavily-coated tongue, vertigo, headache frontal and temporal, yellow skin, more or less constipation, urine high-colored, acid, scanty, etc., the mercurial purgatives are held to possess some special curative powers. This is probably true to a limited extent, not because of any action on the liver, but because they increase elimi- nation from the excretory glands of the lower ilium. Podophyllin, iridin, euonymia, and ipecac, are nearly equally effective, but calomel in small doses (one twelfth of a grain) has remarkable sedative effects on an irritable stomach. The officinal effervescing powders, carbonic- acid water, milk, and lime-water, are excellent remedies to check vom- iting. A mixture in equal parts of carbolic acid and iodine tincture, of which a drop may be taken, well diluted with water, every few hours, is a most valuable remedy to arrest abnormal fermentations and to check vomiting. A mixture of bismuth and carbolic acid with mu- cilage, in mint-water, is hardly less efficient. After the more acute symptoms have subsided, the tincture of nux-vomica and the diluted muriatic acid are suitable remedies to improve the tone of the stomach and to restore the appetite. TOXIC GASTRITIS. Causes. — As already defined, toxic gastritis is an acute inflamma- tion of the stomach, caused by the ingestion of irritant and corrosive poisons. Symptoms. — So far as the symptoms are concerned, there is no essential difference in the effects produced by the different irritant and corrosive poisons. Immediately on swallowing, there ensues a deadly nausea, rapid and uncontrollable vomiting, the matters rejected con- sisting of the contents of the stomach acted on by the poison, shreds of mucous membrane, altered blood-clots, etc. A diagnosis of the form and chemical characteristics of the poison may sometimes be made by observing the character of the stain of the face, lips, and mucous membrane — sulphuric acid causing a friable, blackish eschar ; nitric acid a yellowish, leathery eschar ; caustic potash spreading widely, softening, and liquefying the tissues. In the stomach, dark- brown, greenish, or black discolorations, with masses of sloughing mucous membrane, are observed. It is rare that the whole mucous membrane of the stomach is uniformly attacked. Usually there is considerable discoloration — uniform, indeed, about the cardia, at the greater curvature, and at the pylorus, leaving large portions un- touched. Sometimes only the mucous membrane about the cardia and at the pylorus is attacked (Wilks and Moxon) ; the extent of the 22 DISEASES OF THE DIGESTIVE SYSTEM. action and the resulting appearances depend on the degree of con- centration of the corrosive material. Sometimes the walls of the stomach are perforated, a result more frequently due to the action of alkalies than acids. The mineral poisons — arsenic, the salts of mer- . cury, copper, zinc, nitrate of potash, etc. — produce an intense inflam- mation with vivid redness and injection. Carbolic acid acts super- ficially, and hardens and tans the mucous membrane. Similar results follow the ingestion of certain kinds of food cooked in copper vessels and containing the acetate and other salts of copper, or articles of food that have undergone decomposition, such as sau- sages, hams, cheese, fish, etc. A violent gastro-enteritis is produced in a few minutes or hours after the swallowing of such aliments. Besides the local there are various systemic symptoms, produced by irritant poisons, either due to the diffusion of the poison or to the reflex dis- turbance resulting from violent local irritation. Besides the vomiting mentioned above as occurring immediately or very soon after swal- lowing the irritant, corrosive, or toxic substance, purging sets in, and the same sanies, detritus, and sloughs of the tissues discharged by vomiting pass also by stool. In the case of corrosive sublimate and the metallic salts generally there occur intense colic and tenesmus, and the discharges consist of mucus and blood, and strongly simulate dysentery. Whether or not diffusion of the poison or irritant takes place, there occur great anxiety and depression, a weak, rapid pulse, slow and shallow respiration, cold skin, covered with a cold sweat, retracted features, intense internal heat and thirst, burning in the gullet and fauces — the lips, tongue, cheeks, and fauces, charred, cor- roded, or softened by the contact of the poison. Course^ Duration, and Termination. — The characteristic feature of toxic gastritis is the suddenness with which symptoms arise, after swallowing some solution or eating certain articles of diet. Soon severe pains in the stomach, violent vomiting, and other symptoms occur, the patient having previously been in good health, it may be. Death may occur from the immediate effects of the poison, from the shock of the injury done to the organs, from the shock and subsequent perforation of the stomach, and peritonitis, combined. Recovery may ensue if the injury done is not too great for repair, the patient passing safely through the period of shock and collapse. The evidences of improvement consist in subsidence of the pain and vomiting, in re- turning tolerance to food which is bland and unirritating, in the dis- appearance of all the symptoms of collapse. Surviving the first injury, a fatal result may be subsequently due to the inflammation which fol- lows. The convalescence is necessarily tedious, owing to the very limited surface capable of carrying on the function of digestion. Recovery is apt to be partial, and the nutrition ever after is feeble, owing to the extent of injury — the cicatrices and contraction CHRONIC GASTRIC CATARRH. 23 of the stomach, the stenoses of the orifices of this organ, and of the (Esophagus. Treatment. — Vomiting is to be encouraged by the free use of de- mulcent drinks. If the toxic agent consists of an acid, as speedily as possible weak alkalies, lime-water, soda, common soap, etc., should be administered. If the offending substance is a caustic alkali, weak acids, common vinegar, diluted acetic acid, etc., should be given. The various mineral salts require their appropriate antidotes : arsenic, dialyzed iron, or hydrated sesquioxide of iron ; antimony, vegetable astringents, as green tea, galls, and oak-bark infusion ; mercury and copper, albumen and mucilaginous substances ; phosphorus, turpen- tine, magnesia, etc. ; carbolic acid, saccharated lime. The stomach- pump should be used not only to remove the poison remaining, but to thoroughly wash out the stomach. To allay pain, and counteract the depression of the powers of life, no agent is comparable to the hypo- dermatic injection of morphia. Ice should be given freely, and an ice- bag applied to the epigastrium. The morphia must be repeated at regular intervals. No food should be given but a little cold milk at short intervals. Injections of defibrinated blood may be practiced with great advantage as a means of support. The subsequent man- agement depends on the character of the poison,, and the nature and extent of the injuries. PHLEGMONOUS OR INTERSTITIAL GASTRITIS. Definition. — By this term is meant an inflammation of the walls of the stomach, usually of the submucous layer, and resulting in the forma- tion of an abscess, or in purulent infiltration of the parietes. These abscesses may be single or multiple. Causes. — Phlegmonous gastritis may occur during the course of pyaemia, or be due to haemorrhagic infarction or to hepatic obstruc- tion. These abscesses may be acute or chronic. Symptoms. — The symptomatology of phlegmonous gastritis is ex- ceedingly obscure. The ordinary course is as follows : Usually sud- denly, or after an irregular prodromal stage, the patient is seized with epigastric pain, followed by nausea and vomiting, thirst, a weak and irregular pulse, great distention of the abdomen, and dian'hoea. Pro- found prostration comes on, and finally a low delirium and death. These symptoms do not indicate the nature of the malady. As it is doubtful whether such cases are ever recognized, the treat- ment must be conducted on general principles. CHRONIC GASTRIC CATARRH. Causes. — The chronic form may succeed to the acute. Heredity exercises an . influence in its causation ; not in the sense that the dis- 24 DISEASES OF THE DIGESTIVE SYSTEM. ease is directly traiismitted, but the type of mucous membrane. Bad hygienic influences of every kind, especially miasmatic influences, and all manner of irregularities of life, are causative. The abuse of spir- its, and the habitual consumption of highly-seasoned foods and of con- diments and sauces, hasty and insufiicient mastication, the frequent use of ices, and overfeeding, are the principal causes of chronic gastric catarrh. Pathological Anatomy. — The most important changes occur about the pylorus. The evidences of previous hyperajmia exist in a brown- ish discoloration due to hsemorrhagic extravasation and subsequent changes in the hsematin, and in more or less varicosity of the vessels. There is constantly present more or less hypersemia, but not the intense and vivid injection seen in acute catarrh. The abnormal supply of blood to the submucous connective tissue leads to overgrowth (hyper- plasia, hypertrophy), and this new material contracting, forces the glands into abnormal prominence, causing that appearance known as mammelonated ; but it should not be forgotten that this appearance may be due to a contraction of the organic muscular fiber without the existence of any disease whatever. The gland-tubules also increase in size in consequence of overgrowth of their contents, and they produce a quantity of grayish or yellowish, thick, tenacious mucus, which cov- ers closely and adheres to the surface of the mucous membrane. The overgrowth of connective tissue increases the thickness of the mucous membrane and its resistance to section. Compression of the tubules (glands), by the contracting connective tissue, induces atrophy of their cells. Here and there a gland is obstructed ; its secretion having no outlet, accumulates, and a cyst is the ultimate result. Symptoms. — When a chronic succeeds to an acute catarrh of the stomach, the attacks of the latter become increasingly frequent, and presently it is found that the patient is never free from uneasiness and other painful sensations referable to the stomach. This painful and otherwise disordered digestion is commonly known as dyspepsia. When chronic catarrh exists the patient is rarely free from some disagreeable sensations, but it is after taking food, chiefly, that he experiences a feeling of weight or fullness, sometimes of pain ; but acute pain of a lancinating character, especially when it seems to pass directly through to the back, is more frequently due to neuralgia — gastralgia — or is a symptom of ulcer or of cancer. On the other hand, attacks of neuralgia do sometimes occur in the course of chronic gas- tric catarrh ; but the pain of the latter is more often a sense of sore- ness diffused over the epigastrium, the greater curvature, and is some- times felt only in the left hypochondrium. Sometimes this pain may be relieved by pressure ; but more usually pressure over the stomach, at any point, develops uneasiness, soreness, or pain. As the pit of the stomach, so called (the triangular space under the xiphoid appendix), is CHRONIC GASTRIC CATARRH. 25 occupied by the left lobe of the liver, and as the stomach lies well up in the left hypochondrium, these facts must be taken into considera- tion in coming to a conclusion in regard to the seat of pain. Some- times when the stomach is empty, sometimes when it is full, the pain is greater ; sometimes the pain is relieved by taking food, sometimes it is increased thereby. These idiosyncrasies give to each case a pecu- liar physiognomy. The subjective sense of fullness is confirmed by the objective swelling of the stomachal region. After meals, the dis- comfort caused by the distention is such that the mere pressure of the clothing gives rise to pain. This feeling of distention is due in part to an irritable state of the mucous membrane, but more especially to the formation of the gases of decomposition. In the normal state, the gastric juice has the power to prevent decomposition, or to arrest it after it has begun ; but disease alters these conditions, and food in the stomach may pass through various kinds of fei'mentation accord- ing to its composition — the starchy and saccharine undergoing the acetic, and the fatty, the butyric fermentation. A small quantity of starch or sugar may produce a large volume of carbonic acid, causing great distention, and eructations of a sour liquid (pyrosis). Butyric acid induces a strong sense of heat and burning, gaseous eructations, often highly offensive from the presence of sulphur-compounds with hydrogen. Furthermore, gaseous distention of the stomach affects the muscular movements of the organ, so that the foods are not prop- erly distributed and mixed with the gastric juice. In the regurgita- tions that ensue, particles of food are brought up, the nature of which is recognized by the patient ; it may be acid, bitter, or merely mawk- ish. Again, by the distention of the stomach, the heart is pushed up and its actions hampered, and, through the intimate nervous commu- nications, palpitation and intermittent pulse and a strongly accentu- ated second sound are produced. In consequence of the compression of the great venous trunks the return of blood from the head is impeded, and hence the face has a congested, red, and swollen appearance, and the head feels full, and headache and vertigo are present during the time the stomach digestion is going on. In some cases of chronic catarrh, vomiting of food occurs soon after it is swallowed. Later, if vomiting take place, the food is in various stages of digestion, and the vomited matters are highly offensive from the presence of butyric acid and the sulphur-compounds mentioned above. Sometimes the vomited matters will have a pasty or yeast-like appearance, due to the presence of a peculiar fungus — from its fancied resemblance to a wool- pack, called sarcina ventriculi. Vomiting is not constant nor regular, and in many cases occurs only when improper food has been taken. On the other hand, morning vomiting of topers is a constant and ordinary condition in these subjects. As soon as they arise in the morning a feeling of qualmishness comes on, and they strain a 26 DISEASES OF THE DIGESTIVE SYSTEM. great deal to bring up some acid, glairy, tough mucus, or a quantity of rather thin, frothy, watery fluid mixed with air, and alkaline or neutral in reaction, and consisting chiefly of saliva swallowed during sleep. The appetite is usually diminished, or it may be capricious and rarely excessive (bulimia). Usually but little food in the stom- ach develops a sense of satiety. Certain kinds of food, by the mere sight or remembrance of them, excite disgust and nausea ; and, as a rule, the animal foods are disliked, and acid fruits and fresh vegetables are craved. The saliva is usually increased in amount ; the tongue is pointed, red at the tip and edges, and the mucous membrane is glazed ; the large papillse at the base are swollen and tumefied, and there is present more or less follicular pharyngitis. The intes- tinal functions rarely continue undisturbed ; constipation and flatu- lence are usually present, and the constipation alternates with diar- rhoea. An extension of the catarrhal process from the duodenum to the ductus communis and the smaller ducts causes more or less swell- ing and obstruction and, consequently, jaundice. The nutrition of the body is impaired by chronic gastric catarrh ; the strength is less- ened, and the subcutaneous fat diminishes ; the muscles lose in volume and decline in power, and the various functions are performed with less energy and efiiciency. This depression in the functions is espe- cially marked in the psychical sphere, where it manifests itself in melancholy and hypochondria, the patient being solely occupied with his own miseries, and especially with those sensations and feelings belonging to his own state. The peculiar troubles of this mental state are enhanced by the headache, the vertigo, and the other cerebral symptoms which accompany stomachal diseases. Diagnosis. — The coexistence of the cerebral symptoms just men- tioned with those of chronic gastric catarrh may greatly embarrass the diagnosis, but usually the differentiation may be made by refer- ence to the history of the case, the extended duration of the gastric symptoms, which is incompatible with the fact of a cerebral malady, and the absence of concomitant evidences of disease of the nervous centers. Ulcer of the stomach may be confounded with chronic gas- tric catarrh, but the diagnosis may be made by attention to the following points : In ulcer, there is in front a fixed point of pain, posteriorly a corresponding j^ainful spot ; there is no diffused sore- ness ; there is acute pain as well as soreness ; the pain is aggravated by pressure, by the ingestion of solids and liquids, especially if hot or cold ; there is vomiting of blood. In cancer, there is pain acute or, lancinating or burning, when the stomach is empty or full ; vomiting of food, of glairy mucus tinged with blood, and vomiting of black blood ; rapid and continuous emaciation ; a peculiar icteroid, earthy hue ; a tumor, hard or with nodosities ; enlargement of exteraal glands (the sub-clavicular). CHRONIC GASTRIC CATARRH. 27 Course and Duration. — The duration of chronic gastric catarrh is very variable ; it may last months or years, now better, now worse, depending on the measures, or the neglect of them, employed for relief. Readily enough cured, if the patient will submit to the regi- men necessary, it becomes exceedingly difficult if the causes which produced it continue in operation. Catarrh may terminate in ulcer, or it may lead to stenosis of the pylorus. Treatment. — The ti-eatment of chronic gastric catarrh due to he- patic obstruction, to valvular disease of the heart, and to albuminuria, belongs to the management of these diseases respectively, and need not be considered here. Regulation of the diet is of the first consequence in all stomach diseases. All articles that disagree, whether owing to their nature or to idiosyncrasy, should be omitted. As acetic- and butyric-acid fermen- tations play so important a part in stomach derangements, it is highly important to exclude from the diet those substances the decomposition of which results in the formation of these acids. These articles of diet are the saccharine, the starchy, and the fatty. The mucus acts as a ferment, and these decomposing substances enact the same rdle, so that, when the starches, sugars, and fats, reach the stomach, the fer- mentation begins. To exclude these articles, then, is the first step toward a cure. In lieu of these components of the diet, so important to most persons, the succulent vegetables, as lettuce, celery, spinach, cauliflower, tomatoes, etc., should be substituted. The materials for continuing the fermentations, consisting of mucus and the remains of previous fermentation, must be removed from the cavity, if a continu- ance of the disorder is to be prevented. This can be accomplished in several ways : by the use of an absolute diet until the organ has freed itself of its decomposing contents ; by the administration of emetics and laxatives ; by washing out the organ with the stomach-pump; and, lastly, by the employment of certain medicines. A curative measure of the highest importance is the " skim-milk cure." This consists in the exclusive use of milk for food until the stomach is freed from the materials of fermentation, and has had sufficient rest to recover. The milk is taken in the quantity of four ounces (about) every three hours, day and night, when awake, and for a period of time determined by the cessation of the symptoms for which it was prescribed. During this time nothing whatever is swallowed, except a laxative to relieve the constipation, or medicine for other purposes ; but no medicines should be administered during a course of the milk-cure, unless impera- tively demanded. When, after a few weeks, or a month or two, the symptoms of gastric catarrh have subsided, then some additions to the diet may be made, very gradually, consisting at first of a little stale white bread, then rice, then a soft-boiled Qgg, and so on, gradually, until a suitable diet is constructed. 28 DISEASES OP THE DIGESTIVE SYSTEM. An emetic, occasionally, is highly useful to empty the stomach of decomposing materials, and to prepare a clean surface for the action of medicaments. Saline laxatives may be employed for the same pur- pose. An occasional Sedlitz powder ; now and then a drachm or two of Epsom salts in the early morning, or the Saratoga waters, or Ptlllna, or Friederichshall, etc., are appropriate for this purpose. When there is much biliary derangement, phosphate of soda is highly serviceable. Still more effective for cleansing the stomach is the stomach-pump, or the fountain-syringe used as a siphon. With this instrument the cavity may be thoroughly washed out with tepid water, solution of common salt, solution of potassic chlorate, solution of salicylic acid, etc. As the effects are mechanical, chiefly, and are due to mere wash- ing of the mucous membrane, it usually suflaces to employ warm water. In severe cases the irrigation of the stomach may be practiced daily. Arsenic is a remedy of the first importance in the treatment of catarrh of the stomach. It is best administered in the form of Fow- ler's solution, one or two drops, three times a day before meals, and it should be continued for a month or more. Next to arsenic, the oxide of silver is to be commended, in pill form, one half to one grain, three times a day, also administered on an empty stomach ; but, as argyria may follow its prolonged use, it should not be given for a longer time than one month. When there is much acidity, it may be checked by the mineral acids, notably the muriatic, given before meals. This practice is based on the principle that acids before meals prevent the osmosis of those constituents of the blood which contribute to form the acid gastric juice. Alkalies, although they afford relief, do not effect a cure, except in those cases of acidity of a temporary character due to fermentation of starchy and saccharine food, and accompanied by catarrh of the bile-ducts, and then the alkali most effective is the phosphate of soda. When acid is deficient, good results may be obtained by the use of alkalies before meals, on the well-recognized principle that an alkaline fluid in the stomach will favor the diffusion from the blood of its acid-forming constituents. When abnormal fermentations constitute the chief or only source of discomfort, the most serviceable remedy is carbolic acid, alone or in combination with bismuth. Gaseous eructations are best relieved by the same means. Freshly bumed charcoal, finely divided, is a good remedy, though only palliative, acting merely as an absorbent. After suitable treatment for the relief of the local condition, tincture of nux vomica is an ex- cellent stomachic, especially adapted to the chronic catarrh of spirit drinkers. The bitters in general, with or without the mineral acids, are applicable under the same conditions. It should never be forgot- ten that all special stimulants to the gastric mucous membrane are injurious, and should never be employed until the morbid state is ATONIC DYSPEPSIA. 29 removed. To employ them without proper regulation of the diet is simply to add another source of irritation. It can not be too strongly impressed on the reader that rest, which is essential to the treatment of any diseased organ, is equally necessary to the stomach when it is suffering ; but, as some aliment is absolutely necessary to life, the stomach can never be put into a state of complete repose. Hence the need of a most careful regulation of the diet, so that the condition of rest may be, as nearly as possible, attained. ATONIC DYSPEPSIA. Definition. — By atonic dyspepsia is meant a form of indigestion due to a depressed state of the stomach. It is that form of functional derangement usually called dyspepsia. Causes. — It is often inherited. It is a disease of advanced life, and is then accompanied by those senile changes belonging to that period, and is a consequence of them. It is a symptom in depressed states of the system generally, as, for example, in exhausting discharges, as haemorrhages, leucorrhoea, profuse suppuration, etc. It is produced by all those circumstances comprehended under the term bad hygiene. The most influential factors are improper and excessive alimentation, and severe mental and physical exertion immediately after eating. Morbid Anatomy. — This malady has not, properly speaking, a mor- bid anatomy : besides anaemia and deficient secretion, there are no changes. Various alterations have been noted, as atrophy of the tu- bules, fatty degeneration, increase of the connective tissue, etc. But these changes belong to other states, of which atonic dyspepsia is merely a symptom. Symptoms. — A sense of weight and uneasiness, lasting throughout the process of digestion, suspended for a short period when food is taken, is usually the initial symptom. A feeling as if a foreign body were lodged behind the sternum, or higher up in the oesophagus, often with a sense of oppression or dyspnoea, is frequently experienced. Acute pain is rarely felt, but there is usually some flatulent colic, and pressure fails to develop pain, but rather affords relief to uneasy sen- sations. Digestion is impaired in respect to all classes of foods, fari- naceous, saccharine, and fatty ; and hence, during the process of diges- tion, flatulence from the formation of carbonic acid and eructation of rancid fats are frequently present. More or less intestinal disturbance accompanies the stomach symptoms, and constipation almost always occurs. The appetite is usixally feeble, and the disinclination for food includes all the varieties. There is little thirst, and the ingestion of fluid gives rise to distress. The tongue is too large, and is marked along its borders by the teeth, and is at the same time pale and flabby. The mucous membrane of the mouth is also pale and the gums are soft 30 DISEASES OF THE DIGESTIVE SYSTEM. and spongy ; the tonsils are apt to be enlarged, the uvula relaxed, the voice husky, and there is frequent clearing of the throat. The bodily condition generally is that of depression ; the pulse is weak, excitable, and easily compressed ; palpitation occurs quickly on exertion and fre- quently without effort of any kind, and intermission of the pulse-beat is by no means uncommon. Flatulent distention of the abdomen in- duces oppression of the chest, but dyspnoea may occur without such cause, being due to a nervous state. The skin is usually pallid and earthy, moist and clammy, and the extremities cold. The urine is pale, of low specific gravity, and loaded with the phosphates. The mental condition is in harmony with the general state — that is, de- pressed. There is great inaptitude for mental exertion, an impaired state of the memory and attention, and irritability of temper. Drow- siness supervenes after eating, while sleep at night is restless and un- refreshing. Diagnosis. — Atonic dyspepsia differs from chronic gastric catarrh in respect to the amount of pain, vomiting, and tenderness on pressure, which are less, and the depression which is greater, in the former than in the latter. Treatment. — In this as in other stomach disorders, the first step con- sists in regulation of the diet. It is useful to commence the dietetic management by the milk-cure. Next, as rapidly as possible, nutritious but easily digested articles must be added. As the digestive powers are feeble, food must be given in small quantity but frequently. As the foods disagree, irrespective of their quality, obviously quantity and frequency of ingestion are the points to be considered. As the powers of digestion are depressed, the special aids to this function are indicated : pepsine, lacto-pepsine, in combination with muriatic acid ; pepsine and bismuth with aromatic powder ; tincture of nux vomica, strychnia, and the bitters, especially calumba, with or without muriatic acid ; the mild chalybeates, as pil. ferri carb,, the citrate, malate, or tartrate of iron, etc., are the most appropriate of the medical agents. A small quantity of acid wine at dinner is a good stimulant to the digestive function. A moderate dose of whisky, taken before meals, is a capital remedy to promote the appetite and the digestion ; but it is a dangerous remedy, for it so overcomes the feeling of depression as to be very grateful, and there is therefore a constant temptation to repeat the dose. As, in these cases, there is usually more or less men- tal depression, change of scene, travel, and agreeable occupation, con- tribute materially to the cure. GASTRALGIA. Definition. — Gastralgia is a painful state of the sensory nerves of the stomach, induced by various sources of irritation, and free from fever. GASTRALGIA. 31 Causes. — Doubtless the chief factor is a peculiar state of the ner- vous system, the neurotic temperament, so called, or the nervous state, or hysteria. This condition of the nerves existing, various substances, which under ordinary circumstances would not excite the least distress, now cause severe paio. It is highly probable that the abuse of tea and coffee has no little influence in causing the disease. Symptoms. — The characteristic symptom of gastralgia is the occur- rence of severe paroxysmal pain, felt in greatest intensity at or about the epigastrium, and radiating thence upward over the chest and down- ward through the abdomen. The pain also is felt in the back, and seems to pierce through the body, and it shoots upward to the shoul- ders. The pain is not increased but diminished by pressure, and the patient instinctively lies or presses firmly on the abdomen, or demands to be rubbed or beaten on the back. In the severest cases, the pain is so excessive as to produce profound prostration ; the pulse is small, rapid, and weak, the surface is cold and covered with a cold sweat, and the features are shrunken. In almost all cases, the action of the heart is disturbed, owing to the intimate nervous communications be- tween the two organs ; the pulse is small and weak or intermitting. The duration of the attacks is very variable, lasting for a few hours, for a day or two, or continuing for months vrith intermissions and remissions. Usually the attacks are of short duration, and terminate with eructations of gas, with vomiting, or the more acute pain subsides, leaving a sense of soreness, and occasional lighter pains, which may continue for several days. The attacks may be regularly intermittent, in cases of uterine disease, and when caused by malaria. During the interval, the function of digestion may proceed undisturbed, and the nutrition of the body continue at the normal. Various disorders of the nervous system are usually present, as — palpitations, migraine, hysterical phenomena, notably the globus, etc. In males, hypochon- dria, associated with oxaluria, is not infrequent. Course and Duration. — Gastralgia is an essentially chronic malady, in that the attacks are prone to return from time to time, and the as- sociated disorders continue in the interim to plague the patient. Those cases dependent on malaria, or on the presence of indigestible food, may be cured with comparative facility, but the ordinary cases are not readily cured. Notwithstanding the obstinacy of these cases, gastral- gia is not dangerous to life. Diagnosis. — Gastralgia is to be differentiated from myalgia affect- ing the abdominal muscles, intercostal neuralgia, hepatalgia, neuralgia of the solar plexus, ulcer of the stomach, and cancer. In myalgia the pain is restricted to the affected muscles, and has not the acute and lancinating character of gastralgia, and is unaccompanied by nausea and vomiting. As respects intercostal neuralgia, it is to be noted that the pain is in the left hypochondrium, that painful points can be de- 32 DISEASES OF THE DIGESTIVE SYSTEM. veloped by pressure in the course of the nerve-trunk, and at the spine, and that this affection is unaccompanied by nausea and vomiting. To separate gastralgia from neuralgia of the solar plexus is in some cases extremely diiRcult ; but attention to the following points may prevent error : in gastralgia, there is a history of previous stomachal disorders; in neuralgia of the solar plexus, the inhibition of the heart's action is greater, and the systemic depression is more profound. Hepatalgia and hepatic colic are to be separated by the situation of the pain in the left hypochondrium, by the tenderness in the region of the gall-blad- der, by the symptomatic fever, and by the jaundice. From cancer, gastralgia is differentiated by the age of the subject, by the character of the vomited matters, the persistence of the pain, the cachexia, the emaciation, and the tumor ; from ulcer, by the fixedness of the pain, its constant presence with soreness, the vomiting of blood, etc. Treatment. — During a paroxysm, the first point is the relief of pain. This may be most effectively and promptly accomplished by the hypodermatic injection of morphia, and frequently so small a dose as one twelfth of a grain suffices. As there is always danger of opium- habit in these cases, this fascinating remedy must be used with cau- tion. Opium or morphia is frequently prescribed with bismuth and aromatic powder. Morphia is also used endermically — that is, applied to a blistered surface, about a square inch of surface being denuded. By enema is an efiicient mode of administering the anodyne. When, from any cause, morphia can not be given, the pain, as also the nausea and vomiting, may be ari-ested by creosote or carbolic acid. This remedy may also be administered with bismuth in an emulsion — a combination of the most efficient kind. Equal parts of tincture of iodine and carbolic acid, of which a drop may be administered every hour in a little cold water, is a most valuable agent, not only for the relief of pain, but to stop the vomiting. Arsenic (one drop of Fow- ler's solution) and opium (two to five drops of the tincture) are not unfrequently highly serviceable for the relief of the paroxysms, but they are more generally useful for the accompanying condition of the mucous membrane, and the end organs of the nerves of the stomach. There is no remedy so constantly curative of the local causes of the attacks, and so efficient in preventing their return, as arsenic. For the condition of things between the attacks, next to arsenic, stand the oxide and nitrate of silver. For the strictly intermittent cases, occur- ring at a fixed hour, quinine is invaluable ; but the author has seen cases which were not removed by quinine, but ceased promptly when salicylic acid was administered. When attacks of gastralgia are due to indigestible food, the first duty is to empty the stomach. If vomit- ing is going on, it may be encouraged by large draughts of warm water ; if vomiting has not occurred, it should be induced by an emetic, preferably by apomorphia administered hypodermatically, to ULCER OF THE STOMACH. 33 avoid irritation of the stomach. If acid and fermenting materials re- main to keep up the disturbance, they should be removed by irrigation of the stomach, or by mild laxatives of the saline and antacid charac- ter. It is generally better to remove the contents of the stomach be- fore administering anodynes. The subjects of gastralgia are usually of the nervous, hysterical, and hypochondriacal type, and require chalybeate and supporting remedies. As the stomach in such sub- jects is easily offended, only the milder preparations of iron can be giyen — such as the carbonate, the citrate, lactate, etc. ; but, in some persons of a habit feeble and relaxed, the more astringent prepara- tions do better — for example, the sulphate and the chloride. Excel- lent results are often obtained from the use of the mineral acids, nota- bly the muriate, and especially when administered conjointly with the tincture of nux vomica (Fox). The long-continued use of arsenic in a small dose — one drop ter in die of Fowler's solution — is more effective, according to the author's experience, than any remedy men- tioned. As attacks of gastralgia are, very frequently at least, excited by indigestible food, it is highly important to regulate the diet. Fur- thermore, in these subjects the digestion has been enfeebled by the depressed state of the nervous system. The best results are therefore obtained by a careful regulation of the hours of eating, the quality of the food, and the mental and bodily exercise. In most cases, proba- bly, the treatment should be begun by the milk-cure, and subsequent- ly a dietary should be constructed suitable to the needs of individual cases. In some instances, the frequent use of a small amount of food is more serviceable than the taking of ordinary meals. When the digestion is feeble merely, pepsin and lactic or muriatic acids are most useful. When acidity and heartburn exist, due to the fermentation of the starches and sugars, the mineral acids must not be given after meals, but before, for physical reasons already explained. ULCER OF THE STOMACH. Definition. — By the term ulcer is meant a solution of continuity involving the mucous membrane and one or more of the layers of which the wall of the stomach is composed, with defined margins hav- ing a greater thickness than the adjacent healthy tissues. Sympto- matically, the stomach-ulcer is characterized by pain, disorders of digestion, and vomiting of blood. Causes. — Ulcer of the stomach is a comparatively common disease, and is found to exist in five per cent, of the deaths from all causes. It is present in proportionately greater numbers after thirty-five, be- cause it is an essentially chronic malady ; but it is, really, more fre- quent in youth and middle life, from fifteen to thirty, and it is com- paratively often seen in housemaids of twenty — an age, too, at which 3 34 DISEASES OF THE DIGESTIVE SYSTEM. rupture occurs in greater proportion than at any other. It is probable also that women are more subject to the disease than men, and that rupture occurs more frequently in the former than in the latter. The most influential factors in its pathogeny are, variation in the tonus of the gastric vessels and mechanical arrest of the circulation at the point where the ulcer forms (thrombosis, embolism). There is usu- ally, in these cases, disease of the arterial tunics (atheroma and endar- teritis), which finally causes coagulation of the blood and arrest of the blood-stream in a nutritious artery ; obstruction of the portal circula- tion may induce thrombosis, hsemorrhagic infiltration, etc. The result of a sudden and severe diminution in the amount of blood passing to a part, or of its entire arrest, is to diminish the alkalescence of the deeper layers of the mucous membrane, and to permit the corrosive and solvent action of the gastric juice. It has long been recognized that amenorrhoea, anaemia, chlorosis, the puerperal state, prolonged lactation, and tuberculosis, are also etiological factors, and probably because, in these states, a necrotic process is readily induced, under favorable local conditions. Irritation of certain parts of the brain is followed by ecchymoses and erosions of the mucous membrane of the stomach. Burns of the chest and abdomen sometimes cause ulceration of the duodenum. A peculiar state of the nervous system must, therefore, be regarded as one of the causes of this disease. Pathological Anatomy. — Ulcers corresponding in every respect to those of the stomach are found rarely at the lower part of the oesopha- gus, at the first part of the duodenum (associated with burns on the surface), and in the caecum, as the author has shown. In twenty per cent, of the cases of stomach-ulcer, they are multiple, but rarely as many as five existing at one time ; in eighty per cent, of the cases, the ulcer is solitary. Not all parts of the stomach are equally liable to the ulcerative process. In four fifths of all cases the ulcer or ulcers are found on the posterior wall, the lesser curvature, and about the pylorus. In size they vary greatly, according to age, and prob- ably, according to their nature ; but they are not smaller than a dime, and never attain greater dimensions than six inches by three. In shape they are round or oval, more frequently round. So great is the difference in size, quality, and appearance between the so-called acute perforating ulcer and the round, indurated, and chronic ulcer, that it is difiicult to realize that they are merely stages of the same process. The former is about the size of a dime, or shilling-piece, is round and has smooth edges without induration and increased thickness, fre- quently covered with a clot or containing a mass of slough adherent, and extending in depth to the submucous connective tissue. Ulcers of this description are usually found in young subjects — housemaids, notably — have a great tendency to perforate, and are not unfrequently ULCER OF THE STOMACH. 35 produced by obstruction to the portal circulation (hemorrhagic ero- sion, thrombosis, etc.). The latter or chi-onic form is large in size, having walls of great thickness and indurated, composed of connec- tive and granulation tissue deposited at various times, giving to it a stratified appearance. After many years, such an ulcer presents a crater-like aspect, with shelving sides, and terminates by a small apex in muscular, sub-muscular, or peritoneal layer, or in a perforation. The connective and granulation tissue, of which the crater-like inter- nal surface is composed, is also deposited at the base, and in this way perforation is prevented. Facts are wanting to demonstrate an inter- mediate or transition stage between the two forms of stomach-ulcer. In the course of development of the chronic ulcer, the anatomical ele- ments of the mucous membrane, including the tubular glands, are destroyed, and in rare instances villous or jjolypoid growths appear in the neighborhood of the new formation. In very rare instances the mucous membrane may be largely preserved, and the ulcerative action excavate a cavity beneath. Several small ulcers may coalesce, unite in their long diameters, and thus form an oval excavation along the lesser curvature, or make a girdle around the pylorus. Ulcers of the stomach tend to spontaneous cure. In many instances of death from other causes, ulcers, either healing or cicatrized, have been found, when no symptoms had existed during life, in any sense indicative of their presence. In the process of cicatrization, if the ulceration has not extended beyond the muscular layer, the repair is by union of granulations, and the cicatrix forms a puckered depression. When there is more extensive loss of substance, involving all but the perito- neal layer, there is very great contraction, and a large cicatrix with radiating lines of thickened connective tissue. The peritoneal surface is drawn in, giving to that membrane a puckered appearance. If the ulcer had been large, oblong, and formed by the coalescence of several smaller ulcers, and situated near the pylorus, narrowing of that ori- fice, and consequent dilatation of the rest of the organ, would be necessary results. Sometimes the base of the ulcer forms adhesions to neighboring organs in the process of cicatrization, causing ever after- ward serious interference with the movements of the stomach, and therefore impairing its functions. Secondary cavities are, occasion- ally, formed by a local peritonitis arising from perforation, the con- tents of the stomach being prevented escaping into the general cavity of the peritonaeum by a limiting inflammation which secures firm adhe- sion to neighboring organs, to the omentum, pancreas, liver, the adja- cent lymphatics, the transverse colon, the kidneys, the diaphragm, and the abdominal walls. If cicatrization takes place after these attach- ments have formed to adjacent organs, they are embraced in the cica- tricial tissue, and very great deformity, with serious impairment of function, may result. Unfortunately, these conservative adhesions 36 DISEASES OF THE DIGESTIVE SYSTEM. are not always formed : the ulcerative action may continue, cavities be created in the manner already indicated, or communications be estab- lished between the stomach and colon, or a fistulous sinus be made through the walls of the abdomen externally, or the diaphragm be per- forated and the thoracic cavity entered. When perforation takes place, there being no limiting inflammation, nor adhesion to adjacent viscera, the contents of the stomach are suddenly precipitated into the general cavity of the abdomen exciting general peritonitis. Ulcers situated on the anterior wall of the stomach are specially exj)osed to this danger, since in that situation adhesions can not easily be formed. The larger vessels of the stomach being deeply placed, escape the eroding action of the ulcer, unless the ulceration has proceeded deeply, nearly to the point of perforation. Furthermore, in the process of extension of the ulceration, the vessels resist longer, and become occluded, before yielding to the erosion. Now and then, arterial twigs are entered by a slough, or veins about the ulcer, which have become varicose, as is frequently the case, are destroyed by a superficial ulceration. Re- lapses are comparatively frequent. The cicatricial tissue, being of low type, ulcerates from slight causes. Changes, which have apparently some relation to the morbid pro- cess in the stomach, occur in other organs. It is clear, however, that certain diseases of the arterial system, as endocarditis, endarteritis, have an immediate connection, for embolism and thrombosis are im- portant factors in the pathogeny of ulcer. In about one half of the cases, there is coincident pulmonary disease, very often tuberculosis. It is a popular notion that stomach-ulcers are transformed into cancer ; it is true that cancer sometimes appears at the site of an old ulcer. Symptoms. — There are three important symptoms of stomach-ulcer — pain, indigestion, and vomiting (hsematemesis). It should be known that some very acute cases occur without symptoms. In apparently per- fect health, an individual has a perforation of the walls of the stomach ; an acute peritonitis is immediately lighted up ; intense pain, vomiting of blood, and profound prostration occur, and death takes place in a few hours or in a day or two. The author has met with such a case. More usually ulcer of the stomach is a chronic malady and character- ized by the existence for many months or years of the three symptoms mentioned. Although the pain varies in intensity and differs much in different cases, yet, on the whole, there is remarkable correspondence. In the largest number of cases the pain is felt in front, in or just below the xiphoid appendix ; or in the left hypochondrium in the intercostal space between the sixth and seventh rib, occasionally ; more frequent- ly above the umbilicus, in the neighborhood of the pylorus. Posteri- orly, and this position is even more important, the pain is felt in the region of the last dorsal or first lumbar vertebra, or under the angle of the scapula. The pain in front and behind seems to be continuous, as ULCER OF THE STOMACH. 3Y if it passed directly tlirough the body. This is its distinctive charac- ter — a fixed, gnawing, burning pain, boring through from front to back, and occupying a space which the finger may cover. More or less pain radiates from this central and fixed pain, and is felt in the chest behind the sternum, in the intercostal nerves, in the cervico- brachial plexus, etc. Very great tenderness is experienced on pressure over the vertebra behind and the seat of pain in front. Corsets or a tight dress can not be borne, and, in sitting, the patient seeks a posi- tion more or less bent, to avoid the pressure of internal organs against the sore spot. Besides these, already described, the patient suffers with attacks of gastralgia, sometimes of extreme violence, but they do not occur with any regularity. When the gastralgia comes on, the fixed pain is in- creased in severity, and pain of extraordinaiy violence radiates through the abdomen and chest. During these paroxysms, the action of the heart becomes very feeble, and the vital forces much depressed. An alarming syncope, or general convulsions, may ensue if the patient pos- sess a highly sensitive reflex organization. As the attacks are usually due to the presence of indigestible food, they cease when the stomach is empty ; but they also arise from cold, fatigue, mental and moral emotion — to the causes, indeed, of neuralgia elsewhere. The pain of stomach-ulcer — the fixed pain — is increased by taking food. In a ma- jority of cases the increase of pain is experienced as soon as food enters the stomach ; in a smaller proportion the exacerbation occurs in from fifteen minutes to a half hour ; in others, the most severe suffering takes place when food is supposed to be passing through the pylorus, in about three hours after eating. The character of the food influ- ences the production of pain — indigestible, especially irritating, arti- cles causing greater suffering than bland articles. The increase of pain persists until the food is rejected by vomiting or passes the pyloric orifice. The pain caused by the presence of food in the stom- ach should not be confounded with the attacks of gastralgia, which may arise from hygienic and moral causes as well as improper food. Some cases of stomach-ulcer are free from distress of any kind ; in fact, they continue for months and years with no more local disturb- ance than is produced by chronic gastric catarrh ; but these must be regarded as exceptional. Vomiting is a frequent but not an invari- able symptom ; in a few instances it never occurs ; in others it comes on late in the course of the disease. The vomiting is preceded and accompanied by pain, but, when the stomach is emptied, the pain ceases. Occasionally attacks of vomiting and pain occur when the stomach is emf)ty ; some glairy mucus, with or without blood, only, coming up with a good deal of straining, showing that the disturbance of the stomach is not due merely to the presence of food. If the vom- iting persist, and there be much retching, some bilious matter may 38 DISEASES OF THE DIGESTIVE SYSTEM. finally be brought up. But the great factor is unquestionably food, and especially undigested food ; but more or less gastric catarrh is a constant element in cases of ulcer of the stomach. The time when the vomiting occurs may indicate the position of the ulcer. If the inges- tion of food is followed immediately by pain, the ulcer is probably in the vicinage of the cardia. If situated in the greater curvature, there may be but little vomiting, and that will take place in about an hour after food ; when near the pylorus, vomiting is an invariable symp- tom, and the pain is great, but the pain and vomiting do not come on until two or three hours. It must be admitted that these statements as to the time of the vomiting and the position of the ulcer are only approximately correct. Vomiting of blood is the most characteristic single symptom, but is not pathognomonic. It is absent in about one third of the cases. Hsematemesis may occur only at the monthly period as a vicarious discharge, or merely as an accompaniment of the regular flow. Pain coming on after eating, vomiting of food mixed with blood, and then of blood only, is an extremely significant combi- nation of symptoms. The vomited matter may consist only of blood, red or brownish red, when it comes up immediately ; if retained for a short time, it appears in clots more or less blackish if acted on by the stomach-juices. When held in the stomach for some time, and the amount is small, it may present the well-known " coffee-ground " ap- pearance ; but if the quantity is large, and has been acted on by the gastric juice, and churned up by the movements of the stomach, it will then have a brownish-black, uniformly granular, and homogeneous aspect. As the vomiting usually occurs quickly after the blood is jDoured out, the ordinary and chai-acteristic appearance is that of red- dish blood partly coagulated. Coffee-grounds, blackish and brownish- black masses or particles, belong rather to cancer. The nutrition may or may not be impaired in gastric ulcer. The small perforating ulcer is often met with in young girls of rather full habit but lymphatic in type. The chronic ulcer of long standing, if small, may not affect the digestion sufficiently to lower the body- weight; but, if large, the diges- tion-space is so much abridged, that there must be a constant waste, which the primary assimilation is unable to supply. Much depends on the amount of loss by vomiting, and this is influenced somewhat by the inherent irritability of the stomach. The frequent recurrence of haem- orrhage also seriously impairs the nutrition and induces a cachectic state and a peculiar tint of the skin, which may be confounded with the earthy hue of carcinoma. The tongue may be clean, somewhat furred, red at the tip and at the edges, fissured, but there is no charac- teristic appearance. As a rule, there is obstinate constipation. Ameu- orrhoea is a frequent complication, due partly to the vicarious hsemate- mesis and partly to the jjrofound anaemia to which some patients are reduced. ULCER OF THE STOMACH. 39 Course and Duration. — The behavior of the acute and perforating ulcer has been sufficiently discussed. The chronic and common form has a very variable duration. Well-authenticated cases have existed ten years — an example of which the author has had under observation. From three to five years is a comparatively common period of duration. The chief reasons for their long-continued existence are, their essen- tially chronic character and the frequent changes in their condition--^ now increasing, now improving, almost cicatrized, then a change in the constitutional state of the patient, or indiscretion in food will re- excite ulceration in tissue almost or entirely repaired. At various periods in the course of the chronic ulcer there may occur a chill fol- lowed by fever, exquisite tenderness of the epigastric and umbilical regions, nausea, vomiting, constipation, a quick, small pulse, etc., symp- toms of a local and limiting peritonitis. ' Some cases of chronic ulcer run an entirely latent course ; that is, there are no more pronounced symptoms than those of dyspepsia. Termination. — A large proportion terminate in recovery — complete cicatrization, without any subsequent impairment of the functions of the stomach. The cure may be partial ; there may be adhesions con- tracted to adjacent organs, which alter the shape and impair the mo- tions of the stomach ; contraction of the pyloric orifice, leading to dila- tation and gradual inanition. The ulcer may cause death in various ways : there may be a gradual failure from pain, vomiting of food, vomiting of blood, and by the growth of lesions in other organs (car- diac disease, tuberculosis, etc.). Death may occur by haemorrhage — according to Brinton five in one hundred so terminate. A consider- able proportion — 13 "4 per cent. — die by perforation and consequent peritonitis. This unfortunate accident is announced by a sudden and great depression in the powers of life, and death by shock, or the prompt development of fatal peritonitis. Diagnosis. — Notwithstanding a diagnosis may be made with great certainty in cases presenting typical symptoms, it may be very difficult in other cases. The doubts may occur between ulcer and chronic gastric catarrh, gastralgia, hepatic colic, cancer, and chlorosis. In chronic gastric catarrh the pain after food is much less, and, in fact, in very many cases the distress is alleviated by taking food ; vomiting- is occasional, and there is no vomiting of blood. The paroxysms of gastralgia may be the same as in ulcer, but the behavior of the two diseases, otherwise, is very different. Gastralgia is in paroxysms en- tirely, and between them the patient suffers but little, and does not always have pain after eating, vomiting, and relief by the rejection of food and the vomiting of blood. In hepatic colic the pain radiates from the region of the gall-bladder, suddenly terminates when the cal- culus reaches the intestine, and is followed by jaundice. During the attack, owing to the congestion of the portal system, there may be 4:0 DISEASES OF THE DIGESTIVE SYSTEM. vomiting of blood, but it is never great in amount, and all the symp- toms subside in a few days, the patient being free from any disturb- ance of the stomach afterward. In cancer, the age of the subject, the emaciation and cachexia, the tumor and enlarged lymphatic glands, the vomiting of coffee-ground and blackish and brownish-black mate- rial, instead of the red or brownish-red blood in large amount in ulcer, are the most characteristic differences. It is more difficult to separate chlorosis with amenorrhoea from ulcer of the stomach, because these subjects have the distress after food, the vomiting, and vicarious men- struation by the stomach. Under these circumstances of inevitable doubt, it were better to decide by therapeutic means. The case may be treated as one of gastric ulcer by an absolute low diet ; if it is a case of ulcer, it will improve under this method ; if a case of chlorosis, it will get worse — then a resort to iron and mineral acids will bring about a decided change for the better. Prognosis. — Although the cure of ulcer may be confidently expected in favorable cases, yet such are the dangers from perforation and haemorrhage that the prognosis must be regarded as serious. When tuberculosis and endocardial lesions exist, the gravity of the case is correspondingly increased. Treatment. — The first and most important consideration is to give the stomach rest, which is accomplished by reducing the food taken to the minimum. An exclusive milk-diet accomplishes this object, while at the same time it contains the necessary alimentary principles for the support of the body. All rough, harsh, and coarse ingesta, such as oatmeal, brown-bread, and fruits, irritate the surface of the ulcer, and increase the existing ulceration, and retard healing. Starchy and sac- charine foods are objectionable because they ferment, producing acid which is very irritating to the ulcerated surface. Milk should be given systematically — one gill (four ounces) every three hours, day and night, during waking. If it cause a sensation of heaviness or uneasiness, nausea or vomiting, the addition of lime-water will enable it to be better borne. The meat solution so strongly advocated by Leube, or that of Valentine, can be substituted for milk, if the latter jjrove repugnant to the patient or can not for any reason be used. To aid in supporting the powers of life, rectal alimentation may be employed. Foster proposes to relieve the stomach entirely for a time, supporting the powers of life by rectal alimentation, since the healing process is greatly pro- moted by giving the organ some days of absolute rest. The discovery of the utility of defibrinated blood, as a means of rectal alimenta- tion, made by Dr. Smith, of New York, has added much to our resources. The method consists simply in defibrinating the blood as soon as drawn at the shambles, and in injecting from three to six ounces morning and evening. If rectal alimentation is not em- ployed exclusively, it should be combined with the milk regimen — CARCINOMA OF THE STOMACH. 41 for, the richer the condition of the blood, the more rapidly and per- fectly can repair take place. As the destruction of the mucous membrane was originally brought about by the solvent action of the gastric juice, and as the irritation caused by this is the chief obstacle to healing, it is important to diminish the acidity and to keep the surface of the ulcer clean. These purposes are now ac- complished by mechanical means, by irrigation of the cavity of the stomach by the siphon or the stomach-pump, as the same process is employed in other stomach-diseases ; but caution is necessary in the use of the pump, lest the tube might cause a perforation. The same ob- ject may be accomplished by medicinal means — by the free use of the alkaline mineral waters. As regards the strictly medicinal remedies, the most important is arsenic in small doses, one drop of Fowler's solution three times a day. Next, named in the order of their relative impor- tance, are, oxide and nitrate of silver, in half -grain doses three times a day, and bismuth in fifteen-grain doses. If there be much pain, morphia in the hypodermatic mode ; but, if the alimentation is proper, pain will hardly require attention. The regimen advised should be pursued for several weeks, or until such improvement is manifest as to indicate that cicatrization is pretty well advanced, when the diet may be very carefully enlarged by the addition of rice, soft-boiled eggs, animal broth, etc. ; but the patient should be impressed with the importance of a simple dietary ever after. The accidents which arise should be treated according to their nature. If haemorrhage occur, ice should be applied to the epigastrium, and pellets of ice should be swallowed ; ergotin should be injected subcutaneously, and solution of pernitrate or of chloride of iron should be administered by the stomach. If perforation have taken place, the most absolute rest must be enjoined and the alimentation must be exclusively rectal. The remedy above all others is morphia by the skin, maintaining a decided effect. CARCINOMA OF THE STOMACH. Etiology. — The points of election for the development of cancer in the intestinal canal, named in the order of their relative frequency, are the stomach, the rectum, the caecum, the flexures of the colon. Of all the organs of the body, the stomach is most frequently the seat of cancer — more frequently than the uterus, which comes, strictly, next. As regards age, the majority of cases occur at fifty, but the disease may appear at any time from forty-five to sixty. It is very rare from thirty to forty. According to some authorities, cancer attacks the male sex by j)reference, but careful investigation shows that this view is erroneous, and that the two sexes are about equally affected. The well-to-do classes are said to be more liable to the disease than the 42 DISEASES OF THE DIGESTIVE SYSTEM. poor, and the obese, hearty feeders, rather than the abstemious, but these are doubtful propositions. Predisposition and heredity play an important part in the causation of cancer ; they are, doubtless, the most influential factors. The in- herited tendency may not be traced sometimes, when it exists, be- cause of the behavior of the cancer-germ, skipping over one or more generations and appearing in subsequent ones. All other presumed moral and dietetic causes are rather fanciful. Patholo^cal Anatomy. — The forms of cancer occurring in the stom- ach are the following : scirrhus, or fibroid ; medullary, or encepha- loid ; and the gelatinous, or colloid. As regards the site, the points of election are in sixty per cent, at the pylorus ; in twenty per cent, at the lesser curvature ; and in ten per cent, at the cardia. In the pro- cess of growth, extension is more apt to be vertical than transverse ; but, when the growth is about the cardia or the pylorus, the new for- mation takes an annular direction, causing stenosis. The initial changes in the development of cancer of the stomach are an increased vascularity and the presence of numerous white blood- corpuscles in the cylindrical epithelium of the gastric glands — as in ordinary inflammation — but the changes soon take a special direction and character. Rapid proliferation of the cells of the cylindrical epi- thelium occurs, and assumes a downward direction, penetrating the mucosa, the sub-mucosa, to the muscular layer, into which ultimately long, fibrous bands project. In the loose, submucous connective tissue the growth is most rapid, and here the nodules form in greatest num- bers. The so-called cancer-cells — groups of proliferating cylindrical epithelial cells — lie imbedded in a fibrous stroma, made up from the connective tissue of the mucous membrane. Within and about the stroma an infiltration of small cells appears, and out of or within these are formed numerous minute vessels. Thus, in a short time from the beginning of the process, all of the anatomical elements of the mucous membrane are appropriated by the new formation. In the course of development of scirrhus, the connective-tissue element, the fibrous stroma, takes on a ^preponderating growth over the epithelium cells and the small cell infiltration, with its newly formed vessels.* It is in consequence of this preponderance of the connective-tissue element, whether in distinct nodules or in a dense annular mass, that it presents such a cartilaginous apj^earance on section. A large part of the stom- ach may be converted into a mass of scirrhus, of one or two inches in * Waldeyer, Virchow's "Archiv.," vol. xli, p. 4*70, and vol. Iv, p. 6*7, "Die En- twickelung dei- Carcinome." Also Forster, "Lehrbuch dei" path. Anat.," pp. 110-115, by Siebert, .Jena, 1873. Rindfleisch, " Text-Book of Pathological Histology," Lindsay & Blak- iston, 18Y2, p. 375, confirms Waldeyer's account of the origin of cancer in the mucosa. See also Rokitansky, and especially the great work of Cruveilhier, "Traite d' Ana- tomic Pathologique," where colloid will be found admirably delineated. CARCINOMA OF THE STOMACH. 4.3 thickness, with, nodules and protuberances of greater thickness pro- jecting into the cavity. A dense mass, of half to an inch in thick- ness, much less nodular, may surround the pylorus or the cardia, leav- ing a considerable part of the mucous membrane of the stomach free from disease. No part of the mucosa exists after the cancer is devel- oped ; hence the internal surface of the stomach at that point is the surface of the cancer only, which is usually in an ulcerating state. Medullary cancer, or encephaloid, differs from scirrhus in the less gi'owth of the fibi'ous stroma, and in a much, more luxuriant prolifera- tion of the small cells and their associated vessels. Hence this form of the disease is softer, more vascular, and possessed of a greater power of rapid growth. Some parts of this form of cancer may, and usually do, retain the characteristic fibrous stroma of scirrhus. The internal or gastric surface usually consists of projecting nodules of softened cancer elements, which are easily detached and bleed readily. The ulceration which occurs in the exposed surface within the cavity of the stomach really consists in a process of fatty degeneration, the disintegration being produced by the solvent action of the gastric juice and the mechanical action of the food. Colloid cancer differs from the other varieties in that a gelatini- form degeneration of the cancer-cells takes place, giving the peculiar colloid appearance. The distention of the alveoli by this material di- lates them so that they are larger than in other forms. This variety differs from the others also in that it is more widely diffused through the mucous membrane, and through neighboring organs, and is slower and longer in growth. It is also less common. Cancer, like ulcer, by setting up local peritonitis leads to the for- mation of adhesions, which affect the shape, position, and motions of the stomach. Adhesions may fix the pylorus in or about its true posi- tion, but, when unattached, the weight of the cancerous mass may drag it down, even as low as the hypochondrium, and thus constitute a movable tumor. When the annular deposits form at the pylorus, a stenosis of the orifice and dilatation of the cavity are results. When the same formation occurs at the cardia, the stomach very much con- tracts, and the Ofsophagus immediately above dilates. In the vicinage of the connective-tissue bands, which stretch out through the subjacent elements, especially the muscular, considerable hypertrophy of these muscular elements at first results, but atrophy, from pressure of the newly formed connective tissue, finally occurs,* Those portions of the mucous membrane uninvaded by the cancer elements suffer chronic catarrh, in consequence, doubtless, of the continued hyperemia. That from such a state of the mucous membrane cancer may develop, is a popular notion, not supported by any scientific data. It is true that * Luton, " Cancer de I'Estomac," "Nouveau Diet, de Med.," Paris, 1871. 44 DISEASES OF THE DIGESTIVE SYSTEM. hypersemia of the cells of the cylindrical epithelium ds apparently the starting-point of the development of cancer, but this hypersemia is due to some peculiar irritation in the tissue. Cancer has developed from an old ulcer in some rare instances, but some remnant of gland- tissue must have remained. Cancer of the stomach is usually primary, and in most of the cases is confined to that organ. It is rare, indeed, for the stomach to be secondarily affected ; but the author has seen a case in which cancer of the gall-bladder was followed by secondary deposits in the pylorus — an altogether unique case. In less than half the cases, cancer in- volves other organs as well as the stomach, and notably the liver, which is affected in about one fourth. Secondary deposits in the liver less often occur when the cardia is involved than when the lesser curvature and the pylorus are the sites of cancer. The principal complications of cancer of the stomach are fatty heart, thromboses, pneumonia, tuberculosis, etc. Symptoms. — In a few rare cases cancer has proceeded from its in- ception to its termination in the death of the patient without causing any distinctive symptoms. These are examples of cancerous infiltra- tion of the mucous membrane in the greater curvature, the orifices being unaffected. In the first stage, before a tumor can be detected or the cachexia is evident, the symptoms present are those of a dys- pepsia, which gradually assumes a more aggravated character. There is a good deal of pain from an early period, felt in the epigastrium usually, and increased by pressure, by food, and is also felt poste- riorly. The pain is nearly constant, and, although at times more severe, there are not, as a rule, those violent paroxysmal attacks so often found in ulcer. The pain is acute, often burning, sometimes lancinating, but by no means invariably so ; again, it is a sense of soreness and not severe pain ; rarely it is entirely absent, according to Brinton, in eight per cent.* The disorders of digestion increase with the duration of the case : the appetite declines ; distress after eating becomes greater ; then attacks of acidity and pyrosis, with regurgitation of an acrid, acid liquid, come on. Emaciation and loss of weight proceed at a uniform ratio. If annular deposits have been occurring at the cardia, the pa- tient early becomes conscious of a difficulty in getting food into the stomach, but he almost invariably refers the obstruction to a point higher up. As the case advances, the alimentary substances pass slowly down to the cardia, where they are arrested for a minute or more, some portions trickling through into the stomach, the rest slowly returned by regurgitation, with a distinct gurgling noise. Consider- * " Medico-Chirurgical Review," vol. xx, p. 479, Also Brinton on " Diseases of the Stomach." CARCINOMA OF THE STOMACH. 45 able pain is experienced — a burning pain usually — when the substances swallowed reach the cardia, and as they pass through it into the cavity. This passage through the narrowed orifice is, as a rule, dis- tinctly recognized and accurately described. When the liquid or solid is disposed of, either by regurgitation or by entrance into the stom- ach, there is a feeling of relief, and the stomach digestion goes on with the ordinary facility. In cancer of the cardia, but a small portion of the mucous membrane is destroyed — the deposits being annular — and, as death takes place earlier by inanition than in any other form, there is not much interference with digestion, and these unfortunates suffer horribly from hunger. The epigastrium contracts and is drawn in toward the spine, owing partly to the exceeding general emaciation, and partly to the extreme contraction of the stomach. In the other forms of cancer, instead of arrest at the cardia, the patient feels no distress until the alimentary materials reach the stom- ach, when nausea and other distresses begin. Vomiting is one of the most constant symptoms, occurring in three fourths of the cases. At first the patient brings up in the morning, with a good deal of strain- ing, some tough, glairy mucus, and, it may be, a little bilious matter. Presently the vomiting comes on after eating ; if the cancer is situ- ated just below the cardiac orifice, and does not constrict it, pain, nau- sea, and vomiting, begin almost immediately after the food is swal- lowed. If the posterior wall is affected only, vomiting may not occur until late in the disease, and then may not be a very pronounced symptom. When the pylorus is affected, vomiting is a pretty nearly constant symptom, but it does not occur until some time after the food has reached the stomach — as a rule, not until two or three hours have elapsed. The vomited matters consist at first of the food in various stages of solution, then of mucus, containing sarcina and other minute organisms, and when the case is pretty well advanced there appear small brownish or brownish-black or chocolate-colored masses, of small size usually, which consist of decomposed blood. Vomiting ultimately occurs without the presence of food : it is then the form of vomiting entitled vomiting of irritation. Haematemesis is a fre- quent but not a constant symptom, occurring in somewhat less than half the cases (forty-two in one hundred, according to Brinton). If, however, the vomited matters were carefully searched for altered blood, it would probably be found present in nearly all cases. If the spectroscope were employed to examine all suspicious-looking parti- cles, the absorption-bands between C and D, characteristic of hsema- tin, would be often seen. Vomiting of blood in large quantity, as occurs in ulcer, is quite exceptional in cancer. Usually the blood is derived from small capillaries, but now and then sloughing takes place, and a vessel of considerable size is opened. The author has observed in some cases an enormous quantity of chocolate-colored, homoge- 46 DISEASES OF THE DIGESTIVE SYSTEM. neons, granular material, discharged both hy vomit and by stool, in cases of cancer at the pylorus. The condition of the bowel is that of torpor, but toward the end ichorous matter passing down the intestine excites diarrhoea. In one third of the cases observed by the author, salivation (not mercurial) was a symptom, and was either constantly or periodically present. The saliva had the ordinary appearance. The tongue is red at the tip and pointed, and is usually glazed. The cachexia induced by cancer is characteristic. With the prog- ress of emaciation, decline of strength is to be expected, but the sub- jects of the cancerous cachexia have an extraordinary sense of fatigue, which is felt when no exertion is made. The action of the heart is feeble, the pulse small, weak, and quick ; the respiration somewhat hurried. The least exertion increases the number of the heart-beats and the respiration movements. The skin is thin, dry, harsh, and in- elastic. The complexion is pallid, earthy, and bronzed, combined — a fawn color — and is strongly suggestive of the malady. Toward the end, oedema of the ankles appears — a mechanical result of the throm- boses. The cachexia, though it may be late, never fails to come on. A tumor is found in the proportion of eighty to one hundred cases. In some situations the tumors can not be felt, as when at the cardia, or in the lesser curvature, for here they are covered in by the left lobe of the liver. In other situations they may usually be detected by palpa- tion — suitable attention being given to all the sources of error. The variety of cancer does not necessarily affect the question of a tumor ; but a colloid growth may be diffused through the walls of the stomach, giving to the sense of touch the impression of thickening, and not of a defined tumor. On palpation, the tumor, if it exist, is felt to be hard, somewhat irregular, and nodular, if scirrhus, but softer and more elas- tic, yet well defined, if encephaloid or colloid. Even when in a position to be felt, it may elude search by reason of distention of the stomach, or of adhesions which may change the shape and position of the organ, or the presence of fluid in the peritoneal cavity — a result of the pres- sure of secondary deposits in the liver. Tumor of the liver, of the pancreas, movable kidney, aneurism, may be confounded with tumor of the stomach, and must be kept in view when making a diagnosis by exclusion. The relation of the tumor to the movements of the dia- phragm should be noted ; for a tumor of the stomach does not descend when the lung is inflated with air. When the pylorus remains free the weight of the neoplasm causes it to fall dowm, sometimes as low as the hypochondrium, and it continues movable. Tumors of the liver and spleen descend on full insjjiration, but the pyloric tumor Avhen adherent retains its position, and when movable is not influenced by the respira- tory movements. When a scirrhus lies upon the aorta, a pulsation is communicated to it, but it is not an expansile pulsation, and there CARCINOMA OF THE STOMACH. 47 are none of the other signs of aneurism, yet mistakes of diagnosis are not infrequent. Like ulcer, cancer may result in perforation and general peritonitis ; in the formation of fistulous communications with the walls of the abdomen, externally, with the transverse colon, when there will be stercoraceous vomiting ; with the thoracic cavity ; but these are com- paratively rare complications. Occasionally a large vessel is laid open, and death ensues from sudden and large haemorrhage. In accordance with its nature, cancer tends to spread to contiguous parts, by reason of immediate vascular communication. The cancer elements are much more frequently deposited in the liver than in any other organ. As- cites, icterus, thrombosis of the portal vein, etc., are the most important results of the implication of the liver. Extension of the disease also occurs by the lymphatics, and large nodular masses of degenerating mesentei'ic glands may be felt through the thin parietes of the abdo- men during the life of the patient. The cervical lymphatics, just above the clavicle, also sometimes enlarge, and afford valuable indications of the nature of the malady, even early in the course of the disease. Tuberculosis of the lungs is a frequent complication of cancer of the stomach. Course and Duration. — Cancer of the stomach is an essentially chronic disease. The average duration, according to Brinton, is one year ; but the cases differ in duration according to the anatomical site. Named in the order of their fatality, they stand as follows : cancer of the cardia, of the pylorus, of the lesser curvature, of the greater curva- ture. The maximum duration is three years. Diagnosis. — The differentiation is to be made between chronic gas- tric catarrh, chronic ulcer, and carcinoma. In the eai'ly stages of ulcer and cancer it may be impossible to separate them from chronic gastric catarrh ; but as these cases progress the points of difference become distinct. The following considerations will enable a correct differentia- tion to be arrived at : chronic gastritis may occur at any age ; there is rarely any severe pain, and it is diffused over the whole organ ; vomiting is only occasional, and then of alimentary matters, as a rule ; there is no important variation in the body-weight, and no progressive emaciation. In ulcer, the pain is severe, localized to a small point in front and behind ; there is much vomiting and haematemesis, the blood coming up in considerable quantity, little or not at all altered. The subject of cancer is well advanced in life (from forty to sixty) ; the pain has a lancinating character, and is felt in one place which is the same for each case, but differs in different cases ; there is vomiting, especially vomiting of chocolate or coffee-ground masses of decomposed blood ; above all, the presence of a tumor. Treatment. — Although cancer of the stomach is incurable, much may be done by treatment to render the patient's decline tolerable. 48 DISEASES or THE DIGESTIVE SYSTEM. The first and most important point is to regulate the diet. By the withdrawal of solid food, and the substitution of milk alone, or milk and beef -juice, the greatest relief is afforded, and for a time there may be a gain in weight, but of course this is not long maintained. If the diet is restricted to the articles mentioned, it should be supplemented by that important means of rectal alimentation, the injection of defibri- nated blood. The burning pain is much diminished by washing out the stomach oiice a day with the stomach-pump, especially in dilatation from stenosis of the pylorus. By removing acrid and acid matters in this way, much straining efforts at vomiting will be saved. Of all the remedial measures proposed there is no prescription which is so generally useful in these cases as equal parts of pure car- bolic acid and tincture of iodine, of which one or two drops may be administered in water three times a day. For the vomiting only, a solution in cherry -laurel water of carbolic acid, or a combination of carbolic acid with bismuth in an emulsion, will be found effective. Nitro-glycerine, benzine, and bisulphide of carbon have been used, with advantage, to allay nausea and vomiting. The most effective means to allay pain is the hypodermatic injection of morphia. The stomachal administration of the same agent is inefficient, owing to the diminished absorption power of the organ. Laudanum by enema, morphia in the form of suppository, or the endermic use of morphia, are preferable to the stomach administration. Great care is necessary in the prescription of anodynes, for the need grows rapidly, and the consumption becomes enormous, reducing the patient to a mental and moral weakness dread- ful to contemplate. Arsenic, in the form of Fowler's solution, one or two drops, three times a day, has considerable power to allay pain, and is not without influence in retarding the growth of epithelial cancer. As respects the power to relieve pain, the physiological basis for its employment is the action of arsenic, in toxic doses, on the nervous system of animal life. It has been repeatedly observed that sometimes, in large doses, no vomiting was produced, but coma and insensibility followed. A great many facts have now been accumulated, proving that cancer of epithe- lial origin may be greatly retarded in its growth by the persistent use of moderate doses—- two drops of Fowler's solutibn ter in die. The author's considerable experience in the treatment of carcinoma of the stomach warrants the statement that the best results are obtained by the persistent use of carbolic acid and iodine, in the form advised above, and of arsenic, in the form of Fowler's solution. It may not be needless to observe that these agents should not be given in one prescription — the carbolic acid and iodine together, the Fowler's solu- tion at another time. VOMITING OF BLOOD. 49 HffiMATEMESIS— HEMORRHAGE OF THE STOMACH— VOMIT- ING OF BLOOD. Definition. — Ha3matemesis and vomiting of blood do not adequate- ly name tlie malady, for blood may be swallowed and then vomited. Haemorrhage of the stomach is the correct term. Causes. — Rupture of a stomach blood-vessel is the essential condi- tion of stomachal haemorrhage, notwithstanding, under some circum- stances, diapedesis of the corpuscular elements does occur. Sufficient blood must escape to excite nausea and vomiting. During an inflam- matory stasis, considerable blood may escape from ruptured capillaries, but usually haemorrhage is due to the giving way of vessels of some size ; diapedesis, certainly, is quite inadequate to bring about the es- cape of much blood. There may be disease of the tunics of the blood- vessels sufficient to cause them to give way on slight increase of the blood-pressure. Furthermore, long-continued abnormal pressure will induce slow changes, without invoking other causes to account for their yielding should the pressure suddenly become greater. In this way may we explain the occurrence of gastric haemorrhage in cirrho- sis, acute yellow atrophy of the liver, yellow fever. Certain lesions, acting mechanically on the portal vein, bring about the same results — for example, an aneurism of the hepatic artery, a large calculus, or tumors in the neighborhood of the portal vein. Any obstruction of the portal vein may be the cause of blocking by a thrombus of a ves- sel returning blood from a certain part of the mucous membrane — the effect of this being the production of one or a number of superficial ulcers. Severe and protracted haemorrhage may proceed from such erosions. Still more remotely is the occurrence of gastric haemorrhage, caused by increased pressure in the portal system due to obstructive troubles of the lungs and heart. The haemorrhagic diathesis may manifest itself in haemorrhage from the gastric mucous membrane. Arrest of an haemorrhoidal discharge, which has continued for a long time, is supposed, by a sudden increase in the blood-pressure within the portal system, to be a cause of haemorrhage of the stomach. According to the statistics of Handheld Jones, in seventy-two cases of haematemesis there were fifty-three females to nineteen males — showing a great preponderance in the female sex. As regards age, from twenty to forty there were nine males and thirty-six females, and after forty, eight males and fourteen females. These facts indi- cate that vicarious menstruation through the stomach must be rela- tively frequent. As in forty the existence of ulcers seemed probable, it is rendered pretty certain, by these figures, that ulcer is the most common cause of stomach haemorrhage.* * " Medico-Chirurgical Transactions," vol. xliii, p. 353. 50 ■ DISEASES OF THE DIGESTIVE SYSTEM. Pathological Anatomy. — More or less coagulated blood, acted on by the acids of the gastric juice to a varying extent, is found in the stomach. It is often impossible to discover the source of the haemor- rhage, unless the hsemorrhagic erosions, already alluded to, have formed. They are usually situated in the neighborhood of the pylo- rus. When a large vessel has given way, the rent can usually be found with a coagulum in it. Symptoms. — When a haemorrhage occurs sufficient in amount to produce definite symptoms, the patient experiences a sensation of warmth in the stomach, while the periphery is cool or cold ; distention, nausea, faintness. If the haemorrhage is large, coming suddenly from a vessel of considerable size, without any apparent cause, the patient turns sick, faint, pallid, and cold, the stomach is distended, and then vomiting sets in, the blood rushing up in a full stream through the mouth and nose, or if less in amount it comes uj) by successive acts of vomiting. The faintness usually increases at the sight of blood, and only passes off on the cessation of the bleeding. In rare instances a large haemorrhage occurs, the stomach is fully distended and returns a perfectly flat percussion-note, the patient becomes pale and cold and faint, or he actually does faint and is convulsed, without any vomit- ing, the blood subsequently passing off by stool. A patient enfeebled by disease may be suddenly carried off by a haemorrhage in the stom- ach without vomiting. It not unfrequently happens that, when the blood comes up with a sudden gush, some is carried into the larynx, where it excites coughing, and hence may appear to be coughed up. This fact leads to erroneous interj^retation of the nature of the case, and confusion as to the source of the haemorrhage. The appearance of the blood is different according to the time it has been acted on by the gastric juice. If it comes up at once in large quantities, it is part- ly fluid and partly coagulated, like ordinary blood ; but, if it has been retained, it has a blackish, or brownish-black, or chocolate appearance, and is then rather granular in structure. If but little blood has es- caped and slowly, it presents the " coffee-ground " appearance. The gastric juice decomiDoses the haemoglobin and sets free the haematin, which gives the color to the vomited matters. In concealed haemor- rhage of the stomach, the blood passing into the intestines, and in in- testinal haemorrhage, the same phenomena ensue : there occur sudden distention of the abdomen and colic-like pains, faintness or actual fainting with its attendant symptoms, if the loss of blood be large, and the stools of tarry-like material, altered blood, at first mixed with ordinary faeces, and then consisting of the decomposed blood only. As narrated in the previous article, the author has observed chocolate- colored material in large amount discharged by stool. It assumes this appearance when acted on by alkaline fluids, after the effect of acids. If this be correct, Ave have a means of determining whether VOMITING OF BLOOD. 51 any given discharge of blood originated in the stomach or intestine. Blood so colored may be vomited, but it comes up after the stomach is emptied, and is forced by the act of vomiting from the duodenum, A very singular result of stomach haemorrhage is amaurosis, first ob- served by Graefe, then Fikentscher, and afterward by Hutchinson. No explanation that has been offered satisfactorily explains the oc- currence of double, incurable amaurosis after haemorrhage from the stomach. Course, Duration, and Termination. — Occasionally vomiting of blood is fatal, as when an aneurism ruptures into the stomach. Although the patient may be faint, cold, and convulsed, yet haemorrhage of the stomach is rarely fatal, and the patient slowly emerges from the con- dition of anaemia. The pain of ulcer and cancer is often much re- lieved by vomiting blood ; but the case of idcer may be made much more serious by it in all other respects. Haemorrhage due to cirrhosis of the liver far advanced may be difficult or impossible to control, and may add materially to the dangers of the case, or may cause death by exhaustion. Diagnosis. — The juices of colored fruits (of black raspberries, for example) may be mistaken for blood, especially when vomited in the night. The author has encountered several cases of this kind. The microscope or the spectroscope may be invoked to decide. Much greater difficulty must exist in determining the source of the blood, whether swallowed and vomited, or derived from the stomach or lungs. An examination of the nares will usually demonstrate the origin of the bleeding, if the blood proceeds from any part of the nasal mucous membrane. Blood from the lungs has an alkaline reaction, is aerated, a bright red, and may contain mucus or pus. Blood from the stomach is acid in reaction ; when acted on by the gastric juice, is blackish, brownish- black, or chocolate color, and is not aerated, and may be mixed with food. The act of vomiting brings up the blood from the stomach, of coughing from the lungs (coughing may attend vomiting of blood, and vomiting — the patient swallowing blood coming from the lungs — may attend pulmonary haemorrhage). The previous history of pulmonary disease and the existence of moist rales at the time of the haemorrhage indicate the limgs to be the seat of the haemorrhage, and the absence of all the physical evidences of fullness of the stomach negatives the idea of stomachal haemorrhage. The attack begins in the lungs, by a sense of heat under the sternum, by a soreness in some locality, and by a sense of constriction of the chest ; in the stomach, by a sense of fullness and actual distention of the stomach, followed by nausea. After the attack of pulmonary haemorrhage the patient experiences soreness at the seat of the haemorrhage ; there is more or less elevation of temperature, often a pneumonia or bronchitis of small extent ; moist 52 • DISEASES or THE DIGESTIVE SYSTEM. rales, and the expectoration for several days of small, brownish-bloody sputa. After the heematemesis, only the depression and ansemia are present except stools of altered blood, which are usual. Treatment. — The haemorrhage, which is a vicarious menstruation, is relieved by diverting the flux to the uterus, its natural outlet. This is best accomplished by the use of the appropriate emmenagogues dur- ing the interval, of hot sitz-baths and hot vaginal douches, at the time of the expected flow. In the case of married women, leeches may be applied to the cervix uteri at the time of the menstrual molimen. When due to arrested hsemorrhoidal discharge, leeches should be ap- plied to the anus, and aloes be administered. When an impoverished condition of the blood exists, or when the so-called hsemorrhagic diathesis is the cause of haemorrhage, effort must be directed to improve the composition of the blood, and to ele- vate the tonus of the vessels. When the haemorrhage is occurring, the most absolute repose must be enjoined ; the patient should swallow as rapidly as possible pellets of ice ; ergotin should be injected subcuta- neously, as much as three to six grains at a time, and it may be repeated as often as necessary ; a bag of ice should be put on the epigastrium ; and large draughts of iced alum-whey should be swallowed every few minutes. Ligatures around the thighs, tied tightly enough merely to stop a part of the venous blood in the lower limbs, is an excellent adjunct to the measures above proposed. If this is not done, the legs should hang down out of the bed, and the shoulders should be some- what raised. The salts of iron (chloride, nitrate, subsulphate) may be administered for their styptic effect. A teaspoonful of the tincture of the chloride can be given in four ounces of ice-water. An objection to these ferruginous styptics is the very voluminous and nauseating coagula which they form, and which are apt to excite vomiting. Bran- dy is an excellent local astringent, and is generally serviceable in these cases, owing to the syncope. The stimulant is beneficial in raising the arterial tension, by furnishing a force for the vaso-motor system, which is in a state of paralysis. Tannic acid is a safe styptic, which can be used frequently and in relatively large (ten grains) quantity. Sulphuric acid may be employed successfully, and this has the advantage that a small quantity imparts astringent property to a large amount of water. Next to alum-whey it is the most efiicient haemostatic. If vomiting is obstinate, the one sixteenth grain of morphia hypodermatically will stop it, and contribute materially to the arrest of the haemorrhage. If the haemorrhage has been sufficient to cause dangerous syncope, inhalation of nitrate of amyl may arouse the failing heart, or the injec- tion of digitaline may be tried. Leube advises the subcutaneous in- jection of ether — a syi'ingeful every few minutes — in cases of danger- ous syncope from the haemorrhage. Very great care is subsequently required in the alimentation, and in the use of remedies to remove the DILATATiOX OF THE STOMACH. 53 anaemia. Only milk should be permitted for some days ; but this may be supplemented most advantageously by the rectal injection of defi- brinated blood. DILATATION OF THE STOMACH. Causes. — Dilatation of the stomach is most frequently produced by stenosis of the pylorus. The great cause of narrowing of the pyloric orifice is cancer, but it may be due to chronic inflammation, hyperpla- sia, and subsequent contraction of the submucous connective tissue, or to hypertrophy and contraction of the muscular elements — the so-called sphincter — of the pylorus. These forms of local disease, limited to this locality, are excessively rare, while cancer is common. Exterior pressure, as of cancer of the pancreas, a floating kidney or other tumor, may cause stenosis of the pylorus and subsequent dilatation of the stomach. Dilatation of the stomach may be the result of excessive indulgence in the use of fluids, notably of beer. The author has ob- served several cases, in beer-drinkers, who drank ten, twenty, even forty, glasses of beer habitually every day. Pathological Anatomy. — When stenosis exists at the pylorus, the whole organ is dilated, often enormously so, but the enlargement is not universal and uniform from the beginning ; the dilatation com- mences in the fundus. With the development of the stenosis there ensues hypertrophy of the muscular layer, in accordance vnih the well- known pathological law. In dilatation without stenosis of the pylorus the muscular layer is thinner than normal, pale in color, and more or less advanced in fatty degeneration ; the mucous membrane is, also, thin, pale, and without rugae. Stenosis of the pylorus is caused chiefly by cancer, and hence the lesions peculiar to this new formation will be present. If ulcers have been excavated at the margin of the orifice, have subsequently coalesced, and cicatrized, the results of the contrac- tion of the cicatricial tissue will be seen in a distorted and contracted pylorus. Symptoms. — When stenosis of the pylorus and dilatation of the stomach are results of cancer formation, the symptoms of dilatation are quite dominated by those of cancer. It is necessary, here, to dis- cuss the former only. The symptoms are those of chronic gastric ca- tarrh, or of dyspepsia. There are three signs in addition to those of dyspepsia, which indicate dilatation of the stomach : rather persistent vomiting ; vomiting of food partly chymified and partly undergoing fermentative and putrefactive changes — the physical evidence of en- largement. The cavity having greatly increased capacity, enormous accumulations may take place, and hence when vomiting occurs the amount discharged will be great. The attacks of vomiting are more frequent than is usual in ordinary cases of dyspepsia, and they may become habitual. Regurgitation is a common symptom — particles of 54 DISEASES OF THE DIGESTIVE SYSTEM. partly digested aliment, acid, acrid, and offensive, and foul gases, com- pounds of hydrogen with sulphur and phosphorus, coming up. The bowels are torpid, the faeces dry. The nutrition is much impaired in consequence of the insufficient conversion of the food, and the dimin- ished absorption. Hence the patients affected with this malady waste, and, as the blood is deficient in water, they suffer from muscular cramp, chiefly of the flexors. These cramps were first described by Kussmaul (Leube),* but the author has repeatedly observed them to occur in can- cer of the stomach, in dilibetes, etc., and everybody knows that they occur in Asiatic cholera, the same cause, dehydration of the blood, operating in all these maladies. The physical signs of dilated stomach are as follows : On inspec- tion, an abnormal fullness and prominence of the whole stomach region will be seen ; on percussion, the signs vary according to the state of the organ ; if empty, a tympanitic percussion-note, of a somewhat metal- lic quality and extending from the sixth intercostal space to or below the umbilicus, is developed ; if full, it is high pitched and flat, and, on assuming the upright posture, there is a zone of dullness at the lower part of the space, in the recumbent posture returning a tympanitic note. On auscultation of the dilated stomach, there is almost always heard a good deal of succussion — splashing of the fluid in the cavity, when the body is suddenly and strongly shaken. Another means of diagnosis consists in passing the stomach -tube, and noting the point at which it may be felt through the abdominal parietes. Course, Duration and Prognosis. — Usually the clinical history of dilated stomach is that of the maladies causing it. When it occurs independently, the course and duration are rather indefinite, and the prognosis unfavorable as to cure. Treatment. — The first and most important duty is a careful adapta- tion of the diet to the conditions present. The form of alimentation suitable to these cases is " dry diet," f a diet without fluids. The quantity of other foods should be small, and as far as possible " water- free." As paresis of the muscular layer of the stomach is an important factor in the dilatation, means must be employed to correct this. Strychnia hypodermatically, in the epigastrium, is an excellent expedi- ent. Tincture of nux vomica and tincture of physostigma are effective remedies — ten to. twenty drops of each — three times a day before meals. Great benefit is obtained from the use of galvanism, one elec- trode placed just beneath the mastoid process and the other at the epigastriiim, and a mild current (from five to twenty cells of Siemens * " Ziemssen's Cyclopaedia," article " Diseases of the Stomach," vol. vii. f See my Treatise on " Materia Medica and Therapeutics," article " Alimentation in Disease." INTESTINAL CATARRH. 55 and Halske), slowly interrupted, passed through the pneumogastric. Fermentation should be prevented by the use of the sulphites, carbolic acid, etc., but especially by abstaining from starchy and saccharine substances, which produce a great quantity of carbonic-acid gas. The decomposing foods, the fat acids set free by the fermenting butter and other fats, and the unhealthy mucus which is poured out in great quantity, keep up irritation which renders futile the use of the ordi- nary remedies. This fermentative and decomposing mass must be re- moved from the stomach. The expedient first advocated and employed by Kussmaul — washing out the stomach with the pump or siphon — has proved to be useful, but it does not maintain the same position, as a therapeutical means, as on its first introduction. Recently Ktister * has opposed its use on several grounds, and advised the treatment by muriatic acid, Carlsbad salts, and nitrate of silver. If the stomach- pump or siphon be used, the stomach should be thoroughly washed out every day. The author can not doubt that, if an emetic is first given, and is followed by an active saline cathartic, the stomach will be thoroughly emptied, and as efiiciently as if the stomach-pump were employed. Then, if distention be avoided, a suitable diet en- joined, and remedies to promote contraction of the muscular layer prescribed, the best results can be obtained of which our present re- sources will admit. DISEASES OE THE E^TESTIKES. CATARRH OF THE INTESTINES. Deflnition. — Catarrh of the intestinal mucous membrane may exist in the acute or chronic form. It receives different designations as it affects the various divisions of the intestinal tract. Catarrh of the duodenum is duodenitis; of the ilium, ileitis; of the colon, colitis; and of the ilium and colon together, ileo-colitis. When it is limited to the caecum it is called typhlitis^ and when to the rectum, p>foctitis. Again, the designation is derived from some special characteristics, as cholera morbus, cholera infantum, etc. To avoid repetition, those points in the morbid anatomy in which these several forms agree may be first described with advantage. Pathological Anatomy of Catarrh of the Intestines. — In the ca- * " Allgemeine Med. central Zeitung," ISTG, No. 98. 56 DISEASES OF THE DIGESTIVE SYSTEM. tarrhal process, there ensues first hypersemia of the mucous membrane, which is manifested by redness, swelling, and oedema ; next, nutritive alterations, which consist of granulation of the protoplasm, over- growth and desquamation of the epithelium. The injection occurs most decidedly about the glands, but it may be uniformly diffused, the whole surface affected, or the redness may be in patches and re- stricted to particular localities. One result of active hypersemia is rupture of capillaries and extravasation of blood ; another is increased secretion and exudation, consisting of the products of glands, abnor- mally active, desquamating epithelium, proliferating cells, and migrat- ing white corpuscles. In these changes consists the morbid anatomy of an acute catarrh of a mucous membrane. In chronic catarrh, which succeeds to the acute form, generally, the changes ax'e similar, but possess also special character. Long-con- tinued hypersemia induces changes in the vessels — over-distended they remain enlarged, the veins tortuous and varicose ; remains of old ex- travasations of blood are seen in a brownish, slate-colored pigment deposit, most abundant in the villi. The mucous membrane contin- ues swollen and oedematous ; the cells of the epithelial layer are altered in respect to their nuclei and protoplasm, which have become cloudy and are more or less advanced in fatty degeneration. The glands and agminated follicles become prominent from an excessive formation and accumulation of their contents ; as a result of the pressure of proliferating cells, necrosis occurs, and sloughs separate, leaving ul- cers ; or the glands remain prominent and brownish and slate-colored from changes in previous extravasations. The mucous membrane is covered with a tenacious mucus rich in pus-cells, which strongly ad- heres, or with a more abundant and less tenacious purulent exudation. Owing to an accumulation of their contents, the agminated patches with solitary follicles are enlarged, their orifices appearing as minute black points, the whole forming a very characteristic appearance. In chronic catarrh the anatomical alterations are not limited to the mucous membrane and its glandular appendages. The hypersemia ex- tends to the mucosa ; its vessels, especially the veins, enlarge, and the connective tissue, in some situations, undergoes hyperplasia and thick- ens, forming prominences. Instead of hypertrophy, an atrophic change may result from chronic catarrh, but a very great duration of the dis- ease and the immaturity of early life are necessary. The muscular layer of the intestine, if a catarrh has long per- sisted, may undergo hypertrophy, and, in rare cases, to such an ex- tent as to encroach on the cavity and greatly lessen the capacity of the bowel. CHOLERA MORBUS. 57 CHOLERA MORBUS. Definition. — An acute catarrh of tlie stomacli and intestines, of sud- den onset, and manifested objectively by yomiting and purging. It is also called cholera nostras, sporadic cholera, etc. Causes. — Climatic influences are the most important. It is a dis- ease more especially of summer and early autumn, although it may occur under certain circumstances at any season. Tartar emetic, ela- terium, and other irritants will bring on vomiting and purging not to be distinguished from a severe cholera morbus. Irritants of all kinds, unripe fruits and vegetables, fermentation of foods in the stomach, will excite an attack. Pathological Anatomy. — Death may ensue without there being any defined alterations of structure. In ordinary cases there are present the changes of acute gastro-intestinal catarrh ; the mucous membrane hyperfemic ; the epithelium desquamating ; the glands swollen and prominent ; the blood, thick and of a prune- juice color ; the serous membranes everywhere dry, sticky, and coated with desquamated epithelium ; the kidneys hyperaemic, the epithelium of the tubules also being cast off ; the muscles of the body becoming granular, etc. — the morbid anatomy, indeed, of true cholera, except in degree. Symptoms. — An attack of cholera morbus may be preceded by some diarrhoea, nausea, a coated tongue, and general malaise for a day o'r two, but usually it sets in suddenly and with violence. In the night, as a rule, and usually after midnight, the patient is awakened by a chill or a sense of chilliness, some intestinal pain (colic) and nau- sea, and vomiting then begins ; or, without any premonition, the pa- tient awakes with intense nausea, and then vomits immediately. The vomited matters at first consist of the ordinary contents of the stom- ach. Simultaneously, purging begins, the first evacuation containing more or less of ordinary faeces. Presently the matters discharged by vomit and stool are liquid, whitish, or of a green or yellowish tint, consisting of mucus and sero-mucus. In the severe cases, approxi- mating to the true cholera type, the matters vomited or passed by stool are copious, thin, whitish, odorless, or having a faint mouse-like odor, and consist of blood-serum with mucus and cast-off epithelium (rice-water discharges). The discharges occur in quick succession, and so enormous is the loss of material that in an hour or two the pa- tient may be so much reduced as to be unable to rise from the bed ; the body shrinks, the face becomes pinched and cyanosed, the surface cold and covered with a clammy sweat ; the hands shrivel and have a sod- den appearance ; the voice is husky, the tongue is cold, the breath is cold. The patient is tormented with an intolerable thirst, but the drink is rejected as soon as swallowed. The urinary secretion rapidly di- minishes in amount, and in the worst cases is suspended. The urine 58 DISEASES OF THE DIGESTIVE SYSTEM. contains traces of albumen, casts of the tubules — the desquamated epithelium — and is deficient in the amount of urea and salts. The effect of this enormous waste from the intestinal canal is to diminish the water of the blood, and hence to relax the circulation. The action of the heart becomes so feeble that the pulse may not be felt at the wrist. Another result of the dehydration of the tissues is the occur- rence of cramps, especially in the muscles of the calf, and they cause severe suffering, the patient crying out when they come on. They may occur in the muscles of the upper extremity, and also in the mus- cles of the neck. In some cases, enormous accumulation of the rice- water material may take place because of a paralytic state of the bowel, and no discharge occur by vomit or stool, yet the patient passes quickly into collapse. From the simplest case of cholera morbus, which ends spontane- ously when the stomach and intestines are emptied, up to the severe algid form, there are numerous intermediate examples of every degree of severity. The subsequent clinical history of the cases depends much ou the severity of the attack. The mild case terminates without treatment, and the next day, although somewhat weak, the patient is about as usual. In the severer cases, after several hours the number of the evacuations lessens, and their character is changed, the skin becomes warm, the pulse rises, and the normal is presently restored, but the mucous membrane remains sensitive, and care in alimentation is neces- sary for several days. In the severest cases — those of the cholera type — recovery from the algid stage is gradual, reaction comes on slowly, but passes the norm into a fever, of type remittent and of character typhoid, which may continue a week or more. In the fatal cases, the mode of dying is by collapse, or in the secondary fever by exhaustion. Course, Duration, and Termination. — The cases are very uniform, but differ much in severity. The duration is from a few hours to two or more days, and, in the rare cases of secondary fever, to two weeks. The termination is in a great majority of cases in health, the mortality being about three per cent, of uncomplicated cases. An attack of cholera morbus may be the mere prelude to an acute diarrhoea or dysentery, more frequently the latter. An attack of cholera mor- bus may be the mode of dying from chronic interstitial nephritis. Diagnosis. — The phenomena attendant on cholera morbus are so characteristic that a mistake of diagnosis would seem to be difficult. During the existence of a cholera epidemic, the severer cases of chol- era morbus may be mistaken for cholera, but, as they do not differ in any respect, not even in morbid anatomy, there need be no attempt at differentiation. Cholera morbus, a substantive affection, may be con- founded with choleriform attacks due to uraemia. The distinction is CHOLERA MORBUS. 59 to be made by reference to the previous history, the presence of albumen and casts in the urine, and the cerebral symptoms, which, in some form, occur in uraemia. Treatment. — In simple cholera morbus due to the ingestion of some irritating or indigestible food, or to fermenting materials, no treat- ment may be necessary. When the cause is removed the morbid action ceases. In the more severe cases prompt action is necessary, especially when cholera is prevalent. No remedy compares in effi- ciency to the hypodermatic injection of morphia and atropia — ^ to ^ of a grain of the former and yiir of a grain of the latter.* Those entirely unaccustomed to the action of opium — women, and men of the nervous and impressionable type — should receive the smaller dose. In many cases, a single injection suffices to tenninate the attack. The repetition of the injection will depend on the severity and persistence of the attack, and on the susceptibility of the patient. It is usually better not to repeat the injection within the hour. The effect which it has is most striking : the vomiting and purging cease, the pulse rises, the surface becomes warm, and the cramps are no longer felt. It is rare, indeed, if these results are not obtained promptly, rendering unnecessary any subsequent treatment except some correcting medi- cine In the cases of the cholera type, the patient passing into the algid stage, additional means may be necessary. The use of chloral hypodermatically with morphia is then remarkably beneficial. The author has observed that under these circumstances chloral will re- lieve the cramps and bring about reaction, when morphia, alone or with atropia, had seemed inadequate. Other means of treatment may be employed in conjunction with the hypodermatic injections, or without them. Sinapisms of large size should be applied to the abdomen, but not allowed to remain longer than sufficient to produce a sensation of burning, or the appearance of redness. Pellets of ice may be repeatedly swallowed. Iced cham- pagne, very dry, will sometimes be retained when other things are rejected. Carbonic-acid water and effervescing soda-powders are very grateful and also serviceable. The medicines most easily borne and most efficient are combinations of the mineral acids and opium, of which, the well-known Hope's mixture is a type. Diluted sulphuric or muriatic acids witli the tincture of opium in camphor-water, are the best of these combinations. The mistake is frequently, indeed, usually made, of giving the mineral acids in too large doses, and hence they are immediately rejected. From two to five drops of di- luted sulphuric, or the same dose of diluted muriatic acid, and the same quantity of tincture of opium, should be given from every half hour to every two hours, in a sufficient qiiantity of ice-water. An * " Manual of Hypodermic Medication," third edition. Philadelphia : J. B. Lippin- cott & Co., ISYQ. QQ DISEASES or THE DIGESTIVE SYSTEM. acid solution is much more grateful, and also more easily borne, than any other kind of medicine. Carbolic acid alone, or in a mixture with bismuth, is an efficient means for arresting vomiting. Beside, its properties as an antiferment, it has a local anaesthetic action on the terminal filaments of the nerves in the mucous membrane. The ef- fects of carbolic acid, creosote, and other agents of the same kind, are confined to the stomach, and hence they are of little use in affections of the intestines. Iodine tincture, and carbolic acid, in equal parts — a half grain of each — every half hour, is an effective combination, of great utility in irritable stomach. When remedies of the kind just now mentioned are given by the stomach, they should be supple- mented by enemata of starch and laudanum, repeated according to circumstances. Very small doses of calomel — one twelfth to one sixth of a grain — have remarkable sedative effect on the gastro-intestinal mucous mem- brane, relieving vomiting and suspending the purging. It is often given with opium, with rhubarb, piperine, etc., but such combinations, except that with opium, are of doubtful utility. Aromatic and astrin- gent remedies are much used in various combinations to arrest vomit- ing and purging. Tincture of rhubarb, tincture of colomba, and tinc- ture of opium, make an effective remedy. One of the most generally useful and certain remedies for attacks of cholera morbus is chloro- dyne. As a secret, proprietary remedy it should not be prescribed, but one of the more accurately prepared imitations of the original compound can be substituted. There can be little doubt now that this is a fortunate combination of remedies, adapted to the treatment of gastro-intestinal maladies having the choleriform character. CHOLERA INFANTUM. Definition. — An acute gastro-intestinal catarrh, occurring in chil- dren during the period of the first dentition, and characterized by vomiting, purging, and considerable febrile excitement. It is also called summer cholera and summer complaint in domestic prac- tice. Causes.— Early life— the first two years— owing to the various phases through which the organism is then passing, is the period for cholera infantum. Bad hygiene is the great factor— including damp, ill -ventilated, and confined houses, air contaminated by cesspool and sewer emanations, continuous high temperature, and improper food. Feeding infants the coarse food of adults, or confining them to a diet composed almost entirely of starch, are most fruitful causes of an out- break of the disease, the other conditions being present. This peculiar form of gastro-intestinal catarrh occurs chiefly in cities, in low, ma- larious localities, and is especially frequent on this side of the Atlan- CHOLERA INFANTUM. 01 tic. But Berlin has the bad preeminence, according to Lombard,* of surpassing the American cities in " the frequency of the cholera of infants." Pathological Anatomy. — The changes occurring in cholera infan- tum are those described under the general head of catarrh of the intestines. The implication of the solitary glands and the agminated (Peyer's) patches is somewhat more decided than is there stated, prob- ably, but otherwise the description there given is accurate. A marked degree of cerebral anaemia is represented in a venous stasis, and a good deal of fluid in the subarachnoid spaces. Symptoms. — This disease sets in by two modes of onset : with pre- liminary symptoms ; suddenly. Usually there are prodromes, the child becoming restless, irritable, feverish, before any bowel symptoms are manifest, then diarrhoea comes on, vomiting occurs, and the disease is fully developed. In other cases diarrhoea has persisted several weeks with the usual symptoms, and gradually the phenomena of cholera infantum are added. Again, the disease is suddenly developed : the child, in full health, is attacked, without any preliminary symptoms, with the characteristic vomiting and purging. The first evacuations contain more or less fecal matter, but soon the characteristic watery stools make their appearance. These are so thin as to soak into the napkin; leaving a greenish or greenish-yellow stain, and having an odor of rotten wood, or indeed having but little odor. With these stools are particles of curd, or undigested food passed as swallowed, or yel- lowish masses of mucus turning green on exposure. Simultaneously vomiting occurs of any food or drink swallowed, and with these mat- ters a quantity of sero-mucus, acid, neutral, or even alkaline, according to the time of the vomiting. Usually anything taken into the stomach — water or mother's milk — is rejected immediately; the retching continues, and the mucus coming up after the food is acid ; further retching brings up some serous fluid, which is neutral, and alkaline if it comes from the duodenum. Prolonged retching brings up not only the contents of the duodenum, but mucus and bile from the gall- bladder. The loss by the gastro -intestinal mucous membrane induces rapid wasting. In a few hours the body shrinks remarkably, the eyes are sunken and half closed ; the mouth remains half open, the lips dry and cracked, and bleeding, for the infant feebly picks at the fissures ; the face is shrunken, pallid, with an occasional red spot in the cheeks. More or less pain is felt when the bowels are moved or when vomiting is about to take place, which the child manifests by restlessness and a husky whine or cry. Tenderness on pressure usually exists along the track of the colon, and an erythematous rash diffuses from the anus over the buttocks and genitalia, causing so much tenderness that the * "Traite de Climatologie Medicale," vol. iv, p. Z11. Paris: Bailliere et Fils, 18S0. 62 DISEASES OF THE DIGESTIVE SYSTEM. contact of the irritating discharges excites pain. The mind is, how- ever, rather torpid, the senses not acute, and the attention roused only by strong excitation. The child lies at last in a condition of great exhaustion, indifferent to all surrounding objects, and experiencing the distress which comes from thirst only. Rise of temperature takes place with the first disturbance of the intestinal canal, the fever being of the remittent type, with the remis- sion in the morning, usually. In the early morning is the period of greatest depression. With the rise of temperature in the afternoon, the cheeks may be a little flushed, and the countenance, therefore, appear better. The range of temperature taken in the axilla is from 102° to 104° Fahr. in the pronounced cases. The pulse is very rapid and feeble — 140 to 160 beats in the minute. The number of dis- charges may rise to forty or fifty a day, many of them not more than a teaspoonful of fluid. With the progress of the case, there is a rapid decline in weight and strength ; the pulse becomes more quick and feeble ; the respirations grow more and more shallow, and hypostatic congestion and oedema occur ; carbonic-acid poisoning ensues, with a gradually deepening coma, ending in death. Course, Duration, and Terminations. — The ordinary course is prompt in the fatal tendency, or toward cure, the latter being the natural ten- dency when the child is j^ut under favorable hygienic conditions. The duration of the attack proper is two or three days to one week ; severe cases may terminate .in collapse in a day or two. When recovery en- sues, the duration of the case is prolonged by the subsequent ileo-colitis. If the prodromic symptoms are included, it may be said that the aver- age cases are from one to two weeks, not including the ileo-colitis or the proctitis, which may prolong the attacks several weeks. The most frequent termination is by exhaustion and death by coma from defi- cient excretion of carbonic acid and its accumulation in the blood. The cerebral anaemia may be confounded with acute cerebral conges- tion, and the death attributed, very erroneously, to the latter. Death may happen at the lungs or from failure of the heart. Diagnosis. — The only disease with which cholera infantum can be confounded is true cholera, but, as the therapeutical indications are the same, it is the less important to be correct. Prognosis. — A guarded opinion should always be given, as the case may very unexpectedly take an unfavorable turn. The hygienical surroundings influence the prognosis greatly. The number and fre- quency of the discharges and the readiness with which the symptoms yield to the treatment are important elements in making up a judg- ment. The constitutional condition, the inherited tendencies, and the aliment available for nutrition, are to be carefully considered. When the child is at the breast, and the supplj^ of milk is abundant and good, the prognosis may be more favorable than if the child has been CHOLERA INFANTUM. 63 weaned, and the kind of aliment suitable to tlie case remains un- determined. Treatment. — Immediate attention must be given to the aliment. Instead of large draughts of water, the child should suck some pieces of ice. If nursing, the number and duration of applications to the breast must be regulated. The child is excessively thirsty, and is in- cessant in the demands for nursing. The stomach is quite unable to dispose of it, and it is either soon rejected or passes by the bowels. Once in two, two and a half, or three hours, according to the age, is often enough, and the child should be removed when it has obtained two tablespoonfuls. If fed by cow's or goat's milk, this should be diluted with lime-water. If they do not agree, owing to an inability to digest the casein, which is the usual difficulty, the best substitute is barley-water, of the density of good milk, to which cream is added in the proportion in which it exists in milk. This combination is a nutri- tious aliment of the quality of milk, less the casein. Beef -tea is veiy badly borne in these cases, and the artificial foods prepared for infants are not, in the author's experience, good substitutes for milk. One of the most important remedial agents is the cold bath. The extraordi- nary temperature range, almost reaching hyperpyrexia, is an important element of danger, causing failure of the heart and paralysis of the brain. The cold bath is the most effective means of combating the fever. The child must be very gently and carefully immersed in water at 95° to 100° Fahr., and the cold water gradually added until the thermometer stands at 85° or 80°, or even 60°, if well borne. The duration of the bath is about ten minutes, and the frequency of their repetition depends on the influence which they have on the tempera- ture. Two or three baths per day are required until the fever perma- nently declines. The administration of pure cognac brandy, in a small quantity of very cold water, is an excellent means of checking the vomiting and purging, and of lessening the abnormal heat. From twenty minims to one drachm every two, three, or four hours, according to the age of the subject and the severity of the symptoms, is the proper amount for administration. The opium so much prescribed, and so remarkably beneficial in cholera morbus — a similar state in the adult — ^is a remedy whose utility is most questionable. In the author's judgment, opium should be given only when the other means used has no effect in re- straining the excessive discharges. A most efficient jDrescription is the combination of bismuth and carbolic acid — ten grains of the former, and one fourth to one half grain of the latter, every two hours. It is best administered with some tincture of cinnamon in an emulsion of gum-arabic. It may be given also with mistura cretse. Rhubarb, in doses that are merely astringent, with an aromatic (cinnamon) and an alkali (bicarbonate of potassium), is an efficient remedy, especially in 64 DISEASES OF THE DIGESTIVE SYSTEM. this combination. Infusion of rhubarb, tincture of cinnamon, with some bicarbonate of potassium, makes a disagreeable but extremely- serviceable prescription in these cases. Oxide of zinc, oxide of silver, nitrate of silver, are useful in those cases characterized by severe watery purging rather than vomiting. When the vomiting is excessive, and other medicines are rejected, calomel is extremely beneficial, and, in- deed, in ordinary cases, it has the first position almost as a sedative to the gastro-intestinal mucous membrane. It must be given in very small doses — one twentieth to one tenth of a grain, every half hour or hour. It may be rubbed up with some sugar of milk and dropped on the tongue. When there is much straining, and especially if there be much mucus, and mucus streaked with blood, passed from the bowels, minute doses of arsenic (from one eighth to one fourth drop of Fow- ler's solution) with a little opium (half to one drop), every three hours, are very serviceable. If the discharges are very profuse, watery, and not restrained by the remedies prescribed by the stomach, enemata of starch and laudanum may be used. Counter-irritation by mustard (the skin very little reddened or irritated), or by means of a spice-bag, or, better, a turpentine-stupe, is beneficial, if not carried too far. DUODENITIS— CATARRH OP THE DUODENUM. Definition. — Catarrh of the mucous membrane of the duodenum, which may be acute or chronic. As the ductus communis choledochua opens into that part of the canal, the catarrhal process extends up by contiguity of tissue, and hence catarrhal jaundice may coexist with duodenitis. Etiology. — Climatic changes are very influential in setting up a catarrh of the duodenum. External irritation, if severe and prolonged, will cause hypersemia and structural changes, just as a severe burn will excite ulceration. Probably the most common cause is indigestible aliment, which passes the stomach unchanged, and the excessive use of starchy, saccharine, and fatty foods, which require for their diges- tion and absorption the action of the intestinal juices, of the bile, and of the pancreatic fluid. Pathological Anatomjo — The general description already given ap- plies here. Hyperaemia and oedema occur to a more pronounced extent about the orifice of the common bile-duct, which is so swollen as to encroach materially on the lumen. More or less injection and swelling of the mucous lining of the duct exist to a variable extent. Symptoms. — The anatomical seat of the inflammation influences, to a great extent, the symptoms. In other cases of intestinal catarrh, diarrhoea is a prominent symptom ; in duodenitis, diarrhoea is excep- tional, and more or less constipation is the rule. Pain and disorders of digestion are usually present, and jaundice is a prominent symptom. DUODEXITIS. 65 The pain is felt in the right hypochondi'iac and umbilical regions, and soreness can be developed by deep pressure over the duodenum. The pain is not usually very acute — the sensation is compounded of pain and soreness, but occasionally severe pain occurs in the hepatic plexus. As in catarrh of the stomach there are occasional attacks of gastralgia, so in catarrh of the duodenum there are occasional attacks of hepatal- gia. The paroxysms of severe pain come on gradually, and, after some hours, gradually subside. There is no increased soreness during the existence of the pain or subsequently. There may or may not be present gastric catarrh, as well as duo- denitis. The distress caused by the presence of food is felt about three hours after it has been taken, and is usually referred by the patient to the seat of the disease. The starchy and saccharine ele- ments of the food undergo fermentation, and hence, in about three hours after they have been swallowed, the formation of flatus begins, the small intestines become distended with gas, and some pain, due to the stretching -of the bowel, is felt about the umbilicus. From the third to the seventh day jaundice appears. It is usually announced by a coated tongue, fetid breath, and yellowness of the conjunctiva, head- ache, stupor, and hebetude of mind (cholgemia), with depression of spirits. The yellowness extends, and in a short time the jaundice is universal. The absorption of bile is coincident with swelling of the common duct, and entire absence of bile in the intestinal canal. The stools now have a pasty consistence, of a slate-color, and fetid odor. Gas, discharged previously, had but little odor ; after the jaundice, it has the same fetid character as the stools. The urine is thick from excess of urates, and of a deep-brownish color from presence of bile-pigment. When the jaundice has attained the maxi- mum, there are complete anorexia, nausea, sometimes vomiting of food, mucus, sero-mucus, and constipation, although diarrhoea may occur. The temperature is slightly elevated — 99*5° Fahr. in the morning and 100° to 101° Fahr, in the evening. Pulse corresponds. Course, Duration, and Termination. — The disease is self-limited, and, if permitted to pursue its course uninterrupted, will last two or three weeks, leaving the patient much debilitated. In malarious dis- tricts this malady is exceedingly common, and may be intimately asso- ciated with malarial infection. The chronic form of duodenitis is essentially the same in respect to clinical history and characters, except as to duration and violence of the symptoms, as the acute form. The duration of the chronic form may be several months. The late re- searches of Charcot and Fagge have demonstrated that long-continued obstacle to the outflow of bile leads to structural changes in the liver. The termination of uncomplicated duodenitis is in health. The acute is apt to pass into the chronic form, and the latter to affect the hepatic 5 66 DISEASES OF THE DIGESTIVE SYSTEM. parenchyma in the manner to be hereafter described. Hepatic colic is also one of the results of this disease. Diagnosis. — Duodenal catarrh may be confounded with gastric catarrh, with hepatic colic, and with diseases of the liver proper, accompanied by jaundice. As resj)ects gastric catarrh, the differen- tiation is to be made by reference to the seat of pain and soreness, the time when the distress from the presence of food comes on, the occur- rence of flatulence with bowel-pain, and especially the appearance of jaundice at a certain time after the beginning of the symptoms. Duo- denal catarrh is separated from hepatic colic by the following signs : In the latter, the pain comes on suddenly after some pain and sore- ness in the region of the gall-bladder, and radiates from this point over the abdomen ; the pain is so intense as to produce a cold sur- face, a weak pulse, great depression, and incessant vomiting ; the pain suddenly ceases, and there is complete relief, except some local tenderness ; jaundice follows these symptoms, but disappears in a few days, leaving the j^atient well ; the presence of a gall-stone in an evacuation a few days after the attack. Hepatalgia is a neuralgic attack, occurring suddenly, and lim.ited to the hepatic plexus. It ceases suddenly, leaving the patient well, and the only interference with function is during the existence of pain. Its duration is but a few hours. Treatment. — The first point is regulation of the diet. The diet should be restricted to those substances convertible into peptones in the stomach, as milk, whey, buttermilk, eggs, animal broths, and all saccharine, starchy, and fatty constituents should be avoided. Fresh meats, game, poultry, and fish, without butter or fat, are admissible if the stomach is equal to their digestion. The most rapid progress can be made by adhering to an exclusive diet of milk, and, as there is complete anorexia, this is usually not difilcult. The hyperaemia of the duodenal mucous membrane is relieved by saline laxatives, by the Sara- toga, Carlsbad, or Yichy waters, by Rochelle salts, but especially by phosphate of soda, which should be given in drachm-doses about four times a day. Other remedies, acting similarly, are sulphate of mag- nesia and bitartrate of potassa. The general principle is to use reme- dies which will promote an outward osmotic flow, and thus relieve the congestion and oedema of the mucous membrane. Mercurials are not beneficial. Active cholagogues, as the resin of podophyllin, rhubarb, aloes, etc., are to be avoided on account of the irritation which they induce. To rouse the liver — a favorite phrase — is out of place here, since the obstacles to the outflow of bile are merely mechanical. When malarial infection coexists, quinia is indispensable to restore health. Without any complication of malaria, quinia has a good effect, and hastens the disappearance of the jaundice. When the bile enters the intestine and the intestinal digestion is restored, the jaundice ILEO-COLITIS. 67 may still linger. Diui-etics and purgatives may then be employed to remove the last traces of bile-pigment. ILEITIS— ILEO-COLITIS— CATARRH OF THE ILIUM AND OF THE ILIUM AND COLON. ACUTE DIARRHCGA| CHRONIC DIAR- RHCEA. Definition. — Ileitis is a catarrh of the ilium, either, acute or chronic ; ileo-colitis is a catarrh involving both parts — the whole extent of the ilium and the caecum and ascending colon. This may also be either acute or chronic. The disease is frequently denominated diarrhoea, from a single symptom. Causes. — The causes already given for other forms of intestinal catarrh are equally true of this form. The two great factors are im- proper and indigestible food and the summer temperature. An attack may be brought on by exposure to cold and damp air when in a per- spiring state. The sudden arrest of cutaneous transpiration precipi- tates a vicarious duty on the mucous membrane, with the eifect to induce a general hyperaemia of the ilium and colon. As respects chil- dren, the causes in operation to produce ileo-colitis are the same as those which bring on cholera infantum. Pathological Anatomy. — In this variety of intestinal catarrh, the morbid anatomy has the special feature of enlargement of the agmi- nated patches, which are most abundant and most highly developed in the lower ilium. The condition of the epithelium, of the villi, and of the glands, has been described. Sufficient emphasis has, probably, not been put on the tendency of the swollen glands to ulcerate. In the acute cases the orifices of the solitary glands are here and there eroded ; but in the chronic cases considerable ulcers form. These changes are different in character and very different in extent from those which take place in typhoid. Symptoms. — The acute form of ileitis or ileo-colitis sets in with some chilliness and general malaise, followed by feverishness. Pain in the abdomen, usually about the umbilicus, is felt, and then loose evacuations begin. The number of stools each day varies with the character of food and the extent of the disease, especially in the colon. It would be a mistake to suppose that the diarrhoea is due solely to an irritation of the affected jDortions of the mucous membrane, by the par- ticles of aliment reaching them. Considerable transudation occurs as one result of the hyperaemia : cast-off epithelium, young cells, and mi- nute sloughs mix with the serum, and constitute no small part of the stools discharged. Besides, the chyle imperfectly prepared for absorp- tion, and hurried down the canal by the increased peristalsis, and the fatty, starchy, and saccharine constituents of the food, fermenting in- stead of digesting, unite to form the liquid discharges characteristic of 68 DISEASES OF THE DIGESTIVE SYSTEM. ileo-colitis. As iniglit be exjjected, there is little fecal matter proper, and the stools have a yellow or greenish-yellow color, and, if the evacuations have been very copious, they may be whitish, like the " rice-water " discharges. In children the stools have a somewhat dif- ferent character, owing to the presence of casein, which presents an appearance of putty, or the casein occurs in small, irregular masses. Very often the stools have a bright-green color, or become green on exposure. Just -before the evacuation, considerable pain is experi- enced, and, in children, nausea and vomiting also. The pain is usually increased by pressure, and soreness is developed at any time by deep pressure. As gases are freely generated in food decompositions, the intestines are often suddenly distended, giving rise to pains as of flatu- lent colic. Borborygmi are more or less present. It is a curious fact that mental depression is a very constant condition in cases of ileo- colitis, when there is abundant production of gas. The digestion and assimilation of food being almost arrested, and great waste taking place by the intestinal mucous membrane, it is obvious that the organ- ism must lose ground rapidly. The subcutaneous fat disappears ; the muscles shrink and lose their contractile energy ; the skin becomes dry, sallow, and wrinkled ; the action of the heart is weak, the pulse small and feeble ; the urine is acid, high-colored, and burning. Chil- dren affected with summer diarrhoea, and having from three to six evacuations a day, and vomiting occasionally, rapidly emaciate, are reduced to a skeleton in fact. In the adult the chronic form is known as " chronic diarrhoea," in which, as is well known, the wasting of the tissues of the body proceeds to the lowest point. Course, Duration, and Termination. — In the simplest cases of catarrh of the intestine, due merely to an unusual accumulation of fseces — crap- ulous diarrhoea — the looseness of the bowels is conservative, an effort of nature to be encouraged rather than restrained. In mild, uncompli- cated cases the tendency is to recovery in a few days, but in the severe cases the duration may be several weeks. In the chronic form the duration is indefinite. The acute runs insensibly into the chronic form, and there is no well-marked distinction, except the element of time. Diagnosis. — The distinctions to be made are between duodenal ca- tarrh and catarrh of the rectum (proctitis). In children, ileo-colitis is to be distinguished from cholera infantum. In duodenal catarrh there is little or no diarrhoea, and jaundice appears in a few days, symptoms entirely different from ileo-colitis. In proctitis the stools may be nor- mal, or occur as scybala. There are straining, heat, and irritation about the rectum, and the discharge of mucus, and mucus and blood. In children, ileo-colitis is frequently mistaken for and called cholera in- fantum. The latter is a disease of sudden onset, characterized by choleriform symptoms and a duration of a few days or few hours only. The character of the discharges is essentially different ; in ileo-colitis TYPHLITIS. 69 they contain casein, yellowish or greenish liquid matter, spinach-colored masses ; whereas, in cholera infantum, they are serous in character, colorless, like the so-called rice-water evacuations, and do not leave anything but a stain on the napkin. Prognosis. — In acute diarrhoea, under good hygienic conditions, the prognosis is favorable. In children, summer diarrhoea is amenable to treatment or not, according to the condition in life, and the ability of parents to provide the necessary means. When ileo-colitis has become chronic, and is not readily amenable to the treatment, the prognosis is grave. In adults, for chronic diarrhoea, which has long existed, the prognosis must be guarded. Treatment. — In simple acute catarrh relief is afforded by a pill of opiu.m and camphor. When the evacuations are numerous and profuse — summer diarrhoea, for example — the most efficient treatment is the combination of a mineral acid (muriatic or sulphuric) with tincture of opium. Carefully managed, the same remedies may be administered to infants. Sometimes alkalies agree better. Sodium bicarbonate can be given with or without bismuth in chalk- mixture. Alkalies, however, merely neutralize acids, but the mineral acids check the fer- mentation on which the production of acid depends. When the dis- charges are greenish (" chopped spinach "), the combination of arsenic and opium is highly efficient — for example, one drop of Fowler's solu- tion, and one or two drops of the deodorized tincture of opium. When there ai'e retained matters, the presence of which excites irritation, an emulsion of castor-oil, with two or three drops of turpentine and some tincture of opium, is very advantageous. In the more chronic cases, or after the acute symptoms have subsided, sulphate of copper with a little opium is an admirable remedy — from one thirtieth to one twelfth of a grain of copper sulphate, and one fortieth to one sixth of a grain of morphia, according to the age of the subject. Other astringents, metallic and vegetable, may be employed under the same circum- stances. For children, bismuth is probably the best astringent. Regu- lation of the diet is even more important than the use of medicines. The starchy, fatty, and saccharine articles of food are highly objec- tionable, and should be omitted entirely, as already advised. The same plan of diet suggested in previous articles is applicable here, and need not, therefore, be repeated. TYPHLITIS.— INFLAMMATION OF THE CiE CUM.— CATARRH OF THE CECUM. Definition. — The term typhlitis is restricted to an inflammation of the caecum and its appendix. Perityphlitis is an inflammation taking place in the loose connective tissue on which the caecum rests. Al- though the seat of the lesion and its nature are very different, it is 70 DISEASES OF THE DIGESTIVE SYSTEM. necessary, because of their intimate relations, to consider tbem to- gether. Causes. — Besides the causes of catarrh of the intestines already suf- ficiently set forth, there are special conditions affecting the csecum. The anatomical position of this organ as a receptacle for the small in- testine, the arrangement of its muscular elements, the abundant folds of mucous membrane when empty, and its immense capacity when filled, are properties necessary to its function, but at the same time causes of disease. Pathological Anatomy. — Catarrh of the caecum may exist as a mere catarrhal affection of the mucous membrane, with the changes in the epithelium, in the solitary glands, and in the vessels already described; or as a localized inflammation, usually from the presence of a foreign body, terminating in ulceration ; or as an inflammation of the caecum in general, with a more intense action about the ileo-csecal valve, and implication with thickening of the submucous connective tissue causing stenosis. The second or ulcerative form of catarrh of the caecum will be described hereafter under ulcers of the intestinal canal. The last- named variety remains for consideration. The ileo-caecal valve being more exposed to injury than any other part of the caecum, owing to its position and office, is more liable to be invaded by disease. When a catarrh of the caecum exists, especially the chronic form, the hyperae- mia and swelling are more decided in the neighborhood of the orifice. An extension of the inflammation to the submucous layer occasionally takes place, the connective tissue undergoes hyperplasia, a permanent increase of thickness results, and stenosis is an ultimate effect of the changes. It is only in the chronic form that such thickening and ste- nosis can occur. Symptoms. — There are two forms of catarrh of the caecum — the acute and chronic. Of the acute variety, there are various grades in the severity of the cases, but two are sufficiently defined to require attention — the mild and the severe. In the mild cases, uneasiness, followed by pain and soreness, is felt in the right iliac region, extend- ing up along the course of the ascending colon. On palpation, ten- derness is found to exist in this region and laterally just above the crest of the ilium. The more decided the pressure, the more distinct the pain. Early, and before the inflammation has extended beyond the mucous layer of the caecum, the decubitus and the sitting posture are characteristic — the body is turned toward the right side, and is flexed somewhat to relax the muscles on the right lateral plane. Additional soreness is experienced when the body is held erect, or straightened out in bed. With the first symptoms there may be some accumulation of faeces, and the caecum and ascending colon may be distinctly bulging and prominent, so that they may be recognized on inspection ; but in the mild cases there is no impaction, properly speaking, but on careful TYPHLITIS. 71 palpation the outline of the bo^'el can be made out, feeling rather soft and dough-like. The bowels are usually constipated, for catarrh of the csecum seems to affect the muscularis, impairing its contractile energy, or there may be an appearance of relaxation by reason of an accumulation in the sacculated periphery of the bowel — leaving a cen- tral cavity along which the liquid contents of the small intestines may pass. The author has seen several examples of this, and so important is the recognition of the condition that he now desii'es to emphasize the fact. During the development of these local symptoms, the sys- tem partakes in the disturbance. The attack sets in -with general malaise, some feverishness, a coated tongue, loss of appetite, nausea, and not unfrequently vomiting. In the severe cases, the symptoms are increased in severity in all du-ections. The local pain, tenderness, and swelling are greater, there are impaction of faeces and no move- ment. There are decided fever, considerable restlessness, nausea, and vomiting. The vomited matters consist at first of the contents of the stomach, then of the duodenum with much bilious matter, and ulti- mately, if the impaction persist, of matter that has somewhat the odor of faces. With the development of the case, there occurs great de- pression of the powers of life, the face becomes pinched and anxious, the skin covered by a clammy sweat, the pulse small and rapid, the action of the heart weak. Peritonitis is finally developed by contigu- ity of tissue, or by the bowel giving way at some point, weakened by ulceration. The subsequent history is then the history of peritonitis. In the chronic cases, which may succeed to the mild acute, or, "which is much more common, develop slowly by the operation of the ordinary causes of intestinal catarrh, the symptoms are those of intes- tinal indigestion. There is uneasiness in the region of the ileo-cgecal valve, flatus is felt passing the orifice, and the patient is often con- scious of the difference in density, whether gas, liquid, or solid, of the materials passing the orifice. The bowels are confined and rather dif- ficult to move. When the actions are free, semi-solid, and unirritating, the patient has a keen sense of relief. Rarely, on careful palpation, induration, not hard like that of scu-rhus, but doughy, can be made out. A compai-atively empty state of the large intestine and disten- tion of the small intestines can usually be ascertained ; in that event the lateral portions of the abdomen are rather flat, and the central part around the umbilicus is prominent. Course, Duration, and Termination. — The mild form of acute ca- tarrh of the caecum, if properly managed, is readily cured in a week or two. The severe form may terminate by acute peritonitis within a week, or be relieved, and all pain and tenderness subside, -vvithin two or three weeks. Very frequently entire recovery does not ensue, but the case passes into chronic catarrh, the duration of which is very in- definite. 72 DISEASES OF THE DIGESTIVE SYSTEM. Diagnosis. — It is often extremely difficult to distinguish typhlitis from perityphlitis or frora occlusion of the bowel by other kinds of obstruction. The points of difference between typhlitis and perity- phlitis can be better understood after the study of the latter, and are therefore reserved. Typhlitis in the mild form is distinguished from other affections of the bowel by the local pain and soreness, by the fullness without impaction ; in the severe form, the symptoms of ob- struction are the same as in other kinds of occlusion, but the local pain and the distinct enlargement of the bowel indicate the existence of an inflammation and fecal obstruction of the csecum. In these af- fections, the decubitus of the patient is an important aid to diagnosis. Chronic catarrh of the caecum is recognized by the locality of the dis- tress. As cancer of the csecum behaves in the same way in the early stage of its formation, there may be no means of differentiating ; but, in the progress of the case, the growth of a nodulated tumor, the pro- gressive increase in the pain and obstruction, and the develoi^ment of a cachexia, are sufficient to indicate the nature of the affection. Prognosis. — In the simple form the prognosis is favorable ; in the severe form it is grave, although recovery will ensue in a large pro- portion of the cases if the management is judicious. In the chronic form, when the connective tissue has become thickened, the prognosis as to cure is unfavorable. . Treatment.— In the treatment of acute typhlitis all active purga- tives must be avoided. If there is but little feverishness, and the local tenderness is slight, saline laxatives may be administered from the beginning, in small doses at short intervals, to induce liquefaction of the contents of the bowel. The hyperaemia is lessened by the same means. When free discharges are obtained in this way, the canal should be kept quiet with opium for a few days. The most efficient and, at the same time, safe laxative is sulphate of magnesia. It is a curious fact that this salt will be retained when other salines are re- jected by vomiting. Rochelle salts may be used as a substitute when Epsom salts is not suitable. Different management is required in cases of typhlitis with impaction and arrest of the intestinal movements. If there be fever and much tenderness, no attempt should be made to relieve the bowels by purgatives of any kind. It is in this condition of affairs that opium in some form, especially in the form of the hypo- dermatic injection of morphia, is so serviceable. The patient should be kept thoroughly under the influence of the narcotic. It is better to combine atropia with the morphia, for greater security and increased therapeutical power. No absolute rule for quantity can be laid down, but the decided effects of morphia, as shown in the state of the pupil, the pulse, the respirations, and the somnolence, should be steadily maintained. The fullest curative power of morphia is obtained from a quantity strictly within the limits of safety, and hence no risk need TYPHLITIS. Y3 be had to obtain the best results. As a guide to the administration, it may be stated that one fourth of a grain of morphia and yj-g- grain of atropia is enough for the first dose in an adult, and subsequently one eighth of a grain of morphia and t^ grain of atropia every four, six, or eight hours according to the effect. If there be any reason, moral or physical, which prevents the hypodermatic administration being- employed, the next best mode is the rectal injection of the tincture of opium. As respects the quantity, the rule above given is proper ; it is the degree and constancy of the effect which determine the amount. If the rectal injection is objected to, or the organ is intolerant, opium must be administered by the stomach. The best preparation is the deodorized tincture, and, to secure uniformity in action, the preparation made after an essay of the opium is altogether preferable. This cor- responds in strength to laudanum : sixty drops may be the first dose, and twenty drops every two, three, or four hours succeeding^ the quan- tity to be determined by the effects, as already insisted upon. The- administration of the opium is to be continued until the bowels are moved spontaneously, or until the inflammatory action — the fever and local tenderness — subsides. The effects may be maintained for several days, for a "week or more. As soon as the tenderness subsides, the saline laxative may be then given, in the cautious way already advised — a teaspoonful of Epsom salts in two ounces of water every three hours. With the subsidence of the local tenderness and heat, the quantity of opium can be slowly reduced and the interval between the doses lengthened. If the vomiting be pei'sistent, it may be relieved by milk and lime-water (three parts to one), carbolic acid (gr. ss. in cherry-laurel water), hydrocyanic acid (tti iij), iced champagne, pellets of ice, etc., but when the hypodermic injection is practiced vomiting is a much less pronounced symptom. In robust subjects, in all cases, not characterized by great debility, leeches should be applied at the seat of tenderness, and in numbers according to the state of the patient — from two to ten to be allowed to fill and drop off, and the bleeding be then arrested. Good effects are obtained from coiinter-irritation by mustard, followed by fomentations of turjDentine, or turpentine stupes, and hot poultices, "when heat applications are useful. According to the author's observation in these cases, the external application of ice — in the form of an ice-bag — is more efficient than warm applications. In the severe cases of typhlitis, when the time has arrived for attempts to remove the impaction, the action of the saline laxative may be aided by irrigation of the bowel. It is now known that by this method the bowel may be filled with fluid up to the ileo-cascal valve. Accordingly, repeated efforts by enemata of warm ' soapsuds should be made to soften the masses of hardened faeces which so effectually block the canal. The use of a long rectal tube to convey the fluid beyond the sigmoid flexure facilitates the operation materially. If impaction has Y4: DISEASES OF THE DIGESTIVE SYSTEM. existed for several days, care must be used in distending the bowel, for it may yield to tbe pressure, softened it may be by an inflammatory process involving all tbe layers. INFLAMMATION OF THE APPENDIX VERMIFORMIS. — The usual cause of inflammation of the appendix is the lodgment of an intestinal concretion, grape-seed, or other foreign body.* Cases of inflammation, apparently catarrhal, do, however, rarely occur, and very serious symptoms quickly arise by extension of the disease to the peri- toneal layer. The symptoms are the same as those of the severe form of typhlitis, with some important exceptions to be presently detailed. The appendix differs from the csecum in that it has an entire perito- neal investment, and in that it is free except its point of connection with the caecum. In some subjects the appendix is two inches in length, and hence dips down into the iliac region to the pelvis, and reaches almost or quite to the bladder. When, therefore, an inflam- matory process occurs in it, the tenderness and pain are felt in the iliac region as low down as Poupart's ligament, and not in the csecum. When typhlitis exists, the aj^pendix becomes involved, but death may and does frequently follow from disease of the appendix, without the caecum being implicated. When, therefore, this form of typhlitis occurs, besides the symptoms abeacly set forth, there is pain in the groin, extending down the course of the anterior crural, and through the hip. The tenderness is usually exquisite, and the slightest attempt at palpation gives the patient great dread. The thigh is flexed on the pelvis, and all attempts to extend it cause great suffering. There is no fecal tumor such as is found in typhlitis with impaction, and the bowels are not affected, but all intestinal movements, as the passing of gas through the ilio-caecal valve, cause pain. Peritonitis, much more readily than in affections of the caecum, occurs in inflammation of the appendix. It is often entirely local, adhesions form, and the morbid action is cut off from the general cavity of the abdomen. This is one of the modes by which fecal abscesses are formed. This subject and peritonitis are properly topics for future consideration. PERITYPHLITIS.— As the term indicates, this is an inflammation of the tissue about the csecum — really, of the connective tissue in which the csecum is in part imbedded. This may arise spontaneously — an inflammation of the connective tissue — ^by the ordinary causes of such inflammation, especially trauma. It may be caused by the extension of inflammation from the caecum, by perforation of the caecum. Its special tendency is to suppuration. When well developed there is a * See cases reported by the author in his paper on typhlitis, in the " American Jour- nal of Medical Sciences," October, 1866, p. 351. PROCTITIS. Y5 hard, brawny swelling felt above the crest of the ilium, extending back into the lumbar region. There is not usually acute pain, but a feeling of weight, soreness, with paroxysms of subacute pain, extend- ing into the hip, thigh, and abdomen. There is no necessary interfer- ence with the bowel, unless typhlitis and perityphlitis coexist. The development of the swelling is comparatively slow, but it attains con- siderable dimensions. Suppuration is preceded by an increase of the local distress ; when it has actually taken place, the tension and throb- bing diminish for a time, to increase again as the pus nears the sur- face. The formation of matter is attended by the usual constitutional symptoms. The treatment of perityphlitis is the same as that of typhlitis, except as regards the special attention given to the bowels, and entirely the same if the two maladies coexist. When pus forms in perityphlitis, and when a sero-purulent collection is formed by a limiting inflamma- tion, in inflammiation or perforation of the appendix, there arises the surgical question of an operation for the evacuation of the matter. By the use of the aspirator, the question of suppuration may be early de- termined. It is no doubt sound practice to pursue the method of Buck, and procure the evacuation of pus by a sufiicient opening for free drainage.* CATARRH OF THE RECTUM.— PROCTITIS AND PERIPROCTITIS. Definition. — Catarrh of the rectum is known as proctitis. In the mild form it is the simplest kind of dysentery. In the severe form, as in the caecum, there may be impaction of the colon at and above the sigmoid flexure. The two forms correspond to the same conditions in the caecum. The analogy becomes the more complete by reason of periproctitis — an inflammation of the connective tissue about the rectum. Causes. — Proctitis arises chiefly from constipation. Prolonged retention of hardened fseces sets up an irritation for their expulsion. It is also caused by cold and dampness combined, especially sitting on the ground while in a perspiring state. Distention of the hsemor- rhoidal vessels, by obstructive disease of the liver, as in cirrhosis, is an occasional cause, but the disease then is quite masked by the more important results of the cirrhosis. The habitual use of stimulating enemata and of aloetic purgatives is a fruitful source of proctitis. Pathological Anatomy. — The alterations of structure are the same as those already described. Symptoms. — There are an acute and chronic form, the symptoms of which differ in degree merely. The acute variety exists in two forms, * " New York Medical Journal," vol. ii, p. 38. Numerous cases have been reported of some foreign body discharged by a fecal abscess. Hence, the need of a free opening. Y6 DISEASES OF THE DIGESTIVE SYSTEM. the mild and severe. In the mild form of proctitis, the patient experi- ences a sense of uneasiness in the rectum — a burning, with desire to go to stool. There is much straining, and only mucus passes. The sphincter ani is in a constant state of spasm. Immediately after the passage of some mucus, there is felt considerable burning pain, and a sensation as if something remained, so that the patient returns again and again to the close-stool, and as before passes only some mucus or mucus mixed with blood. This condition is called tenesmus. The pain radiates from the rectum to the hips and back, and a feeling of depression and anxiety, and often of nausea, accompanies it. The colon is distended above the sigmoid flexure, but only some hard, roundish masses of freces, known as scybala, descend occasionally. In the severe f onn all of these symptoms are intensified, the pain is very acute, intensely burning, and widely diffused. The straining is violent, and prolapse of the mucous membrane takes place, the sphincter ani closes over it spasmodically and the protruding portion becomes exces- sively painful, purplish, and bleeding. The mucus discharged is mixed with blood, and sometimes considerable haemorrhage occurs in conse- quence of the yielding of a vessel. The colon aboA- e is impacted with hardened faeces, and its outlines can be distinctly traced by palpation. In the severe form of proctitis there is usually some constitutional dis- turbance— ^some feverishness, headache, and general muscular soreness. The neighboring organs sympathize with the rectum. In the female, the menstrual flow may occur, and, in both male and female, strangury comes on, and with the straining at stool there is simultaneous straining at the passage of urine. The long-continued distention of the colon induces an in'itation of the mucous membrane ; a catarrhal process is set up for the expulsion of the accumulated faeces, but the muscular layer, over-distended, becomes paretic and is incapable of any energetic action ; the inflammation extends and ultimately the peritoneum be- comes involved. The progress of these structural changes is mani- fested objectively by an increasing tenderness along the track of the descending colon, and finally by an extension of the inflammation to the adjacent connective tissue, the formation of a tumor, terminating in an abscess. In the cavity of the pelvis a similar j^rocess may take place, the inflammation of the mucous membrane extending by con- tiguity to the layers of the bowel successively, and at length involving the neighboring connective tissue. The chronic form of proctitis pre- sents nearly the same features. There are usually accumulations of scybala in the sacculated periphery of the colon, but the bowels may be confined or relaxed. The relaxed stools contain a good deal of mucus, and are highly offensive by reason of the decompositions which have ensued in the descent along the colon, and the scybala are coated with mucus. Instead of ordinary mucus, the matter now discharged contains purulent elements — muco-pus — and ultimately becomes en- PROCTITIS. 77 tirely purulent in the rectum. Ulcerations ensue, sloughs separate, and hence the stools contain the debris. The nerves become somewhat accustomed to the irritation of their terminal filaments in the mucous membrane, and therefore the reflex incitement to tenesmus is much less. There are, therefore, less straining, les^ acute pain, but the stools are more unhealthy. Course, Duration, and Termination. — The mild form of catarrh of the rectum has a natural tendency to cure in from four to eight days. The bowels act freely, the colon is emptied, and the tenesmus ceases. In the more severe cases, although a spontaneous cure may result, yet there is great danger of peritonitis, or periproctitis and abscess. When the latter forms, it tends to discharge alongside the rectum, re- sulting in fistula usually, or into the vagina or neighboring organs, forming various kinds of fistulse. The duration of the severe form is determined largely by the character of the treatment. The chronic form is obstinate, and pursues a uniform course leading to extensive ulceration, sometimes perforation and peritonitis, or cicatrization and permanent encroachment on the lulnen of the bowel. Thrombosis of the inferior hsemorrhoidal veins, with subsequent formation of hepatic abscess by deposit of emboli, is a not uncommon result. These changes are all promoted by the fermentations occurring in the rec- tum, the products of which are highly irritating and offensive. Diagnosis. — The symptoms of acute proctitis are so distinctive that the diagnosis is made by them. In women, irritation of the rec- tum and tenesmus are produced by retroversion, especially of the gravid uterus. A vaginal exploration may be necessary to determine the po- sition of the womb : if the symptoms persist after the malposition is rectified, then it may be justly assumed that disease exists in the rec- tum. In women, the eversion of the rectum through the sphincter ani is so readily performed that the nature of the case may be deter- mined by ocular inspection. Exploration of the rectum may be neces- sary to differentiate between ulcer of the rectum and chronic proctitis. Many of the symptoms may be due to haemorrhoids ; an examination should be instituted whenever doubt exists. Prognosis. — A favorable termination may be predicted in every case of acute proctitis, unless implication of the peritoneum, perfora- tion, or periproctitis has occurred. When peritonitis has arisen, the prognosis is extremely unfavorable if it is general, especially if from perforation, but is less gloomy when limited by adhesions. In the suppuration which then ensues, the resources of the organism are severely tried ; in suppuration from periproctitis low down, although the strength may be much reduced, a fatal result is very rare ; but in these cases the local condition may be a mere expression of a dyscrasia, as tuberculosis, and they are to be estimated accordingly. In chronic proctitis the gravity of the case is increased by accidental and conse- Y8 DISEASES OF THE DIGESTIVE SYSTEM. quential complications. The existence of cirrhosis is unfavorable, as it keeps up a constant over-fullness of the inferior haemorrhoidal veins. Obstructive cardiac and pulmonary diseases act in the same way, though not so directly. The more changed the mucous membrane is in structure, the more extensive and deep the ulcerations, and, the greater the hypertrophy of the muscular layer, the more serious the case. A very important complication is thrombosis of an haemorrhoidal vein, with detached emboli, and subsequent multiple abscess of the liver. When this condition of things exists, the gravity of the case is vastly increased. Treatment. — Unless impaction is complete, and the peritoneal lay- er of the bowel implicated, the first duty to be done is to empty the colon of its retained fseces. It is a most serious mistake in treating acute catarrh of the rectum (dysentery), and one frequently made, to employ astringents and anodynes with a view to quiet the straining at stool. When the bowels are freely evacuated, little remains to be done in the ordinary cases. As already indicated, under similar con- ditions, there is no laxative so safe and efficient as Epsom salts. It should be given in solution with dilute sulphuric acid — 3 ij of sul- phate of magnesia and ""1 xx of dilute sulphuric acid in two ounces of water every two hours until the bowel is emptied. The straining at stool and the pain may be then promptly arrested by the hypoder- matic injection of morphia, or by enemata of tincture of opium in starch-mixture, or by opium in some form by the stomach. In the severe cases, the action of Epsom salts may be aided by irrigation of the bowel. A considerable quantity of warm water should be slowly injected, and retained as long as possible to soften the hardened faeces, and successive injections should be practiced at short intervals. These lavements are useful in allaying the excessive irritability of the mu- cous membrane. Other salines may be used, but none are so effective as the Epsom for this particular purpose. Enemata of emollients may be used instead of hot water — for example, infusion of flaxseed, of elm, of camomile, etc. — but they are really less efficient, because they are less solvent of the faeces. Various purgatives, notably castor-oil, have been used to dislodge the impacted faeces, but they do not estab- lish an outward osmotic flow to diminish congestion of the mucous membrane, which is the important action of the salines. In the severe form of proctitis, in robust subjects, and even in the weakly, leeches should be carefully applied around the margin of the anus. If there be much tenderness, an ice-bag should be applied over the descending colon, or warm fomentations, as already advised, for corresponding states. In chronic catarrh of the rectum, the diseased membrane can be reached directly, and the treatment should, therefore, be largely topical. Solutions of tannin ( 3 j — 3 iv), of fluid extracts of hydrastis and rhatany, and of other vegetable astringents, are effective local CROUPOUS OR MEMBRANOUS ENTERITIS. 79 applications if there are no solutions of continuity, but, if ulcerations exist, the most efficient topical application is nitrate -of -silver solution — four grains to a scruple, to an ounce of water. This should be in- jected through a tube carried up to the sigmoid flexure. Next to sil- ver nitrate is the sulphate of copper, but this must be used very cau- tiously. It is important in these cases to maintain a soluble state of the bowels. When constipation occurs, the congestion of the mucous membrane is increased, and vice versa. Hardened faeces irritate in passing the inflamed membrane. As fermentation, producing most unhealthy products, takes place in the rectum, morning and evening enemata of hot water should be regularly used. They give great comfort, and contribute materially to the cure. The wasting caused by chronic catan-h of the rectum demands the use of the most nutri- tious food. Cod-liver oil is highly serviceable as food and medicine. If the digestion is feeble, it should be aided by the mineral acids and pepsin, and by nux vomica. Although medicines by the stomach oc- cupy an inferior position in the treatment of this malady, excellent results are obtained from the use of minute doses of corrosive subli- mate (one fortieth grain ter in die), or arsenic (two drops of Fowler's solution tei' in die), or of sulphate of copper (one sixteenth grain ter in die). CROUPOUS OR MEMBRANOUS ENTERITIS. Deflnition. — By this term is meant an inflammation, subacute or chronic, occurring periodically, and characterized by the formation and discharge of membranous shreds or casts. Causes. — This is a disease of adult life chiefly ; it is rare in child- hood, and does not appear after forty-five. The female sex is more liable than the male ; and nervous, hysterical, and hypochondriacal subjects are more subject to it than are other types. A peculiar state of the nervous system seems necessary to its production. Membra- nous enteritis occurs by extension of the diphtheritic process down- ward, and false membrane also forms in infective dysentery, but the disease under consideration is a distinct affection. It has been attrib- uted to the ordinary causes of catarrh of the intestines — especially to irritants, as drastic purgatives, coarse food, etc. — but such agencies can act only as exciting causes. Pathological Anatomy. — Besides the exudation of diphtheria and of infective dysentery, deposits of a white or grayish-white color, flaky or membranous, and firmly adherent, have been found on the mucous membrane of the ilium and colon. Occurring first in iso- lated patches, the membrane extends laterally along the mucous folds in the small intestine, and in the colon upon the ileo-caecal valve and the folds of the sigmoid flexure (Leube). In other cases (Sir James Simpson) papular and white vesicular eruptions have been 80 DISEASES OF THE DIGESTIVE SYSTEM. found, but no flaky membrane or casts adherent to the mucous mem- brane. The membrane as passed has been carefully examined microscopi- cally and chemically by Da Costa,* whose memoir on this disease is by far the most important contribution which has been made to our knowledge of the subject. The shreds, casts, or membranous masses, consist of " a transparent, amorphous, basement substance, here and there indistinctly fibrillated, and having imbedded in it granules, free nuclei, and small, shriveled, irregular, and rather granular cells." Chemically, this material has the same reactions as mucus (Da Costa) — a fact which might a priori be expected, since this false membrane is nothing more than solidified mucus, the granules, free nuclei, and granular cells found in it being remains of mucus-cells which escaped entire destruction in the process of solidification. The mucous mem- brane of the rectum, in a case examined by Da Costa, was intensely injected. Symptoms. — The attacks are announced by a feeling of soreness and distention of the abdomen, and constipation. There is no fever, the hands and feet are cold and moist, and the general condition that of depression, in which the mind participates. Before, indeed, any local manifestations of disease, there are apt to be attacks of hysteria or hypochondriasis, and the subjects of this disease are nervous, excit- able, neuralgic. The pains have the colicky character, are felt around the umbilicus chiefly, and are exceedingly severe and depressing. They continue for a half hour, for an hour or two, and even longer, and, after a variable interval of some hours' duration, occur again. Thus, during the twenty-four hours, there may be six or more par- oxysms. The distress does not cease with the subsidence of the acute pain : a feeling of rawness and soreness remains, and the abdomen is so sensitive to pressure that peritonitis may be suspected. Very con- siderable tenesmus exists, and more or less mucus, with or without blood, is passed, as in acute catarrh of the rectum. There may be several loose evacuations a day, or the bowels may be confined. After several days of suffering, there will be discharged, with great pain and tenesmus, shreds of membrane or cylindrical casts of the bowel. Great relief is experienced. The soreness subsides, the dis- tention lessens at once, and the tenderness diminishes. The patient is left in a condition of great debility and much emaciated, for during the paroxysm there is complete anorexia, and sometimes vomiting, so that but little food is taken. The paroxysms are rarely single ; in a week or two, or after several months, there is a renewal of the same experiences. In one of the author's cases there were paroxysms sev- eral times a week for three weeks, the patient passing an almost in- * "The American Journal of the Medical Sciences," October, 1871, p. 321, et seq. CROUPOUS OR MEMBRANOUS ENTERITIS. 81 credible quantity of false membrane. The same woman, in an attack three years before, had a succession of paroxysms for six weeks, and was so reduced that her life was despaired of. During the interval of three years there were no paroxysms, but she suffered from constant troubles of digestion. In the cases related by Da Costa, disorders of digestion continued and were very persistent. Acidity, ulcers of the moiith, red, tender, and coated tongue, were marked features. Disorders of the nervous system, also, were very pronounced. Hys- teria, hypochondriasis, headache, impaired memory, and defects of the special senses, are mentioned by Da Costa in the first rank as symptoms. In women, too, the menstruation was deranged, and various diseases of the sexual system were present. In one of the author's cases membranous dysmenorrhcea had existed for some years. As regards the intestinal symptoms, including the pas- sage of pseudo-membrane, variations from the description above given have been noted. The pain may continue during the interval between the paroxysms, although it is much less severe, and the membrane may be present in all the discharges occurring during months or years. Course, Duration, and Termination. — The course of membranous enteritis is irregular, and the duration indefinite. It may occur in paroxysms of a very acute character in quick succession, lasting two or three weeks or more, and followed by an interval of comparative health, to be succeeded after months or years by the same succession of symptoms. Or the cases may be less acute, and continue for months or even years. Diagnosis, — The distinction is to be made between membranous enteritis, dysentery, and tape-worm. The passage of shreds and casts of false membrane separates this malady from dysentery, unless there occurs separation or desquamation of the epithelium in the latter, when the aid of the microscope must be invoked. The smallest shreds of false membrane may be confounded with the strobila of a tape- worm colony, but, as the latter has a perfectly well-defined structure, and has the power of independent movement for a short time, only ignorance could possibly hesitate. Treatment. — The suffering which attends this malady requires re- lief, and the preparations of opium must be used. The most effective anodyne treatment is the hypodermatic injection of morphia. Next to this are enemata of starch and laudanum. No specific treatment has been proposed, and only symptoms are to be prescribed for. In the author's experience, minute doses of corrosive sublimate, of cop- per sulphate, and of arsenic persistently used, are the most effective remedies for the more chronic cases ; for the acute, an emulsion of almond-oil and turpentine, or of castor-oil and turpentine when there is constipation. The author has had good results from tincture of 6 82 DISEASES OF THE DIGESTIVE SYSTEM. nux vomica, and tincture of physostigma, fifteen to twenty drops of each ter in die, for the subacute and chronic cases. DYSENTERY. Definition. — In common language dysentery is known as " flux " ; sometimes as " bloody flux " ; in technical, as ulcerative colitis. It is a disease characterized by tormina, tenesmus, mucus, and mucus-and- blood stools, burning pain, with more or less constitutional disturbance. It occurs in the sporadic, endemic, or epidemic form, and in the latter seems to be propagated by a specific virus. Causes. — It occurs in both sexes and at all ages. Sudden arrest of perspiration by exposure to cold, and especially to cold and dampness combined, is one of the most common causes. Climatic influences are very important factors in its production. It is a disease of those parts of the year in which the change of temperature from night to day is greatest, as in the later summer and autumn, and in warm rather than in cold climates. It is especially prevalent in malarious regions, doubt- less because of the congestion of the portal circulation induced by paroxysms of ague. Agents, whether of food or medicine, producing irritation of the mucous membrane, may cause a dysenteric attack. Is there a specific virus ? Although during the existence of an epidemic the mode of propagation would indicate the existence of a specific in- fective material, yet it is probable that this is nothing more than the dysenteric discharges themselves acquiring increased virulence by the aggregation of numbers of sick under unfavorable hygienic conditions. The dysenteric excreta undergo certain fermentative changes, probably, by which their infective property receives additional strength. They are admitted to the ground-water, in the dried state ; finely divided they are distributed by the air, and in many ways, by the atmosphere, food, and drink, they reach the intestinal canal of man, and there induce the characteristic disturbances and structural alterations of dysentery. As an epidemic, dysentery is a prevalent disease in armies, in jails, in tenement-houses — wherever, indeed, numbers of human beings are crowded together under unfavorable hygienic conditions. Indeed, it seems almost certain that ileo-colitis and ulcerative colitis may be induced by the emanations from fecal accumulations, and by the gaseous products of animal decomposition. Unlike contagious and infective diseases, one attack of dysentery does not confer immunity ; in fact, the tendency is increased with the number of attacks. Pathological Anatomy. — The structural alterations of dysentery may be comprehended in two groups, catarrhal or sero-purulent, and croupous or fibrinous. The first step in the series of changes occurring in the catarrhal form is an intense hyperemia, the mucous membrane being of a deep DYSENTERY. 83 reddish color, with here and there blackish points. The redness is not universal, but at the summits of the mucous folds. This congestion is not limited to the mucous, but extends also to the submucous connec- tive tissue. As a result of this congestion there is over-production of mucus, which is found adherent, but not closely, to the membrane, and the follicles enlarge from an accumulation of their contents, while just around them is a girdle of enlarged vessels. The submucous tissue thickens greatly, and is infiltrated with serum, and this infiltration extends to the muscular layer. Softening of the mucous membrane now ensues, and undergoes disintegration and gradual detachment, leaving still adherent here and there portions of membrane with ragged edges, and a coating of fibrinous pellicle, still in place. The follicles resist the destruction from softening longer than other portions of the mem brane, but finally they slough out. The disintegration of the mucous membrane is the result of an enormous multiplication of pus-cells within the interstices ; the pressure is increased by the swollen vessels, and rapid necrosis (softening) ensues. Recovery readily takes place in the cases of catarrhal inflammation before the softening begins, and after softening if the destruction is not extensive. Repair is effected by cicatrices, which are much smoother, and, of course, devoid of the gland-structures, and are therefore easily recognized. In the fibrinous or diphtheritic dysentery the alterations of structure are very differ- ent. The initial • change, as in the catarrhal form, is an extensive hyperasmia, but, instead of being confined to the summits of the folds, (valvulae conniventes of the small intestines, and the folds from con- traction of the muscular layer in the large) there is a universal deep, bluish-red congestion of the lower end of the ilium, and the whole of the colon. Extensive extravasations of blood infiltrate the whole tis- sue of the mucous membrane, but it is especially invaded and trans- formed by a fibrinous exudation. The proper structure of the mucous membrane disappears entirely, except remains of the tubular glands, and it presents internally a reddish-white surface, variegated with ir- regular blackish and reddish figures. The result of these changes is to convert the membrane into a dense, parchment-like, and rather un- yielding tissue, composed largely of the deposited fibrin. If death do not take place when the alterations of the mucous membrane have reached this point, gangrene ensues. Although the ultimate changes in the two forms of dysentery are so distinct, yet in most cases the alterations found post mortem are made up of both forms, the catarrhal and fibrinous. Those parts of the intestinal wall affected by the fibri- nous inflammation are thicker and more prominent than those attacked by the catarrhal. Hence the surface is uneven, the fibrinous parts dark from the presence of extravasated blood, or reddish- white where the fibrin predominates. Local gangrene patches appear, in size from a copper cent to a silver dollar ; the membrane disintegrates and is de- 84 DISEASES OF THE DIGESTIVE SYSTEM, tached in considerable sloughs, leaving a deep excavation, which extends deeper by succeeding necrosis to the peritoneum. The purulent infil- tration in those parts, the seat of catarrhal inflammation, also leads to extensive destruction of the submucous layer and large excavations beneath the mucous membrane, which is either detached as a whole, or in turn yields to necrosis. These more superficial catarrhal exca- vations contrast strongly with the dark-red or blackish sloughs of the fibrinous. The extent to which the intestine is involved varies greatly. The rectum, the caecum, or the sigmoid flexure, may be alone involved ; the whole of the large intestine, the disease beginning below and ex- tending upward, may be invaded. Repair is possible only when a small extent of the mucous membrane has been destroyed by gangrene. When the morbid process is arrested, the sloughs separate, granula- tions spring up, and the excavations are closed by cicatrices, which by subsequent contraction may seriously encroach on the lumen of the bowel. The structural alterations are not limited to the mucous, sub- mucous and muscular layers. When the ulcers reach the peritoneum, this membrane becomes cloudy, then intensely injected, and fibrinous exudation forms and adhesions are contracted to neighboring surfaces. When perforation ensues, a limiting inflammation may cut off the in; jured parts from the general cavity, and form a purulent collection, or general peritonitis may ensue if the shock does not terminate the history of the case. The mesenteric glands are enlarged, hypersemic, and softened, and often are broken down into abscesses. The liver is very commonly the seat of numerous small abscesses, from embolic obstruction of the radicles of the portal vein. The lungs present in their dependent parts the changes of hypostasis. The heart is small, flabby, and its muscular tissue more or less fatty. Symptoiris. — In the epidemic form dysentery may begin suddenly, without any preliminary symptoms, and with great violence, but in the endemic and sporadic form, and in the milder cases during epi- demics, there is usually a prodromic or preliminary stage. There is more or less catarrh of the intestines, diarrhoea, chilliness followed by feverishness, toward evening especially, and that state of general dis- comfort known as inalaise general. In the mildest cases of dysentery there is no fever, but when the symptoms are at all pronounced there is fever of a remittent type, the exacerbation occurring toward evening. The type of the fever is, of course, determined by the extent of the local lesions. When actual dysentei'ic symptoms come on, which happens in two or three days after the first of the prodromic period, very decided ab- dominal pain is felt along the course of the descending colon and about the sigmoid flexure, and is increased by pressure at these points. These DYSENTERY, 85 abdominal pains, felt also somewhat about the umbilicus, are de- scribed by the term tormina — " colicky pains." There is pain of a burning character in the rectum, but especially a sense of the presence of a foreign body, with the desire to strain for its expulsion. The patient resorts again and again to the close-stools, and makes strong efforts at expulsion, but instead of any fseces being discharged he only brings away some jelly-like matter — mucus — either alone or tinged with blood, and occasionally a hard ball of faeces {scybala), but without any relief. The feeling of bearing down {tenesmus) and the burning pain felt in the rectum and through the hips continue as before, so that he finds it impossible to quit the stool, or returns every few minutes, and each time he sinks back to bed exhausted and unrelieved. At the beginning, before the characteristic dysenteric stools appear, there are loose fecal evacuations containing mucus, voided with great pain. Pres- ently, however, faeces are no longer present in the evacuations ; they consist of a grayish, tough, transparent mucus in pellets or small masses, containing here and there whitish granules, which have been likened to grains of sago. On the second or third day, blood appears in the stools, and the debris of epithelium are mixed with the mucus. In the mildest cases, the course of the disease is ended with these manifestations. These do not differ from the mildest cases seen during the existence of an epidemic ; on the other hand, the most formidable, the fulminant cases, may occur sporadically. In the more pronounced cases, after three or four days, severer symptoms make their appearance — the amount of blood discharged increases ; not only the debris of epithe- lium, but the pellicular neo-membrane (an exudation) and necrosed parts of the mucous membrane are now to be detected in the stools. The stools have no longer any fecal odor, but are very fetid from the presence of gangrenous portions of mucous membrane. The grayish, transparent mucus gives place to a puriform fluid, and there is not only considerable admixture of blood, but a good many clots of pure blood are also discharged, and indeed a real haemorrhage may occur, A stool may consist of a bloody, purulent fluid and scybala, and the next be composed largely of an extremely fetid, brownish fluid con- taining bits of neo-membrane and masses, often of considerable size, of decomposing gangrenous sloughs of the mucous membrane. Some- times a cast of a part of the bowel, consisting of the mucous membrane in a complete cylinder, all of its parts distinct enough for recognition, will be discharged. These ought not to be confounded with the infi- nitely rarer accident of a slough of the bowel itself, several feet in length, cast off by intussusception. As has already been pointed out, in the catarrhal form of dysentery, deep-seated suppuration in the submucous layer sometimes extends widely, and the mucous membrane sloughs off before it has had time to become gangrenous. During the tormina nausea is often felt, and vomiting occasionally occurs. In the 86 DISEASES OF THE DIGESTIVE SYSTEM. severe cases, vomiting is constantly present and adds materially to the gravity. The vomited matters consist of articles of food and drink, of gastric mucus, and ultimately of biliary matters from the gall-bladder. The bladder in severe cases is also affected by tenesmus. The urine is scanty, high-colored, and very acid, and therefore irritating, and so sensitive does the bladder become that a few drops of urine present in it excite the tenesmus, and in the straining both the bladder and the rectum are simultaneously affected. The frequency of the stools repre- sents pretty nearly the gravity of the case. In the mild cases there may be ten to twenty daily ; in the severe cases forty or fifty, and in the fulminant they may reach a hundred or more. Lessened frequency is a good indication when the character is improved. The amount discharged is small unless haemorrhage occurs. Artificial distinctions based on the character of the stools have been made, but these have no practical importance. It must be obvious that a disease affecting so large a part of the intestinal mucous membrane, and of so formidable a character in itself, must quickly impair the bodily forces. Even in the mild cases considerable emaciation occurs and the return to health is slow. In the severe cases, systemic infection results from the prod- ucts of decomposition and from the gangrene, and they wear the aspect peculiar to this state. The weakness early reaches the point that the patient is unable to leave the bed ; the evacuations pass with- out his control ; the anus and neighboring parts become excoriated and bed-sores quickly form. The face wears an anxious expression and is pinched ; the skin is dry, harsh, and wrinkled ; the pulse small, quick, and feeble. With the most painstaking care the person and bedding of the patient will be fouled with the discharges and emit a horribly fetid odor. From this condition of depression the case passes into the stage of collapse, when the pulse ceases at the wrist and the heart beats very feebly, an obstinate hiccough comes on, the skin is covered with a cold sweat, the hands and feet become cold and livid ; the face is shrunken, the eyes deej)ly sunk, the voice husky. In this condition the patient usually betrays a singular apathy, although the mind re- mains clear until the failure of oxygenation of the blood causes carbonic - acid poisoning and stupor. The state of collapse may not come on in this gradual way, but the patient pass suddenly into it, by reason of per- foration of the bowel and the resulting shock followed by peritonitis. Death does not necessarily ensue immediately after the symptoms of collapse have been fully developed. The patient may remain in this low state for several days, now presenting delusive appearances of improvement, now declining. Various complications may arise during the course of dysentery. Thrombosis of the intestinal veins, or a form of phlebitis, or the absorption and deposition in the liver of some un- known morbific material, may excite inflammation and abscess of the liver. This is a common accident in tropical regions and in the interior DYSENTERY. g7 of the American Continent. Hepatic abscess is, however, more fre- quently clue to the milder than the sevei-er forms of dysentery, because of the destruction by gangrene and the rupture of vascular communi- cation, which takes place in the latter. It follows disease of the rectum much more commonly than of the colon or caecum, because of the greater abundance of large vessels in the latter and the comparative sluggishness of the blood-current. Besides abscess of the liver, puru- lent collections are sometimes found, as the author has seen, in the lymphatics at the root of the lungs and elsewhere. Peritonitis is a usual complication, not due necessarily to perforation, but the ex- tension of the ulceration to the peritoneum. Increased tenderness of the abdomen and an exacerbation of the systemic symptoms are results. Course, Duration, and Termination. — In the mild cases the disease usually begins with diarrhoea ; tormina and tenesmus are felt about the second day, when also mucus appears mixed with faeces. About the third day the more characteristic stools are seen, and the disease has attained its height on the fifth and sixth day when improvement begins, and convalescence is established about the eighth day. The signs of improvement are a diminution in the number and frequency of the stools ; the reappearance of faeces, and the disappearance first of the blood and next of the mucus. In the more severe cases the dura- tion is more protracted. The maximum in the intensity of the symp- toms continues for several days ; the state of adynamia is more serious and prolonged, and the return toward health may be by almost insen- sible gradations, lasting several days. The prodromic period in such cases will be about three days, the fully developed period will range from four days to a week, and the period of gradual improvement will last about the same time, so that the whole duration of such a case will be about three weeks, while the convalescence will require a month for full restoration to health. The termination may be in partial recovery, or in chronic dysentery. When this is the case, the more severe symptoms subside, the stools improve in character, but they never become entirely healthy, and the general condition is more favorable. Xow fecal stools, with only a little mucus and blood, are passed, but these may be succeeded by evacuations entirely of pus and blood. With this varying fortune the case may proceed for months, even years, the patient in a feeble state, emaciated, and yet able to keep out of bed, or so reduced as to be unable to sit up except for a little while every day. The prolonged suppuration in these cases in- duces amyloid degeneration of the liver, spleen, and kidneys, the ulti- mate result being anasarca and albuminuria. Another mode of partial recovery is narrowing, contraction, and deformation of the bowels, the effect of which is to impair assimilation and nutrition, so that after a period of improvement a progressive loss 88 DISEASES OF THE DIGESTIVE SYSTEM. of flesh and strength is observed, and ultimately death occurs by ex- haustion. Prognosis. — Opinions must be expressed with caution in the early stages of dysentery, for it is not then possible to estimate correctly the extent of the inflammation, nor its form. A favorable prognosis can be given in those cases which continue mild, and even in severe cases, if the signs of collapse are absent. Whenever the symptoms begin with great violence (fulminant form) a guarded prognosis is judieious. If the symptoms of collapse are persistent, especially if gangrenous sloughs appear in the stools, an unfavorable opinion must be given. In severe and protracted cases that are apparently improving, the probability of a partial recovery should not be lost sight of. Diagnosis. — The symptoms are so characteristic that a differentia- tion is rarely required, except as between simple and acute catarrh of the rectum (proctitis) and dysentery proper. The dysenteric sym.ptoms in proctitis are much less severe ; the discharges consist of mucus and muco-pus, sometimes intermixed with blood, but never the foul dis- charges of dysentery, the shreds of false membrane, the gangrenous sloughs, etc., which constitute so characteristic an evacuation. In croupous enteritis, which is as rare as dysentery is common, there are discharges of shreds of pseudo-membrane with tormina and tenesmus, but the attacks are paroxysmal, the evacuations continue the same, and the subsequent history is widely different from that of dysentery. Treatment. — As in this disease the nutrition of the body suffers severely, the right use of aliment is important from the beginning. If the stomach is irritable, milk, with one fourth lime-water, is the best food. If there is but little nausea, and especially if the digestion re- mains good, the patient can take milk, eggs, beef-juice, ice-cream, boiled custard, oyster-soups, mutton, chicken, and beef broth, and simi- lar articles, but solids and aliments generally leaving much residuum, and especially coarse articles, are highly objectionable, because they increase by friction the irritation of the inflamed membrane. Where there is much depression of the powers of life, egg-nogg (milk, egg, and brandy) may be freely given, and champagne be used to allay vomiting. Of medicinal measures, the treatment by saline laxatives is of the highest importance. Bretonneau, preceptor, and Trousseau, pupil, strongly urged the sulphates, and the author is convinced that the sul- phate of magnesia in solution with dilute sulphuric acid is entitled to the first place as a remedy. It must be given in laxative doses, and at the right time — that is, before the mucous membrane has begun the process of disintegration. It serves a triple purpose : it empties the canal of retained faeces; it lessens hypersemia by setting up an outward osmotic flow ; its after-effect is astringent and sedative. Next to the sulphate of magnesia, and by many given the first place, is ipecac. DYSENTERY. 89 The experience with this remedy, ancient and modern, is now so great that the limit of its curative power is well and accurately defined. It is applicable to the first stage of dysentery, before the mucous mem- brane is stripped off. It must be given, according to recent Indian experiences, in which the author in the main concurs, in scruple to drachm doses, every four to six hours. The effects to be derived from it are these : The first doses empty the stomach thoroughly, then a tolerance is established, and the considerable doses prescribed are car- ried quietly by the stomach, but act on the intestinal canal, produc- ing copious bilious evacuations, so characteristic as to be called " ipe- cac-stools " ; after the purgative action ceases a calmative and astrin- gent action continues. The utility of ipecacuanha ceases with the production of the characteristic stools, and very decided amelioration in the remediable cases usually follows. There is one form of dysen- tery, above all others, in which the ipecac-treatment is signallv bene- ficial — the puerperal. The author has witnessed some remarkable cures in cases of puerperal dysentery, a disease which is well known to be very dangerous to life. As regards the dose, the large quantity of a di'achm prescribed by our Indian colleagues seems unnecessary in our temperate climate. It will be rarely necessary to give more than twenty grains at a dose. It is best administered in milk. The next remedy in point of efficiency for the treatment of the first stage of dysentery is castor-oil, administered in purgative doses, for the purpose of ridding the canal of acrid and fermenting materials, and of retained fjEces, and to secure the after-quietude which succeeds to the action of a purgative. After using one of the agents of the cathartic group as above directed, what remedies are most appropriate for the treatment of that condition in which either purulent or fibrinous infiltration, or both, is taking place ? Under these circumstances an emulsion of oil (almond-oil) and turpentine is very serviceable, and combined with opium, if the pain be very severe. When destruction of the mucous membrane is beginning, the most effective remedies are corrosive sub- limate, sulphate of copper, sulphate and oxide of zinc, acetate of lead, bismuth, arsenic, etc. Of this formidable list, sulphate of copper and arsenic are most effective. They ought to be combined with opium. The author has had excellent results from the use of Fowler's solution, one drop, and deodorized tincture of opium, five to twenty drops every three hours. Sulphate of copper must be given in small doses (one twentieth of a grain) every three hours, with morphia (one eighth to one twelfth of a grain). Bismuth in large dose (3j — 3ij) every four hours is sometimes beneficial, especially if administered with car- bolic acid. Numerous vegetable astringents, OT^dng their therapeuti- cal power to the tannic acid which they contain, have been much em- ployed, with more or less advantage, but they are not equal to the mineral astringents. Applications to the rectum and colon are un- 90 DISEASES OF THE DIGESTIVE SYSTEM. questionably useful. By the method of irrigation the whole of the colon may be safely reached. Excellent results are obtained by wash- ing out the bowels with warm water (100° to IDS'" Fahr.). The patient is placed on his right side, the thighs Avell flexed on the pelvis, the hips elevated and brought to the margin of the bed, the chest and head on a lower level. The anal tube is inserted two or three inches, and the reservoir is placed at a suflicient height to insure the passage of the water. Various demulcent applications may also be made in this way. Very great relief is afforded by the injections of starch and laudanum after an evacuation, or especially after irrigation and washing out the bowels. Much emphasis should be put on the employment of nitrate of silver enemata. They possess a high degree of utility if efficiently performed. A tube which is not acted on by the silver salt should be passed carefully uj) to the sigmoid flexure, and about eight ounces of a strong solution of silver nitrate (3j — 3j to the ounce) should be thrown up. The time for performing this is after sufficient quiet has been obtained by the hypodermatic injection of morphia. So rapidly is the insoluble chloride of silver formed that no ill results can follow the strongest solution employed for this purj)ose ; but, if there be any reason to apprehend mischief, a solution of common salt may be inject- ed immediately after the silver. If the injections are, for any reason, inadmissible, suj)230sitories of cacao-butter containing morphia, morjDhia and tannin, morphia or opium, and acetate of lead, etc, can be used instead. Lately injections and suppositories of fluid extract of ergot, and of ergotin, have been used, and apparently with good results, Ergotin has been given in- ternally, and, in some epidemics, with an apparent utility, which the physiological effects will hardly warrant. It is difficult to understand how it can accomplish anything when in the catarrhal inflammation the mucous membrane is infiltrated with pus, and in the croupous with fibrin. After the use of the saline laxative, or the ipecac, the morbid process continuing, is there no means of securing that quietude of the intestine which will permit the mineral astringent to act on the diseased surface? The author believes that we possess such an agent in the hypodermatic injection of morphia. He therefore urges, from the point of view of personal exi^erience, this means of treatment. Besides giving the remedies an opportunity to act on the diseased surface, the morphia injections suspend that violent reflex peristalsis which does so much injury to the diseased mucous membrane. External ajaplica- tions, if not curative, are grateful. The cold wet pack, the ice-bag, and other cold applications, are sometimes preferred ; but generally warm — rather hot — applications afford more relief. The turpentine stupe is generally more useful than other warm applications. With the be- ginning of the symptoms of collapse, active stimulation may be neces- sary. The best form of stimulant is cognac brandy, as it is at the ULCERS OF THE INTESTINES. 91 same time astringent. Beef -juice and brandy, milk and brandy, and egg-nogg, are combinations of food and stimulant most generally use- ful. As already indicated, the strength must be supported from the outset by suitable nutriment. It is necessary to keep the person of the patient and the bedclothing clean. The discharges should be removed from the apartment as soon as passed, and should be thoroughly disin- fected before going into the common receptacle. A strong solution of sulphate of iron is a cheap and effective agent for this purpose. Some tincture of iodine exposed in a saucer is an excellent deodorizer for the apartment of the patient. ULCERS OF THE INTESTINES. Forms. — Ulcers of the intestinal canal exist in thi-ee forms : Ulcers from mechanical irritation. Ulcers from thrombosis or embolism. Ulcers from tuberculous deposit. There are duodenal ulcers, csecal ulcers, and rectal ulcers, and an anatomical classification might, therefore, be adopted. It will be con- venient, in the description, to study these ulcers, according to their anatomical position, going from above downward. The Nature, Symptoms, and Treatment of Ulcers of the Duodenum. — The first or transverse part of the duodenum is the almost exclusive seat of the ulcer. The pathological history of this ulcer is the same as the corresponding ulcer of the stomach. The great factor in its causa- tion is thrombosis, or embolic obstruction of a vessel. An admirable instance of this accident (the embolus in position, the ulcer forming) has been reported,* confirming clinically that which had previously been demonstrated by pathological experimentation. When the blood- supply has been cut off from a part of the mucous membrane, the digestive juice, no longer opposed by the alkaline stratum beneath, dis- solves or digests the membrane, and an ulcer is formed. At first it is a round, smooth, sharply defined ulcer, but the inflammation which is lighted up cuts off the action of the gastric juice from the adjacent healthy tissues, by a deposit of new material of a granulation-tissue structure, and especially protects the bottom of the excavation ; other- wise perforation would quickly ensue in most cases. As the layers of the duodenum are invaded, not all at once, but successively, and as the distribution of the vessels is fan-shaped, it is obvious that the resulting ulcer must have shelving margins and a stratified appearance. The term " crater -like " aptly enough describes its characteristics. This description of the process by which duodenal ulcers are formed can be applicable to ulcers situated in the first part of the duodenum * Merkel, "Wiener Presse," various numbers in 1866. 92 DISEASES OF THE DIGESTIVE SYSTEM. only, for, soon after the acid contents of the stomach reach the vertical part, they hegin to have an alkaline reaction. It is in the lirst part that the ulcers are found, and they are sometimes partly in the stomach and partly in the duodenum. They are usually single, and occasionally multiple. The cause that gives origin to one may produce several (em- boli), so that it is not uncommon to find gastric and duodenal ulcers existing at the same time. As regards the relative frequency in the oc- currence of ulcers in the stomach and duodenum, respectively, they are found in the former organ thirty times more frequently than in the latter. The duodenal ulcer is found between thirty and forty years of age in a great majority of cases, and becomes very rare after sixty (Krauss).* As to sex, the preponderance is in favor of males, and is so extraordinary in proportion as fifty-eight to six. Accident in the collec- tion of cases had something to do with these figures. Besides the causes already mentioned, burns of the skin, especially of the chest and abdo- men, have induced ulceration of the duodenum. The burns must be of considerable extent to bring it about, sufficient to cause a reflex spasm of the vessels, thus permitting the gastric juice to act on the membrane. If the ulceration reaches the peritoneum adhesions may be contracted to neighboring organs, to the stomach, pancreas, gall-bladder, etc., and fistulous communications may be established ultimately between them. In the process of widening of the ulcer, a vessel may be opened and haemorrhage result, a very common symptom, occurring in one half of the cases. By perforation a local peritonitis may be set up, adhesions con- tracted, and a cavity containing sero-purulent fluid, shreds of tissue, etc., formed ; or the general cavity of the peritoneum may be entered and general peritonitis excited. When an ulcer of the duodenum heals, the puckered cicatrix which results may induce remarkable changes. Contraction of the pyloric orifice and dilatation of the stomach will be results of the cicatrization of an ulcer situated at the entrance to the duodenum ; if lower down, the lumen of the bowel will be encroached on, and dilatation occur above the contraction. An ulcer may be so situated that the pancreatic and common duct of the liver will be ob- structed with the usual results of such obstruction. Ulcers of the duo- denum situated near the pyloric orifice will be accompanied by some of the symptoms of a gastric ulcer situated at or near the pylorus. Vom- iting is a pretty nearly constant symptom, coming on several hours after eating. Tenderness to pressure, and, when the ulceration approaches the peritoneal surface, rather exquisite tenderness, is felt in the posi- tion of the duodenum. Attacks of gastralgia, of enteralgia rather, and of a severe character, occur under the same circumstances as gastralgia in stomach -ulcer. The pain is distributed through the solar plexus and the hepatic plexus also, and is of a very depressing kind, the * "Das perforirende Geschwiir im Duodenum," Berlin, 1865, p. 24. ULCERS OF THE INTESTINES. 93 action of the heart becoming exceedingly feeble, the surface cold, etc. Jaundice may also be present. When this is the case, it would be im- possible to differentiate between ulcer of the duodenum and hepatic colic. Hajniorrhage may take place by emesis or by stool. In duode- nal ulcer it may, in consequence of the size of the vessel (the ascending vena cava, for example), be so large as to cause death immediately. The blood, unless in large amount, is much changed in character by the action of the intestinal juices, as has been pointed out. The diagnosis may be aided by a study of the haemorrhage, the part discharged by vomit having the characteristics of hsematemesis, that passed by stool presenting the appropriate changes. As regards treatment of ulcer of the duodenum, the plan proposed for gastric ulcer is applicable. (See Ulcer of the Stomach.) Ulcers similar in character to the duode- nal, but due to those alterations of the vessels which occur in amyloid degeneration, are occasionally found in other parts of the small intes- tines. The symptoms are obscure, and the diagnosis a mere matter of suspicion. The patient affected with an u.lcer of this kind suffers with the changes wrought by amyloid degeneration, in the liver, kidney, spleen, and other organs. There are emaciation, pallor, cedema, diar- rhoea, etc., and there maybe soreness in a particular locality, and hem- orrhage, to indicate the nature of the intestinal disease, but obviously these are far from conclusive. The general condition is the point to which attention must be directed in these cases, yet no subject in therapeutics is more unsatisfactory than the amyloid disease. The Nature, Symptoms, and Treatment of Ulcers of the Csecum and Appendix Vermiformis. — Ulcers in these situations are usually of me- chanical origin, produced by the retention of hardened fseces, by the impaction of an intestinal or biliary calculus, or of another foreign body, such as a grape-seed, a cherry-seed, a pin, etc. These foreign bod- ies lodge more frequently in the appendix vermiformis, but they may become impacted in a fold of the mucous membrane of the csecum, espe- cially of the posterior wall, for this has a fixed position. The pressure of the foreign body excites inflammation, then softening, and finally perforation. The position of the ulcer affects the result enormously. If it perfoi'ate the posterior wall of the csecum, which is not covered by the peritoneum, the foreign body and other contents of the bowel escape into the loose connective tissue, where an inflammation ending in an abscess is set up. Then the history is that of fecal abscess. Oc- casionally a primary inflammation develops in the perica3cal connective tissue, an abscess forms, and a communication is established with the bowel. The author has had the opportunity to study a case of this kind which lasted two years, and at the autopsy a large pus-cavity in the iliac fossa behind the caecum communicated with the csecum by a con- siderable orifice. As the discharges of matter through the bowel had been paroxysmal, it is probable that the original opening was small. 94 DISEASES OF THE DIGESTIVE SYSTEM. K the foreign body is lodged in the appendix, inflammation is excited, and a perforating ulcer quickly formed. In some cases the whole ap- pendix is inflamed and converted into a diffluent mass. As the ulcer extends, the peritoneum is quickly reached. One of two results must then take place : either a local peritonitis with adhesions, limiting the mischief to that locality, or a sudden rupture into the general cavity of the peritoneum. If the process is slow, the peritoneum forms adhe- sions to the neighboring surfaces ; if rapid, the time is not suflicient to accomplish the task. When a limiting inflammation is thus devel- oped, a cavity is formed, containing the matters which have escaped from the appendix, including any foreign body lodged there, fecal matters, sloughs of the ulcerated surface, serum, and pus. In a short time the process of extrusion begins, the pus makes its way downward under Poupart's ligament, along the sheath of the femoral vessels, and points in the usual situation. In two thirds of the cases the purulent collection takes this direction ; in others it points over the crest of the ilium, and posteriorly, in the lumbar region. Besides the ulcers of merely mechanical origin, the caecum is the seat of that form of ulcer known as the catarrhal — a fact which the author believes he was the first to demonstrate.* It is a fortunate circumstance that these catar- rhal ulcers, which have such a strong tendency to perforate the bowel, are usually situated on the posterior wall ; doubtless in accordance with the now well-known law that those parts most exposed to injury in the performance of their functions are also most liable to disease. In the article on " Typhlitis," the symptomatology and treatment are the same as for ulcer, and indeed there is no well-marked distinction between them clinically, except it may be the vague symptoms of ulcer which precede the perforation for an indefinite period. The rectum is also the seat of ulceration of the catarrhal type. This has already been pointed out, and its symptomatology demonstrated, but more fre- quently ulcers of the rectum have a mechanical origin, are brought on by impacted fseces, the lodgment of a fish or other bone, of seeds, etc. Perforation ensues, an abscess is formed, which points alongside the rectum, in the perineum and elsewhere, leaving troublesome "fistulre. An ulcer of the rectum, healing, may produce narrowing and deformity of the bowel, seriously impairing its functions. But these ulcers of the rectum do not heal readily, for obvious reasons — the frequent mus- cular movements, the passage of rough matters over them, the con- stant presence of irritating solids, fluids, and gases. As regards the treatment of ulcer of the rectum, there are two points — to keep the bowels soluble without frequent motions, and to make topical applications of the solid nitrate of silver. To this might be added a third — stretching the sphincter. This can be done by a * " On Typhlitis and Perityphlitis," " Amer Jour, of Med. Sci.," October, 1866, p. 351. ULCERS OF THE INTESTINES. 95 bivalve rectal speculum, working with a screw, when the parts are exposed for the applications to the surface of the ulcer. The Nature, Symptoms, and Treatment of Tuberculous Ulcers. — Ulcers of tubercular origin are not limited to any anatomical division of the intestine, but they occur most frequently in the lower end of the ilium, to which, indeed, they may be entirely confined. They may occupy the whole extent of the mucous membrane from the stom- ach to the rectum ; they may be confined to the cajcum, appendix, and colon. The deposit of miliary tubercle takes place in the follicles, which become crowded and obstructed, so that the cells undergo fatty degen- eration and atrophy. The miliary tubercle, in preparation for extru- sion, becomes caseous, softens, and carries with it the surrounding textures, thus forming an ulcer, which widens by the addition of new miliary tubercle, destined to undei'go the same process of caseation, softening, and extrusion. The situation of the ulcers has reference chiefly to the distribution of the vessels, which is transversely, and on this anatomical fact has been based a means of distinguishing between tubercular and catarrhal ulcers. This is true only of the early stage of tbe tubercle deposit, and can no longer be depended on when, as subsequently happens, the formation of the ulcers takes place longitu- dinally also. By coalescence their form is greatly altered. The exten- sion of tubercle-ulcers through the muscular layer of the bowel is very slow, and takes place chiefly along the lymphatics, ultimately reaching the peritoneum. Indeed, it is easy to trace with the naked eye the tubercle-masses crowding the lymph-vessels and the lymph-spaces adjacent. Deposits then cloud the peritoneum, a i^atchy exudation forms, and adhesions connect the neighboring serous surfaces, and so usual is this result that perforation by a tubercle -ulcer is rather un- common. Tuberculosis of the intestinal mucous membrane is a local manifestation of a general state ; hence, when these ulcers exist in the intestines, tubercular deposits will be found elsewhere. The most char- acteristic symptom of tubercular ulcerations is an obstinate diarrhoea, wbich resists every means of treatment, and is only palliated. The stools are usually yellowish, are very thin, and contain pus, small sloughs of the mucous membrane, etc., and are very fetid in odor. Colicky pains attend them, and tenesmus also, when, as is frequently the case, the rectum is involved. The stools contain also small, whit- ish lumps (sago-grains), masses of mucus extruded fi'om those spaces which had contained the follicles. Clots of blot, an admixture of pus and blood, and of liquid faeces and blood, are also contained in the evacuations. The approach of the ulcers to the peritoneal surface is recognized by the increased pain, and the tenderness to pressure at vari- ous points. The general condition of the patient is highly significant. Emaciation proceeds rapidly. The evening temperature is high (103' 9f) DISEASES OF THE DIGESTIVE SYSTEM. -105° Fahr.), and the fever is distinctly septicsemic in type. There is, at the same time, pulmonary mischief going on, as a rule, in these cases. Investigation will disclose the fact that an hereditary tendency exists. The treatment consists in the use of opium and astringents, vegetable and mineral. In the course of treatment of an ordinary case, all the resources of the materia medica in remedies of this kind will be exhausted. Under the heading of " Intestinal Catarrh " will be found some remarks on treatment equally applicable in this malady, CANCER OF THE INTESTINES. Forms and Site. — The three forms — scirrhus, medullary, and col- loid — which affect the stomach, occur also in the intestines. As has been stated already in regard to cancer of the stomach, the origin of the neoplasm is epithelial, and the initial change (always, however, preceded by a pronounced local hypersemia) is a proliferation of the cells of the follicles. The new cells extend downward and develop in greatest abundance in the submucous layer. The growth takes an annular direction, and in the contraction, which always results, the lumen of the bowel is encroached on and stenosis produced. As is always the case, those parts of the bowel most active functionally, and in a situation to be most readily injured in the performance of their functions, are most apt to be the seat of cancer ; the rectum, the cae- cum, and the flexures of the colon, are these parts. Cancer of the intestine is usually primary. It is a disease of ad- vanced life (after forty), although the soft variety, the medullary, may occur at any age. Symptoms. — There are three symptoms which have a high degree of significance : pain in a fixed situation ; a gradually develoiDiug ca- chexia ; the i^resence of a tumor. Until these symptoms appear, the diagnosis will be largely conjectural. The pain is at first a mere vague uneasiness ; gradually a sensation of soreness with some tenderness to pressure is developed, and finally there are two kinds of pain — a dull, heavy, tensive soreness, and acute, sharp, lightning-like pains. The pain may radiate somewhat from a center, but the most important characteristic of the cancer-pain is its fixed position. From the mo- ment pain is felt in a part the patient declines in strength and weight, and experiences a feeling of fatigue quite irrespective of any exertion. The complexion slowly changes, until ultimately the fawn-color be- comes well marked. The lips are then bluish white, the surface dry and scurfy, the skin wrinkled, the hair dry and dead-like. In cancer of the stomach and intestines the patients usually suffer from a profuse salivary flow without apparent cause. Sometimes just above the clavi- cle may be felt enlarged lymphatic glands. When the emaciation has removed the fat from the abdomen, a tumor can be felt. Although CANCER OF THE INTESTINES. 97 cancer may form anywhere, it is at certain points wliere we may ex- pect to detect a tumor — the points of election ah-eacly mentioned. In six cases of cancer of the intestinal canal, observed by the author with special reference to this account of the disease, there were two of the rectum, two of the csecum, one at the sigmoid flexure, and one at the angle of the transverse and descending colon. If the tumor is scirrhus, it is felt as a hard, nodular mass ; if encephaloid, an irregular growth, partly hard and partly elastic ; if colloid, a more diffused, less irregu- lar and softer mass, not well defined. Very great mistakes are made as to the size of a tumor, or indeed as to its presence, in cases of can- cer. As the stenosis increases, accumulations take place behind the point of narrowing, and then hard lumps of faeces may easily be con- founded with a nodular tumor. Subsequently the passage of the faeces will give a very different impression, and the real tumor may be detected with difficulty or not at all. The author has observed this state of things in cancer of the caecum and of the flexures. The symp- tomatology of intestinal cancer varies with the site of the neoplasm. When situated at the ciecum, pain is felt in the right iliac fossa ; there the tumor may be detected, and there the patient experiences the sen- sations due to the passage of gas and faeces through a narrowed orifice. Large accumulations of lumps of fgeces and gas may occur at times, presenting the appearance of a large tumor, and may disappear spon- taneously in a day or two, or be made to disappear by gentle pressure and friction, when they pass through the orifice with a sensation of burning pain to the patient and with gurgling quite audible to those around. The same phenomena occur at the flexures when cancer is developing. In the rectum there is severe, burning pain, of a most agonizing kind, whenever the bowels are moved, or indeed in sitting or standing long, and pains radiate through the hips, thighs, and testes. Usually tenesmus is present, and a constant desire to go to stool, when every attempt at defecation causes unendurable pain, so that the patient, if possible, postpones the painful act as long as he can. The exploration of the rectum by the finger will furnish valuable information : hard nodules will be encountered, and masses may be detached from the ulcerating surface for microscopic examination. In one case the author found protrusion of the rectum, and cancer-masses projecting through the anus, while the surrounding tissue (the rectal fossae) were covered over with enlarged veins and filled with nodes of stony hardness. The least attempt at exploration caused intolerable anguish, and the passage of faeces was accomplished by no less suffer- ing. The stools at first only indicate, if they are solid, that they were forced through a narrowed orifice ; they may be loose or constipated. In the progress of the cases, mucus, muco-pus, pus and blood, foul- smelling gangrenous masses, and parts of the neoplasm, successively appear and mark the stages in the growth of the cancer, With the 7 98 DISEASES OF THE DIGESTIVE SYSTEM. increasing stenosis the bowels are less completely emptied ; great accu- mulations finally take place ; and, ultimately, death may he brought about by the protracted constipation. When cancer is situated in the first part of the duodenum, it will finally be accompanied by jaundice and the symptoms of gastric cancer at the pylorus, so that it will be impossible to diagnosticate its position correctly — a failure of little moment. Rupture of the intestine may be caused by an extension of the growth to the peritoneum. Course, Duration, and Termination. — Cancer goes on steadily to a fatal termination, with now and then some delusive ajapearances of improvement. The course and duration vary somewhat with age, powers of resistance, and situation of the neoplasm. Cancer of the colon, unless it develops in a way to cause obstruction of the bowel at an early period, is not so quickly fatal as cancer of the csecum. Can- cer of the duodenum interferes so much with digestion and assimila- tion, and with the hepatic functions, that it causes death by exhaustion comparatively early, A severe haemorrhage from cancer in any sit- uation may determine a fatal result. The duration varies according to the mode of termination ; from one to three years may be regarded as the range. The termination may be by haemorrhage, by perforation and peritonitis, by exhaustion, or by an intercurrent disease — as pneu- monia, pleuritis, pericarditis, etc. Diagnosis. — When there is no pain, but a feeling of uneasiness, no tumor has formed, no cachexia developed, a diagnosis will be impos- sible. From catarrh and ulcer of the intestines, cancer is to be differ- entiated by the age of the subject, the presence of a tumor, and the gradual appearance of a cachexia. The tumor of cancer may be con- founded with floating kidney, aneurism, fecal accumulations, and other growths. Floating kidney is a movable tumor, felt in different posi- tions, in which there may be occasional bowel attacks but no persistent disease, and there is no cachexia. Aneurism is a pulsating tumor, with an expansile movement, and the pulsation in one or both f emorals is retarded by it and altered in character. An apparent pulsation is im- parted to a cancer of the colon by lying over the aorta ; but, if moved away by external palpation, or by a change in the position of the patient, the pulsation ceases, and at no time are the f emorals affected. A cancer of the crecum and of the sigmoid flexure may also come into relation to aneurism of the iliac arteries. The same rules apply as above given. A fecal tumor with colic may cause the merely local symptoms of cancer ; but the history of the case, it may be the age of the subject, will decide, and the cachexia will be wanting. The use of purgatives will settle the question. Prognosis. — No means are now known by which cancer can be INTESTINAL HEMORRHAGE. 99 arrested in its course, much less cured, so that the prognosis is entirely unfavorable. Treatment. — Although there are no curative measures to be under- taken, much can be done to alleviate the distresses of the unfortunate subjects. The most easily digested food, and the varieties which can be utilized by the digestive organs without leaving any residuum, should be directed. The bowels should be kept in a soluble state to prevent accumulations, and to avoid friction of the hardened faeces on an irritable surface. To relieve the pain anodynes become necessary, but the physician must carefully guard their administration, owing to the enormous quantity which the patient will use if left to his own inclination. The author must repeat the statement which he has already made in regard to the utility of arsenic in cancer to relieve pain and retard the growth. INTESTINAL H.E3MORRHAGE. Causes, Symptoms, and Diagnosis. — The subject of gastric hgemor- rhage, which has been fully treated, is occupied with the same ques- tions, except the difference in position, as intestinal haemorrhage ; and therefore only a comprehensive but concise statement is necessary here. Haemorrhage from the intestines arises from all those morbid states which increase the blood-pressure in the portal system — as obstructive diseases of the heart and great vessels, of the lungs, and of the liver, especially ; from rupture of the vessels themselves occurring in the various kinds of ulceration of the mucous membranes, and from mor- bid states of the blood itself, as purpura, etc. The symptoms produced by an intestinal haemorrhage will vary with the immediate cause, with the amount of blood lost, and with the condition of the patient at the time. If considerable, the face becomes deadly pale, the eyes glassy ; there is a rushing and roaring in the ears ; the pulse becomes weak, or ceases at the wrist ; consciousness is lost, and a convulsive shudder passes through the muscular system, and death may ensue, without any escape of blood externally : or there may be mere faintness, and con- sciousness not lost ; a sudden and irresistible desire to have an evacu- ation of the bowels is felt, and blood in clots and partly fluid, or a blackish, semifluid, tarry mixture may be passed. When the haemor- rhage is from the descending colon, the blood discharged — if passed immediately — is unaffected by the intestinal juices, but, if it come from a point high up in the small intestines, it will appear as an homogeneous, tarry fluid, but may, of course, be mixed with faeces. When the blood escapes in small quantity, and slowly, there will not be any systemic evidences of the loss, except a slowly developing anaemia, and the ap- pearance of the blood in the stools will take place in the form already described. When the blood escapes from the rectum it may be passed 100 DISEASES OF THE DIGESTIVE SYSTEM. before, with, or after the fseces, which may be covered with blood, but are not mixed with it. The rectum offers great facility for the deter- mination of the source of the htemorrhage, and an examination will show whether the bleeding is from hsemorrhoids or from an ulcerated surface. "When an ulcer of the rectum exists, the passage of the faeces will cause some blood to flow, which will often be found on the top of the faeces, together with some pus. The importance of intestinal haemorrhage will depend, first, on the nature of the malady which is its cause ; and, second, on the amount of blood lost. If typhoid, or cancer, for example, the importance of the haemorrhage — unless itself sufficient to cause death — is merged comj^letely in the importance of the malady associated with it. Treatment. — In the remedial management of intestinal haemorrhage, the same principles and methods are applicable as were recommended in the cognate disease — gastric haemorrhage. The most absolute quiet must be maintained, mustard-plasters and ice-bags applied to the abdo- men, ergotin injected subcutaneously, alum-whey drunk freely. If time is afforded, the usual iron styptics can be administered by the stomach, or if the source of the haemorrhage is low down they can be administered more efficiently by the method of irrigation or by ene- mata. The author has known of an instance of fatal haemorrhage induced by an injection of a solution of Monsel's salt, given to arrest a haemorrhage — caution is therefore necessary. An intestinal haemor- rhage is a mere symptom ; the treatment of it is necessarily a part of the disease with which it is associated. If it occur during the course of typhoid, very different management will be requisite from that necessary in purpura, or in cirrhosis, etc. Only general rules can therefore be indicated here. ENTERALGIAs NEURALGIA OF THE INTESTINES— COLIC. Deflnition. — The term enteralgia is applied to a neuralgia of the intestines, of a functional character, and is therefore a neurosis, and should be studied with the group of neuroses, but it is convenient to take it up at this ]3oint. Causes, Symptoms, and Diagnosis. — Except for the difference in site, the story of gastralgia might be repeated here. A more con- densed description than would otherwise be proper will now suffice. The causes of this affection can be comprehended in two groups : an irritable state of the nerves themselves ; irritation, by various objects, of the terminal filaments of the nerves (end-organs) in the mucous membrane of the intestinal canal. In the first group must be placed that condition of the nervous system existing in hysteria, hypo- chondriasis, and in the various cachexiae — paludal, plumbic, cupric, syphilitic, etc. ; and in the second, improper food, coarse and irritant ENTERALGIA. 101 articles, as husks of grain, seeds of fruits, etc. ; hardened faeces, im- pactions of faeces, fermentation and flatulent distention of the bowels ; cold, etc. An attack of colic may come on gradually with a feeling of uneasi- ness in the bowels, some nausea, eructations of gas, etc., or it may be- gin abruptly and develop full force at once. When it occurs by either mode, there is felt about the umbilicus a peculiarly severe and depress- ing pain, having the well-known griping quality. There are number- less gradations in the severity of the attacks, from a little griping pain felt for a few minutes, up to a seizure of such severity that the patient may appear as if collapsed. In any case of moderate severity, the suf- fering during the time the attack lasts is great — the patient groans or cries with anguish, the body is doubled up, and the lists are pressed deeply in the abdomen, or the abdomen is lain upon with the whole weight. Meanwhile the pulse is small and weak, the surface cool or cold, the face has an anxious and suffering expression, and is covered with a cold sweat. The abdomen may be hard and tympanitic or retracted, and occasionally tender, instead of pressure giving relief. The kid- neys secrete a large quantity of pale urine, and a frequent desire to micturate is usually felt. Vomiting generally occurs, and affords some relief, but an action of the bowels, which is always sought for, removes all the pain, at least for the time. Sometimes the attack terminates by a discharge of flatus, by eructation or by the bowels, and then relief is experienced. The duration of the attacks is variable — they last from a half hour to several hours, and a succession of attacks is not unusual, carry- ing the case on for several days. When the attacks are plumbic, the colic is known as dry, and obstinate constipation is a prominent symptom — the pain continuing until this is removed. The history of the individual, his occupation as a painter, and the behavior of the case itself, will indicate the nature of the attack. When it is paludal (mala- rious), the attacks will be distinctly periodical. If syphilitic, the pain will occur in the evening, and leave the patient unmolested during the day. The duration of those cases having their origin in a cachexia will depend on the treatment ; for, if the underlying morbid cause fail to be recognized, they may be prolonged indefinitely. Enteralgia may at once be distinguished from all inflammatory affections by the absence of fever, and of tenderness on pressure, and by the early termination of the seizure, leaving the status in quo. It is distinguished from gastralgia by the situation of the pain, and by the relief obtained by an escape of flatus and by an evacuation of the bowels, instead of by vomiting. It is distinguished from hepatic colic by the seat of the pain in the latter, by the tenderness over the gall- bladder, by the appearance of bile-pigment in the urine, and afterward of jaundice. It is distinguished from nephritic colic by the following 102 DISEASES or THE DIGESTIVE SYSTEM. symptoms which indicate the latter : by the pain along the course of the ureter, by the pain in and retraction of the corresponding testicle, by the strangury and bloody ui-ine, etc. The colic of gaseous accumulation is differentiated from the other forms by the fullness and tympanitic distention of the abdomen, and by the passage of gas in both directions. This is the colic of infants. The colic of fecal accumulation is recognized by the fullness of some particular part, and the occurrence of pain in the same locality, fre- quently the csecum and ascending colon, and at the sigmoid flexure. The colic of lead is aasociated with the lead-cachexia, with pallor and anaemia, with a blue line along the margin of the gum, with a slow pulse, with a retracted abdomen, etc. The enteralgia of chronic ma- larial poisoning is known by its prompt occurrence at a fixed time, as has been pointed out. The prognosis is favorable in genuine colic. Treatment. — The important point is to remove the cause which gives rise to the disturbance — if some irritant matters or fecal accu- mulation, an active purgative is indicated. The flatulent colic of infants is quickly and safely relieved by the bromide of potassium and oil of anise in an emulsion — five grains of the former and the eighth of a drop of the latter, every half hour until relieved. For the im- mediate relief there is no remedy comparable to the hypodermatic injection of morphia and atropia. By relaxing spasm, the injection favors the action of laxatives or purgatives. For the treatment of the colic of some cachexise, the appropriate remedies for the cachexia will be necessary : for example, quinia in intermittent colic, iodide of potassium in nocturnal colic, and alum in lead-colic. For the hysteri- cal colic, a combination of Hoffman's anodyne and fluid extract of valerian is effective. Enemata of asaf cetida mixture may also be used. For chronic enteralgia of the bowel — an extremely obstinate affection — arsenic, probably, stands in the front rank. The neuralgiae are, however, considered more fully in another place, to which the reader is referred. OBSTRUCTION OF THE INTESTINES. Definition. — By obstruction or occlusion of the intestines is meant an arrest of the passage of their contents, by obstacles within the bowel, or in its walls, or in the cavity of the peritoneum. When the obstruc- tion occurs in the intestine after it has passed out of the cavity — as strangulated hernia, for example — it becomes a surgical malady. A great many names have been applied to this state : ileus, iliac passion, volvulus, miserere, etc. Causes. — Obstruction or occlusion of the intestines may be pro- duced by causes that are intrinsic, or extrinsic, but they are best con- sidered in three great divisions : 1. Extrinsic, or entirely outside of the OBSTRUCTION OF THE INTESTINES. 103 3. Dis- bowel ; 2. Conditions affecting the walls of the intestines orders within the canal. 1. The extrinsic causes are tumors without compressing the intes- tine ; certain orifices in the peritoneum, as the foramen of Winslow ; bands of connective tissue, remains of former inflammation ; twisting, or torsion, of the bowel. Fio. 1.— The above, from Ziemssen's " Cyclopaedia," illustrates the modo in which torsiOD, or twisting, is effected. Fig. 2. — Con.strietionhyahand of lymph (Ziemtisen). The tumors coming into relation with the intestine, and obstruct- ing by pressure, are of various kinds : floating kidney, displaced spleen, cysts of the peritoneum, tumors of the mesentery, of the ovary, etc., and cancer in various situations. As regards the entanglement of the bowel by passing into certain orifices, especially the foramen of Wins- low, the accident is rare (three cases recorded), but a number of ex- amples have now been noted of retro-peritoneal hernia, first accurately described by Treitz.* The duodeno-jejunal flexure is embraced in a fossa formed by a fold of peritoneum, " continuous on its inner side with the peritoneum covering the transverse duodenum, and forming the inferior layer of the transverse mesocolon." Diaphragmatic her- nia is relatively more common ; Leichtenstern collected two hundred and fifty-two cases. There are certain weak points in the diaphragm — at the oesophageal foramen, just behind the sternum, the space be- tween the lumbar and costal parts of the muscle of the diaphragm — through which parts of the bowel and omentum have passed. Constriction by old bands of adhesion, the result of former inflam- mations, is much more common than the herniary protrusions. The adhesion of the appendix vermiformis to the abdominal wall, or to neighboring parts of the intestine, forms a transverse band in which a knuckle of intestine may become engaged. Similar bands, or bridges, form between the organs in the pelvic cavity, and between the mes- entery and intestine. Some of these bands, owing to changes made by the movements of organs, often quite considerable, attain to great * Dr. P. H. Pje-Smitb, "Guy's Ilospital Reports," thii'd series, vol. xvi, p. 131, " On Retro-peritoneal Hernia." 104: DISEASES OF THE DIGESTIVE SYSTEM. lengths and form constricting loops of Various kinds. Slits are found in the mesentery, especially in the mesentery of the ilium, and low down, into which a fold of the intestine may drop and become incar- cerated. The extremity of diverticula becoming attached by bands of lymph, also form openings into which the intestine may pass. There is, indeed, almost no limit to the forms and varieties of con- stricting bands for the incarceration of some part of the intestine. Occlusion may be brought about by twisting (torsion) of the bow- els. The sigmoid flexure is especially liable to this accident, owing to its shape and to congenital defects, and next the csscum ; rarely does this accident happen to any other part of the canal. In the prelimi- nary changes which occur in the sigmoid flexure preparatory to tor- sion, the mesenterial root shrinks and the two ends of the fold approxi- mate, so that twisting can easily occur if the peripheral part of the fold is full of faeces and therefore heavy. The length and weight of the fold prevent untwisting, while rapid swelling and distention by gas, occurring in that part 6f the bowel above, keep the fold in position.* While twisting of the sigmoid flexure is apt to take place in early life, torsion, or twisting, of the caecum is a malady of advanced life rather — in more than half of the cases occurring from forty-five to sixty years. Owing to the changes produced by old hernias, to the absorp- tion of fat in the mesentery, and to paresis of the muscular layer with resulting accumulation of faeces, a loop of the caecum and ascending colon forms — with a contracted mesentery — the axis of the loop ; the two ends of the loop approximate, and a twist may be readily induced by various forces, as sudden movements of the body, an abnormally long and full ilium, etc. 2. Changes occurring within the intestinal tunics, such as tumors, polypi, hj^datid cysts, carcinoma, etc., cause occlusion by a gradual obliteration of the canal. More frequently is the obstruction due to cicatrices, formed by the closure of ulcers, notably those of dysentery, of typhoid fever, of syphilis, etc. The most important of this group of causes is intussusception. By this term is meant the slipping of one part of the intestine into the adjacent part, so that the peritoneal and mucous surfaces are opposed to each other. This accident always occurs from above downward. Frequently, after death, there are found invaginations, which formed during the last moments of life, but they have no importance. Often a number of them exist at vai'i- ous points. As the part first invaginated remains at the point where it entered, it is obvious that the increase of the intussusception is by a continued * Dr. Kiittner, in St. Petersburg. Virchow's "Arcliiv," vol. xliii, p. 478, "Ueber in- iiere Incarccrationen." A full account of the subject, with admirable plates showing the mechanism of twisting. Ibid., Band liv, S. 34. Also in the same, " A Case of Internal Strangulation," by Jacob Ileiberg, with two illustrative diagrams. OBSTRUCTIOX OF THE INTESTINES. 105 slipping-up of the part below. The accident of invagination may take place at any point of the intestines, but the most common is that of the ilium into the caecum, and this attains the greatest dimensions. In children the ilium may pass into the whole length of the colon, and be felt in the rectum and even pass through the anus. Other forms are of the ilium entirely, of the jejunum into the ilium, of the duodenum into the jejunum, of the colon, etc. Of all the forms of obstruction in the intestinal canal occurring in early life, that of invagination is most usual. Including all ages, half of the cases of intussusception occur before ten. As regards sex, males are more subject to the accident than females. There are two important elements in the mechanism — pai'esis, or distention, of a part of the intestine below ; spasm, or con- traction, of the part above. When the bowel is undergoing irritation and is distended with gas, if, in consequence of the same irritation, violent reflex contraction of the circular fibers is induced, it is not dif- ficult to conceive of the suddenly narrowed portion dropping into the distended. Especially can we conceive this accident happening if the muscular layer of the enlarged portion of the bowel is in a paretic state, and the muscular layer in the narrowed part is in a tetanic or spasmodic state. A different explanation of the mechanism is made by others, especially by Leichtenstern, who affirms that there are two factors involved — a paretic condition of a part of the bowel ; violent peristaltic action. He supposes that the invagination occurs entirely by an inversion of the paretic part of the bowel, and that this inver- sion is initiated by the excited peristaltic action. The differences of opinion are not very wide, after all, and are rather in the interpretation of terms than of the pathological factors. When intussusception oc- curs at the caecum, doubtless the same causes are at work as those which induce protrusion of the bowel in dysentery — a violent tenes- mus with paresis of the muscular layer — a condition of things which may readily arise in the ilium and the caecum. When invagination has occurred, the mesentery being drawn in with the bowel and more or less stretched, the circulation is greatly impeded, especially the return of venous blood. Swelling ensues ; the tunics of the invagi- nated portion of the bowel are infiltrated with bloody serum ; an active catarrh of the mucous membrane is established ; and the peri- toneum becomes intensely hypertemic, and an abundant exudation is poured out, gluing together the contiguous portions of mucous mem- brane. In these cases there is not, necessarily, a complete occlusion — there may be still space for the passage of liquid faeces. The com- pression of the mesenteric vessels induces necrosis of the invaginated portion, which may slough off, and thus restore continuity.* It is * Trousseau, " Cliniquc iledicale," tome iii, p. 196. He has had two cases of this kind. 106 DISEASES OF THE DIGESTIVE SYSTEM. necessary to this result that the invagination be equal on all sides, that union take place in a uniform manner around the bowel. If the invagi- nation is unequal and the line of union irregular after the slough weparates, in the course of contraction of the cicatrix which subse- quently takes place, there may be produced very considerable deform- ity of the intestine, and its lumen seriously encroached upon. Again, when the slough separates, the adhesion may be insufficient, thus open- ing into the general cavity of the peritoneum. Causes of obstruction within the canal of the intestines are quite frequent — relatively more so than the extrinsic causes. First in im- portance is fecal accumulation, forming most frequently in the caecum and ascending colon, and in the descending colon just above the sig- moid flexure. Not unfrequently such fecal accumulation has for a nucleus an intestinal or biliary calculus. The intestinal calculi are composed of ammoniaco-magnesian phosphate, and the carbonate and phosphate of lime, with more or less inspissated mucus (enteroliths). Other foreign bodies accidentally present in the canal may form a nucleus about which the salts above named crystallize or adhere. They are usually oval in shape, but may have a great variety of forms, and they differ greatly in size, the average being about the size of a chest- nut. Large concretions of chalk and magnesia have formed when these substances had been taken medicinally for some time. Stones of great size have formed, alone sufficient to cause obstruction. The usual results of their presence, if they occasion symptoms, are attacks of in- testinal indigestion, colic, typhlitis, ulceration, and perforation of the csecum and appendix. Biliary calculi much more frequently occasion obstruction ; although of considerable size, they have been passed without any trouble. Sometimes, the symptoms of acute intestinal catarrh, pain, flatulence, nausea, diarrhoea, etc., are caused by them ; again, the bowels are obstructed more or less completely by one, or a succession of attacks of impaction, relief from one attack being fol- lowed in a few weeks by another attack of the same character, have been produced by a gall-stone, lodging successively in different parts of the ilium. Now and then complete obstruction has been caused by a gall-stone. They occasionally set up an ulcerative process in the caecum and appendix. An important factor in causing obstruction of the bowel is habitual constipation — that form, especially, which con- sists in a paretic condition of the muscular layer, and a state of dimin- ished sensibility of the mucous membrane. Abnormal flexures of the colon often play an important part in causing an obstinate constipa- tion. Accumulations occur to a very great extent behind the natural and factitious flexures, and in the caecum in old subjects especially, in women leading very sedentary lives, and very careless. Large accu- mulations are not incompatible with daily, even more frequent evacua- tions. The central canal may still continue open and yet enormous OBSTRUCTIOX OF THE INTESTINES. 107 masses remain in the sacculi. Finally, some large fecal masses drop into the canal, and symptoms of occlusion at once appear. Symptoms. — The cause and the seat of the occlusion affect some- what the character and development of the symptoms, but there are certain symptoms common to all forms : these are pain, arrest of the intestinal movements, gaseous distention of the bowels, and vomiting. The pain is not acute and lancinating, but is severe, colic-like, with a feeling of soreness, and is aggravated by pressure. In the beginning the pain is felt about the umbilicus, in the iliac regions, and radiates thence over the abdomen. When tenderness to pressure exists at the outset, it is indicative of the seat of the lesion, but the tenderness is rather a feeling of soreness, and has not the painful character of the tenderness which is developed later on when peritonitis appears. It is important to note that the tenderness and pain cease when collapse comes on — for the author has known this to be mistaken for improve- ment. At first, and usually after the administration of an enema, there may be an evacuation from the lower bowel, and this is often a source of misapprehension, for it is assumed that the canal is not obstructed. It may be regarded as an evidence that the obstruction is above the sigmoid flexure, but it has no higher significance than this. At the beginning of symptoms — of intussusception, for example — some liquid freces may escape, but presently the obstacle to the passage of fecal matters and of gas is complete. Even when those exceptional dis- charges, just referred to, escape, there is no improvem^ent in the feel- ings or condition of the patient ; they do not diminish the fullness and tension of the abdomen. When complete obstruction has existed twenty-four to forty-eight hours, the abdomen is no longer soft and flexible, but the muscles have become rather rigid, and the whole ab- domen is swollen and hard, returning on percussion a note of tympa- nitic quality, except where an accumulation of faeces gives a different tone. In the further progress of the case, more and more gas distend- ing the intestines, they can be distinguished as inflated, sinuous cylin- ders : the small intestines filling the umbilical space, the large in- testine, the flanks, and the lower epigastric region. ISTot unfrequent- ly the abdomen is uniformly distended, the highest point in the centre and falling off in all directions, and the walls drawn as tense as the tightened drum-head. Besides the immediate and local distress thus occasioned, the functions of the thoracic organs are interfered with by the upward pressure. The respiration is thoracic, oppressed, and hur- ried, a distressing hiccough supervenes, and the action of the heart is troubled. Vomiting is a most characteristic symj)tom under certain circumstances. It sometimes begins early, immediately after the ob- struction, and consists at flrst of aliment, then of mucus, mucus and gastric juice, mucus and bile from the gall-bladder forced up by the straining. On the other hand, vomiting may be postponed until the 108 DISEASES OF THE DIGESTIVE SYSTEM. signs of obstruction are well advanced. If vomiting persists, presently the matters returned consist not only of greenish sero-mucus, but of the contents of the lower ilium, and having a fecal odor. Indeed, dis- tinctly formed but not molded faeces have been returned by vomiting, but usually it is a yellowish fluid, having the consistence of soup, and an odor and taste sufficiently definite. The fecal vomiting recurs from time to time, and, if it well empties the intestines of their contents, the abdominal symptoms are improved ; there is much less distress, and the distention is diminished, so that the thoracic organs are not so embarrassed, but this merely local improvement does not help the case otherwise. The gravity of the case is illustrated in the systemic con- dition, which becomes rapidly bad. There is no fever, but a tempera- ture below rather than above the normal. The countenance at first expresses great anxiety, then becomes contracted and drawn, the eyes deeply sunken and surrounded with a livid circle, the nose pinched and blue, the lips blue, the tongue dry, the voice husky and sepulchral, the surface of the body generally cold and covered with a cold sweat, the skin livid and wrinkled, hiccough persisting and more and more har- assing, the breathing more shallow and rapid, the temperature declin- ing a degree or two Fahr. — such is the complexus of symptoms in the approaching collapse. Usually the mind is clear and the anxiety great, but there may be an inexplicable aj)athy, and in rare cases acute de- lirium. Toward the close, the increasing difficulty in hsematosis devel- ops carbonic-acid poisoning, and then stupor ensues. The symptoms of occlusion, due to invagination, differ somewhat from the other forms of obstruction, and must therefore receive attention. The attack usu- ally sets in suddenly as the intussusception occurs quickly, and the first symptom is violent, colic-like pain, which is followed by vomiting, the more prompt and certain the nearer the trouble is to the stomach. In children the first colic-attack is followed after a few hours by relief, which continues for several hours until a new seizure ; but in the case of adults the pain which marks the occurrence of the intussusception continues for several days, after which it is paroxysmal, there being intervals of exemption from suffering. A very troublesome diarrhoea is coincident with the invagination, from ten to twenty, or even thirty discharges occurring daily, and these soon assume a dysenteric charac- ter, owing to the intense congestion of the intestine at the point of in- vagination. This symptom has greater significance, because no other form of occlusion of the bowel presents it. The tenesmus is all the more severe when the bowel descends into the rectum, as it sometimes does in children, and with this condition may be associated involun- tary discharges of mucus and blood, because of paresis of the sphincter ani. There may be considerable variation in the raeteorism in invagi- nation — great distention occurring immediately after the accident has occurred, then subsiding as the diarrhoea goes on. A cylindrical, soft, OBSTRUCTIOX OF THE INTESTINES. 109 yet somewhat resisting tumor can often be detected on palpation, when the invaginations are in certain places : in the ciecura, transverse and descending colon, and at the sigmoid flexure. It is especially in children and in the chronic cases that these invagination tumors can be detected. There are peculiarities about these tumors which should be noted : they change in position somewhat, and in form, under the influence of peristaltic movements excited by the necessary palpation, or occurring spontaneously. In children the descent of the ilium is so very rapid that the rectum may be reached on the second day. An intussusception may induce obstruction at once, and death occurs in from three to six days, partly by exhaustion, partly by the local in- flammation. In other eases, after the immediate closure of the bowel, the canal is partly restored by a subsidence of the local congestion, or the obstruction has at no time been complete : diarrhoea of an exhaust- ing kind comes on ; gangrene of the invaginated portion takes place ; and in children death ensues from the fourth to the seventh day, but in adults the fatal result is postponed to the second, third, and fourth week, according to the acuteness of the symptoms. When, in the pro- cess of separation of the invaginated portion of the bowel already described, the discharge of the gangrenous parts takes place, it does not always occur in its entirety, but shreds and masses of various sizes are cast off, so that, indeed, the fact of such sloughs being present in the evacuations may escape detection. In the only case of invagina- tion in which the bowel itself sloughed off in its entirety, in the prac- tice of the author, the lost piece, a part of the ilium, was eight inches in length, entire as respects the presence of all the layers of the bowel, and showing the evidences of gangrene only at the line of separation. This occurred on the eighteenth day of the disease, the patient recover- ing. Again, cases of intussusception become chronic, last for months, even for a year or two, and then recovery ensues, or death takes place by gangrene, by perforation, by peritonitis, or by all of these accidents combined. Diagnosis. — The diagnosis involves the two questions — 1. Of the form of disease causing obstruction ; 2. Of the seat of the obstruction. 1. Form of Ohstrxiction. — This is usually a matter of inference ; nevertheless, there are considerations which may conduct the observer to right conclusions. Palpation and inspection of the rectum may de- termine the existence of a tumor, an enterolith, or fecal accumulation. Fecal accumulations may also be distinguished by palpation at the sigmoid flexure and at the ctecum, and the diagnosis may be aided by the history of constipation. The occurrence of previous attacks of hepatic colic, if within a reasonable period, would be a presumption in favor of obstruction caused directly by a biliary calculus, or of impac- tion, the calculus serving as a nucleus for the formation of fecal masses. If attacks of typhlitis, of pelvic peritonitis, or of peritonitis 110 DISEASES OF THE DIGESTIVE SYSTEM. in other situations have occurred before, it may be that a knuckle of intestine has been fastened by such a band. If a floating kidney or other tumor has been known to exist in a situation to compress the bowel, when sudden occlusion occurs, the cause will be at once sus- pected. 2. Seat of Obstruction. — The diagnosis of the position at which obstruction has occurred is a little less uncertain than the determina- tion of the form of disease. The distention of the abdomen — the meteorism — may furnish val- uable diagnostic indication. "When the colon at its lower part is obstructed the rectum will be empty, but the transverse and ascend- ing colon will form a prominent roll, the rest of the abdomen being relatively sunken. Ultimately the stretching of the large bowel will render the ileo-csecal orifice incompetent, and then the small intestines will be inflated and the whole abdomen swollen. When, as is so fre- quently the case, the obstruction is at the ileo-csecal valve, the whole of the large intestine will be empty, and then the flanks, and the epi- gastrium will be relatively flat and sunken, while the center of the abdomen, all around the umbilicus, will be prominent and distended. By palpation and percussion the situation of a tumor, or of a fecal accumulation, can be made out. When obstruction occurs in the jejunum or duodenum, the course downward into collapse is more rapid, the vomiting and hiccough more persistent and exhausting than when the same obstruction exists at other points. Furthermore, the abdomen is not distended, may be re- tracted even, and the vomited matters contain no faeces. The urine is scanty in obstructions high up, and plentiful when the obstacle is low down in the colon. If the symptoms have occurred suddenly, and are very acute, espe- cially if peritonitis is present, a tight strangulation is probable — behind a band, in a slit in the omentum, or beneath the attached appendix.* If acute symptoms of obstruction have set in after some violent mus- cular efforts — as jumping — the patient previously free from disease, a twist in a loop of intestine has probably taken place. Has blood passed by stool in a child who has suffered from diarrhoea, and the symptoms of occlusion have come on suddenly, intussusception is the most prob- able nature of the accident. Whenever symptoms of obstruction occur in a woman who has borne many children, or is the subject of external hernia, or in one who has had attacks of peritonitis, the existence of strangulation by bands of adhesion is very probable. f Course, Duration, and Termination. — All of these points have been more or less discussed, but some additional observations may be neces- * Bryant, " The Medical Times and Gazette," vol. i, 1872, p. 363. , f J. Hutchinson, ibid., vol. i, 1858, p. 34. OBSTRUCTION OF THE INTESTINES. HI sary. The various occlusions, even when they have existed to a partial extent for a long time, begin suddenly and with violent symptoms ; their course is rapid, and they terminate in recovery, in partial recovery, in peritonitis, with or without perforation or gangrene. Peritonitis is a common result. It is announced by greater fullness of the abdomen, increased embarrassment of breathing, more frequent vomiting and hiccough, rise of temperature, and deepening of the collapse. The duration in the average is, according to Leichtenstern, six days ; but a child may be killed by the shock of an intussusception in a few hours. They may last two or three weeks. Prognosis. — In every case of occlusion the prognosis is grave ; for, although even very unpromising cases may yield to treatment, yet the result is so usually fatal that the most guarded opinions only should be given. The prognosis is more favorable in cases of impaction by faeces than any other form of obstruction. Treatment. — Until the character of the obstruction is ascertained, no attempt should be made to procure a movement of the bowels by active purgatives or by enemata. If impaction be ascertained, the treatment already described should be put in force. If intussuscep- tion be the cause of obstruction, then certain kinds of enemata are used. Nevertheless, the rule holds good that in obstruction all violent and perturbing measures are improper. On the other hand, the utmost quietude is necessary, in respect to the movements of the patient as well as to the use of remedies. Foremost, and above all measures, stands opium, administered with the view to maintain a quiescent state of the intestinal canal, and not less for its influence over the inflam- mation and spasm which arise in the course of the various obstructions. The most effective mode of administration is by the hypodermatic injection of morphia. The quantity is measured solely by the effect produced. There should be sufficient morphia administered to quiet the i^ain, to lower the pulse, and to maintain a state of somnolence from which the patient may be easily aroused. This is accomplished in adults by one fourth of a grain of morphia and y^-o grain of atropia for the first injection, and by one eighth of a grain subsequently, and every four to six hours, according to the degree of effect. With each subsequent dose from the first, the quantity of atropia should not be greater than ^i-g of a grain, for the effect is much longer maintained than is the case with morphia. When impaction exists, the use of the opium would seem not to be indicated, since constipation is a leading factor, but even in these cases the result of its administration is much more favorable than the treatment by purgatives, which in vain are used to overcome the obstacle ; while, if the opium be persisted in, the bowels move spontaneously. Purgatives failing to remove a fecal accumulation, an invagination, or internal strangulation, increase all the dangers — of gangrene, of perforation, and of peritonitis. It is 112 DISEASES OF THE DIGESTIVE SYSTEM. greatly more efficient to give opium in the form of morphia subcuta- neously, but various preparations of the crude drug may be adminis- tered by the stomach or by the rectum, the object in view being the same. Next to the subcutaneous method, probably the most effective mode of administration is by the rectum. For stomachal use, the best preparation is the official deodorized tincture. If the meteorism be very pronounced, this increases the difficulty of relieving the invagination or the internal strangulation by maintaining an over-distention of the intestine above the point obstructed. The gas may be safely removed by puncture within a fine, long needle of the aspirator. This little operation, by removing an accumulation of gas, has permitted the reduction of strangulated hernia, which had previously resisted the most skillful taxis. Experience has abundantly shown that the distended intestines may be punctured at various points without any ill result, immediate or remote.* An intussuscep- tion through the ileo-csecal valve or an imj)action of the csecum and ascending colon may now and then be overcome by hydrostatic pressure — by filling the intestine gradually with water at 95° from a reservoir placed at a sufficient elevation. Air or gas may be used for the same purpose. A neat way to effect it is, to disengage carbonic- acid gas in the rectum by injecting first a solution of sodium bicar- bonate, and following this with a solution of tartaric acid. About a drachm of each will be required. A firm compress must be held against the anus with sufficient strength to prevent the escape of the gas. Such is the elastic force of the gas, that the intestine is distended, the ileo-csecal orifice expanded, and the intruded bowel forced back. For the success and safety of this expedient, it is essential that it be used before peritoneal exudation and adhesions have formed — before, in- deed, the intruded bowel is much swollen. If put off too long, adhe- sions, to prevent rupture into the peritoneal cavity, may be destroyed, or a softened condition of the bowel will yield before the pressure of the gas, and a rent occur. For these and other reasons, an experiment of this kind should be undertaken early. The distention of the bowel by air forced in by an ordinary pump may be used instead of gas, or tobacco-smoke may be injected, partly to act mechanically, partly as a relaxing agent. The infusion of tobacco was formerly much employed, but rarely now, as an enema to relax the muscular fiber of the intes- tine. It is a very dangerous application, and is not as effective as other means now used. Warm applications to the abdomen afford comfort, if they do not affect the course of the disease. If there be local tenderness — in the right iliac fossa, for example — an ice-bag may be placed over the pain- ful spot, and, if the temperature is elevated, leeches may be used cau- * Trousseau, " Clinique Medicalc," op. cit. INTESTINAL PARASITES. 113 tiously. Whenever, in intestinal maladies, leeches are to be applied, the anal region should be selected. As the strength of the patient is rapidly reduced, much attention should be paid to alimentation. Solid food should not be given. Milk, eggs, and meat-juice are proper. If vomiting persists, lime-water should be added to the milk. Cham- pagne and cracked ice are highly grateful to the patient, and allay vomiting. Stimulants are required as the symptoms of collapse appear. Carbolic acid in mint and cherry-laurel waters is useful to allay nausea and to remove the fetor of stercoraceous vomiting. The author is aware that many practitioners administer various agents in combina- tion with opium, partly to increase its efficacy, it is supposed, and partly on account of some virtue in the remedy. Calomel is most fre- quently so employed, and, as the author believes, to the injuiy of the patient, except when given in very minute doses to allay irritability of the stomach. The relief of internal strangulation, by surgical meth- ods, does not come within the scope of a strictly medical treatise. The reader is referred to papers by Mason and Ashhurst.* INTESTINAL PARASITES. Forms. — Only those parasites having their habitat in the intestinal canal will be considered. Trichinosis, the most important subject in helminthiasis, pertains to the class of general diseases, and will there- fore be treated of in that connection. But twenty-one of the large number of parasites infesting the human body are found in the intestinal canal, and of these only eight are peculiar to man. They are as follows : r Taenia solium, Cestoda (Tape- worms) : < Taenia saginata, I Bothriocephalus latus. 'Ascaris lumbricoides, Oxyuris vermicularis, Nematoda (Round Worms) : \ Trichocephalus dispar, Trichina spiralis, Anchylostomum duodenale. One parasite at a time is the rule— two is not an uncommon num- ber ; but Rosen f reports the case of a child four years of age in whose intestines there were ten lumbricoid worms, an innumerable quantity of oxyures, and four taeniae. According to Davaine, J children are more affected by nematoda (round worms), and adults by cestoda * " The American Journal of Medical Sciences," 1873 and 1874, vols. Ixvi and Ixviii. f " Traite des Entozoaires et des mal. Verm.," par C. Davaine. Paris, 1879. X Ibid. 114 DISEASES OF THE DIGESTIVE SYSTEM. (tape- worms), but Heller* maintains that adults are more affected by both classes of parasites. Origin. — The doctrine of spontaneous generation having received its fatal blow, it is unnecessary to discuss this theory as applied to intestinal worms. It may be regarded as settled that the ova or embryos are admitted from without and conveyed into the intestinal canal by articles of food and drink. Hence, those who handle fresh meats or eat uncooked animal food are specially liable to become hosts of parasites, f Un cleanliness is also an influential factor, and for obvi- ous reasons. General Results of the Presence of Parasites in the Intestinal Canal. — There is scarcely a symptom which has not been referred to worms. Formerly, as an etiological factor, worms had a high degree of importance ; but their influence has been less and less regarded, so that now they are almost wholly overlooked. As is usual, doubtless, the truth lies between these extremes. The presence of parasites in the intestinal canal is not incompatible with perfect health and the entire absence of symptoms. The effects produced are local and sys- temic. The local symptoms are, disorders of digestion, abdominal pains, especially around the umbilicus, and an irritation, usually an itching, around the anus ; but the chief symptom is the appearance of the worm or worms. The remote or systemic signs are very numer- ous : thirst ; salivation ; a capricious, absent, or exaggerated appetite ; emaciation ; irregular action of the heart, palpitations, or intermit- tence of the pulse ; cough, dyspnoea, laryngismus stridulus ; disorders of taste, hearing, smell, vision ; convulsions — such are the varied reflex disturbances produced by parasites in the intestinal canal. They are, however, far from usual ; indeed, they are exceptional, and not deter- mined by the size, number, character, or position of the worms, but on some special susceptibility of the affected person. CESTODA—T.EINIA— TAPE-WORMS. Varieties. — Taenia solium is the form most common in this country, taenia saginata comes next, while the bothriocei3halus latus is rare. Causes. — The development of taenia in its different phases has now been thoroughly demonstrated. Bothriocephalus latus has, however, thus far eluded research. A tape-worm reaches its final growth in the intestinal canal, from an embryo — an intermediate stage in its course of development — admitted into the canal by means of infested meat. Since the introduction of the Russian method of curing diarrhoea by the use of finely-scraped raw meat, and the modern taste of eating rare steaks, etc., tape-worm has become more common. Taenia solium * " Intestinal Parasites," Ziemssen's " Cyelopaedia." f Cobbold, "Entozoa." London, 1864, p. 232. INTESTINAL PARASITES. 115 Fig. S. — Tcenia solium, or solitary worm. a. head, or scolex ; b. tape formed of miiE}' indi- viduals, the last of which, completely "sexual, separate under the name of proglottides, and represent the adult and complete animal. Each solitary worm is a colony. — Van Beneden. Fig. T>. — Bothriocephalus latus. ff, scolex; &, the proglottides; c, the sexual organs. — Van Be- neden. Fig. 4. — a, Eostellum ; &, crown of hooks ; c. c, suckers ; 1, scolex of the tsenia solium ; 2. hooks expanded ; a, heel of the hook. — Van Beneden. Fig. 6.— Bothriocephalus latus, egg.— Van Bene- den. 116 DISEASES OF THE DIGESTIVE SYSTEM. Fig. 7. — Bothriocepha- lus latus, scolex. is derived from the embryos contained in pork, known as cysticercus cellulosics, and T. saginata, from embryos found in beef. The bothri- ocephalus is supposed to be derived from an embryo found in fish, but not correctly so, as it occurs among peoples liv- ing on the seashore and at the borders of lakes, and in the interior of continents as well. Symptoms and Results. — The small intestine is the abode of taenia, but when very long it may reach into the large intestine. The head is fixed against the mucous membrane just below the pylo- rus. The T. solium is usually solitary, but not al- ways, and a number of them may be found in one host. The immense length of the segments dis- charged often gives rise to the impression that there must be several of them to produce such a quan- tity. Although more frequent in adults, no age is exempt, and infants at the breast have been in- fested after feeding on raw beef -pulp. Dr. Armor * reports a case of taenia in an infant five days old. Women are more subject than men to taenia : in one hundred and sixty-four cases, ninety belonged to women and seventy-four to males. Segments or strobila of the tape-worm colony pass in numbers spontaneously, and after the action of medicines ; and now and then the living proglottides migrate, crawl out of the anus, and are felt, cool and moist, wriggling about the hips, thighs, and genitals. Very rarely, portions of a tape-worm are thrown up by vomiting. The length of time they remain in the intestine is by no means a fixed period ; they have been known to exist there ten to twelve years, and even longer ; but there are very obvious difficulties in the way of accurate determination of this point. The presence of a tape-worm when recognized by the patient induces serious inquietude of mind, but not necessarily any disturbance of the bodily functions. Not unfrequently, a tape-worm produces, absolutely, no symptoms. The degree of disturbance caused is determined by the characteristics of the affected person — they who suffer much are ner- vous and easily susceptible to impressions of all kinds. In a large proportion of cases, the presence of the proglottides in the evacuations is the first intimation of the presence of the worm in the intestinal canal. The principal symptoms are : emaciation, notwithstanding an inordinate appetitite ; a feeling of lassitude ; colicky pains felt through the abdomen ; palpitation of the heart, faintness ; salivation ; disor- dered digestion ; pruritus of the anus and nose ; disorders of the special senses, notably feebleness, etc. Sometimes the disagreeable feelings in * "New York Medical Journal," December, 1871. EsTESTIXAL PAEASITES. 117 the abdomen are removed by taking food. Probably the most constant symptom is the colicky pains felt in different parts of the abdomen ; but they are not always present, are intermittent, and vary as much in severity as in situation. Constipation is more usual than diarrhoea, and they may alternate. Itching about the anus and nose is a common symptom, and is rarely absent from one or the other situation, but itching of the anus is more frequent. The nervous phenomena, strictly speaking, are very pronounced, consisting of affections of the special senses, i^ains and cramps in the extremities, choreic seizures, epilep- tiform attacks, hysteria, etc. In a few cases the patients experienced a horrible odor, jDirrely subjective ; others have disagreeable sensations excited by music ; others have impaired vision, sometimes complete amaurosis, now affecting one eye, now the other ; again, there are those who have, instead of itching, a sensation of hypersesthesia or anaesthesia in certain parts of the body, a m.omentary loss of voice or of memory, persistent wakefulness, epistaxis, etc. The most important symptom is the passage of strobila, or, more frequently, proglottides. Each proglottis contains the sexual apparatus complete and a multitude of embryos, and has a power of motion when first detached from the strobila or tape-worm colony. It is then a segment — a moist, whitish, cool, quadrangular body, like a bit of stout white tape, but changing its shape constantly so long as the power of motion lasts. Inspected with an ordinary pocket lens, the uterus and ovisacs, with their lateral branches on one side, and the testicular bodies on the other side, can readily be seen. It is quite possible to differentiate between the T. solium and T. saginata by an inspection of the proglottides — the former being thinner, softer, and more transparent. The lateral branches of the uterus of the T. solium are from nine to twelve in number, and of the T. saginata fifteen to twenty, and the latter are much smaller. Treatment. — There are two separate stages in the process of expul- sion of the parasite — the preparatory treatment ; the exhibition of the tseniafuge. The preparation of the patient consists in the use of a laxative to remove mucus and other matters in which the scolex, or head, is imbedded, and to prevent accumulation of such matters by a low diet, which will leave almost no residuum. Sulphate of magnesia should be administered each morning for two mornings before giving the remedy — one or two teaspoonfuls at a time in sufficient water. The diet should consist of milk, steak, tea, and toast, for the day before and during the treatment. German practitioners cause the patient to take certain articles which experience has shown are highly disagreeable to the parasite — such as garlic, onions, and salt-herring — and accordingly they direct a plateful of herring-salad, a savory dish made up of those articles, agreeable enough to Germans, but highly distasteful to tape-worms ! The medicine need not be given on 118 DISEASES OF THE DIGESTIVE SYSTEM. an empty stomach ; the patient may take a cup of coffee before begin- ning the medicine. Many remedies have been proposed, and opinions are diverse as to their utility. Heller prefers kousso ; Cobbold,* ex- tract of male fern ; while Davaine does not indicate his preference ; and Kuchenmeister,f after an exhaustive examination of the almost innu- merable methods, ancient and modern, declares his preference for the decoction of pomegranate. The author's experience, which has been not inconsiderable, is decidedly in favor of the pomegranate. The most successful treatment of tape- worm the author has any knowledge of, is that of an ignorant barber, who has a secret method which seems never to fail. He does not attempt any preparatory treatment, but administers his medicine (apparently, a decoction of pomegranate) in the morning, the patient fasting, and retires from the house with the worm and his fee at noon. Kiichenmeister prepares his decoction of pomegranate as follows : 5 iij of fresh bark, after macerating for twelve hours in 3 xij of water, are concentrated to 3 vj by a gentle heat, and this fluid is taken in three doses within an hour. He precedes the administration of the pomegranate by one day of fasting, and 2 ij of castor-oil, taken the night before. He prefers to add to the pomegranate the ethereal ex- tract of filix mas and extract of tansy, 3j — 3 ss of the former and 3 ij of the latter. J Heller administers the kousso in a sjDecial manner — by the method of Rosenthal — which consists of compressed balls or disks coated with gelatine. Five drachms is the quantity required for a T. solium, and seven and a half drachms for a T. saginata. The gelatine-coated balls and disks are placed as far back on the tongue as possible and swallowed alone, or aided by some coffee. The tendency to vomit must be resisted — mustard applied to the epigastrium, small bits of ice swallowed, the recumbent posture maintained. Two hours after the last bolus, an ounce or two of castor-oil should be admin- istered, the object being to expel the worm speedily and entire. Heller aflirms that this method is highly successful, but Kiichen- meister thinks kousso an uncertain remedy. The author's experience with it has been unfavorable — it expelled a large quantity of the worm, the strobila, but not the head or scolex ; but it was adminis- * " Entozoa," op. cit., p. 233. f "On Animal and Vegetable Parasites of the Human Body." By Dr. Frederick Kiichenmeister. Sydenham Society edition, vol. i, p. 171. jj. The active principle of pomegranate — pclleterine — ^may hereafter be preferred. In a communication to the "Bull. Gen. de Therap.," July 15, 1879, Dr. Berenger Ferand re- ports comparative trials with the tannate and sulphate of pelleterine, prepared by M. Ch. Tanret, the discoverer. lie finds the tannate more efficient. The dose is forty to fifty centigrammes, administered fasting, the diet the previous day consisting of milk and bread. The remedy is followed by compound tincture of jalap, or castor-oil, or sul- phate of soda. INTESTINAL PARASITES. 119 tered in a decoction, the patient swallowing a great mass of leaves, stems, and flowers, so that vomiting could hardly be resisted.* The method by fern consists in the administration of the so-called ethereal extract — the oleoresin — in 3 ss doses, fasting. It is most pleasantly taken in perles or capsules. If of good quality, and given after suit- able preparation in an efficient dose, it is a successful remedy — ac- cording to Cobbold, the best of the group of taeniafuges. The seeds of the common field pumpkin is a homely but very efficient rem- edy, which deserves to rank among the best of the class. The fresh seeds are rubbed up into an emulsion by the addition of some water^ the woody liber separated by a coarse sieve, and the mixture drunk fasting. Usually no purgative is required, but one should be given if the bowels do not act promptly. The failures are due, simply, to the difficulty of retaining a sufficient quantity. A great many cures have been effected by tui-pentine ; it is, indeed, one of the most efficient of tseniafuges, but the natural repugnance to swallowing such a dose, the powerful effects produced by it, and the subsequent ill resitlts, are such as to hinder its emj)loyment, and to restrict it to the cases which have resisted other means. Large doses, acting promj)tly as a cathartic, are not so injurious as the smaller doses which pass off by the kidneys. From one to two ounces of turpen- tine, and as much castor-oil, are administered together. Kameela — "the glandular powder and hairs from the capsules of rottlera tinc- toria " — is an efficient remedy, without being very unpleasant. The dose is 3 j — 3 iij, repeated every three hours, if necessary. No pur- gative is required. The stools should be carefully and minutely in- spected, for the medicine is not successful if the scolex is not expelled. The head with its row of booklets, its suckers, etc., can be recognized by the naked eye, but an ordinary pocket lens will bring out all parts with sufficient distinctness to render an inspection positive. If the scolex is not found, and is retained, in six weeks to three months the segments or proglottides will be passing again. JBothriocephahis latus is usually classed with tape-worms, and clini- cally properly so, but, zoologically considered, it is not a tape-worm. Its habitat is the small intestine — its scolex attached to the mucous membrane of the duodenum by its suckers. It is found more fre- quently in the adult and in the female. Its size is greater than that of taenia ; its segments are not detached at maturity, and do not main- tain an independent life. Detached parts of considerable extent are expelled at long intervals. It is ordinarily, but not invariably, soli- tary. According to Odier, who has observed many cases at Geneva, the bothriocephalus causes swellings of different parts of the abdo- * An alcoholic extract, under the name of koossin, is now used instead of the crude drug, and it is alleged (Heller) with few failures, but the same success has not attended it elsewhere. The dose is thirty grains. 120 DISEASES OF THE DIGESTIVE SYSTEM. men, irregular stools, nausea, vertigo, palpitations, night terrors, etc. There may be no symptoms at all. When symptoms do occur, they are about the same as those already described for taenia. The expul- sion of the bothriocephalus is accomplished more readily than is the tape-worm. Kousso rarely fails. The oleoresin of filix mas is also successful. Kameela has been found efficient. In fact, any of the remedies already referred to as taeniafuges may be used against this worm. In Switzerland, the secret remedy of Peschier, supposed to be fern, is much used. NEMATODA— ASOARIS LUMBRICOIDES— ROUND WORMS. General Considerations. — The lumbrici are found under all con- ditions of climate — in cold, in warm, in moist, and in dry climates. They sometimes appear so generally as to become epidemic. In cer- tain epidemics of dysentery, Avorms in large numbers appeared in the evacuations. But these observations, made in the last century,* are open to suspicion, for in those times the pathological importance of worms was much greater than now. It is true, even now, under certain local conditions, that worms are very com- mon — so much so as to constitute an epidemic, and, in some epidemics of fever and of dysentery, great numbers of worms appear in the intestinal tracts. The great mode of propagation is by drinking-water. The ova of the round worm resist freezing and a very high temperature, and are surrounded by such a strong envelope as to oppose successfully ordinary destructive influ- ences, and live for years. It follows that, in country places, where human excreta easily gain access to drinking- water, numbers of people may be simul- taneously affected, or in quick succes- sion. Filthy habits of a jDeoiDle — of a community of negroes, for example — contribute greatly to the propagation of lumbrici, by the dissemination of ova through articles of food and drink. The number of ascarides existing at one time in the intestinal canal is various : there may be one, two, or three worms, or they may reach Fig. 8.— a scans lumbriooides — 1, complete worm ; 2, head ; 3, tail of the male ; 4, middle of the body of female. Davaine, op. ciL DsTESTIXAL PARASITES. 121 five hundred or thousands. "When very numerous, they may be grouped in rolls or bundles, distending the whole or a part of the intestine, or occluding it. Their place of sojourn is in the small intestine. They occur in early life chiefly, although Heller asserts the contrary, and are not common under one year and after twenty. Females are more subject to them than males, and feeble, lymphatic, and strumous per- sons more than the robust. Poor aliment, a vegetable diet, and fer- mented drinks favor their development. Autumn is the season of their greatest prevalence. From their origin to the end of their existence rarely does more than a year transpire, but our knowledge on this point is not very definite. Development. — The lumbricoid worm (Fig. 8) is cylindrical in shape, reddish-brown or brownish-yellow in color, and tapers at both extremi- ties ; but the cephalic extremity is larger, and contains at its summit three lips or papillae, having the mouth between them. The male is smaller than the female, and is distinguished by the tail being always turned toward the abdomen like a hook. The ova, which exist in almost incredible numbers, are oval in shape, have an extremely tough, double shell, and dark, granular contents. The eggs when expelled are slow to develop, several months, sometimes years, being required. " They do not lose their jjower of development for several years, and the young embryo, while in the shell, also retains its vitality for years." The subsequent steps in the development of lumbrici are at present quite iinknown. Symptoms. — When few in number, as is the rule, the host being in good health, there are no symptoms of any kind produced by them. ' "WTien very numerous, disorders of digestion, of nutrition, and of the nervous system, are caused ; but these results are not iseculiar to the round worm, and have been alluded to in connection with the tape- worm. The usual symptoms are colicky pains about the umbilicus ; tumefaction of the abdomen ; capricious appetite, now insatiable, now wanting ; occasional nausea and vomiting ; sometimes diarrhoea and stools containing mucus mixed with blood ; whey-like urine ; itching of the nose and anus ; bluish coloration of the lower eyelid, dilatation and sometimes inequality of the pupils ; emaciation ; irregularity of the pulse ; choreic and hysterical seizures ; restless nights, terrors, and grinding of the teeth in sleep, etc. Xo confidence can be placed on the diagnosis of woi-ms when all of the foregoing symptoms are present, for they are much more frequently produced by other causes. Hence, the diagnosis must be largely conjectural unless worms are passed from time to time. One or more may be found in the stools, and not rarely worms are brought up from the stomach, and excite gagging and stran- gling until disengaged from the fauces. If the symptoms above men- tioned persist after the ocular demonstration of the presence of worms, they are probably due to this cause. Chorea and epileptiform attacks. 122 DISEASES OF THE DIGESTIVE SYSTEM. in girls of eight to fifteen, may be due to the presence of worms, and cease on their removal — of which numerous examples have fallen under the author's observation. Occasionally obstruction of the intestine has been caused by a bundle of worms — either within the abdomen, or in a herniary protrusion. Requin narrates a case, the obstruction oc- curring at two points — in the small intestine ; at the middle of the transverse colon. Ascarides crawl up into the pharynx, the Eustachian tube, the nares, and the larynx. Aronssohn has collected several cases, Da- vaine others, of death happening suddenly with symptoms of suffoca- tion due to worms crawling into the larynx. Thirty-seven cases are reported (Davaine) of lumbrici in the biliary passages, in the substance of the liver, or in the cavity from rupture of the duct. The most usual position for them is the common duct, which they obstruct, jaundice results, and ultimately serious derangement of the liver ensues. He- patic abscess is also a result, but, very rarely, of the lodgment of a worm which has passed up into the body of the liver, and excited sup- purative inflammation. In some rare cases a worm has been discharged by an hepatic abscess opening externally. Worms have also been dis- charged externally by fecal abscesses, and they not unfrequently pass into the cavity of the peritoneum through perforations of the intes- tines. The old notion, that round worms could make their way through the uninjured intestine, is now entirely exploded. Treatment. — There are various remedies highly effective in the re- moval of the ascaris lumbricoides. The most generally used is santo- nine, or santonic acid, the active constituent of artemisia santonica. The advantage of this, besides its efficiency, is the slight taste and ease of administration. It should always be explained that the vision of those taking santonine is affected : all objects seem as if looked at through yellow-colored glasses, and also that the urine is stained a deep yellow. In overdoses santonine causes violent nervous symptoms. It is given in the form of powder, rubbed up with sugar, or some ex- tract of liquorice — two to four grains at night, followed by a laxative in the morning. Calomel has considerable vermifuge property, and is often alone sufficient, but is now used as an adjunct to santonine, two to four grains given with the same quantity of santonine. This plan, which is very satisfactory, is still more efficient if the use of the ver- mifuge is preceded by hydrocyanic acid (the officinal dilution), two or three drops, three times a day, for two days. Next to santonine in point of efficiency is chenopodium or worm-seed, which is usually ad- ministered in the form of the oil. Its powerful odor and disagreeable taste are strong objections. Five to ten drops can be given in an ounce of castor-oil, or in the fluid extract of spigelia, also an efficient vermifuge. The fluid extract of spigelia (pink-root) may be giv6n alone in from one to four drachms at a dose, or in the officinal combi- Es'TESTIXAL PARASITES. 123 nation, the fluid extract of senna and. spigelia. Any of the remedies named are efticient ao-ainst the round worm. OXYURUS VERMICUIiARIS.— THREAD-WORM. Description. — This parasite (Fig. 10) derives its common name — thread- worm — from its whitish apearance and size — like a bit of fine sewing-cotton. There are two sexes, male and female, the male being Fig. 9.— Trichocephalus of Man.— 1, female: a, ce- Fig. 10.— Oxyurns Vermicnlaris.— 1. male ofnatu- phalic extremity : 6. caudal extremity and anus; ral size ; 2, female, ib. ; 3, cephalic extremity, c, d. dia estive tube and orary ; f, ori.*ice of sex- magnified, ual apparatus. 2. isolated egg. 3, male : a. ce- phalic extremity; 5. anus: c. digestive tube : d, spicula or penis" ; e, sheath into which it is with- • drawn. only one half the size of the female. The female worm is scarcely a half inch (nine to twelve mm.), and the male is about one fourth of an inch (three to five mm.) in length, cylindrical, tapering to both ex- tremities, but the cephalic end is blunter. The ova are contained in a stout envelope which resists considerable heat as w^ell as cold, but soft- ens in the intestinal canal of man, and discharges its embryo, which indeed may be discerned in the mature eggs, already in process of de- velopment. The habitat of the oxyurus is the large intestine of man, especially the rectum, and they insinuate themselves into the folds of the mucous membrane and skin at the margin of the anus. They are most abundant in early life, and sometimes at the other extreme, in old age. Symptoms. — They excite by their presence in the rectum an intoler- able itching, sometimes severe pain, tenesmus usually, and these sensa- tions are propagated to the genito-urinary organs. The tormenting itching occurs at special times, and is very aggravating at night, when warm in bed. The stools are usually a little relaxed, fetid, and coated with mucus, and occasionally streaked with blood. An inspection of 124 DISEASES OF THE DIGESTIVE SYSTEM. the parts discloses a reddened and roughened integument all about the anus, and excoriations of the mucous membrane caused by the repeated friction of the parts. The worms may often be seen in situ, or in the evacuations, but it is necessary sometimes to administer an injection or a laxative to procure ocular evidences of the presence of these parasites. Besides the local, various reflex phenomena are induced by the irritation of the oxyurus, as epilepsy, chorea, cata- lepsy, etc. Unquestionably, excitation of the sexual organs is thus caused, leading to onanism. Besides the reflex, direct irritation of the genitals in girls is set up by the presence of these worms in the vagi- na, where they deposit their ova and develop in immense numbers. Violent local inflammation and a blenorrhagic discharge are also in- duced in this way, exciting suspicion of gonorrhoeal infection. The oxyurus is not confined to the rectum, nor are its excursions limited to the perineum and vagina. It migrates upward into the large intes- tine, and develops in the csecum ; but the lower part of the ilium is also invaded. So that, although the proper habitat of the parasite is the rectum, it should not be overlooked that they exist in the caecum and in the lower part of the ilium in great numbers. Treatment. — The fact just stated in regard to the jDOsition of these parasites in the intestinal canal is of great importance in the treat- ment. The administration of one of the vermifuges, especially san- tonine, aided by calomel, should be the first step in the treatment. As soon as this has acted, the bowel should be irrigated by a weak decoction of quassia or of aloes. A simple injection will usually suffice, since the santonine has probably displaced all of the parasites above. The decoction should also be used as a vaginal injection, employing a very small tube, so that all of the canal can be reached. As the ova are deposited in the folds of the anus, and are not reached by the injections, the next step consists in carefully sponging out all the folds and crevices of the anus and perineum, and the external genitals also, with a one per cent, solution of carbolic acid. If treated in this thorough manner, the applications being repeated a few times, the parasites will be entirely destroyed, but neglect of any of these precautions will render repeated applications necessary. Solutions of carbolic acid as an injection have been used with success in the treat- ment of the oxyurus, but such serious symptoms have ai-isen in some cases that this practice ought not to be continued. Tricliocephalus (Fig. 9) is rarely encountered. In respect to clini- cal history and symptoms, it does not differ from the round worm. PERITONITIS. 125 DISEASES OF THE PERITONEUM. PERITONITIS.— INFLAMMATION OF THE PERITONEUM. Definition. — Inflammation of the peritoneum occurs in two forms — acute and chronic. It may be limited to a part, or involve the whole of the membrane : in the former it is local, in the latter general peri- tonitis. It may be an independent affection, ox lyrimary, or it may be caused by the extension of a morbid process, from adjacent organs or tissues, or secondary. Causes. — As a primary disease peritonitis is rare, but it may occur at any age, even during intra-uterine life. Intense cold, severe and protracted counter-irritation by blisters, and blows on the abdomen, may excite the inflammatory process. Very much the most frequent cause is the extension of internal lesions of the abdomen — e. g., per- forations of the stomach, intestines, bladder, etc., or inflammation of these organs. To this category may be added the causes of pelvic inflammation of the uterus and annexed organs. It is not unfrequently an intercurrent malady coming on in the course of certain cachexite, as pyaemia, albuminuria, and the eruptive fevers. Pathological Anatomy. — The first step in the inflammatory process is the occurrence of hypersemia, the capillaries being enlarged and dis- tended, and the blood-pressure is so increased within the area of in- flammation that extravasations of blood occur at various points. An arrest of the normal secretion and an abnormal dryness are then evi- dent ; next an exudation, very thin but adhesive, forms on the in- flamed surface and glues the neighboring parts together, but not firmly, for they may be easily separated. Simultaneously, a reddish, serous fluid is poured out into the cavity. Th^ inflammation will now assume one of two directions — it will take the adhesive or exxcdative form. The fibrinous exudation already mentioned is almost pure fibrin and contains but few cellular elements. Presently, however, the cells of the endothelium become swollen, their contents granular, and their nuclei undergo multiplication. If, now, the process ends with the adhesive inflammation, the proliferation of the endothelium will soon be arrested, a delicate connective tissue will be formed from the new cellular elements, blood-vessels soon appear, and a distinct neo-membrane is the result, binding neighboring surfaces together, or forming bands of adhesion of greater or less extent. If the inflam- matory process assumes the other direction, the effusion increases. It is at first sero-fibrinous, i. e., a serous fluid, having masses of flocculi of lymph floating in it. The deposit of fibrin, which in the other form (adhesive) is slight in extent, and which disappears in the process of 126 DISEASES OF THE PERITONEUM. formation of the neo-membrane from the new cells, in this form (exu- dative) is very much increased, and constitutes a coating of consider- able thickness. The endothelium undergoes extensive proliferation ; the connective-tissue corpuscles of the basement membrane also, and new vessels develop. On separation of the fibrin layer from the serous membrane, the latter bleeds from rupture of minute new-formed ves- sels ; it appears dense, thick, and cedematous. The swelling, hypere- mia, and oedema, also extend to the sub-peritoneal connective tissue, and ultimately to the muscular tissue, which in turn becomes softened, pale, and flabby. When the inflammation occurs in the peritoneal layer of the liver or spleen, the tissue adjacent to the inflamed membrane is paler than normal, softened from (Edematous infiltration, and otherwise altered. The effusion poured out into the cavity assumes various ap- pearances and characteristics. The quantity varies from a few ounces, in the dependent parts of the cavity, up to several gallons. It may be sufficient to force up the diaphragm to a level with the third rib, make the heart lie transversely by pushing up the apex, displace the lungs, etc. The effusion may be chiefly fibrinous with but little fluid. When this is the case, the thickest deposits are seen over the solid organs, the liver and spleen, and it may be general, uniting the whole surface, or limited in extent, forming occasional adhesions. The neo-membrane contains vessels, often of considerable size, and having walls of ex- ceeding tenuity. These vessels rupture easily, and considerable haem- orrhage results, and this, mixed with the effusion, constitutes another form, the so-called haemorrhagic effusion. The adhesions, when iso- lated and not general, undergo great changes ultimately, by reason of the extensive motion possessed by the abdominal organs. They may, by subsequent contraction, cause great deformity of organs and seri- ously impair their functions, and in the case of the intestine may induce twisting, encroach on their caliber, and bring about slow occlu- sion. The small intestines may by means of such adhesions be agglu- tinated together, forming an almost solid mass, irregularly rounded, as the author has seen, in certainly one well-marked case. The effusion may be serous — a faint greenish, or greenish-yellow, or milky fluid, similar to the fluid of ascites, except in the presence of flocculi of fibrin, bits of false membrane, and casts of cells of the endothelium. The effusion is sero-fibrinous, when there is a large quantity of fibrin suspended in it. When absorption of the fluid takes place, the solid exudation undergoes the changes already described. The effusion may be purulent. When this is the product of the inflammation, its cause is, as a rule, perforation and the escape of purulent or decomposing matters into the peritoneal cavity. When the effusion is purulent, the amount of fluid contained in the abdomen varies greatly. There may be thick masses of pus, or the pus may be mixed with a quantity of serum, constituting a sero-purulent fluid. I PERITONITIS. 127 The changes of chronic peritonitis are similar to those of the acute form. There is often little or no fluid exudation, and when present is not abundant, and has a purulent or sero-purulent form. The princi- pal fact is the existence of false membrane, either general or in local bands. The intestines, as already described, are sometimes united in a bundle and form a globular mass of some compactness. Occasion- ally a part of the neo-membrane, especially where it has attained the greatest thickness, undergoes a calcareous transformation ; or it may become soft, friable, and granular, doubtless preparatory to absorp- tion, or it may be converted into connective tissue. Divided by mem- branous adhesions, the cavity of the peritoneum maybe converted into various secondary cavities, some containing serous and others purulent collections. The latter may be converted ultimately into a cheesy mass. In chronic peritonitis, tubercular deposit is common, and gray granulations are disseminated through the false membrane and the sub-serous connective tissue. Tuberculous peritonitis. is usually con- nected with tuberculous ulceration of the mucous membrane of the intestine, and tubercular adenitis of the mesentery, and is coincident with pulmonary tuberculosis. Symptoms. — When idiopathic or primary peritonitis occui-s in a previously healthy individual, it sets in with a chill, an intense fever, and very severe local pain and tenderness. If it succeeds to a perfora- tion, the onset of the peritoneal mischief is announced by an intense pain, felt in the region of the accident, and rapidly extending thence over the abdomen. Then the fever movement is but slight. If peri- tonitis from perforation happens in the course of typhoid fever, or in any other adynamic state, there may be few symptoms besides disten- tion of the abdomen and increase of the adynamia. When it results from an extension of inflammation by contiguity of tissue, it is an- nounced by an exaggeration of the fever, by pain and tenderness of the abdomen, and by vomiting — the last-named symptom being espe- cially significant if it has not existed in the case previously. In what mode soever peritonitis may begin, the symptoms most characteristic are, pains in the abdomen, gaseous distention, rapid failure of strength, and fever, somewhat remittent in type, with the remission in the morning. The pain in the abdomen is usually an intense, cutting, bor- ing pain, somewhat more severe at certain places, but felt all over the abdomen. The slightest touch aggravates the pain, and hence the patient avoids movement, suppresses cough, and breathes with the chest-muscles. For the same reason the breathing is short, quick, and superficial, to avoid motion of the diaphragm. The decubitus of the patient is unconsciously assumed to prevent pressure of the muscles on the tender peritoneum. He lies on his back, if the peritonitis is gen- eral, with the thighs flexed on the pelvis and the shoulders elevated, and, when he is told to extend the limbs, he does so very cautiously and 128 DISEASES OF THE PERITONEUM. soon abandons the attempt, his countenance as well as his expressions indicating the increased pain the effort has given him. In the begin- ning of the disease, the abdominal muscles are kept contracted and rigid to guard the peritoneum from injury by movement, but it is also a re- flex state of tonic muscular contraction, which occurs simultaneously in the muscular layer of the bowel, and is due to the irritation of the terminal nerve-filaments in the pei'itoneum. But paresis of the bowel soon succeeds to tonic rigidity, in accordance with another law — over- stimulation, or long-continued, exhausts the irritability of the organic muscular fiber. The bowel then becomes extended by the accumu- lating gas, and soon (on the second or third day) an extreme degree of meteorism is the result, which, in fatal cases, continues up to death. This extreme distention of the abdomen adds to the difficulty and pain of breathing. The sonority of the percussion-note is tympanitic over the course of the large intestine especially, and the abdomen generally, except the dependent parts in the flanks and iliac fossse, where the accumulation of fluid imparts to it the character of dullness. The normal hepatic dullness lessens materially or disappears, because of the displacement of the liver upward and its partial rotation on its long axis. The position of the dullness on percussion varies with the changes of position of the patient. It is occasionally possible to hear a friction-sound by auscultation, but the duration of it in any case is very brief. The tongue is coated and the appetite impaired at the onset. Rarely is vomiting absent. It begins soon after the disease sets in, and at first articles of food and gastric mucus come up, then biliary matters from the duodenum. Vomiting may occur sponta- neously, or be excited by taking medicine, food, or drink. In some rare cases the vomiting has been incessant, and finally stercoraceous. In such cases obstruction is supposed to exist, but not confirmed on post-mortem examination, only peritonitis being found. Constij)ation is the rule in case of peritonitis, but occasionally diarrhoea is present ; then, usually, some coincident disease of the bowel exists, as tubercu- losis or septicaemia, for example. Constipation is the necessary result of the paresis of the bowel ; but paralysis of the sphincter may be so complete as to permit the escape of fecal matters by mere pressure on the abdomen. An extension of inflammation to the vesical peritoneum causes strangury and irritable bladder. Hiccough is a frequent and most distressing symptom, and is due to a reflex irritation of the diaphragm, transmitted from the nerve-endings in the i3eritoneum. The pulse in peritonitis is small, quick, and frequent, the tension high. When cardiac failure comes on in fatal cases it becomes excessively quick and small, and may disappear at the wrist when the heart is still acting. It will range in ordinary cases from 100 to 140 ; when collapse approaches, the pulsations may reach 160 to 200. When col- lapse comes on, the tempei'ature, which had risen to 103° Fahr., sinks PERITONITIS. 129 below normal. As has been already pointed out, the respirations are costal in type, very shallow, and becoming more so with the failure of the vital powers. There is then cyanosis. The countenance is anxious, shrinks ; dark, livid circles surround the eyes. In collapse the surface is cold, wet with a cold sweat, the skin wrinkled and sodden, the body exhales a cadaveric odor, the voice is husky, but the mind remains clear though rather apathetic, and at the last the brain is clouded by carbonic-acid poisoning. Or, instead of an unclouded intellect, there may be delirium from oedema of the brain, and, ex- tremely rarely, unconsciousness soon after the onset of symptoms. In many cases, as collapse develops, the peculiar type of respiration — the Cheyne-Stokes respiration — appears, and is highly significant of a fatal termination. Course, Duration, and Terminations. — The course of peritonitis is rapid, the mortality great. The usual termination is in death. When it arises from perforation, a fatal result may occur in two or three days, and, when it is idiopathic, in five or six ; but the cases of this variety last two to three weeks. Peritonitis due to internal obstruc- tions adds to the severity of the symptoms and the gravity of the case, but its course, apart from the principal malady, is not well de- fined. The gravest cases are those which occur in the course of septic diseases, or are due to the escape of decomposing and irritating matters, by a perforation into the cavity. The only forms which may be re- garded as at all favorable are those due to the extension of a simple inflammation, by contiguity of tissue, from the abdominal or pelvic viscera. In these the inflammation is simply exudative and adhesive, or sero-fibrinous. "When improvement begins, it is announced by a diminution of the pain, lessening of the meteorism, and cessation of the vomiting. A case of acute peritonitis may terminate in a chronic form of the disease. After a period of improvement, grave symptoms will again set in, induced by the changes in shape, position, and func- tions of organs, the result of adhesions, contractions of bands of lymph, etc. Prognosis. — The statements already made sufficiently set forth the grave character of jDcritonitis. The prognosis in the mildest cases must be guarded, and in all severe cases unfavorable. Diagnosis. — Peritonitis is to be differentiated from hysterical ten- derness of the abdomen, rheumatism of the abdominal muscles, and acute painful affections of the various organs. From hysteria it is dif- ferentiated by the hysterical history, by the crying, sobbing, and globus hystericus, by the absence of all constitutional symptoms, and finally by the tenderness being merely an hysterical condition, excessive on the surface, but permitting, when the attention is withdrawn, firm, deep pressure. The suffering of the hysterical state differs from real pain in the disproportion of the expressions and the evidences ; while the 9 130 DISEASES OF THE PERITONEUM. most extravagant terms are used to describe the pain, the countenance is placid. In rheumatism of the abdominal muscle, there will probably have been other cases of the rheumatismal character ; the pain is lim- ited to the muscles, and deep pressure does not increase it, and the con- stitutional state does not indicate a severe disease. In acute painful affections it is sometimes difficult at once to decide, but as a rule these begin rather more abruptly, the pain is more acute, and there is not usually a history of a disease from which peritonitis might be expected to arise. The great majority of cases of peritonitis arise from previous disease in the peritoneal or pelvic cavities ; it is extremely rare, indeed, for an idiopathic case to occur. CHRONIC PERITONITIS. — There are two forms : 1. Succeeding to the acute ; 2. Tubercular. The acute symptoms subside and there is a gradual absorption of the fluid portion of the exudation. A sero- fibrinous exudation may undergo conversion into a purulent ; the fever, which had diminished or ceased, rises again and takes on the septicsemic character — there are chills, fever, and sweats. Rapid de- cline of the vital powers takes place under these circumstances. Or the effusion may become encysted by the formation of adhesions, as already described, and become a pus-depot, which may be converted, ultimately, into a caseous or calcareous mass. In other cases these purulent collections behave as ordinary abscesses, and manifest a ten- dency to find their way externally. Abscesses formed above a line drawn transversely across the abdomen through the umbilicus tend to dissect upward, and make their way out through the lungs ; those below this line tend to pass down along the course of the femoral ves- sels. Although there are many exceptions, this may be considered as a natural tendency. In the dissections made by these abscesses, fis- tulse may be established externally, with different parts of the bowel, with the thoracic cavity, etc. ; or rupture may occur into the perito- neal cavity, again exciting fresh inflammation. The chronic, local, and partial peritonitis, about certain organs, may set up important changes by the metamorphoses of the exudation. Thus, thick and contracting connective tissue about the gall-bladder, and on the upper surface of the liver, compresses the organ, or may obstruct the hepatic duct or the portal vein. The tubercular form of chronic peritonitis is often asso- ciated with the corresponding disease of the lungs, or intestinal mucous membrane, or of both. Its onset is obscure, and development slow, so that weeks or even months may pass before the patient is so reduced as to take to his bed. It usually sets in by colicky pains felt ejjpecially during the time digestion is going on. Constipation alternates with diarrhoea, and there may be, but not invariably, attacks of vomiting, the matters thrown up consisting of mucus and greenish, bilious-looking matter. The attacks of vomiting may coincide with the colic-like pains. PERITONITIS. 13j^ The patient rapidly declines in flesh and strength. There are daily chilliness and febrile movement. The skin is harsh and dry ; sweating usually occurs at night ; the urine is scanty, high colored, and deposits an abundant uric-acid sediment. With the development of these symptoms the abdomen gradually assumes a characteristic condition. By the accumulation of gas in the intestine, and of serous effusion in the cavity, the abdomen enlarges. Notwithstanding a considerable effusion, it is rare that the signs and symptoms of ascites are present. There is dullness in the dependent parts, whatever may be the decubi- tus of the patient, but not such a fluctuation as occurs in ascites. The compression of the vessels, by the effusion within and the direct pres- sure of membranous adhesions, but especially the matting of the small intestines into a globular mass, and the pressure of this tumor-like body on the iliac veins, cause an extensive oedema of the lower ex- tremities, the scrotum, and the abdominal walls. This result is pro- moted by the enlargement of the mesenteric glands, which are also occupied by tubercular deposit. The course of this malady is slow, but the termination by death is not less certain. The reader should not overlook the distinction between a tubercular peritonitis occurring with tubercular phthisis and other tubercular diseases and a peri- tonitis in which tubercular deposit is secondary to the morbid process which had preceded it. Treatment. — When robust subjects are attacked by peritonitis, there can be no doubt of the utility of leeches, ten to twenty applied over the abdomen. In the cases of local peritonitis (typhlitis, for example), if the patient is not very weak, leeches ai'e highly serviceable. There are few, indeed, who can not bear the loss of blood of two or three leeches. The time for their application is the onset of the disease, before solid exudations have occurred. After leeches, or at once, an ice-bag should be applied to the abdomen, or to the part only af- fected. This ceases to be useful, and is better supplanted by warm ap- plications, when exudations take place and the abdomen swells. With the first symptoms, morphia should be administered hypodermatically, and should be repeated eveiy four, six, or eight hours according to the effect, such a degree of narcotism being maintained that pain is re- lieved, the pulse considerably reduced, but yet the patient is easily roused. Atropia should be given with the morphia. The very heroic use of morphia, advocated in some quarters, is not to be commended. The best curative results are obtained from doses that affect decidedly without inducing a degree of narcotism that may be dangerous. At the very beginning, the administration of antipyretic doses of quinia is in a high degree beneficial, and the effect may be maintained by fre- quent exhibition of smaller doses. This ceases to be useful when there is solid and liquid exudation. When effusion occurs, another and a very different kind of medication must be adopted. The decline of 132 DISEASES OF THE PERITONEUM. the vital powers must be retarded by suitable nutrients and stimulants. The local applications should consist of warm fomentations, mustard- plasters, or flying-blisters, or the tincture of iodine. By the stomach the salts of ammonia should be administered, and freely, and morphia continued />ro re nata. Ten grains of the carbonate of ammonium, in an ounce of the solution of the acetate, every four hours, when the exudation is going on, is, the author believes, a remedy of the highest utility. In the peritonitis from perforation, absolute repose, opium, ice, and the avoidance of all foods and drinks, are the proper measures. ASCITES— DROPSY OF THE ABDOMEN. Causes. — The chief factor in the pathogeny of ascites is mechani- cal obstruction of the vessels, the portal system, and the most common cause of this obstruction is cirrhosis of the liver. Tumors, as aneu- rism of the hepatic artery, tubercle masses, cancer, and hydatids, in a situation to compress the portal vein, will also cause an effusion into the peritoneal cavity. Increase of pressure in the portal system may be due to obstructive disease of the heart or lungs. Again, dropsy of the peritoneum may be a part of general dropsy, especially in chronic nephritis. Accumulation of fluid is a result of peritonitis, acute or chronic, but this does not, properly, constitute ascites. Pathological Anatomy. — The amount of effusion which exists in ascites varies from a few ounces to many gallons. It is usually of a pale straw-color, or it may have a greenish tint, and is transparent, and may be free from flocculi, or any foreign constituents. Its reac- tion is alkaline, and its specific gravity below that of the serum of the blood. It contains albumen or albuminate of soda, but the proportion is less than is present in the blood-serum, but greater than other serous exudation except hydrothorax. The biliary acids and pigment are also foi^nd in the ascitic fluid, when jaundice exists, and creatine and crea- tinine are very common constituents. In many cases fibrin is held in solution, and slowly coagulates in an exceedingly fine reticulation of fibers. Sometimes ascitic fluid is reddish from the presence of blood derived from ruptured capillaries ; again, blood may indicate the probability of cancer. The peritoneum long in contact with fluid is altered in character and appearance by imbibition ; it becomes sodden, cloudy, and thickened, but these are not inflammatory changes. The distention of the cavity and the displacement of organs disturb the relation of the parts. Symptoms. — As a rule the beginning of ascites is obscure, and it is not discovered until the sense of fullness and tension directs attention to the part, or an examination of the abdomen is made for the pur- pose, existing lesions rendering it probable that effusion has occurred. An increasing fullness of the abdomen is the most important objective ASCITES. 133 symptom. It is not wholly fluid, but the distention is in part due to flatus in the intestines and fecal accumulations, the result of consti- pation caused by pressure on the sigmoid flexure. If the patient is erect, the fluid distends the iliac and hypogastric regions ; if lying down, the fluid flows to the sides ; if turned upon one side, the fluid takes a corresponding position — so that the dullness on percussion varies with the posture of the patient. With the increase in the amount of fluid the girth of the abdomen enlarges, so that in cases of large effu- sion the abdomen may be two or three times larger than the normal. When the effusion is great and of long standing, the umbilicus is forced outwardly, and forms a tumor with thin walls, and soft and fluctuating in character. The physical signs are characteristic : On mensuration, the increased circumference ; on palpation, a peculiar wave-impulse communicated through the intervening fluid, when a slight blow is made on one side ; on percussion, a tympanitic note over the distended bowel, and a region of perfect dullness correspond- ing to the position of the fluid. The wave of fluctuation is best felt by laying the hand extended flat on one side of the abdomen, and gently tapping the opposite side. The distended abdomen forces the diaphragm upward and therefore embarrasses the respiration and the cardiac movements ; the urinary secretion is diminished because of the pressure on the renal arteries and veins, and of the escape of fluid into the peritoneal cavity ; constipation I'esults from the compression of the sigmoid flexure. The integument of the abdomen has a glis- tening appearance, arising from stretching and cedema, but the skin generally is harsh and dry. The lower extremities and the scrotum also are much sw^ollen, when the ascitic fluid is sufficient in weight to compress the vena cava and iliacs. Course, Duration, and Termination. — The course and behavior of ascites depend much on the cause producing it. Usually the effusion occurs slowly, as, for example, in cirrhosis, in which disease there may be months occupied in producing sufficient effusion to distend the ab- domen. In idiopathic ascites, the accumulation may take place in one or two weeks. The amount of increase in the blood-pressure may vary greatly when an obstruction, cardiac, pulmonary, or hepatic, is the cause of the effusion. Idiopathic ascites is shorter in duration than the other forms, and terminates in health in a few weeks. The dura- tion of the other forms is a question of the course and behavior of the malady, of which ascites is usually a symptom. When dependent on obstructive disease of the heart, lungs, or liver, especially the liver, the duration is indefinite. The fluid may be removed by treatment, and return again and again, for the original cause remains. Prognosis. — The question of recovery is determined by the presence or absence of certain organic changes. If the effusion is simply peri- toneal, the prognosis may be favorable. If it is a symptom of cardiac. 134 DISEASES Or THE PERITONEUM. pulmonary, or hepatic disease, the prognosis is unfavorable, for these maladies being incurable the effusion will recur, if at any time it may be removed. Diagnosis. — Ascites must be differentiated from ovarian tumors, pregnancy, distended bladder, chronic peritonitis, and enlarged spleen. As ovarian tumors are so often accompanied by effusion into the peri- toneal cavity, mistakes are frequent, ovarian tumors being confound- ed with ascites, and vice versa. The distinction lies in the following considerations : Ascites is almost always preceded by obstructive diseases of the heart, lungs, or liver, especially by cirrhosis, and the derangements of health which the existence of these obstructive dis- eases always implies. Ovarian disease does not necessarily impair the health, and is not preceded or accompanied by the lesions pertaining to ascites. In ascites the enlargement of the abdomen is uniform, begins at the dependent part, whatever that may be, and the dullness on percus- sion changes with the position of the patient ; ovarian tumor begins in the iliac fossa of either side, the growth is obliquely upward, does not change its position according to the posture of the patient, nor does the dullness change. The tympanitic percussion-note, derived from percussion over the distended intestines, is in ascites above the fluid ; in ovarian tumor, to the side and behind. When fluid in the cavity coincides with a tumor, the latter may be felt by suddenly dis- placing the fluid, and coming down on the tumor with the hand. An exploration through the rectum, by the method of Simon, will enable a diagnosis to be made at once ; by conjoined manipulation through the vagina, a tumor can usually be easily defined. In pregnancy the tumor develops in the middle line of the abdomen with an inclination to the right ; it is firm, inelastic, and non-fluctuating. Changes in the length, density, and size of the neck of the uterus, and in its functions (arrest of menstrual flow), and in the mammae, with the other evidences of pregnancy, accompany the growth of the uterine tumor. After the fourth month the sounds of the foetal heart and the placental souffle, together with the hallottement, indicate the nature of the case without doubt. The author has known a distended bladder mistaken for ascites. Applying the same method already described for the diagnosis between ovarian tumor and ascites, the difference becomes at once apparent. In all cases of critical examination of the pelvic organs, the catheter is used, or ought to be, to prevent error and to facilitate the exploration. The local and physical signs may be precisely the same in ascites and chronic peritonitis, but the clinical history is so different that a differen- tiation may be made by reference to the origin, causes, and symptoma- tology of the two affections. Peritonitis is accompanied by pain and tenderness of the abdomen, by an increased thickness of the walls, by persistent vomiting, and by alternating constij^ation and diarrhoea ; in ASCITES. 135 ascites there is usually no tenderness, the walls of the abdomen be- come very thin from absorption of fat and atrophy of the muscles, there is no vomiting except such as is due to hepatic disease, and there is persistent constipation. The spleen may be uniformly and exten- sively enlarged so as to fill the cavity, but it differs from ascites in the following particulars : The enlargement is from the left hypochon- drium downward ; it is firm, inelastic, and non-fluctuating ; the dull- ness maintains with the tumor a constant position, which does not fol- low the movements of the patient. Treatment. — There are, besides artificial means, two outlets to the effusion — by the intestinal canal ; by the kidneys. Dry diet has, from the earliest period, been regarded as a most efiicient plan of treatment. As it may be tried without interfering with the remedial management proper, it should be enforced in suit- able cases. Dry diet consists in absolute disuse of fluids of every kind, and the use of water-free food. It is extremely irksome, but, if patiently carried out, will contribute materially to relief or cure, as either may be practicable. If this method be unavailable, the oppo- site plan, or the free use of water and diluents, should be enjoined. The best of all diluents for this purpose is skimmed milk, which should be taken with regularity and in as large quantity as the pa- tient can bear. An intelligent medicinal treatment of ascites must be conducted with reference to its cause. Here only the remedies for the removal of the effusion can be discussed. As the cavity is a closed sac, diuretics are not very efiicient. The treatment by hydragogue carthartics is the most generally serviceable, and of the remedies be- longing to this group the most useful is the compound jalap powder. Several watery evacuations must be passed daily to make any impor- tant impression on the effusion ; this result is most easily accomplished by the administration of one or two drachms of the compound jalap powder in the early morning, to avoid interference with the digestion. If the jalap is not efficient, elaterium may be substituted ; but in the author's experience the former is to be preferred. Notwithstanding the little utility of diuretics, advantage should be taken of any good arising from them. Bitartrate of potassa, in the form of cream-of- tartar lemonade, is an excellent diluent, unless the dry diet is used. Digitalis, especially in the form of infusion, is the best of the diuretics proper. These remedies may be given jointly. To urge the kidneys to their highest activity, the functions of the skin should not be ex- cited, and the cutaneous capillaries must therefore be kept contracted by lessening the warmth of the covering or clothing. An increased action of the skin is generally more serviceable in ascites than diuretics are, unless an obstructive cardiac or pulmonary disease is the cause of the effusion. Most excellent results are now obtained from the use of jaborandi or pilocarpine in the treatment of ascites. Warm clothing, l^Q DISEASES OF THE PANCREAS. vapor-baths, and pilocarpine may be used jointly, to maintain constant diaphoresis. Removal of the fluid by tapping is a useful expedient in cases not relieved by the methods advised, but so rapidly does reac- cumulation take place that this measure should not be practiced too early. It should not be adopted until the embarrassment of breathing is so great as to prevent sleep. The relief it affords is immense, and is accomplished now so readily that there is a constant temptation to employ the aspirator trocar before the proper time has arrived. The puncture is made in the middle line — the Unea alba — two or three inches below the umbilicus. It is not necessary to draw off all the fluid, but a sufficient quantity to afford relief. The puncture should be carefully closed. It is sometimes difficult to do this, and the ascitic fluid is permitted to drain away indefinitely ; but the prac- tice is bad, for the admission of air to the cavity sets up a septic pro- cess, and may excite a fatal peritonitis, as the author has seen. IDIOPATHIC SUPPURATIVE PERITONITIS is a term applied to a form of peritonitis apparently arising from exposure to cold, and oc- curring in children. It has the clinical history of peritonitis — sudden onset, fever, small pulse (dicrotic), rapid decline in strength, pain in the abdomen, meteorism, nausea and vomiting, constipation, vesical tenes- mus. Pus may be evacuated through the rectum, bladder, vagina, or externally. It is in a high degree probable that the peritonitis is not a primary but a secondary affection, and is due to perforation. The enormous accumulation of gas and its extreme fetidity lend support to this view. Other cases having similar symptoms, and terminating by the discharge of matter, may be examples of the subperitoneal phlegmon.* DISEASES OF THE PANCREAS. PRELIMINARY OBSERVATIONS.— So little is definitely known of the diseases of the pancreas that many systematic wi'iters omit the subject entirely. There are, however, some practical points which should receive attention. The pancreas has an office in connection with the digestion of certain kinds of foods. Like the salivary secre- tion, the pancreatic fluid transforms starch into dextrine and grape- sugar. Although its ferment loses its activity in the presence of an acid, yet the pancreatic juice has the power to complete the digestion * Sec the paper by M. le Dr. Besnier, "Arch. Gen. de Med.," September, 1878. \ PANCREATITIS. 137 of peptones that have escaped final action of the gastric juice.* The emulsionizing, or preparation of fats for absorption, is another func- tion of the pancreatic fluid. It therefore supplements the action of all the digestive juices. This fact suggests that which experiment has demonstrated — that the pancreas is not essential, and that the pro- cess of digestion can be carried on without its aid. The diseases af- fecting the pancreas, in regard to which positive information exists, are pancreatitis, acute and chronic, and tumors of the pancreas. PANCREATITIS.— In the acute form, the changes consist in hyper- a5mia, increased size and density of the organ, and, it may be, hasmor- rhagic extravasation. The inflammation proceeds to suppuration in a portion of the cases, at first in isolated depots, which may subsequent- ly coalesce, forming a large one. Peritonitis may arise when the superficial parts of the organ are occupied hy abscesses, and gangrene and sloughing may ensue when there is considerable haemorrhagic ex- travasation. Almost nothing is known in regard to the causes of the disease. Men seem to be more frequently affected than women. As pancreatitis seems to have occurred more often several centuries ago, it is highly probable that the excessive use of mercury was an efficient cause. As the functions of the pancreas are merely auxiliary, it is not surprising that but few symptoms are produced when the organ is the seat of an inflammation. Pain, becoming very acute and depressing, is one of the earliest symptoms ; it is felt in the epigastrium, and radiates to either shoulder and to the back ; there are restlessness, precordial anxiety, faintness, nausea, and vomiting. After much straining, some bilious-looking watery fluid is brought up, but this does not afford relief. There is considerable gaseous distention of the abdomen, and a good deal of gas comes up by eructation. Constipation is also a symptom, f From the beginning there is fever ; the pulse, at first full and tense, soon becomes small, feeble, and irregular. The symptoms of depres- sion make rapid progress, and in a few days (four to six) the patient is in a condition of collapse, with shrunken features, cold surface, cold extremities, and failing heart. The marked anxiety and depression from the first and the weak and irregular action of the heart indicate an implication of the solar plexus ; for similar symptoms are produced artificially (crushing-blow exi^eriment). It Avill be difficult to distin- guish this affection from hepatic colic, or gastralgia, except by the fever, the rapid and irregular action of the heart, and the early col- lapse, which are wanting in these two disorders, which also terminate in a few hours — one with jaundice and returning health, the other ■with complete relief and immediate resumption of the functions. The * Dr. W. Kiihne, Virchow's " Archiv.," Band xxxix, p. 130. t Oppolzer, " Uber Krankheiten des Pancreas," "Wiener med. Wochen.," ISBT, No, 1. 138 DISEASES OF THE PANCREAS. termination, after a very rapid course, is usually in death ; but there may be a gradual decline into a chronic state, ending in abscess or slow induration. Acute pancreatitis may be secondary to other affections — there may occur in it, during the course of acute infectious diseases, the changes included in the term parenchymatous degeneration. The chronic interstitial pancreatitis, affecting parts of the gland, is the form which the chronic inflammation most usually takes. The connective tissue undergoes hyperplasia, and the proper gland-struc- ture wastes. When the whole organ is involved, there may be an entire disappearance of the proper gland-structure, or a part of it may be converted into a connective-tissue bundle. As in cirrhosis of the kidney, cysts are formed by obstruction of ducts. Calculi form in the ducts, and the duct of Wirsung may be entirely occluded by a cal- culus, inducing dilatation of the ducts and atrophy of the gland-sub- stance. Abscesses may also result from the pressure and inflamma- tion caused by calculi. Chronic j^arenchymatous pancreatitis is a less usual form of chronic inflammation. It is probably more frequently secondary than primary — i. e., due to the extension of suppurative inflammation from neighboring parts. The symptoms are most in- definite. It is supposed that the appearance of an excess of fat in the stools, salivation, emaciation, and gastric disturbances, may be due to chronic inflammation of the pancreas, but none of these symptoms are distinctive. The treatment must be entirely symptomatic. Pain must be re- lieved by morphia hypodermatically, the stomach symptoms by car- bolic acid, bismuth, pepsin, ingluvin, hydrocyanic acid, etc., and the chronic interstitial change is best treated by minute doses of corrosive sublimate, iodide of potassium, and similar remedies. CANCER OP THE PANCREAS.— Much more is known in regard to this than to any other affection of the pancreas. The ordinary form of cancer affecting this organ is scu'rhus, and scirrhus character- ized by a denser stroma. Medullary and colloid have also appeared in the pancreas, but very rarely. Scirrhus of the pancreas ' is more fre- quently secondary than primary, and even as a secondary disease it is very rare, occurring in cancer cases in the proportion of about six per cent. only. It develops most frequently in the head of the pan- creas and occurs there as a secondary disease, and extends thence over the body of the organ. It is more frequently confined to the head than to other parts of the organ ; in 200 cases there were 33 in which the disease was confined to the head, and in 88 the whole organ was af- fected.* A tumor of the pancreas of considerable size must impinge on neighboring organs ; it may compress the ascending vena cava, causing * Ancelet, " Etudes sur les Maladies du Pancreas," Paris, 1866, p. 34. CANCER OF THE PANCREAS. 139 oedema of tlie lower extremities ; the ductus communis choledochus causing jaundice, the pancreatic duct, causing dilatation and the for- mation of concretions, the ureter causing hydronephrosis, and the duodenum causing stenosis and dilatation of the bowel above and subsequently of the stomach. It is usual for cancer of the pancreas to extend to and implicate other organs, which may be bound down into a uniform mass, in which the point of initial dej^osition may not be distinguishable. The duodenum, the stomach, the gall-bladder, the kidney, the liver, mesenteric glands, and peritoneum may all be in- cluded in a mass of which the beginning was in the head of the pan- creas. Ulcerations into neighboring organs may also take place — as into the stomach, duodenum, vena cava, portal vein, splenic artery, etc. Cancer of the pancreas is more frequent in males than in females ; in Dr. Da Costa's * cases there were 24 males and 13 females ; nearly twice as frequent, which is the proportion noted by other observers. As is the rule with scirrhus in all situations, the morbid growth makes its appearance from forty to sixty years of age. Pain is an early symp- tom, and, as it appears without cause, is persistent and rather increases than diminishes, and as progressive emaciation and feebleness accom- pany it, esjDecially if the age of the subject be suitable, it is extremely suggestive of malignant disease. The pain is situated in the epigastric region and radiates through the numerous ramifications of the solar plexus, into the back, through the abdomen ; it is pretty constant, with paroxysms of great severity in which the suffering is agonizing ; it is increased by the erect posture, and is relieved by bending the body forward. The presence of a tumor has a high degree of importance, but it is not always found, and when discovered may be misleading. A tumor is discovered in not more than one third of the cases, owing to the depth at which the pancreas lies. The head of the pancreas has been often mistaken for scirrhus. If enlarged lymphatics be felt, and especially if the cervical lymphatics are enlarged, support will be given to the supposition that an existing tumor is malignant. In a small proportion of cases, an excess of fat in the stools is a symp- tom which throws light on the case. The appearance of jaundice, the passage of blood by stool, oedema of the lower extremities, and disorders of digestion, are coincident with the extension of the new growth to neighboring organs, and rather confuse than clear up the diagnosis. In Da Costa's 37 cases, jaundice was present in 24, dyspep- sia in 25, dropsy (anasarca or ascites) in 15. "With the development of these symptoms there is a corresponding increase in the gravity of the constitutional state. The general condition and the cachexia, such as have been described as belonging to cancer of the stomach, are present in these cases. The duration varies somewhat. The most severe termi- * "N. A. Med. Chirurg. Review," September, 1858, p. 883. 140 DISEASES OF THE LIVER. nate in a few months, and but rarely is any case protracted beyond a year. The rate of progress is influenced by the complications — by the pressure on neighboring organs and interference with their functions. Sudden death may be due to erosion of a large vessel. CYSTS OP THE PANCREAS Chronic interstitial pancreatitis is the chief factor in their causation, as in the production of the corre- sponding cysts of the kidney. Ducts being obstructed by the growth of the connective tissue (hyperplasia), the contents of the acini — the secretion — accumulate, the walls yield to the increasing pressure, and thus a cyst is formed. Hasmorrhage into such cysts, purulent trans- formation, and albuminoid degeneration, effect important changes in the contents of these cysts. Obstruction of the duct of Wirsung by a calculus, by neoplasms, by cancer of the duodenum and tumors, will cause a cystic degeneration of the whole gland. CALCULI OP THE PANCREAS.— These are concretions, consist- ing of carbonate and phosphate of lime, which have crystallized about a bit of inspissated mucus or other organic matter. To produce them there must be a catarrhal state of the mucous lining of the ducts, a change in the secretion toward an excess of its earthy constituents, or an obstruction leading to retention of the secretion. The pancreas is also liable to amyloid and fatty degeneration, and is sometimes the seat of secondary tubercular deposits. The diseases of this organ are, however, chiefly of pathological interest. DISEASES OF THE LIYER. CONGESTION OP THE LIVER. Definition. — By congestion of the liver is meant an increase in the amount of blood in the organ. Owing to the mechanical arrangement of its vessels, the circulation in the liver is influenced by the condition of the heart and lungs, by the state of digestion, and by the action of the diaphragm and abdominal muscles. It is therefore peculiarly liable to suffer from changes in its blood-supply. It may be active (malaria, excesses in eating), or passive (mechanical stasis from ob- struction at the heart or lungs). * Forster, " Lehrbuch dcr pathologischen Anatomie," Jena, 1873, p. 257. CONGESTION OF THE LIVER. 141 Causes. — The increased fullness of the portal vein and hepatic ar- tery during the process of digestion is a physiological state, which becomes pathological when excesses in eating and drinking are habitu- ally committed. The admission of irritating substances to the blood, as alcohol, highly stimulating condiments, the salts of lead, phosphorus, etc., increases the tendency to congestion. In malarious regions, con- gestion of the liver is produced and maintained by the absorption of malaria, especially when in sufficient quantity to cause febrile attacks. Without the objective evidence of malarial infection afforded by fever, the spleen may greatly enlarge (ague-cake), and the liver be kept ab- normally full of blood. Obstruction and regurgitation of the mitral orifice and of the right cavities induce abnormal fullness of the venous system, and ischaemia of the arteries. After the lungs, the liver is the first organ to suffer the passive congestion thus caused. The same result is produced when an obstructive disease of the lungs maintains congestion on the venous, and ischoemia on the arterial side of the systemic circulation. A state of the nervous system may affect the circulation in the liver to a great extent : injury of the semi-lunar ganglion causes im- mense congestion (Frerichs). Section of splanchnic nerves and the action of curare and some other poisons have the same effect. A fit of anger has brought on an attack of jaundice. Indeed, the facts prove that the nervous system, probably through the vaso-motor nerves, ex- ercises an immediate influence over the circulation of the liver, the mechanism consisting in an increased or diminished blood-supply, by paresis or spasm — by the action of the dilator or constricting fibers of this system. Congestion may also occur in consequence of sudden arrest of an habitual discharge, and has followed a successful operation for htemor- rhoids.* Pathological Anatomy. — When the congestion is the result of mechanical obstruction at the heart or lungs, the changes which are entitled " the nutmeg-liver " are seen on section of the organ. At the center of each lobule the dilated radicle of the hepatic vein, enlarged and congested, may be discerned, while the neighboring parts of the lobule are pale, and the radicles of the portal are by comparison less full of blood, and really contain less because of the increased pressure from dilatation of the central vein. On section, a greater quantity of venous blood flows out than is normal, and the whole organ is darker and larger. The hepatic cells are either normal or present in places, some cloudiness from albuminous infiltration, commencing fatty de- generation, and some brown-pigment deposition (Forster). The com- pression exercised upon the hepatic ducts interferes with the discharge * Murchison, "Diseases of the Liver," 1877, p. 134. 142 DISEASES OF THE LIVER. of bile ; and staining of the lobules about the eenti'al vein is a result, causing that appearance known as " hepatic icterus." The consistence of the liver is augmented by the congestion if it continue for a length- ened period. The bile is not changed in its composition (Frerichs), A catarrhal state of the ducts is set up as a consequence of the con- gestion, and in due course hypereemia of the portal radicles of the gastro-intestinal canal takes place, and a catarrh of the mucous mem- brane results. Long-continued hyperaemia of the liver establishes a slow atrophic degeneration of the organ, consisting in wasting and disappearance of those cells lying in contact with the dilated central vein, their places being supplied by connective tissue having a granular appearance. The disappearance of these cells and the contraction of the newly formed connective tissue cause a diminution in the size of the liver, and an increase of its density, so that this state is often confounded with cirrhosis ; but the substance of the organ has not the density, nor are there present the prominences which give the nodular aspect to the latter. Symptoms. — Acute congestion of the liver usually begins with a general malaise / aching in the limbs and back ; some slight rise of temperature toward evening ; headache ; a coated, yellowish tongue ; loss of appetite, even repugnance to eating ; nausea. More or less un- easiness, usually a feeling of weight and of tension, and tenderness, are experienced over the hypochondrium ; lying on the left side causes a veiy unpleasant sensation of weight and dragging ; buttoning of the clothing can not be borne ; and the easiest position is recumbent, with the decubitus toward the right lateral plane, so that the congested organ can be well supported against the ribs. On the other hand, many patients seek a different position and can not bear any pressure against the hypochondrium. On percussion, the area of heijatic dull- ness is enlarged in all directions. In the normal state the upper bor- der of the liver is parallel with the lower border of the sixth rib on the mammillary line — in ordinary quiet breathing ; on full expiration the liver rises on a line parallel to the fifth rib, and on full inspiration it falls to the seventh. The lower border of the liver in health cor- responds to the inferior margin of the ribs, or extends a finger's breadth below. If the liver is enlarged by hyperaemia, the hepatic dullness will extend across the epigastrium to the left hypochondrium. It is highly important to note that the area of dullness does not rejare- sent the actual size of the organ, for the thin margins do not return a dull sound on percussion. Especially will misconception occur on this point when the ascending colon is distended with gas. Again, the area of hepatic dullness may be greatly enlarged downward by altera- tions in the form and shape of the liver, when congenital, produced by tight lacing, etc., or displaced downward by effusion in the thorax, tu- CONGESTION OF THE LIVER. 143 mors, etc. Although percussion affords the most certain physical evi- dence of enlargement of the liver, inspection may afford some assist- ance in making a diagnosis, as by the eye an enlargement of the hepatic space may be discerned. By palpation, the liver may be felt project- ing below the ribs, and its smoothness or nodulation, its density and resistance, may be readily determined. By mensuration, the diameter of the two sides may be compared, when it will be found, if the con- gestion is considerable, and the atrophic change has not occurred, that the right is enlarged. A very characteristic symptom in these cases is a light grade of jaundice. If there be no recognizable tinting of the skin, the sclerotic will be distinctly yellow, and the complexion will have the so-called " muddy " aspect. The integument in the cardiac liver is somewhat earthy, faintly yellow, or fawn-color, as in various cachexise. In the acute congestion due to temperature changes, to malarial infection, to excesses in eating and drinking, etc., there is usually some gastro-duodenal catarrh, and catarrh of the bile-ducts, and consequently an obstacle to the outflow of bile, with more or less intense icterus. The urine in every case contains some pigment, and varies in tint from pale sherry to a port-wine color, and casts an abun- dant deposit of urates with much pigment matter. In the more severe cases there is considerable gastric disturbance, and vomiting of bile, and large, so-called biliou.s discharges take place by the bowels. The stools, after the ordinary fecal evacuations, consist of a greenish-yel- low or brownish matter, semi-fluid or thinner greenish or yellowish liquid having the appearance and consistence of stored-up bile. Some- times a large quantity of such material is discharged, giving great re- lief, the pain, soreness, and heaviness in the side and the headache and feverishness disappearing. Such acute cases are due to climatic, mala- rial, or dietetic causes. In the cases of congestion due to cardiac dis- eases or j)ulmonary obstruction, the symptoms of hepatic congestion come on slowly ; there occur a gradual tension and weight in the right hypochondrium, a slow increase in the size of the liver, an enlargement of the area of hepatic dullness, and, usually, a very slight appearance of icterus, combined with more or less cyanosis, producing a violet-yel- low or greenish coloration. Often, in protracted examples of this form of congestion, there exists extensive gastro-intestinal catarrh, with dis- turbed digestion, nausea, vomiting, diarrhoea, etc. In those cases of congestion of the liver due to psychical impressions, jaundice is the main symptom ; there exists really a congestion in biliary production, with more or less hyperemia, but there is no marked enlargement, tenderness, or heaviness in the hepatic area, and the patients experi- ence the sensations belonging to an intense icterus, consisting of itch- ing of the surface, depressed spirits, slow action of the heart, muddy urine, and a general yellowness or jaundice. Course, Duration, and Termination. — The subsequent behavior of 144 DISRASES OF THE LIVER. cases of hepatic congestion offers wider differences than exist in the clinical history. The cases of congestion due to obstructive diseases of the heart or lungs develop slowly and continue indefinitely, and their course and duration are those of the cardiac or pulmonary dis- ease. In these cases important alterations occur in the liver ulti- mately ; it undergoes atrophy, obstruction to the portal circulation is added to the stasis in the general venous system, and ascites slowly forms. In the acute cases due to climatic and hygienic causes, the course is short, but the symptoms are violent. The whole duration of such an attack will not be more than a week or ten days, and the termination is in health. The same causes which produce the attack will operate in the future, and other attacks will succeed, and ulti- mately, in some cases, chronic disease of the liver will be established ; but, if the causes cease, the effects will also. In the nervous cases, the jaundice reaches its maximum in a few hours, and then begins to decline, and usually lasts four or five days, terminating in re- covery. Diagnosis. — The acute form of congestion may be confounded with jaundice from catarrh of the bile-ducts, the symptoms being much the same ; but the duration of the cases differs, and the latter is preceded by symptoms of gastro-duodenal catarrh, while in the former these symp- toms succeed to the disturbance in the hepatic functions. The conges- tion due to obstructive pulmonary or cardiac disease is diagnosticated b^ its clinical history and the association of the two groups of lesions. The contraction of the liver, which succeeds to enlargement in the cases of nutmeg-liver, may be confounded with cirrhosis ; but, as these states have been confounded by pathologists, the differentiation is not important from the clinical standpoint. Treatment. — The treatment of the cases due to pulmonary or car- diac obstruction is a question of the management of the lesions, cardiac or pulmonary, as the case may be. Not unfrequently, before the heart and lungs are incommoded in mitral disease, the hepatic functions are so disturbed as to demand attention. The timely prescription of digi- talis may afford relief, not given by the remedies for disorder of the liver. As the condition is one of abnormal fullness of the venous sys- tem of the liver, relief is afforded in those of full habit by leeches around the anus. Unfortunately the need for digitalis, to diminish the leak at the miti-al and for leeches to unload the distended veins, con- tinues. Free wateiy evacuations, produced by salines, are highly use- ful ; but in the progress of this disease the congestion of the mucous membrane excites a catarrh and diarrhoea, so that the limit of utility by saline purgatives is soon reached. In the acute congestion due to climatic or malarial causes, no remedy is so efiicient as a full dose of quinia (grs. xv — 3j) with morphia (gr. ^ — |). Small doses frequently repeated may, if preferred, be employed, but the large dose is more SCLEROSIS OF THE LIVER. 145 efficient. A mild saline laxative, to keep the bowels soluble (the Sara- toga waters may be used), is necessary, and elimination by the kidneys should be maintained by the use of lemonade and diluents. Fomen- tations, turpentine-stupes, etc., applied to the hepatic region are ser- viceable. When the attacks are due to errors of diet, spirituous liquors, and similar abuses, there must be a change in the habits of the indi- vidual. Abstinence, the use of a laxative, and quiet, will effect a cure, provided the excesses have been recent, and alterations of structure have not occurred in the liver. INTERSTITIAIi HEPATITIS — SCLEROSIS OF THE LIVER— CIR- RHOSIS. Definition. — By the term interstitial hepatitis is meant an inflam- mation of the intervening connective tissue. An induration of the organ is the result of this process, and hence it is entitled sclerosis, just as this term is used for corresponding states of other organs — as sclerosis of the kidney, sclerosis of the lungs, etc. Cirrhosis is the French term derived from the Greek word hirros (red), so named on account of the color of the liver. As a very inappropriate designation, it should cease to be used. Causes. — This is a disease of adult life, and rarely occurs before the period of puberty, chiefly because the conditions are wanting at this time. Griffith reports a case in a child of ten ; Cayley, in another child of six ; and Murchison, in a boy of ten. Nothing definite as regards the cause was known in the first two, notwithstanding a searching in- vestigation ; in the other, the abuse of spirits, medicinally and other- wise, was ascertained.* Murchison has never met with an example of hob-nailed liver in which excess in the use of spirits had not been made out. There can lae no doubt that the male sex is more frequently at- tacked than the female, not because there exists any inaptitude in the latter, but because of the difference in habits. The great factor is the free use of alcoholic liquors. The amount which constitutes excess differs in different individuals ; in some subjects a small amount of alcohol, daily, suffices to set up the interstitial inflammation, when an- other person would not be affected by it in any way. It is highly probable that hereditary syphilis is a cause, but there are obvious dif- ficulties in the way of a correct determination of this point. The form of atrophy which succeeds to the chronic stasis of the liver in obstruc- tive cardiac disease is often confounded with sclerosis proper, but the change begins by an atrophy of the hepatic cells next the intra-lobular vein in the former ; whereas, in the latter, the atrophy begins in the peripheral cells. * "Transactions of the Pathological Society," vol. xxvii, 1876, pp. 186, 194, 199. 10 146 DISEASES OF THE LIVER. Sclerosis has been observed to follow impaction by gall-stones and. the paludal cachexia. Pathological Anatomy. — In the first stage, the organ is somewhat increased in size and hypersemic ; its parenchyma is somewhat denser, by reason of the presence of a viscid, reddish-gray material, which consists of fine connective-tissue elements, containing spindle-shaped cells (Forster).* The development of this material imparts to the par- enchyma a granular aspect. The color of the organ is at this period a brownish-red, whence the name cirrhosis, or it may be greenish by staining of the bile -pigment ; or the deposition of fat may give it a pallid ajDpearance. Thus far, there is an actual addition of material to the organ, and it is somewhat increased in size. The next step con- sists in the contraction of the new connective tissue and induration. The substance of the liver is distinctly harder, and, on section, the knife is resisted as if passing through fibrous tissue. The surface of the organ is unequal, nodulated, and traversed by distinct, thickened bands of connective tissue (whence the English term "hob-nailed"). The line of section presents a granular appearance, due to the contract- ing of the intervening connective-tissue elements, and the consequent forced elevation of the softer material of the lobules. The peritoneum is opaque, thickened by organized exudation, the results of local peri- tonitis, and adhesions are formed to the diai^hragm, between the liver and gall-bladder, etc. The apj)earance of the hepatic tissue is due to a hyperplasia of the connective tissue (Glisson's capsule) surrounding and compressing the groups of cells. The cells themselves, where the growth of connective tissue is sufficient to compress them, undergo a change partly fatty, partly pigmented, and in some places amyloid. The abnormal pigmentation is due to compression of the terminal ducts and stasis of the bile. The vessels of the liver are variously damaged. In those parts where the greatest destruction of cells has occurred, the radicles of the portal vein are obstructed, and the radi- cles of the sub-hepatic are also closed by compression and lose their connection with the capillaries of the portal. The hepatic artery be- comes dilated, and supplies the newly formed vessels of the recently developed connective tissue. f The important alterations occurring in the liver lead to secondary disorders of a serious kind. The interrup- tion to the circulation by closure and obliteration of many of the he- patic capillaries — portal and hepatic — necessarily causes stasis in the whole range of the portal system, including the chylopoietic viscera. The formation of bile is impaired, diminished, and at many points en- tirely su]3pressed. The glycogenic and urea-forming functions are dis- * Op. cit., p. 264. ■j- Cornil, " Note sur I'etat anatomique des canaux biliaires et des vaisseaux sanguins dans la cirrhose du foie," " Bull, de I'Acad. de Med.," " Gaz. Med. de Paris," 1873. SCLEROSIS OF THE LIYER. 147 ordered to the some extent ; consequently the depuration of the blood and the function of digestion, in so far as the presence of bile is neces- sary to the latter, ai'e hindered or prevented. Symptoms. — The initial symptoms are those of congestion — some heaviness, and dragging in the right side, and increase in volume, the liver projecting a finger's breadth below the ribs. There will be pres- ent, usually, some pain and tenderness on pressure, and now and then acute pain with a febrile movement indicative of local peritonitis. A slight icterode hue of the skin may also appear, and rarely jaundice. Again, in other cases, before symptoms referable to the liver mani- fest themselves, gastro-intestinal disorders — gastro-intestinal catarrh — occur. The appetite is poor, and food occasions distress ; there is acidity, and acid matters are regurgitated : often in the morning there are much nausea and great straining, seme acid, glairy mucus and bil- ious matter coming up after much effort. The bowels are sometimes relaxed, sometimes constipated, and now and then blackish, tar-like, semi-solid discharges occur. As intestinal hyperasmia is always pres- ent, and sero-mucus constantly poured out, diarrhoea soon comes to be the usual condition. A troublesome meteorism is a constant symptom, and this is due to decomposition of certain foods and a paretic state of the bowels. There are also cases, but rarely, in which the devel- opment of sclerosis takes place silently, and the first symptom to awaken attention is ascites. As respects size, the liver usually enlarges at first, but contraction soon comes on, and a considerable reduction takes place, the area of hepatic dullness being correspondingly re- duced. There are cases, however, in which the sclerosis takes place while the organ continues enlarged — a condition known as hypertro- phic Gclerosis. As the splenic forms a part of the portal system of veins, a constant stasis is maintained in the circulation of the spleen, and hence this organ remains swollen ; but there are variations in its size, due to the fonnation of a collateral circulation, and occasionally to the development of a sclerosis in the organ. A constant stasis is also maintained in the intestinal mucous membrane, with the results already mentioned. An attempt at compensation for the obstruction in the venous system of the abdomen is made by enlargement of cer- tain communicating veins, which in health are but slightly auxiliary to the regular route of communication. On the surface of the abdo- men, from the xiphoid appendix to the pubis, veins appear, which were previously invisible ; they are the communicating veinules between the epigastric and internal mammary, forming an irregulai', feather- shaped figure ; interlacing vessels also form along the rectus muscle, laterally ; communication is established between the parietal veins and the accessory vena porta of Sappey, and those branches of this acces- sory portal, communicating with the epigastric and internal mammary veins, foi-m a cushion, bluish in color, of distended vessels around the 14S DISEASES OF THE LIVER. umbilicus (caput Medusae) : communication also takes place between the inferior mesenteric and the hypogastric veins, through the hsemor- rhoidal, and between the anastomoses of the portal with the oesopha- geal and diaphragmatic veins. Haemorrhages result from the stasis — hsematemesis or vomiting of blood, and intestinal haemorrhage ; the vessels yield under the in- creased pressure ; or thromboses form in the stomach-veins, solution of the affected mucous membrane occurs, and an ulcer is the result. The author has seen two cases of cirrhosis in which frequently recur- ring hsematemesis caused death, the haemorrhage coming from small ulcers in the vicinity of the pylorus. The black, tar-like stools which are passed now and *then in contracted liver consist of blood altered by the intestinal juices. The same obstruction of the portal circula- tion leads to tbe formation of haemorrhoids, which often bleed freely and thus afford relief. Besides the interference with the digestive function due to the"gastro -intestinal catarrh, the solution and absorj)- tion of certain kinds of food are prevented by the absence of the bile. These are especially the fatty and saccharine matters, and bile has the peculiar property of aiding the absorption of fats. Further, it plays the part of an antiseptic agent, and prevents the decomposition of food in the small intestine : when bile is absent the faeces are not only want- ing in the proper color, but they have a peculiarly fetid odor — the odor of decomposition — and the gas passed has the same foul smell. A gradual emaciation is the necessary result of this morbid condition of the intestinal digestion. The integument of .the face, neck, and fore- arms acquires a peculiar, earthy, icteroid hue, but a real jaundice is not common in cases of sclerosis. Sometimes with the first conges- tion, which initiates the morbid process, jaundice is a symptom, but it soon disappears and the earthy, fawn color, so characteristic in these cases, gradually develops. In those cases of sclerosis succeeding to impaction by gall-stones, jaundice has been a prominent symptom. When the cells have atrophied, and the canaliculi are obliterated, re- sorption of bile is no longer possible. The very considerable inter- ference with the process of digestion produced by sclerosis and the retention in the blood of those effete materials which it is the func- tion of the liver to remove induce an unhealthy condition of that fluid, and hence venous stigmata appear on the face and nose, and bleeding occurs from the nose, lungs, peritoneum (peritonitis haemor- rhagica), and elsewhere.* The urine is small in quantity, high colored, brownish, deficient in urea, but loaded with urates which are deposited in great abundance along with much coloring matter. Q^^dema of the feet and ankles succeeds to ascites, and the genitalia become much swollen. But the clinical history and treatment of ascites have been sufficiently discussed. * "Thfese de Paris," 1814:, Azmi Ahmed, "Des heraorrhagies dans la cirrhose." SCLEROSIS OF THE, LIVER. 149 Course, Duration, and Termination. — The course of interstitial hepa- titis is essentially chronic. The first stage, or period of congestion and enlargement, often escapes notice, and only the stage of contrac- tion, with its accompanying accidents, comes under observation. The duration is not fixed, and the termination is governed by the extent of the contraction and the consequent interference with function, but especially by the existence or appearance of such complications as mitral disease, emphysema of the lungs, and chronic interstitial nephri- tis. Fibroid change, such as occurs in sclerosis of the liver, may mani- fest itself simultaneously in other organs, as fibroid lung, fibroid heart, fibroid kidney. Obviously, the course and duration of the hepatic dis- ease will be much influenced by the coexistence of this form of degen- eration in other organs. Toward the end of some cases, brain symp- toms arise which were at one time supposed to have the same relation to retention of effete products removed by the liver in the normal con- dition as the cerebral symptoms in albuminuria had to the failure of kidney excretion. By Flint this toxic material is supposed to be cho- lesterine, and hence the term cholestersemia which be applies to these cerebral symptoms. This condition of the brain takes the form of stupor, and low-muttering delirium, passing into deep coma. In a few cases sopor and gradually deepening stupor come on early. These mental symptoms are, however, mixed up with the perturbation due to alcoholic excess, so that it is impossible to assign to each factor its proper influence in the development of this state. A large proportion of cases end before these mental symptoms are reached, cut off by in- tercurrent maladies, such as pleuritis, pericarditis, pneumonia, etc., or die exhausted by haemorrhage. Some cases proceed to a typical end- ing by gradual failure, worn out by the difficult breathing from exces- sive accumulation of fluid, the constant upright position, the ulcerated legs, the bleeding haemorrhoids, repeated tapping, stupor, delirium, and gradually deepening coma. Diagnosis. — When all the usual symptoms of sclerosis are present, and the subject of them has been given to alcoholic intoxication, there can be no difficulty in coming to a diagnosis by exclusion. Further- more, sclerosis is greatly more frequent than any of the diseases with which it may be confounded. The difficulties of differentiation occur with pylephlebitis, fatty liver, hydatid cysts, cancer or tuberculosis of the peritoneum. In pylephlebitis or inflammation with thrombosis of the portal vein, there may be present the same symptoms as in sclero- sis, but they arise suddenly, and are not preceded by the symptoms of congestion and a history of alcoholic abuse. Fatty liver is one of the complications of phthisis, and also occurs in the obese, or in those hav- ing the tendency to obesity and who eat and di-ink freely and. lead sed- entary lives. Although the symptoms referable to the liver are similar to those which are present in sclerosis, there are important points of 150 DISEASES OF THE LIVER. difference. In fatty liver emaciation is wanting ; the organ is enlarged and smooth, instead of being contracted and nodulated. In hydatid cyst, there is a slow, gradual, and painless enlargement, with but little interference in the function of the liver, and without the secondary gas- tro-intestinal disorders. On palpation, a large, soft, elastic growth can be made out, and having that peculiar symptom, the "purring tre- mor." These symptoms are all wanting in sclerosis. Cancer differs from sclerosis in that the pain is greater, the wasting more rapid, the liver presents large protuberances, and secondary deposits in the mes- entery can be felt in advanced cases. Cancer and tubercle of the peri- toneum are accompanied by symptoms much like sclerosis. They may be differentiated by attention to the following points : In sclerosis, there is enlarged spleen ; the urine is deficient in urea but contains leu- cin and tyrosin, and casts an abundant deposit of urates and coloring matter ; in cancer or tubercle, the spleen is not enlarged ; the urine contains its proper proportion of urea, and is pale and watery. In can- cer or tubercle of the peritoneum, there is great tenderness of the abdomen ; the ascites develops quickly ; the strength and flesh rapidly decline, and there are usually cancer or tubercle deposits in other organs. Prognosis. — The course of sclerosis is usually continuously down- ward, and hence the prognosis is unfavorable. The author believes that the opinions as to its incurability, based on experience, must be somewhat modified now, in view of the results of modern treatment. Treatment. — At the outset the author must condemn the use of mercurials given with a view to correct the hepatic secretions. The secretory function is disturbed, because the liver-cells have atrophied and the ducts are closed. When this result is reached, no treatment can modify the case, for remedies can not restore lost parts. Before important changes have occurred, although new connective tissue has formed, and some contraction has taken place, the author believes that much may be done to arrest the morbid process. There is a group of remedies which have a selective action on the liver, the metals chiefly: gold, silver, copper, arsenic, mercury, and phosphorus, which have the property of improving the nutrition of the liver if used in a small quantity for a long period. The most eflicient of these are the chlorides of gold and sodium, the corrosive chloride of mercury. Fowler's solu- tion, and phosphorus in the form of phosphites or phosphates. When there is much irritability of the gastro-intestinal mucous membrane, two drops of Fowler's solution, with two to five drops of opium tincture, three times a day, will be most easily borne. If there is less imtabil- ity, the chloride of gold and sodium (^^ gr.), or corrosive chloride of mercury (^Jy gr.), ter m die, can be administered. No good result should be expected unless the remedies are kept up for several months. The author has seen surprising results by the long-continued use of ABSCESS OF THE LIVER. 151 sodium phosphate in these cases — given in 3j— 3 j doses three times a day. The good effects of both remedies may be obtained by joint administration — the phosphate in solution, the chloride in pill form. When it is considered desirable to give phosphates and arsenic to- gether, phosphate of soda and arseniate of soda may be combined. If there is a suspicion of syphilitic taint, the iodides of potassium and ammonium and the bichloride of mercury are the appropriate medica- ments. The mineral acids, which at one time were supposed to be effi- cacious in the treatment of this hepatic disorder, are now rarely em- ployed, except to facilitate digestion. The nitro-muriatic bath is a serviceable topical application, especially the general bath, to improve the condition of the skin, which is dry, harsh, and scurfy. Attention to the diet is of the first consequence. Fats and saccharine foods, not undergoing solution and absorption, decompose and add to the existing mischief. The continued use of skimmed milk freely is a dietectic measure of the highest importance. Those components of a diet con- vertible into peptones should be directed, and the most easily digest- ed substances only. When ascites forms, it must be treated according to the principles already set forth under that head ; the activity of the kidneys must be maintained, and puncture practiced according to ne- cessity. LOCAL PARENCHYMATOUS HEPATITIS— SUPPURATIVE HEPA- TITIS—ABSCESS OF THE LIVER. Definition. — The hepatitis which terminates in suppuration is local- ixed to a special part, and the rest of the organ, outside the area of suppui-ation, continues comparatively normal. It is a parenchymatous inflammation in that the proper structure of the organ — the gland-cells — is the seat of the inflammatory process. It is a suppurative hepatitis, in that the tendency is to the formation of matter, and the resulting ab- scess is the special feature demanding attention. Murchison makes an appreciative distinction between pyaemic and tropical abscesses — the former, a result of blood-poisoning ; the latter, caused by inflamma- tion of the liver. It is the latter form which is intended by the term suppurative hepatitis, but the post-mortem changes and the clinical history, so far as the liver itself is concerned, are the same in the two forms. Causes. — External injury but rarely excites suppurative inflamma- tion, and a blow on the right hypochondrium will more frequently cause an inflammation of the hepatic peritoneum than of the hepatic substance. Blows are more apt to cause abscess of the liver in warm than in cold countries. Climate is one of the principal factors.* A * Sachs, " Uebcr die Hepatitis der heissen Lander," Berlin, 1876. Separat-Abdruck aus von Laneenbeck's " Archiv," Band xix. 152 DISEASES OF THE LIVER. warm climate, an alluvial soil, and miasmatic influences, are more influ- ential in combination than climate alone. Abscess of the liver is very common in the great interior valley of North America — along the Mississippi and its tributaries, within the malarial area — as it is in India, and because of the same etiologic and climatic conditions. Without producing the objective phenomena of fever, malaria dis- turbs the hepatic functions, but the disturbance is still more decided when the poison is intense enough to cause fever. Dysentery and ulceration of the intestines have so frequently coincided in appearance with, or have preceded, abscess of the liver, that a causal relation is sup- posed by many to exist between them. In the interior valley of this continent, at Cincinnati, the author saw many cases which had succeeded to attacks of malarial fever, and to dysentery— especially proctitis — the lesions of which are situated chiefly or wholly in the rectum. Fre- richs,* Murchison,f and some other systematic writers, after a thorougli examination, maintain the opposite view, that the supposed relation be- tween abscess of the liver and dysentery is merely coincident, and is not causal. Waring's | statistics seem quite conclusive against the view that such a relation exists : thus, " out of 2,758 cases of dysentery treated in the Madras Presidency, abscess of the liver occurred 68 times, being in the proportion of 2^ per cent, nearly." In the same author's 300 cases of abscess of the liver, " hepatitis was the j)rimary affection in 131, or 43 per cent., while only 82, or 27 per cent., were admissions from dysentery." Budd § holds that a poison generated in the intestine by the decomposition of materials from ulcerations is the chief factor in the causation of abscess. Moxon || also maintains that "almost all tropical abscesses are secondary to dysenteric or other ulcerations, and that primary abscess of the liver is at least as doubtful as primary suppuration of the brain." The concurrence of hepatic abscess and dysentery is too frequent not to be related in some way ; it is clear that many, but probably not a majority, of the cases thus originate, and, when so caused, the abscesses are pygemic, multiple, and secondary. Large abscesses of this kind are due to the coalescence of neighboring smaller ones. A large number are doubtless due to hepatitis — the so- called tropical abscesses. A variety of causes are concerned in the production of others. The habits of individuals are not without influ- ence, especially the use of stimulants, highly seasoned dishes, condi- ments, etc. Suppuration has been caused by the impaction of calculi, * " Diseases of the Liver." Translated by Murchison. Syd. Soc, vol. ii, p. 108. f " Clinical Lectures on Diseases of the Liver," etc. Second edition, p. IVY. X " An Enquiry into the Statistics and Pathology of some Points connected with Ab- scess of the Liver, as met with in the East Indies." By Edward John Waring. Trevan- drum, 1854. § " On the Diseases of the Liver," p. 83, et seq. \ " Transactions of the Pathological Society of London," vol. xxiv, p. 116, 18Y3. ABSCESS OF THE LIVER. 153 by the lodgment of a liimbricoid worm, etc. It is a more common malady in men than in women, and from the twentieth to the thirty- fifth year. A case is reported by Grainger-Stewart, in which abscess of the liver followed dilatation of the bile-ducts.* Pathological Anatomy. — That a certain projDortion of cases of hepatic abscess are due to embolic deposits, coincident ulcerations existing in the intestine, is probably true, but the facts of observation which support this theory are surprisingly few. Frerichs f reports one of embolic blocking of a vessel at the site of a commencing abscess, and a few others have been recorded. Forster J holds that a miasmatic infection of the blood is caused by the ulceration in the intestine. Whether it be due to such infection, or to the formation of a thrombus and subsequent embolic blocking of a veinule of the liver, or to hepa- titis, or to any other cause, the initial lesion is a hyperoemia of the hepatic cells at the site of the abscess. The cells become cloudy and granular by the presence of an albuminous matter deposited in them. Liebermeister maintains, but he is alone in this opinion, that the initial change is in the connective tissue ; but Rokitansky, Virchow, Frerichs, Forster, and others, refer the first changes to the cells of the hepatic parenchyma, and the alterations in the connective tissue to a subse- quent period. Those parts of the hepatic parenchyma in which the liver-cells are undergoing disintegration, at first have a reddish-yellow appearance, and at some points contain patches of pigment of a bright yellow color, and are surrounded by a translucent pale-gray ring. The acini, the seat of this process, are distinctly enlarged, become softer, and disintegrate. The center of each inflamed patch early becomes yel- low, which indicates the beginning of suppuration. The size of these points of suppuration is at first small, but those in close proximity coalesce, forming an abscess — a purulent collection. These abscesses are filled with pale-yellow pus, and the borders of the collection con- sist of dark-red, disintegrating gland-tissue, projecting in the form of softening shreds into the purulent depot. They vary in size from a pea to a hen's egg, or may attain much larger dimensions. Important changes take place in these purulent collections as they grow older : the walls become smooth, and are lined by connective tissue, the pus thus becoming encysted, or absorption occurs, the walls of the abscess approximate, unite, and ultimately nothing remains but a linear cica- trix. So perfectly does repair go on and is completed, that in some years afterward scarcely a trace of the original mischief can be de- tected. In other cases no limiting membrane is produced, the inflam- * T. Grainger-Stewart, " The Edinburgh Medical Journal," January, 18Y3. f " Diseases of the Liver," op. cit. X " Lehrbuch der pathologischen Anatomie von Dr. August Forster." By Dr. Siebert. Jena, 1873, p. 26*7. 154 DISEASES OF THE LIVER. mation extends, and an enormous purulent collection, which tends to external discharge in some direction, is formed, and enlarges by con- tinual accessions of purulent matter. It does not often happen that such a collection bursts into the peritoneal cavity, exciting fatal peri- tonitis, but it tends to perforate the abdominal wall, or dissects down- ward along the spine, discharging in the inguinal region or by the sa- crum posteriorly, or it ulcerates through into the stomach, duodenum, or colon, or makes its way upward, perforates the diaphragm, the lungs, and is discharged through the bronchi. These abscesses have also entered the vena cava (case of Colin *), have ulcerated into the pericardium, etc., but such accidents are comparatively rare. The size of an abscess of the liver varies from an ounce or two to a gallon. In 69 cases in which this point was noted, 16 contained one to two pints, and 12 two to three pints ; and these may be regarded as of the usual sizes. As respects limitation by a neo-membrane, the cases are not numerous in which definite statements are made ; in 53 the abscesses were encysted in 36 and not limited in 17, but it is doubtful if this relation exists throughout a large number of unse- lected cases. Of Waring's 300 cases, 169, or somewhat more than one half, remained intact ; of the remainder, much the largest number of the spontaneous discharges occurred by the thoracic cavity — 42 — and of these 28 occurred through the right lung. As respects the lobe of the liver, which is usually the seat of the abscess, the statistics of vari- ous observers agree. Selecting Waring's 300 cases for exemplification, we find that the purulent collection was in the right lobe, alone, in 163, and in both right and left in 35, The number of abscesses present at the same time is influenced greatly by the cause ; in the pysemic, there may be a dozen or more ; in the other form, from one to three usually. Although fetid decomposition is not uncommon,f yet true gangrene is very rare. Symptoms. — Notwithstanding the importance of the organ, abscess of the liver of considerable size may exist without there being any local or systemic symptoms to indicate its presence. These latent cases occur in the course of chronic dysentery and pyremia, and fail of recognition because masked by existing symptoms, or they are latent because the inflammation occurred in the deepest part of the right lobe^ and did not involve the peritoneum, nor did the abscess compress the bile-ducts, and was limited by a neo-membrane. A typical case fol- lowing a recognized injury, or due to impaction of calculi, will present characteristic symptoms, and the diagnosis will be easy, but many other cases may not only be diflicult of recognition, but in some a diagnosis will not be possible. The onset is marked by the phenomena which attend an inflamma- * "Gazette Hebdomadaire de Med. et dc Chir.," No. 33, 1872. f Rigal, "L'Uuion Med.," No. 134, 18Y3. I •ABSCESS OF THE LIVER. I55 tory affection ; a chill, or chilliness, aching of the back and limbs, head- ache, a drj' skin, a coated tongue, bilious vomiting, increased action of the heart, a rise in the arterial tension, are the systemic symptoms. Locally, there is a feeling of uneasiness, constriction, weight, dragging, and often considerable pain and tenderness, especially if the hepatic peritoneum is involved. In some cases a pain is felt in the to]) of the shoulder — a tensive pain — and it is experienced in the right shoul- der when the right lobe is affected, and in the left shoulder if the left lobe is the seat of mischief, and in some cases in both simultane- ously. Its value as a symptom is not great, for it is present in other hepatic diseases, and may be a merely rheumatic or neuralgic pain. On palpation and mensuration, an increase in the size and density of the liver can usually, but not invariably, be made out. The area of hepatic dullness is increased in all directions, and may be considerably so if the purulent collection is a large one. Pushing up the diaphragm and displacing the lung, the area of dullness and the absence of voice and breath sounds may extend up to the fourth, to even the lower margin of the third rib, and downward several finger-breadths below the margin of the false ribs, furnishing all the signs of hydropneurao- thorax.* Jaundice is present in less than one third of the cases, and then varies much in intensity, but it is general, and the urine is loaded with bile-pigment, and, when the liver is much damaged, contains leucin and tyrosin instead of urea. Jaundice appears early in those cases of ab- scess due to the impaction of calculi — soon after or with the initial symp- toms, which are those of hepatic colic — and much later in those which are the usual cases, due to the pressure, on the hepatic duct, of the ab- scess. When pus forms there is usually a decided rigor, and these shiv- erings recur irregularly, and are followed by fever and sweats. Like the other characteristic symptoms, these are often entirely absent. The fever, chills, and sweats are much more pronounced in the so-called pyjemic abscesses than in those arising from hepatitis. The irritability of the stomach is enhanced by the occurrence of suppuration ; the fre- quency and persistence of the vomiting at this period is an important indication, much insisted on by Maclean f and Fayrer.;^ The vomiting may have the bilious character, with a large evacuation of bile, and the alvine dejections may have the same character ; the vomit may consist of watery mucus, and, rarely, of blood. There will be an increase of the dysenteric symptoms, if this disease had been in existence when the abscess formed, or diarrhoea or dysentery may occur when suppura- tion takes place. The size of the liver lessens somewhat, and the area of hepatic dullness diminishes when pus forms, if the abscess be in- * Rigal, "L'Uuion 5Ied.," Xo. 134, 1873. f " The Diagnostic Value of Uncontrollable Vomiting." Dr. W. C. Maclean, " British Medical Journal," August 1, 18*73. X Sir Joseph Fayrer, ibid., September 26, 1873. 156 DISEASES OF THE LIVER. closed ; but, if no limiting membrane is formed, the dimensions of the organ gradually enlarge. The diminution in size is maintained, and a gradual return to the normal is the rule, when the pus is ab- sorbed and the cavity cicatrizes. Fluctuation is felt and can be de- tected only when the purulent collection attains to great dimensions. If the abscess tends to spontaneous recovery by absorption, or after discharge of pus, the local pain and tenderness subside, the pulse falls to the normal, the stomach is no longer irritable, appetite returns, and digestion is resumed. If, however, the abscess enlarges, the distress in the hepatic region and the tenderness increase ; movements, esj)ecially of breathing and coughing, awaken deep-seated soreness and pain ; breathing becomes difficult by pressure on the lungs ; the heart is some- times displaced upward and to the left, which adds to the existing pr^ecordial uneasiness and to the difficulty of breathing ; and a harass- ing and painful short, dry cough, induced by irritation of the pneu- mogastric and phrenic nerve-filaments, adds greatly to the distress. As a tendency to discharge through the right lung exists in a large proportion of cases, the base of this lung and the neighboring pleura are affected by a localized i^leuro-pneumonic process, with the usual physical and rational signs of that complication. Adhesion of the pleural surfaces takes place, and a channel is formed communicating with a bronchus, through which discharge occurs. Less often a sec- ondary suppurating cavity is constructed by the pleural adhesions. Rarely the pericardium is opened, and death caused by sudden disten- tion of the sac with pus. If riipture takes place into the peritoneal cavity, this untoward accident is announced by sudden, intense pain and collapse ; if into the intestine, purulent and bloody evacuations indicate it, while lessened size of the liver and less tension and pain also coincide; if the pus dissects outwardly through thehypochon- drium, a large, puffy, and fluctuating tumor forms. The variations in the symptoms of hepatic abscess are very re- markable. There may be no local symjDtoms — no pain, no tenderness, no enlargementr "When the purulent collection tends downward below the ribs, there may be fluctuation, and when it has attained to great dimensions ; but it is a comparatively rare symptom. In much the largest number of cases, the pus forms in the ujDper and superior part of the right lobe, in a situation where fluctuation can not be developed. Pain may be entirely absent : in ^Taring's 300 cases of hepatic abscess, pain was not present in 20. The reflex shoulder-pain is much less con- stantly experienced ; it is more frequently wanting than it is felt. Gastric derangement of any kind may not exist, and the patient may have a good appetite. The importance of severe vomiting as a symp- tom of suppuration is not impaired by the fact that exceptional cases are encountered, but vomiting and severe and uncontrollable vomiting are highly significant, andvery rarelyabsent. Vomiting is increased by ABSCESS OF THE LIVER. 15Y extension of disease to the peritoneum, and by pressure of an enlarging abscess directly upon the stomach. Although the bowels may be un- disturbed in exceptional cases, dysentery is present in a considerable proportion — according to Waring, in 82 in 300 cases — but dysentery sometimes succeeds to the abscess, and is apparently caused by it. As- cites occasionally occurs when the abscess compresses the portal, and jaundice usually accompanies it, for the common or hepatic duct is en- croached on at the same time. Course, Duration, and Termination.— So much obscurity exists in regard to the initial symptoms, so much variation in the behavior of cases, that no defined course can be laid down. The duration is equally uncertain and irregular. A typical case without complication may pass thi-ough its several stages in about seventy days if the pus is discharged by a favorable channel; if the pus undergoes absorption, and the cavity closes by cicatrization, several weeks longer will be necessary. The initial symptoms will occupy less than a week, for suppuration appears in a short time after the hyperoemia, and the breaking down of the he- patic tissue proceeds rapidly, so that an abscess of considerable size will form in seven to ten days. Then comes on a period of septicaemic fever — remittent in type, with irregular sweats, in the acute cases with ab- scess of large size, and intermittent with long periods of freedom from fever in the subacute and chronic cases, with abscess of moderate size. The course of abscess of the liver is much affected by the development of a limiting neo-membrane. When this membrane is formed, if no complications are present, there may be a "latent period" of consider- able duration — a period characterized by the absence of local and sys- temic symptoms. This quiescent state may continue several weeks, months even ; then acute symptoms arise, which are often misinter- preted, and supposed to be the initial symptoms, and the abscess formed, the product of the recent disturbance. If, on the other hand, there is no limiting membrane formed, and the suppuration extends, the septi- caemic fever persists, and the patient sinks into a typhoid state, with low-muttering delirium, and death from exhaustion. Cases of acute abscess without complication, discharging in a favor- able direction, recover with considerable promptitude. Early and suc- cessful use of the aspirator for the evacuation of pus shortens the du- ration of a case materially. Convalescence is very tedious when fistulous communication exists through the lungs, the parietes of the abdomen, and elsewhere. The author has met a case of fistula of the right hy- pochondrium discharging somewhat after eighteen months. During the existence of such purulent formation and discharge, night-sweats, diarrhoea or dysentery, a poor appetite, and feeble digestion combine to maintain a condition of debility for a long time, or there may be a continuous, gradual failure, terminating in exhaustion and death. In the acute cases which terminate fatally there are usually intense hectic, 158 DISEASES OF THE LIVER. profuse sweats, uncontrollable vomiting, and rapid failure of the vital powers. The cases associated with dysentery are very protracted and very fatal ; they rarely cicatrize, and less frequently discharge exter- nally than do the uncomplicated cases (Frerichs). The condition of patients who recover is not always that of health. Very often the in- testinal digestion is impaired because of the insufficient supply of bile, and the functions of the stomach and intestines are interfered with by adhesions and contracting bands of lymph which limit the movements of these organs and narrow their capacity, or obstruct the passage of their contents. Prognosis. — How favorable soever may be the apparent condition in any case of hejiatic abscess, the prognosis must be guarded, for un- expected complications may arise, and the known dangers are uncer- tain in their behavior. The pyasmic abscesses are more numerous, are due to a poisoned state of the blood, and are always fatal. The direc- tion taken by the abscess is an important element in coming to a con- clusion ; discharge by the lungs is most favorable ; by the external in- tegument the next, and by the intestinal canal, third. Early evacua- tion by the aspirator lessens materially the dangers and must enter into the question of prognosis. In eighty-one cases of hepatic abscess evacuated by operation, collected by Waring, there were fifteen recov- eries — 18'5 per cent. In McConnell's,* fourteen cases in which the aspirator was used, six died and eight recovered — fifty-seven per cent. Both sets of statistics were gathered in India, but the former were cases which occurred before 1850, and the latter since the aspu'ator came into use. Of twenty-five caSes of recovery without interference, also by Waring, there were ten in which the matter was discharged through the lungs, and seven by stool. The size of the abscess, its position, the condition of the patient in resj^ect to digestion and nutri- tion, and especially the presence or absence of complications, are ele- ments which must be taken into consideration in coming to conclu- sions. Diagnosis. — Hepatic abscess may be confounded with echinococcus of the liver, dropsy of the gall-bladder, scirrhus, abscess of the ab- dominal wall, efi^usions, especially purulent, into the right thoracic cavity, etc. A tumor or enlargement formed by echinococci is unaccompanied by pain or tenderness, the growth is slow and without constitutional disturbance, when palpated is elastic, fluctuating, and furnishes that most characteristic sensation, "the purring tremor." An abscess of such a size would be accompanied by pain, tenderness on pressure, by septicaemic fever, at least frequently ; there would be wasting and diarrhoea, often severe vomiting, and the sense of fluctuation would * Eemarks on pneumatic aspiration with cases of abscess of the liver treated by this method. "Indian Annals of Medical Science," July, 1S72. ABSCESS OF THE LIVER. 159 be free from purring tremor. The very important aid to diagnosis afforded by the exploring trocar should not be neglected, and its indi- cations may indeed be decisive. The fluid of an abscess is purulent, and, if hepatic, contains portions of the tissue of the liver ; * if of a hydatid cyst, a straw-colored, serous fluid, containing the character- istic echinococcus booklets. An enlarged gall-bladder is a pyriform tumor of variable size, elastic and fluctuating when its contents are fluid, or hard and nodular when enlarged by calculi. When the ac- cumulation is a product of the metamorphosis of bile and mucus, the growth is very slow, and the symptoms nil — a very different history from that of abscess ; on the other hand, a purulent fluid forming, will be accompanied by hectic, sweats, emaciation, etc., and a differentia- tion is not possible. In cases of this kind there has been a history of attacks of hepatic colic ; the last one having determined the series by a closure of the cystic duct. Abscesses of the abdominal wall of large size, and situated in the right hypochondriura, may be very confusing, but the distinction may be made by the history, which does not in- clude any disturbance in the hepatic functions, and has not been pre- ceded by any symptoms of disease of any kind. The history begins with the formation of a tumor in the hypochondrium. The most cer- tain means of diagnosticating consists in the microscopic examination of the purulent matter, and in determining by the passage of the aspi- rator needle that the pus is contained in an abscess exterior to the ribs. It is impossible to decide between an hepatic abscess and an abscess formed between the hepatic and parietal peritoneum, which may be the result of a local peritonitis, or of an hydatid cyst undergoing de- struction by suppuration. Multiple abscess of the liver has been mis- taken for cancer of the stomach.f The pain, vomiting, wasting, may mislead, but the marked difference in the history of the two affec- tions, as well as the local symptoms, ought to prevent such an error. The most difficult problem in the diagnosis of hepatic abscess is the distinction between abscess and empyema, or hydrothorax. Besides the evidence of the accumulation of fluid filling in the space from the diaphragm to the fourth, even to the third rib, there are almost always present the symptoms of a pneumonia in preparation for the evacua- tion by the lung. The physical signs will be the same, but the his- tory of the case will exhibit important differences : in the one case the accumulation of fluid will have been preceded by the signs and symp- toms of pleurisy or pleuro-pneumonia ; in the other, by the signs and * Dr. Samuel Fenwick, "Lancet," November lY, 187*7, "On the Detection of Particles of Hepatic Structure in Abscess of the Liver." The pus is shaken up with some distilled water and put aside in a conical wineglass. When settled, it is examined with the mi- croscope, or it is shaken up with some distilled water to which a few drops of ammonia have been added, and then, after subsidence, examined. f Dr. W. Crumb, "Philadelphia Medical and Surgical Reporter," March 14, 1873. 160 DISEASES OF THE LR^ER. symptoms of hepatic inflammation. Here, again, the aspirator may be invoked to make the diagnosis clear — the presence or absence of bits of hepatic tissue will prove the abscess to involve, or not, the liver- substance. Treatment. — As suppuration occurs so promptly after the initial hypersemia, it is doubtful whether any effort to prevent the formation of pus can be successful, but the extension of the area may be checked or limited. As soon as the symptoms manifest themselves, a large dose of quinia (twenty grains) should be given at once, and decided cinchonism be maintained by the same dose at proper intervals, or by smaller doses more frequently. That quinia has the power to check the migration of the white corpuscles is well established, but it is equally true that large doses are necessary to accomplish this. Mor- phia should be combined with it, unless some contraindication exist, and especially if there be much pain and the peritoneum be involved. Warm fomentations and turpentine-stupes should be applied over the right hypochondrium. At the earliest moment when the existence of pus can be made out, or there are good reasons to suspect its presence, an exploratory puncture with the aspirator should be made. The re- cent experiences of Cameron,* Condon, f and Sachs J have demon- strated that when the pus can be reached and evacuated a very large proportion of eases recover immediately. It is a remarkable fact that many cases in which the symptoms of abscess exist, and yet no pus is found, are greatly benefited by the puncture. The modern experiences have demonstrated also that, penetrated by suitable needles, no injury is done to the liver, and that repair takes place so perfectly that after death no trace of the operation is visible. The necessity for early evacuation of the pus consists in this, that only a portion of these ab- scesses are confined by a limiting membrane, and that those thus re- stricted do not long remain encapsulated, but tend to make their way externally. In Condon's collection of cases there were eight of abscess evacuated by the trocar, of which four recovered, and three of heija- titis, without suppuration, in which the trocar was inserted deeply in the right lobe, all of which were much relieved by the puncture and promptly cured. In Sachs's collection of twenty-one cases there were eight recoveries after puncture — being in the proportion of thirty-eight per cent. Under the old system of using the knife or trocar, when the pus was already pointing, as represented in the statistics of Waring, there were sixty-six deaths in eighty-one cases, making the percentage of recoveries 18'o. When the abscess is large, and repeate'd punctures * "The London Lancet," 1863, June 6th and loth— "On the Treatment of Acute Hepatitis in its Suppurative Stage." f Ibid., August, 1877, Dr. E. H. Condon — "On the Use of the Aspirator in Hepatic Abscess." ^ " Ueber die Hepatitis der heissen Lander," etc., von Dr. Sachs in Cairo, op. cit. ACUTE YELLOW ATROPHY. 161 are necessary, the author has had excellent results from the injection of tincture of iodine ; it lessens the formation of matter and prevents its decomposition. Mercury was formerly much used in all hepatic affections, but that it is injurious in abscess is now disputed by no one. It is probable that the sulphides, so much and successfully employed in external suppuration, will be found adapted to the treatment of hepatic abscess. The sulphides of sodium and calcium and the sulphurous mineral waters are suitable agents to be so exhibited. As the vital resources of the patient are severely strained, the strength should be carefully husbanded from the beginning. The diet must be generous, and stimulants judiciously administered. When suppuration has oc- curred, the alcoholic stimulants must be given freely. For the dysen- tery present in so many cases, ipecac is the best remedy, if prescribed in the necessary quantity — 3j every three or four hours. If thei'e are present old ulcerations of the intestinal tract, copper sulphate is an efficient remedy ; but usually the astringents in turn will be adminis- tered in vain. GENERAL PARENCHYMATOUS HEPATITIS— ACUTE YELLOW- ATROPHY. Definition. — As the hepatitis terminating in suppuration is con- fined to a part of the liver, it has been designated Local Parenchyma- tous He]Datitis, while the term General Parenchymatous Hepatitis is applied to Acute Yellow Atrophy, which consists in an acute diffused inflammation involving the whole organ, and terminating in atrophy. Various names have been applied to this disease, as " malignant jaun- dice," " typhoid icterus," " hsemorrhagic icterus," etc. Causes. — Various theories have been proposed to account for the origin of acute yellow atrophy. It has been referred to an excess in the production of bile, to stasis of the bile, to sudden saturation of the hepatic cells with biliary matters contained in the blood of the portal vein. Budd supposes it to be caused by some special blood-poison of unknown nature, which acts especially on the liver. These hypotheses are without facts to support them. That it is an acute, diffuse, paren- chymatous inflammation is established by the most recent investiga- tions, but the exciting cause of this inflammation remains unknown. That it is in the nature of a specific morbid poison seems probable, since other organs are simultaneously attacked. There are certain points in the etiology of the disease, however, which are well known ; it occurs most frequently in the female sex, and during the state of pregnancy. According to the statistics of Frerichs, in thirty-one cases of this disease twenty-two were females, and one half of these were attacked during the state of pregnancy. It occurs from the third to. the sixth month of pregnancy, and in comparatively young subjects, 11 162 DISEASES OF THE LIVER. under forty, and rarely indeed after thirty years of age. Other causes have been supposed to exert an influence in its production : as anger — a violent passion having been the apparent cause in cases reported by the older writers — venereal excesses, syphilitic infection, and local miasms. Acute atrophy of the liver has been induced by the changes resulting from typhus fever. A condition analogous to it is brought aboiit by the action of phosphorus, arsenic, antimony, and certain other minerals, and a similar state has been induced by subacute alco- holismus (Rendu). Pathological Anatomy. — The liver presents a most characteristic appearance — it is much smaller, flattens out by its own weight, is soft so that it tears easily, and has a uniform yellow color. The peritoneal layer is roughened and wrinkled. On microscopical examination, the changes seen are those due to interstitial and parenchymatous exuda- tion. There is, at first, an hypersemia, traces of which are discoverable at various points, the rest of the organ being ansemic, a result of the subsequent atrophy and obliteration of vessels. Between the lobules there is deposited a grayish-yellow material, which widens the inter- lobular space, and in those cells which are still recognizable is con- tained a quantity of an albuminous and fatty matter mixed with pig- ment.* In the place of the disintegrated cells there is formed a quan- tity of brownish, fatty granular matter ; fat-globules ; pigment ; bac- terian colonies, f and needles of tyrosin and leucin. The ultimate radicles of the portal system and the hepatic artery are obstructed or obliterated. The kidneys also undergo characteristic changes, espe- cially in the cases occurring in pregnancy. The organs are thoroughly stained by the icteric urine, especially the endothelium of the tubules, and besides the cells of the endothelium have become infiltrated by a granular albuminous matter, and are iindergoing fatty degeneration. The urine is heavily loaded with bile-pigment, and usually contains some albumen ; the urea is diminished or has disappeared, and is re- placed by leucin and tyrosin. In the normal condition of the liver it is now regarded as probable that the urea which is eliminated by the kidneys is produced in the former organs by the metamorphosis of the albuminoids. The blood contains considerable urea, and much leucin in acute atrophy of the liver. The spleen is usually, but not invari- ably, increased in size. The muscular tissue of the heart undergoes more or less fatty change, but this alteration is common to many acute diseases. Spots of ecchymosis form in the peritoneum, the gastro-in- testinal mucous membrane, in the skin, etc., and indicate the destruc- tive changes which have occurred in the blood. Symptoms. — This formidable malady begins insidiously — as a sim- * Drs. Lewitski und Brodowski — Virchow's " Archiv," Band Ixx, p. 421 — "Ein Fall Ton sogennanter acuter gelber Leberatrophie." f Ibid., Band xliii, p. 533. Waldeyer. ACUTE YELLOW ATROPHY. 163 pie catarrh of the stomach and duodenum, with a slightly coated tongue, nausea and vomiting, headache, tenderness of the epigastrium, and a slight icterode hue of the skin which gradually deepens. There are some acceleration of the circulation and slight fever, which, how- ever, are not constant, for the pulse may and usually does have the feebleness and slowness belonging to jaundice. The duration of these mild symptoms is by no means constant — they may occupy a week or more ; and, from the appearance of decided jaundice to the onset of the serious symptoms, there may be a few houi's to two weeks. Some- times the severe symptoms come on with the jaundice and a day or two before the temperature rises. An obstinate insomnia now begins, and the headache becomes intense. This period has, by some,* been entitled the icteric period. According to Frerichs, these symptoms of gastro-duodenal catarrh exist in about one half of the cases, and the duration of them may be from three to five days, although in some cases they last two to three weeks. In one casef an attack of jaun- dice preceded, by several months, the fully developed attack. A rise of temperature either precedes or accompanies the serious symptoms — the toxcemic period. The pulse becomes very rapid, rising to 140, but suddenly again, without any apparent reason, it may be, or in consequence of haemorrhage, falling to 70 or 80. These fluctua- tions, which may occur several times a day, are peculiar to the dis- ease. When the cerebral symptoms come on, the pulse becomes uni- form at 140 to 160. The temperature line is of the remittent type, with a morning remission (102° Fahr.) and an evening exacerbation (104° Fahr.). Jaundice is constantly present, and gradually deepens from its first appearance ; and intermixed with it are large brownish ecchymotic patches, but these are not always present. The tongue and gums are brownish, dry, and covered with sordes and crusts, and the breadth is fetid. There are much nausea and vomiting, and severe pain is experienced in the epigastrium and through the right hypochondrium, and pressure over the hepatic region awakens severe pain. A diminution in the size of the liver can be readily made out by percussion, and at the same time and relatively an increase in the dimensions of the spleen. There is constipation in the beginning, followed by more free, tarry stools, the product of intestinal haemor- rhage. Dui-ing the first vomiting, mucus and bilious matters are dis- charged ; but, when the toxemic symptoms come on, blackish, gru- mous blood, or " coffee-grounds," are ejected. There are more or less epistaxis, bleeding of the gums, as well as vomiting of blood, and ecchyraoses form at various places. The urine is usually normal in quantity, acid in reaction, and has the normal specific gravity. When * Jaccoud, vol. ii, p. 418. f Dr. Joseph Coates, "The British Medical Journal," June 26, 18Y5. 1Q4. DISEASES OF THE LIVER. delirium and coma exist, the urine is either retained or passed invol- untarily. Very great changes are noted in its composition : the urea is diminished in amount, the phosphate of lime disappears, and a quan- tity of leucin and tyrosin and extractives are substituted. It contains also bile-pigment and traces of albumen, and cast-off epithelium deej)ly stained with bile-pigment. There must necessarily accumulate in the blood those excrementitious matters which it is the office of the liver to separate from the blood, and this fluid is deprived of those con- tributions to it made by the action of the bile in the digestion of cer- tain aliments. We can not therefore subscribe to the doctrine of Flint, who assigns to cholesterin the toxic effects, which are doubtless produced by several excrementitious matters. Instead of the "cho- lestergemia " of Flint, we hold to the older term, cholasmia or acholia. These poisonous materials act on the nervous system in a manner similar to a narcotic poison, producing at first a stage of excitation, followed by depression. A hypochondriacal state, with irritability and restlessness, is the first manifestation of mental disturbance, but this is soon followed by noisy delirium. From this state to low-mutter- ing delirium and coma the transition is quick ; or convulsions, local twitching, cramps, and general epileptiform attacks occur, soon pass- ing into coma and insensibility. Sometimes death takes place in te- tanic spasms.* Course, Duration, and Termination. — The behavior of acute atrophy of the liver is irregular : the prodromic period, the stage of jaundice, and the toxsemic stage, are uncertain in duration, but the last stage follows a more uniform plan. After the development of the jaundice period, from the rise of temperature and the insomnia which mark the onset of the toxsemic stage till death, the most usual period is five days. The prodromic stage may last a week or two, the jaundice stage from a day or two to two weeks, the toxsemic stage a week, but the rule is that the whole course of the malady is included within a week. The termination is in death. Some successful cases have been reported, but it is doubtful if they were genuine. It may be that many cases treated carefully at the outset have been an-ested and cured, but such cases are, as far as we are informed, simply cases of jaundice from catarrh of the bile-ducts. When the hepatic cells are disintegrated, a cure can hardly be possible. Diagnosis. — Acute atrophy is probably more frequently overlooked than recognized. It is impossible to differentiate the gastro-duodenal catarrh of this disease from the ordinary examples of the same dis- ease. Great importance must be attached to the increased headache, rise of temperature, and obstinate wakefulness which mark the onset of the toxsemic stage. As so many of these cases occur in pregnant * Morand, "Gazette dcs H6pitaux," 20, 21, 1SY3. AMYLOID LIVER. 165 ■women, they are apt to be confounded with puerperal fever, puerperal septicaimia, etc. ; but the physical signs of a rapidly diminishing liver, the nervous phenomena, the haemorrhages, and especially the changes in the urine, will serve to distinguish between them. Treatment. — Frerichs reports a supposed case of acute atrophy, which got well under purgatives and mineral acids. This appears to be the routine treatment. If the disease had any relation to the amount or quality of the bile, the use of podophyllin, euonymin, ipe- cac, and other remedies of the same group, is indicated, and mineral acids should be given freely, well diluted, in small doses frequently repeated. As the disease is a diffuse parenchymatous inflammation, the best results will be obtained from the use of a large dose of quinia and morphia in the incipiency, but will be useless when the liver-cells have begun to disintegrate. The author advises the trial of very small doses of phosphorus, as early as possible, as this remedy affects the organ specifically, and an action of antagonism may be discovered between them. This remedy, as all others, will fail to do the least good, if disintegration of the cells has occurred. Alcoholic stimulants should be pushed freely, notwithstanding a condition not unlike acute atrophy has been lately observed from subacute alcoholismus.* AMYLOID LIVER. Definition. — By this term is meant a degeneration of the liver caused by the deposit of an albuminoid material, termed amyloid, because of a superficial resemblance to starch-granules. This disease is also called " waxy liver," and " lardaceous liver," in recognition of the peculiar physical condition of the organ. Causes. — The chief cause of amyloid degeneration of any organ is prolonged suppuration, especially in connection with diseased bone, and the morbid process is then general, the liver suffering in common with other organs. A variety of explanations have been offered to ac- count for the production and deposit of this amyloid matter. The theory of Dr. Dickinson, which assumes that this matter is a form of fibrin, altered by the loss of its alkali, which in the normal state is intimately associated with it, is the most plausible. According to this theory, long-continued suppuration gradually removes in the pus the alkali from the fibrin, which is then deposited in various organs in the form of the amyloid matter. How this dissociation of alkali and fibrin is effected is not explained. Although the explanatory theories are inadequate, the fact of the relation between suppuration and amyloid deposit is not disputed. The suppuration of tubercular cavi- * M. H. Rendu, " Note sur deux cas d'alcocilisme subaigu ayant donne lieu h. des acci- dents comparables ^ ceux de I'ictere grave." "La France Medicale," September 17, 1879. 1QQ DISEASES OF THE LIVER. ties, of scrofulous abscesses, of intestinal and leg ulcers, etc., may also, althougli less frequently, be a cause of this degeneration. Next to suppuration, the most influential factor is chronic syphilitic infection, and then chronic malarial poisoning. The abuse of mercury is an alleged cause which Frerichs disposes of satisfactorily. This morbid state occurs more frequently in men than in women, and attacks by preference the most active period of life — from twenty to forty years of age. ^ Pathological Anatomy. — The liver presents a very characteristic appearance : it is uniformly enlarged without alteration of the form and relation of its parts, and sometimes its dimensions are enormous. It presents to the naked eye a pale grayish, glistening, opaline, trans- lucent appearance, and to the touch a doughy consistence. On section the surface is homogeneous, and resists the knife almost like cartilage, and is anaemic and whitish ; and when the disease is far advanced no trace remains of the proper structure of the organ.* There may be parts only, or the whole organ, affected by the change. The deposits may be in patches, small or large, and restricted to parts of the organ, or be uniformly distributed through it, and may be so limited in amount as not to increase its size (Frerichs).f Cirrhotic or fatty degeneration may coexist with the lardaceous, when, of course, the appearances will correspond. The reaction with iodine and sulphuric acid affords a striking test of the amyloid deposits. The parts to be examined must be carefully cleansed, and a solution of iodine with iodide of jDOtassium in water, or diluted tincture of iodine, brushed over, when they assume a mahogany color, quite different from the yellow color of the healthy tissue. This reaction may be sufficiently characteristic of itself, but, if to the iodized surface is now added some diluted sulphuric acid, the affected parts, after some minutes or hours, take on a violet tint, more rarely bluish. The violet may be very deep, almost black. Orth | advises that a large and thin section be laid in a saucer of water con- taining some iodine, and, when the changes are complete, placed on a white plate. The reaction will be very distinct. Microscopically, the structural alterations affect first the arterioles and capillaries ; their diameter is increased, the lumen narrowed, even closed ; the intima, the endothelium, and the muscular coat, more rarely the adventitia, are invaded by the deposits. The cells become cloudy, granular, then clear, bright, and homogeneous, and the nuclei disappear. When the process is completed, the cell is transparent, glistening, and brittle, easily breaking up into small fragments.§ The amyloid change is not * Wagner, " Manual of General Pathology," p. 322. New York : William Wood & Company. 18'76. \ Op. cit. X Orth, "Diagnosis in Pathological Anatomy," p. 321. Riverside Press. 1878. § Forster, op. cit., p. 272. AMYLOID LIVER. 167 confined to the liver, but involves the spleen, the kidneys, the lymphatic glands, the intestinal mucous membrane, and other organs. Those por- tions of the liver remaining unaffected by this morbid deposit are in a state of congestion, and are softer ; or parts of the organ are attacked with fatty or ciri'hotic degeneration, or syphilitic gummata may be mixed up with the amyloid deposits. Symptoms. — There are probably no exceptions to the statement that amyloid degeneration occurs in subjects already in a cachetic state by the existence of one or more of the causes already mentioned. The symptomatology is necessarily that of the malady with which this degeneration is associated, up to the time of the development of those signs by which the disease of the liver is recognized. The liver is usually enlarged, and often considerably so, extending several finger- breadths below the margin of the false ribs. The organ is smooth, firm to the touch, almost of stony hardness, it may be ; its borders well defined, free from pain or tenderness, unless there is present local peritonitis. This increase of size has gone on without any local uneasi- ness to call attention to the organ. The spleen is also enlarged, and is firm in texture, as a rule, but the waxy degeneration does not always affect it when enlarged in the course of amyloid liver. Jaundice is exceptional, unless the common duct or the hepatic duct is obstructed by enlarged lymphatics. As the amyloid change first affects the branches of the hepatic artery, the portal is not interfered with until later. Ascites exists in about one fourth of the cases, and is often pre- ceded by oedema of the lower extremities, the result of a general hydrje- mia. The appetite is usually poor, but in exceptional cases is voracious. Food in the solid form excites uneasiness soon after it is swallowed, and is rejected by vomiting, or passes unchanged in the faeces, unless it is very bland and capable of entire solution in the stomach. The fatty, starchy, and saccharine articles of the diet undergo decomi^osi- tion in the intestine, and a great deal of gas — the foul compounds of hydrogen with sulphur and phosphorus — is the result. The amount of bile passing to the intestine lessens with the increase of the deposit in the hepatic cells, and ultimately the secretion is arrested, and the office of the bile in preventing putrefaction and in emulsionizing the fats terminates. The obstruction to the portal circulation maintains a constant hypersemia of the gastro-intestinal mucous membrane. As a result of these causes, the stomach and intestines become irritable, and frequent liquid stools, now pale from the absence of bile, now dark from the presence of blood, are passed. Amyloid degeneration also invades the arterioles of the mucous membrane and the substance of the villi, and destructive ulcers are formed in consequence (Frerichs). The urine is pale, abundant, of low specific gravity, and contains waxy casts and a trace of albumen. It is not surprising, in view of the structural alterations and impairment of functions, that the sub- 168 DISEASES OF THE LIVER. jects of amyloid degeneration present a peculiar, anaemic, and pallid appearance, are breathless on the least exertion, and emaciate rapidly. Course, Duration, and Termination. — As amyloid degeneration is preceded by suppuration, or some chronic wasting disease, the moment this change begins escapes recognition. Indeed, the peculiar deposits have been quite extensively distributed before any characteristic symp- toms appear. When the process once begins it extends at a pretty uniform rate, and death takes jjlace by exhaustion and general dropsy, or the end is reached by an intercurrent malady, as pneumonia, pleurisy, etc. Its course is essentially chronic ; its duration months or a year or more ; its termination fatal. Notwithstanding the unfavorable prognosis, the disease is not always fatal, and cures have been report- ed, especially of those cases having a syphilitic history. Diagnosis. — The enlargement of the liver due to amyloid deposit is to be differentiated from fatty liver, hydatid disease, cancer, etc. From fatty liver it is distinguished by the greater firmness of texture, the well-defined margin, and especially by the accompanying disorders of the spleen, kidneys, and intestinal canal. From hydatid disease it is separated by the same signs, and by the characteristics of the hyda- tid tumor, which enlarges painlessly, is elastic, and furfiishes on pal- pation the "purring tremoi'." The changes in the liver pi'oduced by cancer are secondary to the original deposit, which is most frequently in the stomach, and the enlargement of the organ is hard, nodular and irregular. The urinary secretion is not affected in cancer, but jaundice is often present. Prognosis. — Few if any cases of true amyloid disease recover, and indeed recovery can hardly be possible when the hepatic cells are en- tirely filled with such a material. Cases presenting the signs of amy- loid degeneration, but not far advanced, have recovered. Although the prognosis is grave, it is not necessarily fatal. Treatment. — Prophylaxis necessarily occupies an important position in the therapeutical management of this disease. As so many — much the largest number — owe their origin to suppuration of bone and to syphilitic infection, it is highly necessary to stop the influence of these morbid processes at an early period in all cases. If there be any rea- son to suspect constitutional syphilis, ajDpropriate treatment should be at once instituted, and the most efficient remedy under these circum- stances is a compound of iodine : the compound solution of iodine — ten drops in water, three or four times a day, may be given ; or, if there be much anaemia, the sirup of the iodide of iron, and especially the siru]D of the iodides of iron and manganese. The author has had the best results from the persistent use of the iodide of ammonium in small doses frequently repeated — five grains every four hours, and well diluted with water. Budd urges the employment of the muriate of ammonia (ammonium chloride), but the iodide, the author believes, CARCINOMA OF THE LIVER. 169 is mucli more efficient. Mercurials are injurious. The diet should consist of those alimentary princijiles which undergo digestion and ab- sorption in the stomach — as milk, animal broths, eggs, fish, etc. ; and starches — as bread, potato and rice — sugar in any form, and fats, ought to be avoided, because they require the action of the intestinal juices. The food-supplies should be small in quantity, and given frequently, because of the intolerance of the gastro-intestinal mucous niembrane. Inunction of fat, especially of cod-liver oil, is a highly useful addition to means for promoting the nutrition. CARCINOMA OF THE LIVER. Etiology. — Nothing is definitely known as to the origin of cancer, in any situation, but there are certain facts connected with its develop- ment which it is important to recognize. It is a disease of advanced life, and is more apt to appear from forty to sixty than at any other vigintennary. But cancer of the liver appears in early life relatively more frequently than cancer of the stomach. It occurs with about equal frequency in the two sexes. Heredity, although the fact can not be expressed in figures, is doubtless the most influential factor in its genesis. Pathological Anatomy. — The ordinary form of cancer is found in the liver, the variety being determined by the relative proportion of the fibrous stroma, the cells, and the juice ; it is most frequently medullary or encephaloid. When infiltrated with pigment it becomes melanoid, and, when vessels predominate, telangiectatic cancer, but these are accidental differences. The cancer formation may be in nodules or isolated masses, or diffused through the hepatic parenchyma. The size of the nodules varies from the dimensions of a pea to those of a child's head (Forster), and they are in numbers inversely as their size. There may be one or two of large size, or a great many of small size, distributed through the substance of the organ. Those on the surface are rounded, with a central umbilication, produced by a fatty metamorphosis of the center of the mass and contraction of the pe- ripheral portion. The peritoneum is adherent usually, and is cloudy, thickened, and covered with a membranous exudation, or it may re- main normal. The consistence of the masses varies with the form of the cancer — it is soft, brain-like, or almost creamy, or it is hard and cartilaginous. The explanation of the origin of the growth differs, but it may be stated that the cancer develops from the interlobular con- nective tissue. The branches of the hepatic artery are intimately con- cerned in the morbid process ; they increase in size, and permeate the new formation, while the branches of the portal vein shrink. With the development of the cancer-cells (by division and endogenous for- 170 DISEASES OF THE LIVER. mation of the connective-tissue corpuscles — "Wagner *) the proper he- patic cells disappear. The new vessels developed from the branches of the hepatic artery have very delicate walls, and are liable to rup- ture, infiltrating the cancer-masses with haemorrhagic extravasation. When the periphery of the organ is reached by the new foi-mation, haemorrhage may take place into the peritoneum, and sudden death ensue from this cause. The branches of the portal vein are compressed, or they may be filled with cancer-cells. The lymph vessels and glands may also become filled and infiltrated. The bile-ducts are compressed and disappear, except the larger ducts, which become dilated into pouches with retained bile, or pass unchanged through the cancer- masses. The growth of cancer' is not continuous and uniform, but paroxysmal, as it were — now rapid, now slower ; and when the forma- tions have existed for some time they undergo a fatty metamorphosis. It is this change in the interior of the nodules which leads ultimately to the umbilications already mentioned. The hepatic parenchyma not invaded by the cancerous new formation remains unchanged, or is more or less hypersemic, or undergoes atrophy. The size of the whole organ is usually increased, and sometimes it attains extraordinary dimensions, weighing ten, fifteen, or twenty pounds (Frerichs). Can- cer of the liver is rarely primary, but is secondary to a deposit elsewhere, most frequently in the stomach. Of ninety-one cases col- lected by Frerichs, forty-six were secondary to cancer in organs hav- ing a vascular communication with the liver, and cancer was primary to the liver in scarcely one fourth of the cases. The author has met with one case of jDrimary cancer of the gall-bladder, the morbid pro- cess apparently beginning in the exudation of a local peritonitis caused by the passage of hepatic calculi. Symptoms. — Cases of cancer of the liver are occasionally encoun- tered in which no characteristic symptoms existed ; the patient has ill-defined uneasiness in the right hypochondrium, disorders of diges- tion, and low spirits ; he emaciates progressively, is cachectic, and ultimately dies. Again, cancer of the liver has a clinical history which is merely the conclusion of a series of symptoms referable to cancer in another organ, notably the stomach. The defined symptoms of hepatic cancer are apt to be obscured by some leading condition associated with it, as ascites. Those attacked with cancer are advanced in life as a rule. Before any symptoms of disturbance in the hepatic func- tions manifest themselves, there are present disorders of digestion, flatulence, and constipation. Then feelings of uneasiness, of weight, of tension, and of pain in the right hypochondrium are experienced. On palpation, soreness is developed by pressure, and the liver is felt * " General Pathology." Translated by Drs. Yan Duyn and Seguin. New York, ISTS, p. 503. CARCINOMA OF THE LIVER. m stretching beyond the margin of the ribs ; it is indurated, irregular in outline, and nodulated. In the further progress of the case, the liver extends downward still more, and nodules can be easily made out ; the area of hepatic dullness is increased in all directions, but chiefly down- ward, and there may be a good deal of spontaneous pain and exquisite tenderness on pressure by reason of a local peritonitis. Jaundice is not present in the ma- jority of cases, and exists only when the lymphatic glands in the fissure or the cancer nodules are enlarged suiR- ciently to compress the hepatic or common duct. Ascites is present in about one half of the cases, and is pro- duced more frequently by peritonitis than by compression of the portal, but this vessel is obstructed occasionally by cancer thromboses. The ascites may be so considerable as to produce great distress by embarrassment to respiration and by interference with the circulation. The ascites may be ij: 4. S;;;;:;.;:-^^ | in part due to the watery condition of ^ the blood. The fluid is a pale, straw- Fig. ll.-Area of Dullness in Cancer of the colored serum, or it contains flocculi ^^^®''" of lymph and is turbid, or it is mixed with blood, the source of which has been heretofore alluded to. Gastro-intestinal catarrh is set up by the congestion of the portal system ; haemorrhoids form ; haemorrhages occur from the intestinal mucous membrane, and an obstinate watery diarrhoea succeeds to the constipation which was an early symptom. All of these causes combine to produce a cachectic state. The com- plexion gradually assumes the char9,cteristic earthy or fawn color, emaciation is extreme, the feebleness is excessive, the hands and feet are cold, the skin is dry and harsh, and the expression is dejected and worn. Course, Duration, and Termination. — The course of cancer of the liver and its duration are much influenced by its form — the medullary proceeding to a fatal termination more rapidly than scirrhus. As already stated, the progress is not uniform, the growth at times being suspended and then again quickening into renewed activity. Cases terminating in eight weeks have been reported, and others continue with varying fortunes for months and years. There is but one mode of termination, that in death. Diagnosis. — It may not be possible to diagnosticate cancer in those cases without any local symptoms, or in the incipiency of any case. When, however, the enlarged and nodulated liver can be 172 DISEASES OF THE LIVER. felt, the difficulty of diagnosis is much less, especially if the patient is of advanced age, and the cachexia, the ascites, etc., are also pres- ent. Distinction is to be made between cancer, abscess, echinococ- cus, and amyloid disease ; in all these the liver is enlarged (as a rule) and projects downward, but, in cancer, the organ is nodulated and indurated ; in abscess it is smooth and softer, and may be fluctu- ating ; in echinococcus it is smooth, elastic, and having the j)urring tremor ; in amyloid it is smooth and uniform, but indurated. They differ in their clinical history and in their cause, in their duration and in their termination, so that a diagnosis can, in well-marked cases, be readily made. Treatment. — The treatment must necessarily be palliative and symp- tomatic, as there is no remedy for cancer in any situation. Anodynes will be required to relieve pain. Careful regulation of the diet, ac- cording to the conditions present, and the timely administration of stimulants will be demanded. Ascites will require the treatment in- dicated for that disease, especially the tapping — for the interference with repose caused by a distended abdomen is one of the most distress- ing complications. EOfllNOOOOCUS OP THE LIVER (HYDATID DISEASE OF THE LIVER). Definition. — By the terms echinococcus of the liver, hydatid dis- ease, cystic degeneration, multilocular cyst, etc., is meant the penetra- tion into the liver of the scolex of the sexually immature taenia echi- nococcus. The embryos, gaining access to the intestines of man, mi- grate, and, doubtless chiefly by the portal vein and bile-ducts, reach the liver in which the cyst or cysts develop, sometimes attaining im- mense size. Causes. — As the echinococcus is the taenia of the dog, only those who live in a humble way, with their animals about them, suffer from these migratory parasites. As the ova are discharged with the excrement of the dog, it is obvious that they can gain admission to the human stomach only through the most filthy practices, or by carelessness in the obtaining and storing of drinking-water and food. In Iceland, more than in any other part of the world, do the people suffer from cystic disease — as large a proportion as one sixth of the pojDulation being infected. This preponderance of the disease is due to the number of dogs and to the promiscuous way in which the members of a family and their dogs live together in their wretched hovels. The disease occurs at the middle period of life chiefly, and rarely in the young. In the only case of echinococcus of the liver met with by the author, the patient, a male, was forty-two years of age. Pathological Anatomy, — When the echinococcus (or two or more) HYDATID DISEASE OF THE LIVER. 173 lodges in the liver it is presently enveloped in a tough, fibrous, yellow- ish-white membrane, constructed out of the adjacent connective tissue, and closely adherent. "Within this adventitious membrane is contained the embryo, inclosed in a clear, translucent sac made up of numerous concentric layers. This sac of the embryo is the mother-sac, and in the interior of it a number of so-called daughter-vesicles, and still other, granddaughter-vesicles, are developed, and ultimately the mother-sac, with its investing membrane, attains to extraordinary dimensions. The daughter-vesicles vary in number from a few up to many thousands, and in size from that of a pea to that of a goose-egg. The fluid of the sac is clear, opalescent, weakly alkaline, and of a specific gravity of 1"008 to 1"013 ; it contains no traces of albumen, but a large proportion of sodium chloride and some crystals of cholesterine and hasmatoidine.* The inner membrane of the daughter-vesicles is lined with a germinat- ing layer, from which the embryos spring ; and scolices, attached as well as free, can be observed within the sacs. These scolices are the immature tceniro, and can be recognized with a low power — sixty diam- eters — as possessed of a head, four suckers, and a row of booklets. When detached, these scolices have the power of active motion, and can withdraw their probosces and booklets within their own cavity. There are hydatids without daughter-vesicles, and others entirely with- out a scolex, which were denominated by Laennec acephalocysts, and by Kiichenmeister,f sterile echinococci. There are great variations in the size, number, and position of the cysts. They are found in all the lobes, but most frequently in the right, bm-ied in the sub- stance or projecting from the surface of the organ. Usually but one cyst exists, but there may be several — as many as five or six. It follows that the size, shape, and appearance of the liver will vary with the number, position, and growth of the cysts. It may attain a sufficient size to distend the abdominal cavity, or at least make a great protrusion in the right side. With the growth of the cyst, the hepatic tissue is correspondingly atrophied, by being encroached upon, while the rest of the organ remains intact, or undergoes hyper- trophy, or is hypersemic. As a rule, the cysts do not obstruct the large blood-vessels and bile-ducts ; hence the infrequency of ascites and jaundice ; yet both may be encroached upon — even obliterated. It sometimes happens that communication is established between bile- ducts and the cyst, by the breaking through of the duct in the course of development of the cyst, and, bile entering, the growth of the echi- nococcus is arrested. The cysts sometimes penetrate the common duct, also the gall-bladder, and rarely the portal vein. They may be dis- charged through the ducts and a cure be thus effected, but, if they * Davaine, "Traite dea Entozoaires." Paris, 1872, p. 0*79. f " Animal and Vegetable Parasites," op. cit. 174. DISEASES OF THE LIVER. enter the veins, thrombi form, with the usual disastrous results. Echi- nococci-cysts may undergo calcification. The adventitious envelope hecomes thicker and tougher, and calcareous salts are deposited ; ex- pansion and growth are prevented ; the parasites die, and are found flattened and contracted. In other cases there is developed in the interior of the capsules a dense, honey-like or puriform fluid, which had previously been clear and then milky, and remains of the scolices, especially the booklets, are found floating in, or mixed with, the con- tained fluid. Crystals of hsematoidinae and bile also are found mixed with the contents of wasting cysts. Fig. 12. Isolated Scolex of the Tonnia echinococcus, from the Pig Fig. 12.— Tcenia eeldnococcus, from the Pig. Fig. 14. — Tcenia ecMno- coceus, from the Dog. A great many cysts are destroyed and cease to grow, as has been described, but many continue to enlarge, pushing up the diaphragm and displacing the heart, and reaching cometimes as high as the second rib (Frerichs). Others, growing downward from the under surface of the liver, push aside the stomach, and force the abdominal organs into the pelvis, or, but rarely, compress the ascending vena cava, causing cedema, varicose veins, etc. A cyst may rupture into the cavity of the chest — into the pleural or pericardial sac, causing fatal inflamma- tion, or excavate a cavity in the right lung, and shreds and parts of the vesicles be discharged through the bronchi by expectoration. A cyst HYDATID DISEASE OF THE LIYER. 175 may also rupture into the peritoneum, producing fatal peritonitis, or into the intestines, and be slowly discharged by stool. Rupture within the abdomen is usually due to a blow or other injury, but is sometimes spontaneous. The echinococcus multilocularis, which was formerly mistaken for colloid cancer, but has since been accurately described by Virchow, differs from the ordinary form, in that it is a very firm, hard tumor, consisting of dense fibrous tissue, containing cavities filled with a gelatinous material. On account of its tendency to ulcerative degeneration, Yirchow called it the " ulcerative multilocular echinococ- cus-tumor." Friedreich * holds that the development of this form takes place in the gall-ducts and blood-vessels. Symptoms. — A cystic tumor of small size, deeply placed, and not so situated as to interfere with other parts, may not cause any symptoms, and therefore remain undetected. But a cyst of considerable size, pro- jecting from the liver, or which has increased the size of the organ, and especially if it has encroached upon neighboring parts, will cause sufficient disturbance of function to lead to its early recognition. If a cystic tumor increases to any considerable extent the volume of the liver, there will be a feeling of weight, heaviness, and dragging in the right hypochondrium, and some disorders of digestion ; if it hap- pen to be near the hilus of the organ, the portal vein and the com- mon or the hepatic duct may be pressed upon, causing ascites and jaundice ; if near or at the upper convex surface of the right lobe, the diaphragm will be pushed up, and a dry cough and dysp- noea will be the result. The degree of enlargement is necessarily various. The tumor may fill in the whole space from the inferior border of the second rrib to the pelvis, displacing the tho- acic and abdominal organs, and forc- ing out the intercostal spaces. The tumor may take various forms : the liver may be uniformly enlarged ; there may be a growth projecting from the borders of the organ, and having a globular or hemispherical form similar to that of the gall-blad- der ; or, one lobe may be the seat of the growth, the other remaining intact. On palpation, an hydatid tumor is elastic, resisting but soft, fluctu- ating, and, in somewhat more than half the cases, presenting the pecu- Fia. 15. — Liver enlarged by Hydatid Cysts. * Virchow's " Archiv," vol. xxxiii, p. 16, " Ueber multilokuIarenLeber-echinokokkus.'' 1Y6 DISEASES OF THE LIVER. liar fluctuation known as " jsurring tremor," or "hydatid purring" — a sensation aj)preciated by the sense of touch as the trembling of a bowl of jelly appears to the eye. The tumors are not painful, and it is exceptional for any tenderness to be felt on pressure. Jaundice or ascites occurs only in the rather rai'e event of a tumor near the hilus, or so situated as to compress the vein and duct. Dyspnoea and cough occur when the cyst develops into the thorax ; irregular action of the heart, when this organ is pushed from its position ; constipation and vomiting, when the intestines and stomach are encroached upon ; swol- len and (Edematous feet and ankles and enlarged veins, when the cava is compressed. All of these symptoms arise, when the form and direction of the cyst develop them, without any constitutional disturbance, and if such disturbance occur it is due merely to the interference of the growth with important functions. If the echinococcus burst, new symptoms arise. If the stomach is entered, there will be some local pain, and the parasites will be rejected by vomiting, often in immense numbers ; if the intestine is perforated, the parasites are discharged by stool, and recovery may ensue in either case. If the vena cava is entered, sudden death with the symptoms of asphyxia takes place. If the pleural cavity receive the echinococci, pleuritis is excited, and the cysts, with the products of inflammation, may be subsequently dis- charged through the lung by a bronchus. If the pericardium is sud- denly filled with echinococci, the action of the heart is disturbed, and fatal pericarditis quickly excited. Course, Duration, and Termination. — The hydatid disease is essen- tially chronic in its course. The development of the cyst is affected by its surroundings ; and in the interior of organs, subjected to pres- sure on all sides, the growth is slower than if it is deposited on the surface. They last from one or two years up to thirty, but the most usual duration is two to four years. They may undergo a spontaneous cure : the echinococci die, or on the opening of bile-ducts they are killed by the entrance of bile, and subsequently shrivel up ; they are discharged through the stomach and intestine, or by the bronchi, and recovery slowly ensues. Death is not unfrequently produced by echi- nococci — by gradual failure of the powers of life ; suddenly, by en- trance of the parasites into the vena cava or the pericardium ; and gradual failure by pneumonia, or suppuration, or pysemia. Diagnosis. — Echinococci of the liver may be confounded with ab- scess, cancer, dropsy of the gall-bladder, aneurism, and hydrothorax. It differs from abscess, cancer, and hydrothorax by the absence of pain and constitutional disturbance ; from abscess, by the character of the fluctuation ; and from cancer, by absence of the hard, non-fluctuating nodules of the latter. From dropsy of the gall-bladder it is distin- guished by the lack of a history of attacks of hepatic colic, their ces- sation and the enlargement of the gall-bladder coming on slowly ; but HYDATID DISEASE OF THE LIVER. 177 the distinction is most certainly made by the use of the aspirator, since it has been shown that this organ may easily and with perfect safety be penetrated by the needle. From aneurism, echinococci are readily differentiated by the existence of a heaving, expansile pulsation in the former, without the peculiar fluctuation of the latter. There is more real difficulty in separating hydatids pushing up the diaphragm, from effusions into the pleural cavity, as the physical signs are the same. An attentive consideration of the previous history will aid materially in arriving at conclusions. The growth of echinococcus is slow and painless, and the development of the local symptoms is free from that ' disturbance which precedes the occurrence of an effusion in the chest. But, above all other means for coming to a correct conclusion, must be placed the use of the aspirator and the microscopic examination of the fluid. Prognosis. — "VYhen the echinococcus is large, and its particular direction unknown, the prognosis is grave. The early use of the as- pirator enters largely into the question of prognosis, for early punc- ture will insure the death of the parasite. When discharge takes place by the stomach and intestine, the prognosis will be favorable ; and recovery may also be expected in those cases discharging by the bronchi, provided the right lung is only so far damaged as to permit the passage of the cysts. When there is a large suppurating cavity in the right lung the prognosis is unfavorable. Treatment. — There is no medicinal treatment which can in any way affect the origin or growth of the echinococci. Fortunately, we possess simple surgical measures by which these cysts may be safely and cer- tainly closed. These are, puncture by an aspirator needle and with- drawal of some of the fluid, and electrolysis. Whenever a cyst can be reached by the needle, it can be subjected to either of these expe- dients. The simple puncture and withdrawal of some of the fluid con- tained in the mother-vesicle should be tried first, as this has succeeded in numerous instances. This failing, the method by electrolysis should be practiced. Dr. Hilton Fagge and Mr. Durham * report eight cases in which electrolytic decomposition was employed with entire "success. Two needles connected with the negative pole were inserted into the sac, and the positive pole, in the form of a large sponge-electrode, was applied on the integument in the neighborhood. Ten cells were used to furnish the current, and the needles were permitted to remain ten minutes. As, in the process of electrolytic decomposition, hydrogen and the alkalies (potassa, soda) appear at the negative pole, it is obvious that the parasites must be killed by the electrolytic action. Besides these measures, iodine has been injected into the mother-sac with success. * " Medico-Chirurgical Transactions," vol. clir, " On the Electrolytic Treatment of Hydatid Tumors of the Liver, with an Addendum on Simple Acupuncture." 12 178 DISEASES OF THE LIVER. ANEURISM OF THE HEPATIC ARTERY.— The author can add one to the few examples of aneurism of the hepatic artery. The size of the tumor in the reported cases has varied, but the tumor can not always be felt, or rupture takes place before it has attained sufficient dimensions to be felt through the abdominal parietes. In one instance the liver was displaced by it. Usually, long before the existence of a tumor can be made out, severe pains are exj^erienced in the right hypochondrium. The attacks of pain are at first paroxysmal, and can hardly be distinguished from hepatic colic, but in the further progress of the case there are constant pain and soreness in the right hypochon- drium, and paroxysms of severe pain. The pressure of the aneurism on the hepatic plexus is the cause of the early appearance, severity, and persistence of the pain. Jaundice is usually present, due to pres- sure on the hepatic or common duct, and, in the case referred to by the author, ascites was the prominent symptom. The interference with the hepatic functions, the constant suffering, etc., cause rapid failure of the vital powers ; the flesh wastes, the skin appears earthy or jaundiced, the digestive functions are disordered in consequence of the absence of bile, and ascites may slowly accumulate. Death takes place by rupture and escape of the blood into the peritoneal cavity. In one case (Frerichs) blood was regurgitated by the stomach, and it reached this organ by a circuitous channel ; communication by a very small orifice was established between the sac of the aneurism and the gall-bladder, and a small quantity of blood continually passed from the gall-bladder to the duodenum, and thence by retching into the stomach. THROMBOSIS OF THE PORTAL VEIN is a result of various ob- structive conditions, as cirrhosis, chronic atrophy, cancer, and tumors. The symptoms due to the thrombosis are those of obstruction to the portal circulation, and occur rather abruptly in the course of the chronic malady associated with it. The pressure in the initial radi- cles of the portal vein is suddenly increased, and free transudation of blood occurs along the intestinal mucous membrane, haemorrhoids form, and a watery diarrhoea takes place. The spleen enlarges, and ascites develops with great rapidity. Efforts toward a compensatory circulation are made by the communicating veins, which suddenly appear enlarged on the surface of the abdomen. The urine becomes scanty and of high specific gravity. The patient presents a very de- cided cachexia, the strength rapidly fails, and death occurs in a few days or weeks. The obstruction by the thrombus is not always com- plete, so that an imperfect circulation is maintained. In that case the symptoms will be less formidable and the progress less rapid. The only remedy which offers any prospect of relief is ammonia, which has the power to dissolve coagula. Unfortunately, the stasis PYLEPHLEBITIS. 179 in the portal system so hinders absorption that remedies do not readily enter the blood. As Halfourd, of Australia, has demonstrated the innocuousness of the intravenous injection of ammonia, this expedient should be practiced in such cases. It consists in the injection of one part of aqua ammonite to two parts of water into any convenient vein. If, however, there be any movement of blood in the portal, the am- monia should be administered in the form of the carbonate — five grains every three hours. The usual remedies for ascites will be necessary. SUPPURATIVE INFLAMMATION OP THE PORTAL VEIN, or SUPPURATIVE PYLEPHLEBITIS. — This is always a secondary dis- ease, and has its origin in suppuration occurring at some point in the distribution of the portal vein. An inflammation occurs in the tunics of the vessel, which become soft and discolored by the presence of a fluid and fibrinous, purulent exudation, and by imbibition of the hsematine. The intima especially is discolored, brownish, yellowish, or greenish-yellow, and is covered with layers of fibrin and pus. The changes extend to and involve the adventitia. A thrombus forms in the vessel and undergoes characteristic alterations, softens in the cen- ter, becomes yellow, the fibrin breaking up into a granular mass, and the hsemoglobulin disintegrating and gradually forming, with the rest of the thrombus, a purulent-looking fluid. Thrombi form most fre- quently in the hepatic branches of the portal, and emboli in some cases are deposited in other parts of the liver, and secondary pygemic abscesses occur in various parts of the body. Suppurative inflammation of the portal vein is associated with and is dependent upon ulcerations in various parts of the intestinal mucous membrane, or suppuration and abscesses in the mesenteric glands, or the inflammation and ulceration following impaction by gall-stones, etc. The symptoms, therefore, succeed to those of the malady which caused it. The initial symptom is pain, and it is felt in the umbilical region, in the iliac region, or in the hypochondrium, according to the branch of the portal implicated ; then follows a severe rigor, which, after a period of high temperature, terminates in a profuse sweat. These paroxysms, intermittent in type, are repeated, not in a regular order, but at uncertain intervals. In the interval the temperature is rather subnormal ; during the j)yrexia the temperature rises to 105° or 106° Fahr., and the sweats are most exhausting. The liver enlarges and is tender, and jaundice appears. The spleen also enlarges, doubt- less because of the obstruction in the portal circulation. Usually there is a profuse diarrhoea, the discharges consisting of a reddish, watery, and fetid fluid, sometimes of bilious matter. The abdomen becomes tender, and is much distended ; vomiting comes on ; the exhausting alvine discharges continue, and hence the powers of life rapidly decline. 180 DISEASES OF THE LIVER. The secondary deposits excite local distress, and each addition to the area of suppuration increases the hectic fever. Deposits in the brain cause delirium and stupor, but, without these, low-muttering delirium comes on, with a typhoid state, and death occurs in a gradually deep- ening coma. The fatal result may occur in one week, or may be post- poned to six weeks — the average being about three. The diagnosis must always be a matter of extreme difficulty, and can, indeed, be made only when the cause is clear and all the symp- toms appear in their proper relation. It will be impossible in any doubtful case to differentiate between pylephlebitis and abscess of the liver. The treatment is without utility. While this is true, it is certain, however, that much may be done to relieve pain by the hypodermatic injection of morphia. It is in a high degree probable that large doses of quinia may be very serviceable in checking suppuration, and the free use of alcohol is certainly applicable in the same direction. The combination of morphia and quinia, with the conjoined administration of alcoholic stimulants, offers the best prospect of relief. DISEASES OF THE BILIARY PASSAGES: CATARRH OP THE BILE-DUCTS. Definition. — By catarrh of the bile-ducts is meant an inflammation of the mucous membrane, with an increased production of mucus. Very rarely there occurs a croupous inflammation, associated with infectious maladies, as pysemia, diphtheria, etc. Cause. — Catarrh of the biliary passages may arise spontaneously from climatic causes or from malarial influence. It occurs, therefore, more frequently in the autumn, when cool nights succeed to warm days, and when malaria is most rife. Malaria may induce jaundice by catarrhal swelling of the bile-ducts, without any febrile disturb- ance.* Catarrh of the bile-ducts is usually a secondary disease, sec- ondary to duodenal or gastro-intestinal catarrh, which extends by con- tinuity of tissue up the bile-ducts. A variety of causes are concerned in the production of duodenal catarrh — notably, excesses in eating and drinking. Usually the attacks are excited by some article of food which especially disagrees, but a catarrhal state of a chronic kind has preceded the acute attack. Pathological Anatomy. — More or less extensive hyperemia is the initial lesion. The common duct is more affected than any other part of the canal-system, but the catarrhal process may extend to and in- volve the canaliculi. The mucosa is swollen, the more decidedly near the duodenum, and is coated with a tenacious mucus, so that the * " De3 Affections Paludeennes du Foie," par MM. A. Kelsch et P; L. Kiener, " Arch. de Physiologie normale et pathologique," 1878, p. 571, et seq. CATARRH OF THE BILE-DUCTS. Igj lumen is much narrowed or obstructed. The mucous secretion of the gall-bladder is increased in amount and mixed with the bile, stored up more abundantly because the obstruction at the outlet existed while the hepatic and cystic ducts were still pervious. The viscid mucus and sero-mucus poured out from the surface of the membrane contain cast-off epithelium, abundant nuclei, and white corpuscles, and the endothelium itself undergoes proliferation. The obstruction below preventing the escape of bile, and the mucus and sero-mucus accumu- lating by continued production, the ducts above become dilated, and the tissue of the liver presents the usual appearance of bile-staining when there is a biliary stasis. After several days the hypersemia less- ens, and a quantity of dead endothelium is cast off, still more effectu- ally blocking the passage ; but the contents of the bile-ducts gradually liquefy, and the lumen is restored to its former dimensions by the escape of these matters into the duodenum. Th e whole process will occupy several weeks. This fortunate solution of the catarrhal process is not always effected. The soft tissue of the liver-parenchyma is ex- ceedingly liable to degenerative changes. Recent researches (Charcot,* Legg f ) have demonstrated that mere mechanical blocking of the com- mon duct leads in a short time to fibroid degeneration (increase of the connective tissue, interstitial hepatitis) and atrophy of the gland-cells. It has long been known that persistent attacks of catarrh, or the fre- quent repetition of them, will lead to changes in the parenchyma ; but these late investigations, by demonstrating the readiness with which pathological alterations occur in the hepatic parenchyma, have added much to the pathogenetic importance of catarrh of the bile- ducts. Rarely, isolated portions of the liver remain obstructed, and dilated duets, surrounded by parenchyma deeply stained with bile and much altered, exist in patches throughout the organ. Symptoms. — The signs and symptoms indicating the onset of the malady are not the same for all forms. The form due to alternations of temperature at certain seasons commences abruptly with some pain, soreness, and sense of weight in the right hypochondrium ; constipa- tion exists, the tongue is coated, and the appetite absent ; and there are some feverishness and general malaise. There are also much de- pression of spirits and a feeling of illness, greater than the actual lesions warrant. In from three to five days the eyes become yellow, and icterus, or jaundice, then gradually appears over the whole body. Usually the fever disappears in two or three days, the skin becomes dry and harsh, and the surface cold. The pulse is slow, the action of the heart weak, and the strength depressed. When this form of jaun- * "Legons sur les Maladies du Foie, des Voies Biliaires et des Reins," Paris, 18'7'7, p. 354. f " St, Bartholomew's Hospital Reports," vol. ix ; various articles in the "British Medical Journal," etc. 182 DISEASES OF THE LIVER, dice is produced by malarial infection, the symptoms will develop more slowly, unless, indeed, the disturbance in the hepatic functions is accompanied by malarial fever — intermittent or remittent. The most usual determining cause of catarrhal jaundice is gastro-intesti- nal, especially duodenal, catarrh. In some subjects a chronic catarrh exists, and but little additional disturbance sufGlces to close the duct. In others an acute catarrh is brought on by some indigestible food or improper drink. In either case, the patient experiences a good deal of nausea, has a heavily coated tongue, headache, and a somewhat muddy complexion, and there may be more or less fever, or none at all. The jaundice does not appear at once ; there must be sufficient time for the extension to the bile-ducts to take place, which will require from one to two weeks. The bile-pigment tints all the tissues of the body, the secretions, and even pathological products, as effusions into the ven- tricles and thoracic cavity. The urine soon assumes a brownish color, like that of port or black coffee, and is heavily loaded with urates. Some drops of the urine placed on a white porcelain surface, and a little nitric acid made to flow against it, will exhibit the following re- action at the margin where the two fluids come in contact : a greenish tint, quickly followed by blue, violet, to red. This play of colors may not be seen, but bilirubin, where touched by nitric acid, should take on a greenish hue, being converted to biliverdin. During the febrile stage, if fever has existed at all, the pulse rises ; but when jaundice appears, if no fever is present, the action of the heart is slowed and the tension of the vascular system lowered. The pulsations may de- cline so much as twenty or thirty to the minute. This dej)ression of the circulation is due to the action of the biliary salts on the heart itself, for the same effect is produced when the pneumogastric has been previously divided. No bile passing into the intestine, certain substances fail to be digested, especially the fats, and the foods pres- ent there decompose, and a great quantity of fetid gas is formed. The results, then, of the absence of bile are white, pasty, or grayish- white, or gray, slate-colored stools, having a very offensive smell, and flatulence. The presence of bile in the skin excites in most persons a great deal of unpleasant itching, which may, indeed, be troublesome enough to prevent sleep. The vision is yellow from the presence of bile-pigment in the humors of the eye. The liver increases in size, and extends a little beyond the margin of the ribs, and the gall-blad- der is also sufiiciently distended to be felt, in thin persons, projecting beyond the margin of the liver, or be made out by careful percussion. If the gall-bladder partakes in the inflammation, it becomes tender. Usually in from two to five days after the jaundice appears, the un. pleasant symptoms subside — the fever ceases, the tongue cleans, and the appetite returns, and only the jaundice and the torj)id state of the intestines remain. In a few days the stools become darker and then CATARRH OF THE BILE-DUCTS. 183 normal, the fetid odor disappearing at the same time. The coloration of the tissues and the pigment in the urine continue until the work of elimination is complete, and hence high-colored urine is the final symptom. Course, Duration, and Termination. — Cases pursuing the ordinary- course, having the catarrhal period, the jaundice j^eriod, and the period of convalescence, last from three to six weeks, and terminate in complete recovery. Not all cases pursue this favorable course. The resolution may be postponed, and the case assume a chronic char- acter, leading to changes in the hepatic parenchyma, consisting in increase of the connective tissue and an atrophy, largely fatty, of the hepatic cells. The existence of a chronic catarrh of the duodenum invites attacks of acute catarrh involving the ducts, the result being the same — changes in the hepatic parenchyma. Catarrh of the bile- ducts becomes much more important from this point of view. Diagnosis. — At the beginning, catarrh of the biliary passages may be confounded with the initial symptoms of acute yellow atrophy, but the sex and the condition of pregnancy are so influential in causing the latter that we have in these etiological factors means of differ- entiating in two thirds of the cases. The subsequent behavior of the two maladies differs so widely as to eliminate all doubt. When the jaundice appears there is a possibility of confounding it with the jaun- dice which sometimes comes on in the course of cirrhosis and cancer, but an attentive examination of the history of each, and their course, will prevent error. Treatment. — This is one of the very few conditions in which mer- curials may be prescribed in hepatic diseases, not with the view to increase the outflow of bile, but to allay irritation of the mucous mem- brane. From y*^ to -i- grain of calomel, rubbed up with a little sugar, may be administered every four hours for a few days. Simultaneously, whether malaria is or is not an element in the case, two antipyretic doses of quinia (10 — 15 grains) should be given daily until jaundice appears, and for a few days subsequently to its full development. To maintain free action of the kidneys by salines is highly useful by favor- ing elimination. The ordinary effervescing powder, or the aperient effervescing powder, if constipation is decided, is well adapted to ac- complish the object. The Saratoga waters, or Vichy, or Kissengen, or Carlsbad, may be drunk freely to accomplish the same purpose. In the chronic cases, with persistent plugging of the bile-ducts, which means also persistent jaundice, the most effective remedy is sodium phosphate in 3 j doses ter in die, and kept up until the jaundice de- clines. This is also the most appropriate and effective remedy in those cases of chronic gastro-duodenal catarrh with occasional at- tacks of catarrhal jaundice. Recent experimental (Rutherford) and clinical experience has shown the value of euonymin and iridin as 184 DISEASES OF THE LIVER. cholagogues. Two grains of the former and four of the latter, given at night, and followed by a saline, afford excellent results. The min- eral acids were formerly held in great esteem in the treatment of these hepatic affections, but it is now known that alkalies are more service- able. The local application of the acid-bath to the right hypochon- drium is an excellent counter-irritant, but the difficulty experienced in preventing injury to the clothing is a strong objection to its use- Careful regulation of the diet is most necessary. Solid food should be withdrawn for the time being, and all fatty, saccharine, and starchy substances also, for these require the action of the bile either for their solution and absorption, or to prevent their decomposition. The most suitable aliments are skimmed milk and beef -juice. The former should be given freely every three hours, and, if the stomach is irritable, a little lime-water should be added. The utility of the milk is twofold — as an aliment and as a diuretic, Bitartrate-of-potassium lemonade is an excellent diuretic in these cases to remove the last staining of the bile. As the catarrhal inflammation subsides, the diet may be increased but it should consist of milk, eggs, fresh meat, fresh fish, and the suc- culent vegetables. OCCLUSION OF THE BILIARY PASSAGES. Causes. — The pressure of tumors, as cancer of the pancreas, aneurism of the hepatic artery, etc., is an exterior cause ; the impaction of a cal- culus, adhesion of opposed surfaces in exudative inflammation, etc., are internal causes of occlusion of the bile-ducts, Eesults of Occlusion. — The mucus formed all along the canals con- tributes somewhat to the accumulation of fluids when the outlet is closed, but the chief constituent is bile. The neck of the gall-bladder is not unfrequently closed by an impacted calculus, the sac becoming enormously distended with a transparent, faintly greenish fluid, result- ing from the transformation of the mucus and of the bile stored up before occlusion. The author has seen one example of occluded orifice of the cystic duct, in which the contents of the gall-bladder consisted of forty-four biliary calculi without any fluid. As the gall-bladder is an organ of convenience and not of necessity, its closure does not dis- turb the hepatic functions. It forms sometimes — for the secretion oi mucus continues — a tumor of considerable size, and pyriform shape, which may be felt projecting from under the liver. Occlusion of the common duct (ductus choledochus) or of the hepatic duct leads to dila- tation of the biliary passages and to changes in the structure of the liver. The whole organ is at first enlarged, but it subsequently under- goes atrophy by the pressure, and death ultimately ensues from the blood-poisoning. BILIARY CALCULI. 185 BILIARY CALCULI (CHOLELITHIASIS— GALL-STONES). Causes. — In the normal state the bile does not contain any solid constituents. The formation of calculi or concretions is determined by the precipitation of a crystallizable substance from the bile — choles- terine — which is held in solution by glycocholate of soda. The mucus formed in catarrh of the biliary passages effects a decomposition of this compound. It is probable that this result is promoted by changes in the composition of the bile, and that the cholesterine may be in excess, and hence held feebly in its combination. Calculi form more frequently after than before the middle period of life, for then choles- terine becomes more abundant ; and they are encountered in the obese, in hearty feeders by preference, and in the sedentary. Females are more liable than males, especially fat women who eat rich food and take no exercise. Pathological Anatomy. — Cholesterine is the principal constituent of biliary calculi, and exists in the crystalline form chiefly. The ac- tual proportion of this constituent to the others is from seventy to eighty per cent. More or less bile-pigment enters into their formation ; also the carbonate of lime and earthy phosphates and carbonates ; and a particle of mucus or some foreign body is the nucleus about which the other materials crystallize or aggregate. Occasionally there is a single concretion of large size, which fills the gall-bladder, but usually they are very numerous — sometimes amounting to five or six hundred. When there is a single gall-stone it is ovoid or globular, to adapt it to the shape of the sac, but, when there are several, they assume the octa- hedral shape, with smooth facets. They do not always assume regular shapes : some are covered with warty masses ; others are leaf-shaped, etc. In color they are brownish or yellowish-brown, but in exceptional instances are found in all colors from white to black. They are very light, the specific gravity varying from 1-500 to 1-800.* Gall-stones usually contain a nucleus, composed for the most part of mucus, and cholesterine and bile-pigments are deposited in alternating, con- centric layers around it. The nucleus is not always in the center, and there may be several nuclei, and hence the arrangement of the layers is irregular, and there may be deposits of earthy matter and pigment, without cholesterine, etc. Gall-stones may be found in any part of the biliary passages. They are rare in the interior of the liver, and they are not often found in the hepatic duct, because of the in- creasing caliber below, but are found usually and in the largest num- bers in the gall-bladder. By pressure the walls are irritated and a catarrh is set up, and also ulcerations of the mucous membrane of con- siderable depth and extent are induced. The walls of the gall-bladder, * Thudichum on " Gall-stones," p. 10. 186 DISEASES OF THE LIVER. excited to frequent expulsive efforts, undergo hypertrophy, and the mu- cous membrane becomes reticulated. Inflammation of the peritoneal investment is excited, and the remains of exudations and adhesions are usually found. Not unfrequently the mouth of the gall-bladder is oc- cluded by an impacted calculus, or permanently closed by inflamma- tory adhesions. The gall-stones may be forced down, producing pains in the passage through the cystic duct, or, the mouth of the gall-blad- der being closed, they remain and produce no further mischief. Gall- stones may become impacted in the cystic, hepatic, or common duct ; inflammation and ulceration, with perforation, result. Symptoms. — When gall-stones are free in the biliary passages with- out obstructing them, they give rise to some pain in the right hypo- chondrium of an intennittent character, and pains radiating thence to the shoulder, umbilicus, lumbar region, etc. There is present usually nausea, even vomiting, and there may be chills, followed by fever and sweats. These symptoms are due to the irritation of the ducts, without their occlusion. If concretions are impacted in the hepatic duct, there are pains, jaundice, and enlargement of the liver. When calculi escape from the gall-bladder into the cystic duct, if of sufficient size to irritate the mucous membrane and excite spasm, the phenomena of hepatic colic ensue. Sometimes, after a fit of anger, or the receij)t of evil tidings, but most frequently in about three hours after a meal, a pain of exceeding violence is suddenly felt at the margin of the liver and in the right por- tion of the epigastric region. The pain has a boring, burning, lanci- nating character, and radiates through the abdomen and chest and into the shoulders and back, but the situation of the greatest anguish is in the region of the gall-bladder. The pain is so atrocious that the patient writhes with the agony, rushes up and down the room, or tosses from side to side if in bed. The surface is cold and covered with a cold sweat, and often a severe rigor occurs simultaneously. There may be clonic spasms affecting the right side, or an epileptiform seiz- ure, with loss of consciousness, may occur. Intense nausea accompanies the pain. At first the food is thrown up, but presently, after repeated retching, only some mucus, acid and watery ; but the vomiting affords no relief. The action of the heart is feeble, and the circulation is cor- respondingly depressed. The severity of the seizure is influenced by a variety of circumstances — by the size and roughness of the concretion, by the length of canal to be traversed, and by the' condition of the nervous system. The duration of the seizure varies from a few hours to several days, and the first attack is apt to be more severe than any succeeding one. When the attack continues for several days, the pain does not always persist even for hours, for there are remissions in which only an acute soreness remains, and the exacerbations behave as regular attacks. It is highly probable that in these cases several concretions are passed in succession. Again, when the calculus passes from the BILIARY CALCULI. 187 cystic to the common duct, tliere is a feeling of relief, but a new par- oxysm occui's when the calculus becomes engaged in the duodenal ori- fice of the ductus choledochus. Inflammation in the peritoneum may be excited about the site of impaction, and involve the neighboring structures, or the duct may become gangrenous. The calculus, by preventing the outflow of bile in the hepatic or common duct, causes jaundice, which is not a usual symptom in impaction of the cystic duct ; although it may be present, the surrounding swelling being sufficient to prevent the flow of bile through the common duct, or it is probable that jaundice may be due to the disturbance in the hepatic plexus of nerves. The pain suddenly ceases sometimes by the dropping of the concretion into the duodenum. Jaundice usually succeeds to the pain, and is not often seen during the time of greatest suffering. Sometimes a calculus will remain impacted in the common duct for weeks or even months ; jaundice persists, the bile accumulates, the ducts dilate, until suddenly the impaction is overcome, and violent bilious vomiting and diarrhoea announce the delivery. When the concretion remains per- manently impacted, the liver undergoes the changes already noted ; the connective tissue multiplies, the gland-cells waste and undergo fatty metamorphosis, and the organ shrinks in size (Charcot). Careful search should always be made in the evacuations for the calculus. The fseces should be thoroughly mixed with water, the solid particles allowed to subside and the fluid portion poured off, and this operation must be repeated until the last solid parts are reached. Sometimes — most frequently, j^robably — there is but one calculus, but there may be a hundred. A marvelous change takes place in the patient as soon as the calculus reaches the intestine. The pain ceases, as well as the nau- sea and vomiting, the bowels act spontaneously, the appetite returns, the jaundice soon disappears, and the state of health is fully restored. Course, Duration, and Termination. — From the initial pain to the termination of all symptoms may not be longer than two days, or, if jaundice is present, five days. If a number of calculi pass, the duration of a case is indefinitely prolonged. The severe cases of this kind last several weeks. The usual termination is in health, but death from ulcerative perforation and subsequent peritonitis is not uncommon. Now and then a calculus ulcerates through the duct ; in the peritonitis which follows, adhesions are formed, limiting the mischief to the im- mediate neighborhood ; a purulent depot is thus created, and gradually a fistulous communication externally is established, and the calculus is discharged with the pus. Sometimes such a purulent depot opens communication with the intestine, stomach, or bladder. The last- named terminates fatally ; the discharge by the stomach, intestine, and externally is often successful. After the calculus reaches the intestinal canal, it may serve as a source of new mischief by forming the nucleus of an impaction of the bowel. 188 DISEASES OF THE LIVER. Diagnosis. — The only maladies with which hepatic colic may be confounded are hej)atalgia, gastralgia, and enteralgia. The locality of the pain, the absence of local soreness, the absence of jaundice, the absence of calculi in the stools, separate these neuralgic affections from hepatic colic. Prognosis. — A favorable opinion may be expressed in most cases, but the prognosis must be guarded when the pain does not yield, and when the vital powers begin to flag, especially if local tenderness and fever indicate peritonitis. Treatment. — The severe pain demands immediate attention. There are two methods of relieving it : by the inhalation of ether, and by the hypodermatic injection of morphia. The action of the former is temporary, and, of course, the relief is confined to the period of un- consciousness. This may be sufficient, but usually prolonged adminis- tration is necessary. The hypodermatic injection is more effective. From -jig^ to ^ of a grain of morphia is usually sufficient for an ordinary case, but, if the suffering be very great, J to | grain of morphia may be required. The combination of morphia and atropia is both more effective and safer, and hence atropia should be given, j^ grain at each injection. Not only does this remedy remove the pain, but it is the most efficient means of preventing or subduing peritoneal inflam- mation. Anodynes can not be given by the stomach ; anodyne ene- mata are insufficient in this malady — so that the choice of remedies is much restricted. Five minims of chloroform every half hour, in an emulsion or dropped on sugar, has been proposed, but in the author's experience it is usually rejected, and excites nausea even by its odor. It has been gravely proposed to administer it as a solvent of gall-stones, and to relieve the suffering by effecting a solution of the impacted calculus. Trousseau had, it was supposed, disposed of this notion, but it has been revived again. Chloral has also been employed to relieve the pain, but it has not much anodyne power, and is besides very of- fensive to the stomach in these cases. Warm baths and hot fomenta- tions to the right hypochondrium contribute to relief. Undoubted advantage is derived from the use of leeches, when, the symptoms persisting, tenderness develops and fever arises. Prophylaxis is highly important. The author has had abundant and highly favorable experience with the plan which is about to be recommended, and he therefore urges it on the attention of his readers: The diet must be carefully regulated. All fats and articles containing fat in any form are rigorously excluded. Saccharine substances are also prohibited, and the starchy constituents of the diet are reduced to a little white or corn bread — potatoes, beans, peas, and rice being ex- cluded. Lean meat of all kinds, eggs, fish, fruit, and the succulent vegetables are permitted freely. Wine at dinner is allowed, but malt liquors and spirits are forbidden. Daily exercise is directed. All ir- SPLENITIS. 189 regularities of life of every kind are given up. The remedy -whicli, above all others, has the power to effect the solution and disposition of calculi, is phosphate of soda. This is prescribed in the dose of a drachm three times a day, dissolved in sufficient water, and taken before meals. This remedy is continued for several weeks or months, and, if there are present evidences of gastro-intestinal catarrh, jL of a grain of the arseniate of soda is added to each dose of the phosphate. While success seems always to attend this practice, the author has been constantly disapjjointed in the remedy of Durande (ether and turpentine), and in the administration of chloroform, with a view to its solvent action on retained calculi. As the catarrhal state of the bile-ducts, succeeding to catarrh of the duodenum, is the great factor in the causation of gall-stones, it is highly important to correct it. Without attention to the plan of diet above indicated this can not be accomplished ; but the persistent use of phosphate of soda can do much, even without a change in the habits of life, toward bringing about a cure. Vichy-water, and our own Saratoga Yichy, as well as the alka- line waters of this country, which are so abundant, should be used daily in connection with the plan above indicated. Dr. T. H. Buckler, of Baltimore, strongly recommends the use of the hydrated succinate of the peroxide of iron ( f jss — 3 vjss water — a teaspoonful ter in die) as a remedy to jDrevent the formation of calculL The use of this remedy is based on some theoretical notions respecting the oxidizing power of succinic acid and its solvent action. Buckler also urges the use of chloroform during the paroxysms of colic, as a solvent of cholesterine. DISEASES OF THE SPLEEiSr. ACUTE SPLENITIS. Definition. — By the term acute splenitis is meant acute inflamma- tion of .the spleen. Perisplenitis is a designation apjDlied to inflamma- tion of the investing tunic or capsule, and of the peritoneal layer of the organ. Acute splenic tumor means an acute enlargement — a con- dition present in various acute infectious diseases. Causes. — Our present knowledge of the etiology of spleen-diseases is very unsatisfactory. Hardly anything is known of idiopathic spleni- tis. Of the secondary, or metastatic malady, our information, if not full, at least contains some certain data. That splenitis arises from 190 DISEASES OF THE SPLEEN. embolism is now well known. Inflammation of neighboring parts ex- tends to and involves the spleen. Direct injury, as a blow over the left hyj)ochondrium, may excite inflammation in the spleen. A case arising in this way the author had under observation during life, and was present at the autopsy ; hence the account given of the disease in question is derived largely from this experience. Pathological Anatomy. — Local, or circumscribed, splenitis is in- duced by embolic blocking of a vessel or vessels, and hence the infarc- tions may be one, or two, or three in number ; they may be in the sub- stance, or at the periphery of the organ.* These infarctions vary in size from a pea to a hen's-egg, are wedge-shaped, and when near to- gether may coalesce. These infarctions undergo the usual transfor- mation, and a purulent collection is the ultimate result of the changes. A limiting membrane may form, and the pus become encapsulated, or the boundaries of the purulent depot may be constituted of the rag- ged, disintegrating, soft, splenic pulp. The pus tends to make its way externally, and when the capsule is reached adhesions form, usually to the diaphragm. In the author's case, as a result of a powerful blow on the left hypochondrium (which, however, left no external trace of the injury), the whole organ was turned into a brownish purulent col- lection of eighteen ounces' capacity. Adhesions had been formed with the diaphragm, which was softening, and adhesion of the opposed pleural surfaces indicated the preparation for discharge by a bronchus. The abscess may break into the peritoneal cavity, with the effect of inducing fatal peritonitis. Symptoms. — As the systematic writers are not agreed as to the character of the symptomatology, the author describes it wholly from his own observation. After the injury, or we may also suppose the embolic obstruction, in a day or two, pain is experienced, deeply in the right hypochondrium. The sensation is rather of an aching char- acter, which becomes soreness and tenderness when the organ is com- pressed — a feat that is accomplished by pressing upward under the ribs when the patient takes a full inspiration. There is usually pain developed by taking a deep breath, which becomes catching and acute when the peritoneum is invaded. Neither on palpation nor on per- cussion can an increase in the volume of the spleen be made out with certainty. In about a week after the initial symptoms, a rigor oc- curred, followed by fever and sweats, and these appeared irregularly up to the end. The face was pallid, the lips white, the sclerotic glis- tening, the body emaciated, and the weakness extreme. The appetite was lost, there was occasional vomiting, and diarrhoea supervened toward the termination of the case. Presently a harassing, dry cough, accompanied with pain and an obstinate hiccough, made its appear- * Billroth ; Virchow's " Archiv," Band xxiii, p. 473 : " Der haemorrhagische Infarkt und seine Metamorphosen." ENLARGEMENT OF THE SPLEEN. 191 ance. An increase in the left side through the hypochondrium and an enlargement of the area of splenic dullness now became evident. Death occurred by exhaustion on the forty-second day from the first symptoms. Course, Duration, and Termination.— Nothing can be more ill-de- fined than the course of splenitis. The duration of cases of inflamma- tion terminating in abscess may be not more than a month, and yet cases have continued several years (Mosler). Splenitis may terminate in resolution without symptoms. This is the most probable explana- tion of the existence of cicatricial depressions on the surface of the spleen, found in cases dying from other causes. Cases proceeding to suppuration terminate by discharge through the lungs, of which a successful case has been reported, or communication is established with the stomach, the transverse colon, the left kidney, or with the general cavity of the abdomen. Diagnosis. — If endocardial lesions exist, and sudden pain followed by swelling occur in the splenic region, and subsequently there arise the usual symptoms of suppuration, or if, as a result of a blow, pain and tenderness and swelling develop in the left hypochondrium, the spleen may be presumed to be the seat of the mischief. Prognosis. — As those cases of splenitis which terminate in recovery are never recognized, the question of prognosis does not come up for solution. "When abscess occurs, the prognosis is unfavorable. Treatment. — If the existence of splenitis, from any cause, is as- certained, quinia must be freely administered, and cinchonism main- tained. There are two good reasons for this practice : quinia checks the migration of the white corpuscles and the process of suppuration, and lessens hypergemia of the spleen. No therapeutical fact is better established than that quinia reduces the size of the spleen when it is enlarged by hyperemia. Quinia is, therefore, peculiarly adapted to the treatment of splenitis. Purgatives act on the spleen in two modes ; by reflex action, and by diminishing the general blood-pressure. Sa- line cathartics should be used to maintain free action of the intestines. Warm fomentations, turpentine-stupes, and hot jDOultices should be applied over the left hypochondrium. If suppuration is clearly ascer- tained, the aspirator should be used without delay, just as it is now employed in a similar state of things in the liver. The strength must be kept up by suitable food and stimulants. ENLARGEMENT OF THE SPLEEN.— Owing to its peculiar ana- tomical structure, the spleen is especially liable to variations in size, strictly within physiological limits. In the acute infectious maladies the organ undergoes a change in size of a pathological character. In typhus, typhoid, puerperal, and the eruptive fevers, the spleen en- larges, but in the fevers of raarsh-miasm the change in size is greater. 192 DISEASES OF THE SPLEEN. In certain parts of this country — the Wabash Valley, for example — a splenic tumor of extraordinary size (ague-cake) sometimes develops under the influence of malaria without the objective phenomena of fever, but with the same bodily changes as occur in intermittent and remittent fevers. Obstructive diseases of the heart, lungs, or liver, by causing stasis in the venous system, give rise to enlargement of the spleen, and especially does this result follow sclerosis, and acute yel- low atrophy of the liver. In the condition of enlargement which occurs during the course of fevers — excepting from consideration malarial fevers — the spleen is excessively soft, the splenic pulp almost diffluent, the capsule and trabeculse easily torn. In the acute enlargement which accompanies the febrile movement of malarial fevers, there is really no alteration of structure — the pulp and trabeculae and the Malpighian bodies having their normal appearance and structure, but the increase is due to an immense venous congestion. On the other hand, in the enlargement which occurs without fever, or produced after successive at- tacks of fever, the organ is dense, firm, and paler, due to the great devel- opment of the trabeculae and corresponding diminution of the splenic pulp. In these cases of chronic enlargement due to malarial infection, the organ may attain considerable size, greatly distend the abdomen, and reach to and even extend beyond the umbilicus. There is in these cases an extreme anaemia — a pseudo-leukemia — the superficial veins of the abdomen are enlarged, the legs are swollen, and there is some effusion in the abdomen — results of the mechanical pressure. A splenic tumor of medium size, formed in the mode above indicated, may lodge on the aorta and be confounded with aneurism. MISPLACEMENT OF THE SPLEEN, or MOVABLE SPLEEN.— Changes in the position of the spleen are effected by effusions in the left thoracic cavity, which displace the organ downward. When en- larged and in the condition of "fleshy spleen" above described, the spleen may descend considerably by its own weight, and thus seem more enlarged than it is really. The movable spleen, like the movable kidney, is displaced from its position, and its vessels with the omen- tum are stretched and ultimately assume the shape of a pedicle — an irregularly rounded cord — of which the author has seen several capital examples. Such a spleen may be moved by a change in the position of the patient, or by palpation, and may lie across the abdominal artery and be lifted up synchronously with the arterial pulsation, or be dis- placed downward into the iliac fossa, and may rotate on its horizontal axis. Changes in the structure of the organ necessarily occur under these circumstances ; the blood-supply is lessened, or thromboses form in the vessels ; there are shriveling and atrophy, pigmentary and fatty degeneration, etc. AMYLOID SrLEEX. 193 AMYLOID DEGENERATION OF THE SPLEEN.— Thi« disease con- sists in the deposits of the amyloid matter, either in the form of small patches, forming the ^v^ell-known " sago-spleen," or in a general diffu- sion of the material through the whole organ. In the former the patches may be very numerous and almost unite, but there still remains normal spleen-tissue between them. In the latter form the texture of the spleen is firm and tough, but easily divided with the knife, although not readily broken up into a pulp, and it has a brownish or yellowish- brown color, and no part remains untouched by the new deposit — the pulp, the trabeculge, the Malpighiau bodies, the vessels, all are changed in structure and physical properties by the amyloid matter. The test for this matter is iodine — Lugol's solution — which when brushed over colors the tissues yellowish, but the amyloid matter red or reddish brown : now, on the addition of sulphuric acid, while the yellowish parts remain yellow, the amyloid becomes a dark violet. The amyloid, or lardaceous, or waxy degeneration of the spleen occurs, simultaneously with the same form of degeneration in the liver and intestinal canal, and hence the symptomatology is rather that of the disturbance in the function of the other organs. These symptoms have been detailed in the remarks on amyloid liver. The only contribution made to the symptomatology by the alterations in the spleen are, the increased area of splenic dullness and a greater degree of anaemia and pseudo-leukemia. The great cause of amyloid degeneration of the spleen as of other organs is suppuration, espe- cially protracted suj^puration in connection with bone. Next to this are the syphilitic cachexia and inherited syphilis. Chronic alcoholism and chronic malarial poisoning are supposed to have some influence in its production, but it is extremely doubtful whether they have any real influence. ECHINOCOCCUS OF THE SPLEEN.— The embryo of the taenia echinococcus is deposited in the spleen as in other organs, and more frequently in the spleen than in any, except probably the liver. The liver is reached readily by the portal vein, and the spleen directly, as the two organs come into contact. When established in its home, growth begins, chiefly by the development of daughter-vesicles in the mother-sac. The symptoms produced are due to the size to which the sac attains, the pressure on neighboring organs, and the interference with the circulation in the great vessels of the abdomen. The slow- ness of the growth, the absence of constitutional disturbance, the free- dom from j^ain, and the absence of symptoms except those due to the size of the tumor, separate the echinococcus from other tumors of the spleen. The sense of fluctuation, and especially the purring ti'emor, serves to distinguish this from hypertrophy of the spleen. The employ- ment of the aspirator-needle will contribute to certainty of diagnosis, 13 194 DISEASES OF THE BLOOD-FORMING ORGANS. but the presence of booklets and the absence of albumen can not always be depended on, for the booklets may be absent, and albumen may be present in echinococcus tumors of the spleen. For further details the reader is referred to the subject of echinococcus of the liver. DISEASES OF THE BLOOD-FORMING ORGANS. LEUCOOYTHEMIA— LPUO.EMIA. Definition. — The terms leucaemia and leucocythemia were proposed by rival claimants for priority of discovery — Virchow and Hughes Bennett. The term leucocythemia, proposed by Bennett, seems to the author a more correct designation, meaning white-cell-hlood, than Vir- chow's leucaemia, which means vihite blood. The morbid change which has given the name to the disease is the enormous increase of the white corpuscles of the blood, accompanied by enlarged spleen and enlarged lymphatic glands, and by alterations in the marrow of bones. By Trousseau it is designated adenie. and by Griesinger anaemia, splenica. Causes. — The excessive production of leucocytes, which is the chief element in this disease, must necessarily be due to a functional and nutritive irritation of the blood-making organs. The evidence of this is afforded in the enlargement of the spleen and lymphatic glands. But the cause of this remains unknown, and hence the real nature of the malady continues an insoluble problem. Leucocythemia occurs at all ages and under every kind of social circumstance, but it attacks by preference the male sex, the most vigorous period of life — thirty to forty-five — and those who have been weakened by hardships and excesses. Menstrual irregularities have been supposed to "have an influence in developing it, and, in twenty-one cases of this disease oc- curring in women, there were sixteen in whom some disorders of the uterus had existed (Hosier).* It is probable that these sexual irregu- larities were rather coincident than causal. The cachexise of chronic malarial poisoning and of syphilitic infection have been invoked to account for its production, but no satisfactory data have as yet been published, although there are examples of accidental association. Re- garded from the analogical point of view, leucocythemia may be classed with scrofula, cancer, tubercle, and other infectious diseases, * Ziemssen's " Cyclopaedia," vol. viii, " Diseases of the Spleen." LEUCOCYTHEMIA. 195 which, beginning at one point, or focus, diffuse thence over the body. The morbid alterations characteristic of this disease begin in the spleen, then attack the lymphatic glands, then the marrow of bones, and thus become general. Morbid Anatomy. — The most constant lesion is in the spleen, which is increased in size, either uniformly, its form and shape being pre- served, or some part of the organ undergoes the change. Not only the size but the firmness and density are increased. The color be- comes a reddish blue ; the pulp undergoes hypertrophy, but the nor- mal relations of its elements are preserved ; the trabecule may be more distinct, or may be obscured by the overgrown pulp ; the Mal- pighian bodies are rather increased in number, very distinct, but less consistent than normal. The trabeculae and pulp may be coated with a yellowish, fibrinous exudation ; there may be seen white granules disseminated throughout the organ, and near the surface patches of indurated tissue, the remains of hemorrhagic infarctions. The change in the lymphatics consists in an initial hyperaemia, then hyperplasia of its constituent parts, first of the cellular elements, then of the stro- ma and vessels. They enlarge in proportion to the addition of new material, from a bird's egg to a goose-egg or larger. They have a smooth, rather glistening, appearance, and to the touch are soft, non- elastic, and sometimes fluctuating. All of the lymphatic glands in the body may be engaged, or the process may be confined to a few. Usually those situated about the hilus of the liver and spleen are en- larged. Similar changes take place in the lymj)hatics of the digestive tract, beginning in the follicles of the tongue and tonsils, of the stom- ach, and in the glands of Peyer. Corresponding changes occur in the marrow of long bones, and in the cancellated tissue of the ribs and sternum. The marrow is abundantly infiltrated with lymphoid cells, and the vascular network with its delicate connective tissue, which exists in the normal condition, disappears, and only the larger arterial branches remain. The result is that the marrow, instead of its rose- color, becomes yellowish or greenish yellow.* In somewhat more than one half of the cases the liver is enlarged and changed in struc- ture by reason of the development of the new lymphadenoid tissue of the organ. It increases in size, sometimes immensely so, and weighs from four to eighteen pounds. This change is at first a mere prolifera- tion of the lymph-cells ; then occurs an infiltration of lymph new for- mations, or these are collected in masses or nodules, like tubercle. The cells penetrate the lobules from without inward, and by their numbers dispossess the hepatic cells, which atrophy and disappear, only spots of pigment remaining. f The most important change is that which gives the name to the disease, the increase of white cells in the blood. * Mosler, op. cit. \ Rindfleisch, "Pathological Histology," pp. 183, 473, American edition. 196 DISEASES OF THE BLOOD-FORMING ORGANS. The gross amount of blood is not lessened, but its specific gravity is reduced from 1055 to 1040, even to 1035.* The color is paler than normal, and purulent looking. The proportion of white corpuscles is relatively greatly increased ; but the numbers vary from one to ten, to one to two ; indeed, the white and the red may be equal in num- bers ; the white may even prejDonderate. The white corpuscles may differ from the normal in being larger ; in sjDlenic leucocythemia they contain one or several nuclei ; sometimes the cells are smaller, and there is one large nucleus ; and occasionally transitional forms ai'e dis- covered between the white and red, such as are found in the cell- masses of the marrows. The red corpuscles are both relatively and absolutely diminished in numbers, the water and fibrin are increased, the iron diminished, and certain abnormal ingredients are present, as formic, lactic, and acetic acids, hyj)oxanthin, uric acid, leucin, tyrosin ; but, of these, lactic and formic acids and hypoxanthin only are con- stantly present (Mosler). According to the same authority, the reac- tion of the blood in this disease is not acid, but alkaline. The morbid processes of leucocythemia are not those of a merely splenic disease — a local malady. Hyperplasia of the spleen is, however, the first link in the chain ; from this organ, immense numbers of leucocytes pour into the blood, and also, it is probable, some products of the splenic pulp, as lactic and formic acid, and hypoxanthin, etc. ; the next step consists in the transplantation and subsequent development of hetero- plastic materials in other organs, as the liver, etc. Symptoms. — According to the preponderance of the leucsemic pro- cess in the spleen, lymphatics, or marrow of bones, the disease is en- titled splenic leucocythemia, lymphatic leucocythemia, and myelogenic leucocythemia — for these organs seem equally to possess the power of producing white corpuscles and introducing them into the blood, and one may perform the ofiice for the others. When the spleen is re- moved there are very few defined disturbances of the functions, as the lymphatics and the marrow of bone perform the necessary offices. It is the siDlenic form of the disease which is usually encountered, or the splenic-lymphatic, and the lymphatic very rarely, and the myelogenic never. The development of leucocythemia is so gradual that the be- ginning of symptoms usually passes unnoticed, unless preceded by syphilitic or other lesions, to which attention has been directed. There is usually a history of the gradual appearance of weakness and ansemia, inability for mental and especially for any physical exertion, headache, ringing in the ears, vertigo, palpitation. There are, as the anaemia gradually develops, alternations of an improved state with more de- cided decline, but the constant tendency is downward. These pro- dromal symptoms last from a few months to several years, the average * Wagner, " Manual of General Pathology," p. 546, American edition. LEUCOCYTHEMIA. 197 being about eighteen months. As the cases progress, the condition of anaemia becomes more profound ; the lymphatics of the neck, or groin, or other superficial parts, are found to be somewhat enlarged, and now careful palpation discloses enlargement of the spleen. There are, then, extreme pallor, weakness and exhaustion, and breathlessness on the slightest exertion. The headache, vertigo, and tinnitus continue, and the mental state is depressed, hypochondriacal, and irritable, " due to the accumulation of white corpuscles in the capillary vessels of the brain."* The vision is obscure and amblyopic. There are now and then, without apparent cause, attacks of profuse sweating, and scaly and pustular eruptions. There is usually some feverishness toward evening, and the pulse is always accelerated. Oedema of the ankles, puffiness of the eyelids, and some effusion in the cavities are results of the hydrgemia. The changed condition of the blood also induces the hemorrhagic cachexia or diathesis, and bleeding occurs from the nose, mouth, and other mucous surfaces, and from slight woundSj so that the least abrasion or cut gives rise to severe hsemorrhage. The ves- sels remain unaffected except by capillary thromboses, due to the aggre- gation and adhesion of white cells, and such changes in their walls as are produced by imperfect nutrition. A soft-blowing murmur — anaemic murmur — is audible at the base of the heart. The appearance of the blood is very characteristic. A ready method of demonstrating its char- acter has been mentioned by Sir William W. Gull f — that is, " puncture the finger of the patient, and receive the blood on to a piece of white linen, or a lawn handkerchief, and put by the side of it a similar stain of blood from a healthy subject. The full color of the latter contrasts strikingly with the stain of the former, which is hardly of a blood-color, and translucent." The relative proportion of blood-globules is best ascertained by counting, employing for this purpose the hsemacytometer as arranged by Gowers.J In order to constitute leucocythemia, it has been attempted to fix arbitrary numbers, but, while the proportion of white to red corpuscles must be increased very largely above the nor- mal, yet no definite number can be stated, and hence the diagnosis must rest rather on the concurrence of the splenic and lymphatic en- largements with increase of the white corpuscles. It may, however, be stated, as an approximation to the truth, that the relative proportion of white to red should be reduced to one to six, in order to constitute true leucocythemia. It has already been stated to what extent the dis- proportion may be carried in this disease when fully established. "When the spleen has reached its maximum, the abdomen is greatly enlarged, * Ollivier et Ranvier, " Xouvelles Observations pour servir a I'Histoire de la Leucocy- themie; " "Archives de Physiologic," vol. ii, 1869, p. 518. ■f "Transactions of the Pathological Society," vol. xxix, 18*78, p. 383. jf. The author uses the instrument of Dr. W. R. Gowers, as made by Hawksley, of Lon- don. 198 DISEASES OF THE BLOOD-FORMING ORGANS. and prominent, but in oi'dinary cases an increase of size, and usually of density, can be ascertained on palpation. The mesenteric glands can usually be felt through the abdominal walls, enlarged and firmer. The inguinal, cervical, and other lymphatic glands, are also enlarged. A capital illustration of these is given in the plate accompanying Sur- geon-Major Porter's case, * as reported to the London Pathological Society. The tumors of the tongue and tonsils interfere with mastication and the act of swallowing ; the gums become sjDongy and tender. The appetite may be keen ; it may be normal ; it maybe wanting entirely. Constipation at first is present ; then diarrhoea alternates with consti- pation, and finally diarrhoea persists. The urine has a higher specific gravity than normal — from 1020 to 1030. The urea is greatly dimin- ished, but the uric acid is increased, and hypoxanthin is present, in the cases of splenic leucocythemia. Course, Duration, and Termination. — Leucocythemia is essentially a chronic malady. Its origin can not be often determined, because there is a slow development of uneasiness in the splenic region, fullness of the abdomen, breathlessness on exertion, and anaemia and pallor of the skin. The swelling of the spleen, until its size is considerable, escapes recognition ; when, however, the external lymphatic glands enlarge, attention is earlier directed to the nature of the case. Then an ex- amination of the blood furnishes conclusive evidence. When the hsemorrhagic diathesis comes on, bleeding may be so severe as to ex- haust the patient rapidly, or death may occur suddenly by cerebral haemorrhage. The course and duration of cases are materially affected by the hemorrhagic diathesis. When this does not exist, the progress is much slower and the duration more prolonged. The glandular and splenic enlargements may become enormous, and the patient die ulti- mately of exhaustion, death being preceded by cerebral symptoms — delirium, stupor, and insensibility. The case may be terminated by some intercurrent malady, as pericarditis, pleuritis, pneumonia, etc. The symptoms of the first stage, as already stated, continue for months, even years, the average being about eighteen months, and the second stage, or fully developed malady, lasting about one year. Probably the average duration of the whole disease is two years. Diagnosis. — In the first stage of this malady a distinction is not possible from ordinary ancemia and chlorosis. When, however, the spleen enlarges, and the lymphatic glands also, and the anasmia be- comes extreme, the picture of the disease is complete, and no one pos- sessed of any knowledge could fail to recognize it. In the early stage, the persistence of the ansemia under appropriate treatment, the ex- treme degree of pallor, the breathlessness under slight exertion, the * "Transactions of the Pathological Society," vol. xxix, p. 339, op. cit. LEUCOCYTHEMIA. 199 vertiginous sensations, the lioemorrhagic diathesis, must awaken sus- picion as to the character of the malady, before the splenic disease manifests itself. Treatment. — Unfortunately, we possess no specific against this dis- ease, and hence the treatment must be symptomatic. Iron, which is a specific in anaemia, has no influence of a curative kind in leucocythe- mia, but it is useful as supplying a material needed in the process of repair. There are several remedies which affect the spleen, in a way which indicates a specificity of action : they are quinia, ergotin, and electricity. Quinia, iron, and ergotin can be given together in pill-form — five grains of quinia, one grain of reduced iron, and two grains of ergotin, should be administered three times a day. Simultaneously, electi'icity can be applied in the form of f aradic electricity to the sple- * nic region, or by means of an insulated electrode in the rectum, and the other over the spleen, A slowly interrupted galvanic current is, the author believes, more efficient. Good results are obtained from the local application of the ointment of the biniodide of mercury — un- guentum hydrargyri iodidi rubri — to the splenic region. The oint- ment should be thoroughly rubbed in while the direct rays of the sun are falling on the part, or before a bright fire. The ointment is rubbed in daily, until the skin begins to vesicate, when it must be discontinued, but resumed again when the skin has recovered from the effects of previous applications. As the breathlessness on exertion, the vertigo, the mental troubles, the effusions, the haemorrhages, etc., are due to the impoverished blood, attention must be directed to the central lesion, rather than administer remedies for individual symptoms. In some cases good results have apparently followed tranfusion of blood ; but they were examples of the hajmorrhagic diathesis, rather than of true lencocythemia. In the latter disease transfusion is useless — three cases in which it was employed by Stoll, of Wurzburg, having proved fatal. As the function of blood-production is at fault, attention to the first steps in the process is necessary : in other words, careful alimentation is of great importance. Whether the appetite be languid or voracious, to insure thorough digestion, pepsin and muriatic acid should be ad- ministered after each meal.' As, in the progress of the disease, the liver and intestinal glandular apparatus are disabled, fats, starches, and sugars should be excluded from the diet as far as possible, and the patient be fed on fresh meats, milk, eggs, and fish. Cases not yielding to the plan above indicated may be treated with arsenic, arseniate of iron, especially Fowler's solution, and the phosphates or compound sirup of the hypophosphites. These remedies should, of course, be pushed, especially the phosphates, for no immediate results can be ob- tained from them. Arsenic has been administered hypodermatically, and injected directly into the substance of the enlarged spleen with asserted advantao^e. 200 DISEASES OF THE BLOOD-FORMING ORGANS. MELAN^SMIA. Pathogeny. — The term raelanoemia is ai^plied to a condition of the blood in which are found small brownish or black masses, scarcely so large as a red-blood globule, of pigment matter. Sometimes these par- ticles are oval, or round in shaj)e, sometimes irregular, and rarely stratified by the presence of a colorless capsule (Rindfleisch). Occa- sionally true j)igment-cells are observed. This pigment is found every- where in the blood, but exists in greatest quantity in the spleen, which becomes, according to the quantity, a chocolate, brownish, or blackish color. The spleen may, indeed, be almost the sole place of deposit, ^but the liver is next in respect to place and quantity, and after the liver ai-e the lungs, brain, and kidneys. Opinions differ as to the origin of the pigment, but the weight of authority is in favor of the splenic origin, and that it is a product of the disintegration of the red-blood corpuscles. As during malarial fever this destruction of the red cor- puscles is more rapid than in any other form of acute infectious dis- ease, melantemia is a product of malarial diseases. The pathological changes characteristic of this state are found in the spleen, liver, lym- phatic glands, marrow of bones, etc. The spleen is enlarged, its con- sistence soft, if there have been recent attacks, and firmer if consider- able time has elapsed. The color depends on the quantity of pigment, and is dark slate, or brown, or black. The deposits of pigment take place chiefl}^ along the veins, which are bordered by a dark line, and to a less extent along the arteries, and the whole splenic pulp may be tinted by it. The lymphatics and the marrow, also, contain pigment, which, with lymphoid cells, is found in the vicinity of the vessels. Characteristic changes, due to pigment deposition, also occur in the liver. As elsewhere, the pigment deposits are found alongside the vessels. According to Rindfleisch,* small extravasations of blood in Glisson's capsule, and in the parenchyma of the liver, initiate the pig- ment formation. The pigment granules accumulate about the branches of the portal vein and hepatic artery, about the intralobular and he- patic veins, but the hepatic cells are not involved. The whole organ has a steel-gray or blackish tint. Ultimately the nutrition of the organ may be so impaired that atrophy results. As the pigment granules may be larger in caliber than the blood corpuscles, they will necessarily be arrested in those organs having a fine capillary network. Pigment embolisms of the cerebral vessels are, consequently, results of this process. Pigment blocking of the cerebral capillaries has precisely the same effects that other emboli produce : collateral hypersemia, extravasations, and oedema, with the important structural alterations following in their wake. * "Pathological Histology," American edition, p. 18*7. MELAN^MIA. 201 Symptoms. — Melantemia is an accident or complication of the se- verer cases of malarial fever. The changes in the spleen and liver do not cause symptoms, except the enlai-gement of the former organ, to be made out by palpation and percussion. The cerebral symptoms are, however, very pronounced. There are present, when the pigment embolisms occur, more or less intense headache, vertigo, delirium either low-muttering, or active and furious, passing into stupor, coma, and insensibility. There are occasionally paralysis and epileptiform at- tacks, but usually the motor disturbances are not more than twitchino-s of the muscles, ptosis and weakness of the muscles of the extremities. In cases seen by the author the delirium was wild — delirium ferox — and the motor troubles were those of paresis of muscular groups. In the author's cases also there was a very high temperature, to which the cerebral disturbance may have been in part due. In the more chronic cases, without fever, there are persistent headache and vertigo, the strength is easily exhausted, the nutrition inactive, and the surface, especially of those parts of the body exposed to the light, has a bronzed appearance. In such, we may assume that the pigmentation of the brain is confined to deposits alongside the vessels, and does not in- clude embolic obstruction of the capillaries by pigment masses. When the last-mentioned condition exists, there will be more decided mental symptoms, epileptiform attacks, paralysis, etc. In the milder form, recovery may ultimately ensue if the patient be removed from mias- matic influences. In those cases of capillary embolisms, it is doubt- ful if recovery ever can take place. Nevertheless, treatment must be pursued from the symptomatic standpoint, for it may be that success will eventually be the reward of persistent efforts. Treatment. — There are two therapeutical indications : to check the waste of red-blood globules ; to effect the solution and extrusion of pigment. Quinine, iron, ergotin, and digitalis — which may be com- bined — are the most efficient remedies for the first indication ; pyro- phosphate of sodium for the second. If the symptoms are acute, quinia must be given in large doses — twenty to forty grains a day — if less so, five, even three grains three times a day. The other remedies should be prescribed accordingly.* The utility of the phosphate of sodium consists in its power to maintain the alkalinity of the blood, in its effects on the hepatic secretion, and in its influence over the meta- morphosis of tissue. HEMOPHILIA. Definition. — The term haemophilia is applied to a congenital state characterized by the habitual occurrence of haemorrhages. As the * 5. Quinise sulph. 3 j, ferri redacti gr. x, ergotin 3j, digitalis gr. x. Make into ten wafers. One wafer three times a day. 5 • Sodii pyropiiosphat. § j, ferri pyrophos- phat. 3j. M. Take a teaspoonful in sufficient water three times a day before meals. 202 DISEASES OF THE BLOOD-FORMING ORGANS. disposition to bleeding is inherited, and is transmitted in families, persons so affected are called " bleeders." Causes. — Heredity is the most important factor in its causation. It is an unfortunate fact that families of bleeders are remarkable for fertility. The males are affected thirteen times more frequently than females (Immermann *), but, on the other hand, women transmit the disease more certainly than males — for example, a male bleeder mar- rying a healthy woman, without taint of haemophilia, has children usually free from this hereditary disposition ; but a female bleeder marrying a healthy male has quite uniformly bleeder children. Again, if a woman, member of a bleeder family, but herself not a bleeder, marry, she will have some children who inherit the family taint. The disposition to bleeding usually manifests itself about the first denti- tion, and in a large proportion within the first year. The haemor- rhagic diathesis existing, a slight injury will suffice to start the bleed- ing : thus, lancing the gums, leech-bites, the Jewish rite of circum- cision, slight cuts or abrasion of the skin, have been followed by un- controllable haemorrhage. The bleeding having once occurred, the tendency to attacks is thereby greatly increased. Symptoms. — There does not seem to be anything peculiar in the bleeders as respects bodily conformation, temperament, habits, and disposition, except the htemorrhagic diathesis, although it is said that they are usually persons of superior mental endowments (Leggf). There are two distinct forms of haemorrhage : the external, in which the blood pours out on the surface of the wound or abrasion ; the ijiter- stitial, in which the blood diffuses into the interstices of the adjacent tissues. Frequently, if not usually, both forms occur at the same time. The external form may be the result of injury, and is therefore tr^aii- matic, or it occurs spontaneously, and is named accordingly. The ex- ternal and traumatic form is single, for it is comparatively rare for more than one point of injury to exist at a time. On the other hand, the spontaneous haemorrhage, indicating a more active state of the vice, may occur simultaneously at several points. The most usual site of the spontaneous haemorrhage is the mucous membrane, especially of the oral and nasal cavity ; of the stomach and intestines ; of the bron- chi ; of the genito-urinary passages — named in the relative order of fre- quency. Recent cicatrices, that are still vascular, ulcers of the skin, and irritated surfaces, invite the haemorrhage. Again, in the most perfect specimens of haemophilia, bleeding occurs without any change in the skin to start it, and takes place from the fingers, toes, lobes of the ears, back of the hand, etc. By far the most common form of bleeding is * Ziemssen's " Cyclopaedia," vol. xvii, article " Haemophilia." f Dr. J. Wickhara Legg, " Treatise on Haeinophilia," London, 1872, H. K. Lewis, p. 158. I HiEMOPHILIA. 203 epistaxis, which occurs, according to the statistics of Grandidier,* four times more often than hemorrhage from the gums, which comes next in frequency, then intestinal haemorrhage, haemoptysis, hsematuria, haematemesis, etc., as named. The blood escapes from the smallest capillaries, under very strong pressure, and persists obstinately, in spite of the most powerful means to arrest it, hours, days, and weeks together. The result is an extreme degree of anaemia — the skin pallid, the face drawn, lips retracted, the mucous membrane white and sticky, the pulse small, weak, or not to be felt at the wrist ; a soft, systolic murmur at the base, and a venous hum over the great veins ; or the action of the heart may be too feeble to be recognized. Consciousness may be lost, and death occur in syn- cope. Owing to the extreme cerebral anaemia, there may be illusions, hallucinations, or attacks of convulsions, as in animals bled to death (Kussmaul and Tenner f). In the syncope, a hemorrhage which could not be arrested may cease spontaneously. Notwithstanding the enor- mous losses of blood, its reproduction takes place quickly, and between the seizures the bleeders may present the rosy hue of health. The amount sometimes lost seems almost incredible — in one case (Coates) reaching the enormous loss of three gallons in eleven days. The state of the blood in bleeders varies with the conditions of health and after loss by hcemorrhage — that is, becomes more watery with loss — but other- wise there is no difference in composition as compared with healthy blood, except that the former contains somewhat more red globules and more fibrin than the latter, or is richer than ordinary normal blood. The interstitial bleedings occur chiefly in the skin and subcu- taneous connective tissue, and when traumatic are observed in parts subject to injury, as the back, buttocks, trochanters, while the spon- taneous are observed mostly on the soalp, the scrotum, and the legs. Very small extravasations are called petechioe ; larger ones, ecchynioses. The blood undergoes the usual changes of extravasated blood : at first a bluish red, then brownish, with green borders, then yellowish — sev- eral weeks being occupied in these transformations. Sometimes con- siderable accumulations of blood are formed, constituting blood-tumors, and are found about the false ribs, on the back, on the inner face of the thighs, in the popliteal space, and on the lower extremities. They vary in size from a hickory-nut to a goose-egg, and attain even larger pro- portions, and also vary in firmness according to their position. They are of a bluish-black color, and are surrounded by a rose-colored zone, tender to the touch, and signifying the formation of a limiting mem- brane. These tumors may undergo the usual preparatory changes and be slowly absorbed, or suppuration may occur, and discharge of pus and * Schmidt's " Jahrbiicher," vol. cxvii, p. 329, " Bericht iiber die neucrn Beobachtun- gen und Leistungen ein Gebiete der Haemophilie seit," 1854. t Sydenham Society edition. 204 DISEASES OF THE BLOOD-FORMING ORGANS. shreds of tissue take place, with considerable haemorrhage. The only changes to account for the phenomena of hsemoi^hilia are abnormal disposition and arrangement of the superficial vessels of the body. The superficial vessels are abnormally large, the intima remarkably thin. On the other hand, the lumen of the large arteries (aorta and pulmonary) is found to be narrow. The intima of both classes of vessels is usually in a state of fatty degeneration. There has usually existed an hypertrophy of the left ventricle. These changes in the vascular system, and the condition of vascular fullness and congestion, which marks the healthy state of bleeders, together with the abnormal richness of the blood, serve in a measure to account for the extraordi- nary clinical history of this disease. Complications. — In the bleeder families neuralgic and rheumatic affections seem common. Toothache and myalgia are said to be fre- quent. Rheumatic joint and muscular affections also occur. Duration and Termination. — The duration of hgemophilia is the life of the individual. If the bleeder escape the accidents of childhood, there may be no manifestation of the diathesis until after adult life. A young woman died on her marriage-night, from haemorrhage occasioned by rupture of the hymen. A single haemorrhage may take life in a few hours, as in the case just narrated, or death may result from several weeks of bleeding. The usual result is death. Such small operations as extraction of teeth, circumcision, leeching, etc., are very apt to cause death, while vaccination is much less dangerous. Of 152 bleeder boys, 133 died before attaining twenty-one years of age.* The haemorrhagic disposition may disappear in middle life, but this has happened in nine cases only ; and, when it does cease, rheumatic and gouty attacks are experienced. Treatment. — All injuries must be carefully guarded against. Bleed- ing from any abrasion or puncture should be restrained by pressure, if possible. Every form of astringent vegetable and mineral has been used. Epistaxis, which is the most usual form of hemorrhage, is best arrested by plugging the nares and the application of ice, and by the administration of ergotin. Bleeding from the gums is more easily handled, in that the styptic preparations of iron, the actual cautery, and compression can be used. In haematuria, krameria, infusion of digitalis, ergotin, and gallic acid should be administered. Of the sys- temic remedies there can be no question as to the superiority of ergot and digitalis, and experience is in harmony with physiological ex- periment. Cures have apparently followed the use of ergot. The administration should never be subcutaneously, and the dose of the aqueous extract will range from two to five grains, as often as may be necessary. When attacks are impending, a brisk cathartic of Ep- * Grandidier, op. cit., p. 333. SCORBUTUS. 205 som salts should be administered to lower the blood-pressure, and the diet should consist of fruits and vegetables only. Sulphuric acid in dilute solution should be taken as a drink. Full doses of digi- talis, the patient maintaining absolute recumbency, should then be administered, and when the haemorrhage comes on the exhibition of ergotin, etc., should be practiced. This method is the best now known for arresting the attacks of bleeding. SCORBUTUS— SCURVY. Definition. — Scurvy is a disease of nutrition, in which the blood is so far impoverished that transudations occur, and large hsemorrhagic ecchymoses become visible in various places. Causes. — This disease occurs more frequently in men, because their occupations expose them more to its causes, and in the feeble and cachectic, especially those who are debilitated by syphilis and mercu- rialism, and by marsh-miasm. Scurvy usually occurs in bodies of men, as soldiers and sailors, who are under the same evil influences, and hence numbers are attacked nearly simultaneously — the cachectic falling victims before the robust. The chief factor is defective ali- mentation, not in respect to quantity so much as quality. The contin- ued use of salted meat and fish and the absence of fresh meat and fresh vegetables for a long period from the diet are the great cause, and all other influences are merely adjuncts. When such fresh vegetables as jjo- tatoes, cabbage, and onions, are supplied, although the other components of the ration may consist of salted and dried meats, scurvy will not oc- cur. So well is this fact understood now, that some one of these arti- cles always enters into the diet of armies and prisons, and, if not attain- able in a perfectly fresh state, are supplied in the form of " desiccated vegetables," sauerkraut, etc. Garrod, and afterward Hammond, at- tempted to show that the constituent, the absence of which is the cause of scurvy, is potash ; and that those vegetables most effective in pre- venting and curing scurvy are remarkable for the quantity of potash which they contain, and of these the potato stands at the head. Un- doubtedly, bad hygienic influences exert an influence in the produc- tion of scurvy. Living in houses that are dark, damp, and confined, want of exercise, depression of spirits (defeat), ennui, all have more or less effect in depressing the bodily functions, and thus favor the ill effects of an improper diet. Pathological Anatomy.— Cadaveric rigidity is slight ; suggillations are extensive on the dependent parts ; petechise and ecchymoses are found on the body and the extremities ; the skin is muddy, inelastic, and scaly. The petechial spots are formed by an extravasation pro- ceeding from the capillary network about the hair-follicles, while the larger ecchymoses come from the vessels of the derma. The indura- 206 DISEASES OF THE BLOOD-FORMING ORGANS. tions of the connective tissue, subcutaneous and deeper, are due to infiltration by coagulated blood. The subsequent changes in the clots are the explanation of the appearance presented by these indura- tions, and depend on the greater or less amount of red globules, and on the solution of the fibrin, or its organization. The fibrin may be- come organized to that extent in which muscular atrophy and con- tractions resulting in deformities must ensue. In a similar manner, an extravasation into the substance of a muscle may lead to atrophy, the muscular elements being supplanted by indurated connective tis- sue. These atrophic alterations and deformities are results of long- standing changes. Recent extravasations, in scorbutus, under appro- priate management, undergo the same regressive changes as a blood- clot in the normal state, though somewhat slower, and nothing is found post mortem after the process is completed. The mucous mem- brane of the mouth is the seat of extensive h£emorrhagic infiltration, and is therefore swollen and spongy ; but in old cases the gums may be thickened and indurated, due to the formation of new connective tis- sue. There is more or less eifusion into the serous cavities of a straw- colored or sanguinolent serum ; the membranes are injected, or coated with exudations, or stained by spots of hremorrhagic extravasation. The heart is flabby, soft, pale, and haemorrhages are found in its mus- cular substance. The lungs are somewhat oedematous, the posterior and dependent parts the seat of hypostatic alterations, and catarrhal and croupous inflammation products are found at the base and else- where. There may be extensive solidification from croupous pneumo- nia, or hsemorrhagic infarctions. There are numerous ecchymoses in the bronchi. The peritoneum is altered in the same manner as the pleura — the evidences of inflammation existing on the visceral and parietal layers in the form of exudations and extravasations. The intestinal mucous membrane is altered by hsemorrhagic spots and ero- sions, and sometimes by extensive losses of substance. The liver is not usually affected. The spleen, although often unchanged, is some- times enlarged and softer than normal, and occasionally there are found hsemorrhagic infarctions. The kidneys may be healthy, but the mucous membrane of the pelves, ureters, and bladder contains ero- sions and ecchymoses. Important alterations occur in the blood — the number of red globules diminished ; the white relatively increased ; the iron, potassa, and albumen lessened. Symptoms. — The onset of scurvy is so gradual that the patients do not know when it began. They become a little paler, and fatigue more readily, but after a time there is an appearance of ansemia, and such a degree of weakness that the least effort gives rise to exhaustion, and to a sense of prsecordial oppression and weakness and palpitation of the heart. The increasing weakness is accompanied by a sense of soreness and fatigue in the muscles, like that induced by prolonged SCORBUTUS. 207 hard work, but rest in bed relieves, as exercise increases, these sensa- tions. These muscular pains are especially felt in the back and the calves of the legs, and have a rheumatic character, and are often sup- posed to be rheumatic. The scorbutic subjects become exceedins^ly sensitive to cold, and continually seek the fire or put on additional clothing. They are somnolent, apathetic, and indisposed to any effort, mental or physical ; are dejected in mind, and wear an expression of sadness. The facies presents an unearthly aspect ; the eyes are sunken and surrounded by livid aureola ; the lips are thin, retracted, cya- nosed ; the skin sallow, pallid, dry, scaly, and earthy, and here and there may be found indistinct spots of bronze discoloration. The sub- cutaneous fat has diminished, the muscles are soft and small, and the body-weight is reduced. Such are the symptoms of the initial or prodromal stage. They indicate ansemia, and are suggestive of scor- butus only because of the surroundings, and the presence of other cases. The duration of this period is from a week to two or three months. This prodromal stage may be wanting, but in the cases ob- served by the author * was always present. The scorbutic stage first manifests itself in the gums, which become of a dark-bluish color on their margins, especially at the incisor teeth, and are swollen, projecting between the teeth, and bleeding with a touch. The gums are also quite painful, so that mastication and the mere contact of sapid substances are distressing ; but those portions of the gums without teeth are free from these troubles, and hence the toothless, at the extremes of life, are exempt from scorbutus of the mouth. Again, it sometimes happens that these changes in the gums are entirely absent, and the first manifestation of trouble consists in suggillations and subcutaneous extravasations of blood and intestinal haemorrhage. On the other hand, there are many instances in every collection of cases, in which the only manifestation has been in the mouth, coupled with anemia and muscular feebleness. In the severer cases after the prodromal stage, the weakness increases to such an extent that they become unable to retain the upright posture, and will fall into syncope in the attempt to assume this position. The action of the heart becomes very feeble, and any exertion brings on severe palpitation, with a sense of extreme prascordial oppression. Fever now comes on, in many cases not as a necessary element in the disease, but a symptomatic expression of a local inflammation of a serous mem- brane or other inflammatory trouble. The characteristic hrvAt of anse- raia is audible at the base of the heart and along the great vessels. In the further progress of the case the gums become much swollen, * The author saw some cases of scurvy when serving in the regular armv as medical ofiBcer in 1857, during the winter spent in Utah, the command being on half rations, with- out any fresh vegetables. The description above is, in the main, based on these observa- tions. 208 DISEASES OF THE BLOOD-FORMING ORGANS. rise up to a level with the teeth, are horribly painful, and undergo ultimately an " ichorous disintegration," or diphtheritic sloughs form ; in either case, fetid, decomposing sloughs are cast off, leaving the teeth bare or loose. Serious deformities are necessarily produced by these losses of substance when cicatrization occurs. Extensive hoemor- rhagic extravasations take place in the skin, chiefly of the lower extremities and body, but rarely on the head or face. There may be purpuric petechias, the size of a hemp-seed, or vesicular or papu- lar efflorescences, or large hsemorrhagic spots of irregular size, or vesicles of large size filled with a bloody serum. The least injury or contusion is followed by a suggillation. The skin, too, may become the seat of extensive ulcerations, gangrenous sloughs and haemorrhage. The subcutaneous tissue may either suddenly or gradually become affected by indurations often of great extent. They are at first red, and tender, but presently become brownish, and the epidermis peels off, leaving a discoloration ; or, in severer cases, an acute inflammation is set up, the skin gives way, and a great quantity of blood with shreds of tissue, often gangreneous, is discharged, leaving a more or less extensive foul ulcer. The muscles undergo similar changes — are occupied by indurations, the result of extravasation of blood into their substance, and either acutely inflame, there being great local tenderness and heat, and symptomatic fever, or the process goes on more slowly without fever. Haemorrhages take place from various mucous surfaces : epistaxis ; haematemesis ; intestinal haemorrhage ; haematuria. Fortunately, haemorrhage from the broncho-pulmonary mucous membrane is not common, except in cases of incipient phthis- is. Haemorrhages take place also on the serous surfaces, and haemor- rhagic effusions, the result of inflammation, are not infrequent in the pleura, pericardium, and peritoneum. Enlargement of the spleen, often to a considerable extent, occurs in a portion of the cases. Al- buminuria is present in the severer cases very often, and the urine is otherwise changed in character and composition. The most notable change besides the albuminuria, is the diminution, not only in the amount of urine secreted, but in the relative amount of its solids. Complications. — The periosteum, cartilages, and joints are affected in the worst cases. Extravasations take place under the periosteum, causing a painful swelling, which may take on an inflammatory char- acter if the extravasation be large. The epiphyses of the long bones become swollen, soften somewhat, and may be detached even. Haemor- rhagic effusions occur in the articulations, causing painful swelling, inflammation, and fever. Meningeal haemorrhage is a very rare acci- dent, but haemorrhage into the substance of the brain never occurs. Extravasations of blood also take place in the anterior chamber of the eye and under the conjunctiva. Severe inflammation may be the result. Hemeralopia, or night-blindness, has long been associated with SCORBUTUS. 209 scurvy, but cases of scurvy are without it, and it often exists quite apart from scurvy. The profound alteration in the fluids and solids of the body caused by scorbutus invites attacks of other maladies. A frequent complication is croupous pneumonia, and a cause of death in many cases. Hoemorrhagic infarctions, usually several, sometimes are also found in the lungs. Ulcerative endocarditis and haemorrhagic pericarditis are complications which quickly cause a fatal result. Diagnosis. — Until the characteristic change has occurred in the gums, on the skin, etc., the anaemia of scorbutus is not distinguishable from other diseases characterized by this state. When, however, the gums swell, and there are petechise on the skin, and indurations be- neath, it is impossible to confound it with any other malady. Course, Duration, and Termination. — The usual course of scorbutus consists in the prodromal period, the fully developed attack character- ized by the swollen and sloughing gums, the hsemorrhagic affections of the skin, the extravasations into the subcutaneous areolar tissue and muscles, the inflammatory hsemorrhagic exudations of the serous mem- branes, the profound cachexia, and the period of restoration. The duration is usually jarotracted, and is influenced by the hygienic sur- roundings. When the disease is fully developed, the continuance of the causes will keep it in action and increase the morbid process, while i^ecovery, even in an apparently hopeless condition, takes place promptly when the proper aliment is supplied. The earlier the ap- propriate means of cure are applied, the more perfect the restoration. Serious deformities may result from the inflammations of the muscles, bones and joints, and death quickly follows the lighting up of pleu- ritis, endocarditis, peritonitis, etc. These evil results only occur when the disease has been unusually protracted and severe. Death usually results from hasmorrhages, from exhaustion, from a serous inflamma- tion, or fi'om pneumonia, but the mortality depends almost wholly on the failure of the necessary supplies, and not on the virulence of the disease. With the progress of knowledge, scorbutus is becoming much less common. No longer are witnessed the frightful cases in armies, on shipboard, and in prisons, such as were very common only a century ago. Treatment. — The prophylaxis as well as treatment of scurvy, above all things, necessitates the use of anti-scorbutic food, fresh vege- tables of all kinds, especially the potato and sauerkraut, and lime- juice. In the English navy, lime-juice is most depended on ; but ships and bodies of troops ai'e also supplied with "desiccated vege- tables," the ordinary vegetables, including cabbage, onions, potatoes, etc., compressed into tablets and carefully dried. Desiccated or con- densed milk is also utilized for the same purpose. Whenever attain- able, fresh meats are extremely serviceable, and, in their absence, canned meats, beef-juice, and similar preparations, can be made to 14 210 DISEASES OF THE BLOOD-FORMING ORGANS. supply their place. Yeast has been found by Neumann * to be highly beneficial, and also the barm of beer. Medicines play a secondary part in the treatment of scurvy. In accordance with Garrod's and Hammond's potassa theory, we may prescribe cream-of-tartar lemon- ade, to be drunk freely. Quinine and sulphuric acid, either alone or in combination, are used to diminish transudations and to improve the tone of the system in general. Tincture of the chloride of iron and ergot are given to arrest haemorrhage. There can be no doubt, if the author can depend on his own observation, of the value of whisky as a remedy for the scorbutic state, and to lessen or prevent the extrava- sations of blood. An ounce of whisky every four hours is generally the most useful amount. Turpentine is a highly efficient stimulant and hasmostatic under the same conditions, and is the best dressing for the ulcers in the skin. Alum, tannin, subsulphate of iron, and chloride of iron, are the most useful local styptic applications for ar- resting epistaxis, and haemorrhage from superficial wounds, or ulcers of the skin. Ergotin can, at the same time, be administered by the stomach. Red cinchona-bark in powder is an excellent dressing for the ulcers of the skin. As the various manifestations and localizations of the disease are due to the cachexia, no time should be wasted in treating them, but every effort put forth to improve the condition of the body in general. PURPURA— PURPURA H.EMORRHAGICA— MORBUS MAOULOSUS. Definition. — The term purpura means a bluish-red or purplish dis- coloration, produced by extravasation of blood ; purpura simplex is applied to the simplest form of this malady, in which there are only minute extravasations in the skin (petechise), and no haemorrhages into other parts ; purpura hmmorrhagica indicates a condition of things in which not only petechiae appear in the skin, but ecchymoses, vibices, and hasmorrhages occur. Besides the variations in intensity as ex- pressed in the names applied to the disease, there are differences in character. Although a very large proportion of cases of purpura, whether simple or haemorrhagic, are entirely free from fever, there are cases of both forms in which fever is present — the febrile form (pur- pura febrilis). There are other cases, complicated with rheumatism, one or several joints being affected — rheumatic purpura (purpura rheumatica). Causes and Symptoms. — Purpura is not limited by climate, race, sex, or social condition, but it occurs more frequently in females, and is more common from fifteen to twenty than at any other age. It ap- pears to be strictly sporadic. Convalescents from fever seem to be * Imraermann, op. cit. PUEPURA. 21;!^ specially liable to it. The disease usually begins abruptly, the first manifestation being epistaxis. In a few cases there is a prodromal period, of a few days, possibly a week, in which there are some languor and inaptitude for exertion of any kind, sometimes with feverishness, sometimes Avith rheumatic pains, and slight swelling of the joints, usually the ankles and knees. The next symptom is the occurrence of petechioe on the lower extremities and body, less on the arms, and rarely on the face. These petechite or bluish-red spots, vary in size from a pin's-head to a pea, and change in color successively from blr- ish-red to greenish, brown, and yellow. As successive crops come out, the appearance of the skin is peculiar, the different colors of dif- ferent ages being curiously intermingled. Slight injuries, blows and contusions, are followed by extravasations, bluish-red spots of irregu- lar size making their appearance. So long as the disease is limited to these manifestations, it is entitled purpura simplex ; but hasmorrhage from the mucous surfaces is very common. The mucous membrane of the mouth is a not unusual source of haemorrhage, but the spongy and sloughing gums of scurvy are entirely wanting, as also the diph- theritic and inflammatory exudations. Hssmorrhages may also occur in the subcutaneous areolar tissue, in the serous cavities, from the cere- bral meninges, but these are exceptional ; whereas the hgemorrhages from the mucous surfaces is the special feature, and may be the only condition present. It has been observed a few times that the haemor- rhages have come on suddenly, without any other symptoms, in appar- ently healthy and vigorous subjects, and without impairing the general health ; usually, however, the repeated losses of blood cause an extreme degree of ansemia, manifested by pallor, emaciation, weakness and breathlessness on slight exertion, faintness on assuming the erect pos- ture, swollen ankles, etc. Before haemorrhages occur, the condition of the blood seems normal; but in the further progress of the cases the blood becomes watery, the white corpuscles increase in number rela- tively, and the red corpuscles decrease, but the coagulability of the blood is at no period lost. Besides the presence of blood on the mucous surfaces and on some of the serous membranes, there are j^ost- mortera changes to be noted. The haemorrhages are mere extravasa- tions, and under no circumstances inflammatory. The disease may therefore be regarded as a ^^ transitory hcernorrhagic diathesis'''' (Im- mermann). An important result of the disease, due directly to the haemorrhages, but persisting after they have ceased, is anaemia. It is in a high degree probable that the anaemia, which is increased by the haemorrhage, is also a principal factor in their causation. Urticaria is another complication, and seems to be associated with stomach de- rangement. A much more rare accident is the occurrence of slough- ing and perforation of the intestines, produced^ by haemorrhagic ex- travasations into the tunics of the bowel. 212 DISEASES OF THE BLOOD-FORMING ORGAXS. Course, Duration, and Termination. — The -vrhole course of the dis- ease includes the prodromal period, the purpura simplex, the period of hcemorrhage, and the subsequent antemia. The duration is influenced materially by the number and amount of the haemorrhages. An ordi- nary case will last two or three weeks, but when there are repeated haemorrhages the disease may continue for several months. Although most cases recover, death sometimes happens from exhaustion, from internal haemorrhage, from some intercurrent malady, and from jDer- foration of the bowel. Diagnosis. — Purpura may be confounded with scorbutus, hemo- philia, progressive pernicious ansemia, leucocythemia, and cerebro- spinal meningitis. From scuiwy it is differentiated by the absence of changes in the gums, of the indurations of the subcutaneous areolar tissue and of the muscles, of the hemorrhagic inflammation of the serous membranes, etc. From hemophilia the distinction is made by reference to the history, especially the heredity, by the period of life, by the bleeding from trivial wounds, so characteristic of hemophilia, and not of purpura. The distinction of purpura from progressive per- nicious anemia rests on the fact that in the former the anemia is pro- duced by the bleeding, in the latter the bleeding comes on afterward and is due to the poverty of blood. From leucocythemia the distinc- tion is made by the enlarged spleen and enlarged lymphatics, with the growth of which a marked degree of anemia is coincident, and to which the hemorrhagic tendency succeeds. The initial symptoms of cerebro-spinal meningitis may be almost identical with those of pur- pura : purplish spots, pains in the joints, with some slight feverishness, but in a day or two the occurrence of nervous phenomena decides the question. Prognosis. — Most of the cases terminate in recovery. A guarded opinion must be expressed when the hemorrhages recur again and again, and when the disease occurs in broken-down subjects. Treatment. — The usual treatment consists in the administration of the mineral acids, especially the sulphuric, and of the preparations of iron, especially the tincture of the chloride. "With these remedies must be conjoined a suitable dietary, fresh air, sunshine, and moderate exercise. If constipation be present, the most appropriate laxative is sulphate of magnesia with dilute sulphuric acid. If hemorrhages that are threatening come on with a strong pulse, flushed face, headache, and excitement, digitalis, quinia, and ergotin are the appropriate medi- caments. If there be weakness and debility, quinine and alcoholic stimulants moderately should be prescribed. The local means for arresting bleeding consist in subsulphate of iron, tannin, alcohol, ice, or it may be hot water, which is sometimes more effective than cold. For the after-anemia iron should be pushed. ANEMIA. 213 AN JEJMIA— OLIG-ffiMIA. Definition. — The term anoimia, which signifies want of blood, con- sists of a deficiency of its nutritive constituents. Oligmmia, which signifies poverty of blood, is a more correct term ; but the former is too firmly fixed by usage to permit a change. Although fi'om the etymological point of view aniemia must be used to indicate a defi- ciency of blood, yet, by common usage, it is understood to mean pov- erty of the blood, and in that sense is erajiloyed in this work. Causes. — The tendency to ansemia is influenced by sex, age,, and peculiarities of individual constitution. The female sex is more liable than the male, for the reason probably that the former are by nature less endowed with the nutritive constituents of blood. Compared to the body-weight, and still more decidedly by sex, the blood of women contains fewer red corpuscles, more water, and less albumen and salts, than the blood of men. While the average number of red globules in the blood of healthy adult males is 141 '1 per 1,000 parts, in the healthy adult female it is 127*2 (Becquerel and Rodier*). The ex- tremes of life — youth and old age — are more liable to anaemia than the period of maturity. In early life the needs of the growing organism are such as to require the utmost amount of pabulum from the blood ; the interchanges are more rapid, the consumption of material greater, and hence the more ready development of anaemia if other circum- stances coincide. In old age, on the other hand, the productivity is diminished, and hence the waste may easily exceed the demand if there be any disturbance either in the preparation of materials for the blood or in the retrograde metamorphosis of the tissues. There are those also who have a natural tendency to anaemia, a peculiar type of constitution. They are in a condition the opposite of plethora, are deficient in the amount and quality of blood, and seem to be unable to produce it effectively. Sometimes they are persons of full habit, but possess a lax fiber, and are pale and weak. A powerful exciting cause of anaemia is an insufficient supply of food. Again, the food being abundant, ansemia may be the result of poor digestion, and faulty and imperfect assimilation. The food abun- dant, and the primary assimilation active, anaemia may result because of a deficiency in the supply of oxygen to complete the cycle of pro- cesses terminating in healthy blood. When the products of digestion are pouring into the blood, oxygen is needed to burn off the effete, excessive, or improper materials, and to perfect the preparation of the new materials. Light is also necessary to this process. Moderate exercise, by increasing the rate of organic movements and the con- sumption of oxygen, favors the preparation of the blood and improves * " Pathological Chemistry," translated by Dr. S. T. Speer. London : Churchhill, 1857. 214 DISEASES OF THE BLOOD-FORMING ORGANS. its quality. The absence or imperfect supply of food, light, air, and exercise, impairs the vital processes and induces anseraia. Excessive exertion and fatigue, by the over-consumption of material, directly contribute to the production of the anaemic state. Heat acts similarly, in that prolonged high temperature increases the rate of circulation and the interchanges of waste and repair, while at the same time it inter- feres with supply by lessening the appetite and the digestion. Fre- quent repetition of the sexual orgasm, profuse menstrual flow, pro- longed lactation, hsemorrhages, are very powerful causes of anaemia. Diseases of the organs concerned in nutrition, notably the digestive organs, malignant growths, albuminuria, the slow absorption of various mineral, vegetable, and gaseous poisons, and numerous pathological processes, either produce or are accompanied by ansemia ; but in this relation the position of ansemia is quite secondary. Pathological Anatomy. — The changes found post mortem in ansemia from haemorrhage are simply the appearances due to an exsanguine condition of all the organs and tissues. They are paler, drier, more compact, and free from blood. If death has been preceded by a wast- ing malady, not only is there the condition of bloodlessness, but the body is shunken, the subcutaneous fat has disappeared, the muscles are thin, and the serous cavities contain more or less fluid. Patches of fatty degeneration occur in the muscular tissue of the heart — chiefly in the papillary muscles — and to the eye present the appearance of yel- low spots and strise. A similar (i. e., fatty) change is to be found in the intima of the great vessels, notably the aorta. Fatty change also takes place in the gland epithelium of various organs — the kidney epithelium, the hepatic cells, the gastric-gland epithelia, etc. The blood has a brighter tint than in the normal condition, due to a diminution in the number of red-blood globules, and in the quantity of hsemoglobin. In the ansemia due to loss of blood, the amount remaining after death is much below the normal ; under other circumstances, the diminution may be but slight. The blood is also thinner, and has less power of coagulation, the clot lacking in firmness, whence it must be concluded that the fibrino-plastic substance and the fibrinogen are below normal. Symptoms. — The simplest and purest form of ansemia is that caused by sudden and considerable loss of blood, as from wounds of arteries, unavoidable and post-partum haemorrhage, etc. The symptoms are eminently characteristic : the skin becomes waxy white ; the sclerotic pearly and glistening, eyes sunken ; the face ghastly and shrunken ; the lips pallid and bluish and retracted over the teeth ; the nose pointed and cold ; the finger-tips white, waxy, and cold ; the surface of the body is cold, and the temperature reduced below the normal ; the pulse is small, very quick, exceedingly feeble, and may cease to be felt at the wrist ; actual fainting may occur ; consciousness restored, faint- ing maybe repeated, and this may occur many times ; the attacks of ANiEMIA. 215 syncope may be accompanied by epileptiform convulsions as in ani- mals bled to death (Kussmaul and Tenner *) ; death may ensue in the syncope, or there may be a gradual restoration, the first change for the better consisting in a return of the pulse at the wrist, followed by warmth of the surface. But the weakness is yet extreme, and fainting occurs from the least exertion ; or, when any effort is made, the face flushes, the heart beats rapidly, there is much oppression of the chest, and a sense of utter exhaustion. Excessive thirst is one of the immedi- ate results of loss of blood, but the appetite for solid food returns very slowly. The urine is necessarily small in quantity after haemorrhage, but the relative proportion of urea is increased. When restoration is taking place, the urea is less, the specific gravity of the urine falls below the average standard, until the normal state is reached. The most common form of anaemia is that induced by wasting discharges — prolonged lactation, for example — by disturbances in the function of nutrition — primary and secondary assimilation — by the eachexiae — notably the malarial. This form of anaemia may be called chronic, while that already discussed is either acute or subacute. In chronic anaemia there exist pallor, or an earthy hue or fawn color of the skin, wasting to a greater or less extent, by disappearance of the subcuta- neous fat, and a flabby state of the muscles : the skin is wrinkled, dry, and inelastic, the hair and nails appear dull and lusterless ; the temper- ature of the surface below normal ; the cutaneous circulation, the ten- sion of the arteries, and the force of the cardiac contraction lowered ; the anaemia hruit audible at the base of the heart and over the great venous trunks ; sometimes a haemorrhagic tendency develops ; the function of digestion is wanting in energy, the appetite capricious, the bowels constipated ; the urinary secretion is rather scanty, and may contain albumen, etc. ; the sexual system is depressed, both male and female, and, while the sexual appetite is lessened in the male, amenor- rhoea is present in the female, or there may be menorrhagia. Not all anaemic persons become paler by reason of diminished vascularity of the skin; those of dark complexion and the dark-skinned become darker. The emaciation, or at least the lessened fullness and roundness of the form due to anaemia, may be supplanted by cedema, produced by the changes in the composition of the blood. When the diminution of albumen reaches a certain point, the fluid normally contained in the tissue is not taken up by the blood-vessels, whence more or less cedema results, and, under the same circumstances, accumulation of serum takes place in the serous cavities. In this process there necessarily exist both "hypalbuminosis" and "hydraemia" — the former meaning a diminished amount of albumen ; the latter, an increased amount of water. The hypalbuminosis is the most important factor in the pro- * " On tbe Nature and Origin of Epileptiform Convulsiona, caused by Profuse Bleed- ing, etc." Sydenham Society translation. 216 DISEASES OF THE BLOOD-FORMING ORGANS. duction of the wasting or marasmus of anaemia. Not all parts lose in weight uniformly — the fatty tissue comes first, and next the spleen, liver, and voluntary muscles; and, as respects the muscular system, those waste least that are kept at work, as the heart and respiratory muscles. The weakness of the muscular system, which is so prominent a symp- tom in anaemia, is due largely to the diminished production of force, rather than to changes in the muscles themselves. The poor quality of the blood and the inactivity of the tissue-changes are the causes of the lessened evolution of force. A temperature below the normal is another result of the same causes. Among the most important of the symptomatic disturbances of ■ anaemia are those of the nervous system. The organs of special sense are peculiarly alive to external impressions, and hence loud sounds, bright lights, and sharply sapid substances, make an unpleasant impression. The sensory and motor apparatus are similarly affected. Hyperaesthesia and hyperalgesia — neuralgia — ^are among the most' disagreeable of the symptoms which occur dui'ing ansemia. Hysterical seizures, epileptoid attacks, are also results of an imperfect nutritive supply (" anaemia of the brain "). When the antemia is extreme, as in cases of inanition, or from any cause, there is usually delirium, it may be, having a violent maniacal character, or low-muttering, or cheerful, busy delirium. The anaemia may result in syncope with temporary loss of consciousness — attacks frequently due to mere enfeeblement of the heart's action. As regards the condition of the organs of circulation, it is to be noted that the cardiac movements are feeble, the sounds muffled and indistinct, and the arterial tension low. The diminished power of the heart to move the blood leads to stasis in the venous system, which may result disastrously by oedema of the lungs, or hypostatic pneumonia, or by thromboses. More or less diffi- culty of breathing is a constant symptom, but there may be extreme dyspnoea when some sudden effort is made. The impaired breathing power is the product of several factors : 1. Of the increased irritabil- ity of the respiratory centers ; 2. Of imperfect depuration of carbonic acid, and insufficient supply of oxygen. Course, Duration, and Termination. — The course of anaemia is that of the malady with which it is associated or on which it is dependent. If due to haemorrhage, or some sudden accident, it is acute, but the usual course is chronic. It has no defined duration, and is in no sense a self -limited disease. The progress of recovery is influenced by age, sex, and the recuperative powers of individuals. While women bear loss of blood better than men, they possess less restorative energy. The hygienic circumstances and the social condition are important elements in the process of reconstruction — for those who are most favorably placed have the best chance of recovery and the least delay in convalescence. Anaemia may result in death, in recovery, or in incomplete recovery. When the anaemia has been extreme, and the AN.EMIA. 217 destruction of red-blood globules great, recovery is rarely, if ever, com- plete, and the patient's bodily vigor remains more or less below the normal. Prognosis. — The cause of the malady and its associated states enter largely into the question of prognosis. When the ansemia is simple, due, for example, to sudden loss of blood, or to prolonged lactation, or to malarial infection, or to sexual disorders, or to diseases of diges- tion — all of which are perfectly remediable — the prognosis is favor- able. When, however, anaemia has been produced by excessive loss of blood, and a condition of extreme debility has persisted for weeks ; when associated with great mobility of the nervous system, and with protracted amenorrhoea, the prognosis must be guarded in respect to complete recovery. When anaemia is associated with cancer, albumi- nuria, suppuration of bone, amyloid degeneration, phthisis, scrofula, etc., the prognosis is unfavorable. Treatment. — As the condition to be remedied consists in an im- poverished state of the blood, obviously treatment must be directed to the organs concerned in the elaboration of blood ; the organs of digestion, including the liver and pancreas, and the organs for the production of the corpuscular elements — the spleen and lymphatic system. The first step consists in the rectification of any existing dis- ease of the digestive apparatus, if remediable ; the second, in the sup- ply of suitable aliment ; the thii-d, in the administration- of certain medicines needed in the construction of the blood ; and, fourth, in the admission of air, sunlight, and suitable exercise to an important place in the treatment, for these are required to perfect the final stage of the conversion of aliment into blood. If the digestion is feeble by reason of a deficiency of gastric juice, muriatic acid and pepsin should be administered after meals. If there be torpor merely, this may be overcome by the use of nux-vomica tincture, or the simple or aromatic bitters — these acting as local stimulants to the stomach-glands. If the appetite is languid and the stomach is equal to the digestion of the ali- ment taken, it will sufiice to depend on the third group of remedies. A suitable supply of properly proportioned food is of the very highest importance. The albuminous or nitrogenous constituents — fresh animal food, eggs, milk, etc. — are the most necessary, but vegetables and fruits are also useful. If the digestive organs support food badly, it should be given in small quantity at short intervals, and, if solid food can not be managed by the stomach, beef-juice and milk can be given instead. The blood plasma may also be supplied directly by the rectal injection of defibrinated blood on the plan of Dr. Smith, of Xew York, A^hich is a most important addition to our resources in the treatment of anaemia. A moderate quantity of alcoholic food is also highly ser- viceable — say, a tablespoonful of whisky three time a day — but it should always be remembered that a taste for alcoholic beverages is 218 DISEASES or THE BLOOD-FORMING ORGANS. quickly formed under these circumstances. The medicines required are those actually used in reconstruction of the blood, viz.,- iron, man- ganese, and the phosphates. As iron and manganese exist together in the blood (1 to 40), and also throughout nature, it is very useful to follow this indication and administer them together. There is another view of the utility of iron — promulgated chiefly by Brown- Sequard — that it acts solely by increasing digestion, and that the food taken in increased quantity under its use contains sufficient iron to supply the requirements of the blood ; but the former view is that chiefly entertained. The saccharated carbonate of iron and manga- nese is an excellent preparation, or the dried sulphates of iron and manganese may be prescribed in pill-form, with or without extracts of mix vomica, gentian, or calumba. The question of the comparative utility of the vegetable or mineral-acid compounds of iron frequently arises. Notwithstanding the jDaradoxical character of the statement, it is generally true that the more irritating and astringent preparations are better borne, and they are certainly more effective. Next to iron and manganese are the phosphates, especially the phosphate of lime. In the anosmia of lactation there is a very marked deficiency in the quantity of phosphate of lime, and in all forms more or less reduction of the proper amount of this substance. The sirup of the lacto-phos- phate is the best form for the administration of this agent, if well and genuinely prepared. Pyrophosphate of iron may be given with the phosphates, as compound sirup of the phosphates ; or the elixir of the phosphate of iron, quinine, and strychnine may be prescribed under the same indications. When purpura, or the hsemorrhagic diathesis, or allied states of the blood exist, great advantage is derived from the conjoint administra- tion of ergot or digitalis with quinine ; for iron is not well borne when the hsemorrhagic tendency exists, although the blood may be deficient in this constituent. Among the remedies for promoting the nutrition of the body, cod-liver oil takes a high place. It is usefully administered with the phosphates, especially in those cases in which anfemia is associated with impaired nutrition of the nervous system, and lowering of the general nutrition in cases of pulmonary disease. In the ansemia produced by phosphorus, carbonic-acid narcosis, coal- gas poisoning, etc., transfusion has been successfully employed. Unin- jured new elements introduced into the veins, the condition of ansemia is at once removed. The operation of immediate transfusion of human blood is alone justifiable under these circumstances, for lamb's blood will not functionate properly. When the food is undergoing final con- version into blood, the oxygen of the air is necessary to complete the changes. Hence some exercise, short of fatigue, should be taken about three, hours after the meals, for at this time the products of digestion are pouring into the blood, and then the oxygen is espe- CHLOROSIS. 219 cially needed. Moderate exercise eflEects a proper distribution of the blood in the body, increases the absorption of oxygen, and the excre- tion of carbonic acid and urea. In proper limits exercise promotes the metamorphosis of tissue, and is therefore serviceable in ansemia, but, carried to fatigue, waste is greater than repair. The method of combined rest, massage, faradization, and forced feeding, practiced by Weir Mitchell,* is extremely useful in these cases, and Avill often suc- ceed when other means fail. CHLOROSIS. Definition. — Chlorosis and ansemia are usually regarded as identical disorders, but they differ sufficiently to be treated separately. The peculiarities of chlorosis are simply referred to the sexual condition, and it is therefore, according to this view, an ansemia occurring in girls about the period of puberty. The term chlorosis relates to the pecu- liar tint the complexion assumes in this disease, and in common lan- guage it is designated " green-sickness." Etiology. — Chlorosis is a disorder of the female sex almost exclu- sively, and those cases occurring in males are examples of modified ansemia. Puberty, or the period of sexual evolution, is the time of life when this disorder develops — from the fifteenth to the twentieth year. An inherited disposition seems to exist in many cases, for no- thing is more common than the references of the mother to her own experience when the daughter betrays the first signs of the malady. The type of constitution which is thus transmitted is distinctly of lowered vitality — " the gelatinous descendants of albuminous parents " is the apt phi-ase descriptive of the constitutional state. These sub- jects are light, fair, full, round, but white, having blue eyes, soft tis- sues, and feeble muscles. Menstrual irregularities seem closely asso- ciated with chlorosis, either as cause or effect. According to Virchow, abnormal narrowness of the aorta is an important factor. If an hered- itary predisposition exist, or congenital defects in the vascular system, the ordinary contingencies of social life may suffice to develop it — es- pecially the cultivation of the emotional life — but it occurs quite inde- pendently of erotic sentimentality. On the other hand, this condition of the system comes on without any apparent cause, or spontaneously. Hammond, who has made an elaborate study of chlorosis ("Journal of Psychological Medicine "), maintains that it is an affection of the nervous system, the blood-changes being secondary. Pathological Anatomy. — The body is fairly well nourished, and the subcutaneous fat pretty well distributed. The organs are generally pale. The serous cavities contain but little fluid, and there is no oedema * " Fat and Blood, and how to make them." 220 DISEASES OF THE BLOOD-FORMIXG ORGANS. of the inferior extremities. The most important change occurs in the blood, and consists in a diminution of the red corpuscles. This can now be readily detei-mined by actual count, using the haemacytometer, as modified by Gowers, for this purpose. As the u'on of the blood is re- duced in this disease, it is probable that the diminished staining power, which is so consf)icuous an alteration, is due as well to diminution of the hrematin as to loss of corpuscles. In chlorosis the albuminates and the leucocytes are not diminished, unless an anaemia develops in the course of the former, when the alterations peculiar to the latter are superadded. Neither is the volume of the blood apparently reduced. We owe to Yirchow the important fact that in recurrent and persistent chlorosis, abnormalities exist in the vascular system : the aorta and arterial system, generally, are smaller in caliber, and thinner, the in- tima having a " trellis-like " arrangement ; and the tunics of the ves- sels are affected by fatty degeneration in spots, and striae of a yellowish color, especially the intima. These spots are found in greatest numbers about the origin of the ascending aorta, and on close examination are found to be a collection of minuter spots, each corresjjonding to a connective-tissue corpuscle, which is advanced in fatty degeneration. The heart may be normal, may be abnormally small, may be somewhat hypertrophied, but the alterations of this organ are not constant. The spleen, the lymjDhatics, and the marrow of bones, are not affected in any way. Symptoms. — Girls about the period of puberty are the subjects of chlorosis. "With or without disorders of menstruation, the affected person experiences a change in her feelings, and becomes morose and despondent, or capriciously vibrates from an extreme of high spirits to corresponding dej)ression, but low spirits is the habitual state of the largest number. There is no reason to believe that erotic feelings are mixed up with the gloomy fancies which dominate the mind, but nym- l^homania is in rare instances present as a symptom. Hysterical mani- festations may also occur, but do not .constitute a necessary part of the malady. As respects the actual condition of the sexual organs, there are two forms of derangement which happen in chlorosis : there are the amenorrhoeic form and the menorrhagic form — cases in which the menstrual flow is absent ; cases in which the flow is excessive. After an attack of menorrhagia, or after the failure of the flow to ap- pear, the changes in the mental state above mentioned manifest them- selves. Then the complexion changes. Fair-haired and white-skinned girls (blondes) become pallid, and waxy, and puffy, but without oedema ; dark-haired and dark-skinned girls (brunettes) assume a muddy, grayish coloration, with bluish-black rings under the eyes ; the sclerotic being pearly and glistening, and the mucous membrane of the mouth pallid. There is present, constantly, a strong feeling of fatigue, and the least exertion causes weariness, while strong mus- CHLOROSIS. 221 cular effort induces exhaustion. Muscular effort of any kind starts the heart into tumultuous action, and brings on difficult breathing and a sense of oppression. The anaemic bruit heard at the base, and over the great vessels, exists in chlorosis as in anaemia. The pulse is rather full, but soft, the action of the heart irregular, the breathing not rhyth- mical, and a dry, barking, or noisy cough is not unfrequently present. The appetite is usually capricious — now satisfied with difficulty, now indifferent to food, but characterized by sudden desire for unusual arti- cles, or by craving for pickles, slate-pencils, chalk, etc. Attacks of cardialgia are frequent and severe, and may indicate the presence of a gastric ulcer — a not infrequent complication of chlorosis. Course, Duration, and Termination. — The course of chlorosis is af- fected by the social circumstances, and the treatment still more, by the presence of the changes described in the vascular system. There are several important complications which affect the behavior of chlo- rosis. The first is anaemia, the development of which increases the gravity and adds to the duration. Phthisis develops in a considerable proportion of the cases, and in part doubtless because of the narrow- ing of the aorta. Perforating ulcer of the stomach is an occasional and very fatal complication. The explanation of its relation to chlo- rosis is, probably, the existence of fatty change in the intima of a stomach- vessel, thrombosis, and rapid solution of the mucous mem- brane. Chlorotic subjects — those affected with the changes in the tunics of the arteries, certainly — are very liable to attacks of endocar- ditis. Yirchow, to whom we owe our knowledge on the subject, has further pointed out that during pregnancy, and in the ]3arturient state, they are apt to suffer from ulcerative endocarditis of a most malignant character. Paroxysms of hysteria and attacks of chorea are not infrequent, especially the former. Chlorosis is also a large and important element in the formation of exophthalmic goitre, but the cases are too rare to give this fact importance here. The duration of chlorosis is very un- certain. It is not a self -limited disease, and manifests no tendency to spontaneous cure. It may terminate in recovery, in partial recovery, or in some intercurrent malady, as pneumonia, typhoid fever, endo- carditis, perforating ulcer of the stomach, cerebral haemorrhage, etc. The prognosis is favorable for simple, uncomplicated cases, but must be guarded for cases which recur, as they may be examples of chloro- sis with vascular changes. Treatment. — As lessened haematin and haemoglobulin is the essen- tial element in chlorosis, the administration of iron is the main jjoint in the therapy. The combinations of iron with a mineral acid (tincture of the chloride, sulphate, etc.) are usually more effective than the so- called mild preparations. The addition of manganese is useful, be- cause of the intimate association of these minerals in the blood-glob- 222 DISEASES OF THE BLOOD-FORMING ORGANS. ules. The utility of iron does not consist solely in supplying to the organism of the chloritic a material which is deficient, but in stim- ulating the appetite and the digestion, so that more food is taken and disposed of more easily. It follows that iron must be given in large doses in this disease, and experience is in harmony with theory on this point. Excellent results are obtained from the conjoined or simul- taneous administration of iron and the phosphates — notably from the pyrophosphate of iron and lactophosphate of lime. Again, many cases do better — the majority, within my observation — by the combination of iron with some agent having the power to exalt the cerebro-spinal functions, as arsenic and strychnia. An excellent prescription, not- withstanding the chemical incompatibility, is the pil. ferri carb. with arsenious acid or arseniate of iron ; or. Fowler's solution may be given separately, after the chalybeate. Strychnia, iron, and manganese sul- phates can be given in pill-form. Hammond, influenced by his theory of the nervous origin of chlorosis, holds that arsenic is the true rem- edy, and his experience supports his theory. The author has seen the best results from a combination of iron and arsenic, and this fact he urges upon the attention of his readers. A generous diet, out-door air, and moderate exercise, are essential elements in the therapy of chlorosis. The combined treatment of rest, forced feeding, massage, and faradization, advocated by Weir Mitchell in these cases, seems to succeed in many wonderfully. The measures above recommended, combined with suitable hygiene, rarely fail, however, to effect a prompt cure. No treatment will accomplish more than a temporary cure in those cases associated with changes or abnormalities in the vascular system ; for the chlorosis will recur from time to time, and possibly the case terminate at last with ulcerative endocarditis in the pregnant or parturient state. PROGRESSIVE PERNICIOUS AN2EMIA— ESSENTIAL ANiEMIA— MALIGNANT ANiEMIA. Definition. — By the term progressive pernicious ancemia is meant a form of anaemia of most severe character, progressive and fatal, and accompanied, toward the termination, by a fever. Causes. — This disease occurs usually in women from fifteen to forty years, who have been repeatedly pregnant or subjected to debili- tating influences, as uterine haemorrhage, or to bad hygiene. It is not known why, in some cases, these etiologic factors will cause anse- mia, and, in a few rare individuals, excite the far more formidable, indeed malignant, ailment. Pathological Anatomy. — There is little or no emaciation due to the disease. There may be a good deal of fat under the skin, and the body may present an appearance of fullness and roundness, due to a ■ PERNICIOUS ANJSMIA. 223 general oedema ; but usually the oedema is about the ankles. The skin may contain petechia} of a purplish or brownish tint, scattered over the trunk and limbs. There may be ecchymoses, having the va- rious colors characteristic of extravasated blood at different periods, and vibices, due to the same cause, and produced by pressure. There is more or less serum in the various cavities, and the organs generally are pale and bloodless. The changes in the heart and arterial system are the same as already described (see Anemia), and consist in fatty degeneration of the cardiac muscles (papillary) and of the intiraa of the aorta and principal arteries. The alterations in the composition of the blood are also similar to those of anaemia, but they are more ex- tensive and profound. The volume of the blood is lessened, the red corpuscles are fewer, the albuminates of the blood diminished, and the fibrin is deficient. There is no constant disturbance in the normal ratio of the white and red corpuscles, although cases have been re- ported in which the leucocytes were increased. Symptoms. — The exact beginning of pernicious anaemia usually passes unnoticed ; an unwonted paleness, a sense of fatigue on the least exertion, hurried breathing, and palpitation of the heart, at length attract attention. This may be entitled the chronic form. In a few cases, happening during pregnancy, the onset is rather sudden, and extreme pallor, palpitation, and breathlessness on making any effort appear within a short period. The progress is comparatively rapid in both forms after the symptoms are fully developed, and in a short time the weakness is such that the j^atient is confined to bed, is unable to rise, and faints on attempting to assume the erect posture. Various local haemorrhages take place, as epistaxis, bleeding from the gums, menorrhagia, extravasations under the skin and into the retina. The haemorrhages into the retina are very common, and consist, on oph- thalmoscopic examination, of small, blackish, brownish, or yellowish- brown spots, or larger patches covering more or less of the fundus. They may, when very minute, not affect the vision, although present in great numbers ; but an extravasation in the retina of considerable size obscures the field of vision correspondingly (Immermann). Small extravasations or larger haemorrhages may take place in the brain, with the usual results. A constant symptom is fever, but it does not appear until near the end of the case, and does not pursue a definite plan or type. When death is imminent, the fever not only ceases, but the temperature declines below normal, falling to 9.5° Fahr., or even lower. Course, Duration, and Termination. — Although pernicious anaemia has been separated from allied states, yet in its course and behavior it strongly resembles anaemia and chlorosis, especially the latter, or more closely a combination of the two. It seems, as it were, anaemia added to chlorosis, and the worst features of each fully developed. 22 i DISEASES OF THE BLOOD-FORMING ORGANS. The duration is not self -limited, and hence varies greatly. The acute cases usually terminate within two months, but the more chronic ones continue for three or four months. The mode of dying is by exhaus- tion usually, but life may be unexpectedly terminated by sudden pa- ralysis of the heart, or by cerebral hemorrhage. Diagnosis. — Pernicious anaemia is distinguished from ansemia and chlorosis by the severity of the symptoms ; from albuminuria by the absence of albumen from the urine ; from leucocythemia by the nor- mal condition of the spleen, liver, and lymphatics ; from Addison's disease by the absence of the bronzing. The prognosis is highly un- favorable, no cases of cure having been reported. Treatment. — There is no specific plan of treatment. The anaemic symptoms require iron ; but, if haemorrhages are occurring, iron must be discontinued, when arsenic, ergot, and quinia may be substituted. A generous diet and stimulants must be administered from the begin- ning. Unfortunately, thus far no results have followed the treatment, and the cases have pursued their evil course until the end. THROMBOSIS AND EMBOLISM. Definition. — By the term thrombus is meant the formation of a clot in a blood-vessel — an ante-mortem coagulation. The mechanism of its formation and the pathological changes associated with it ave called thrombosis. A detached clot, or parts of a clot, or any new formation circulating in the blood-current, is designated an embolus, in the jdIu- ral emboli, as fibrin embolus, fat embolus, pigment embolus, etc. The secondary obstruction and the changes consequent thereon, produced by an embolus, are known as embolism — as cerebral embolism, pulmo- nary embolism, etc. Causes. — The process of coagulation of the blood consists in the precipitation and consolidation of certain of its constituents, which, under normal conditions, remain fluid. When a blood-clot forms, the fibrino-plastic substance acts on the fibrinogenous, the former contained in the blood corpuscles, the latter in the liquor sanguinis. This forma- tion of fibrin, by the reaction between two other principles, is like the production of prussic acid by the reaction between amygdalin and emul- sin, or of the volatile oil of mustard, by myrosin and myronic acid. The formation of fibrin, or the coagulation of the blood, only takes place in the vessels when there occurs a slowing of the current, or when there is a change in the parietes of the vessels. In diseases characterized by abnormal increase of the fibrin {hyperinosis), should the blood-current be much reduced in rapidity and force, coagulation will take place. Thus in post-partum haemorrhage, a thrombus not in- frequently forms in the pulmonary artery. When the vis-a-tergo is weak, and an obstacle is placed in the capillary region in front, tlirorabi THROMBOSIS AND EMBOLISM. 225 may form in the veins next the capillary system — as, for example, in the pulmonary veins, in chronic interstitial pneumonia ; in the renal veins, in parenchymatous nephritis, etc. Again, when vessels are divided, haemorrhage is arrested by thrombi which close the divided extremity. Thrombosis, the result of changes in the tunics of the ves- selsj is more frequent in relation to disease of the arteries than of the veins. Foi'merly the notion was entertained that phlebitis played an important part in the process of thrombosis and embolism ; that the intima was the seat of exudations and other products of inflammation to which the formation of a clot was immediately due, but it is now known that inflammation of veins is interstitial ; that the tunica intima, deprived of its nutritive materials, undergoes necrosis, and becomes a foreign body, about which coagulation of blood takes place. This, however, is a comparatively rare cause of thrombus formation, as this process occurs in the veins. It is in the arterial system that those changes take place which enter so largely into the phenomena of thrombosis and embolism — the results of endocarditis and endarteritis. The formation of vegetations in endocarditis, especially on the valves is a fruitful source of embolisms. In endarteritis slow degenerative changes occur in the walls of the vessels, the internal layer (intima) becomes involved — thickened, roughened, necrotic — and then thrombi form. Any foreign body, as a needle introduced into a vessel, will induce coagulation and the gradual formation of an obliterating thrombus. An embolus is formed when a portion of a thrombus, de- tached from the parent clot, enters the blood-current. The density of the clot and its position are important elements in the detachment of emboli. The softer the clot the more easily it is broken up, and, if situated near to the entrance of a communicating vein, the more cer- tain a portion of it will be broken off from the main mass. The coni- cal shape which the thrombus assumes, jn-ojecting beyond the point of attachment to the intima, and floating freely at its end, are physical conditions favoring its separation. Besides the action of these forces, emboli are detached by coughing, vomiting, sudden jars, straining muscular movements, etc. After fractures an immense number of fat emboli may enter the systemic circulation, and now and then a phle- bolithe is a cause of obstruction ; cancer products may penetrate the blood and be distributed widely ; multiple embolisms may be caused by the entrance, from a depot of putrefactive matters, of putrid fer- ments ; and pigment emboli may be a product of malarial fevers. Pathological Anatomy. — Recent thrombi consist of soft, brownish- red coagula, either in the form of a plug which fills the vessel and entirely shuts off the circulation, or in a plaque or tablet attached to one side of the vessel-wall, permitting still a part of the blood to pass through. In the case of the lattei-, successive deposits of fibrin pro- duce a stratified clot, which may ultimately obstruct the vessel. When 15 226 DISEASES OF THE BLOOD-FORMING ORGANS. a vessel is ligated, tlie clot formed does not extend beyond the first communicating vessel, but, when the thrombus is spontaneous, the coagulum may increase by successive deposition of material until it extends into a neighboring vessel. If a thrombus is suddenly formed, there will be a uniform distribution of the red and white globules throughout the coagulum ; if slowly formed, the mass will have a stratified arrangement, due to the adhesion of the white corpuscles to each other, and their accumulation along the walls of the vessel, and on the surface of the clot, so that, when a section is made of a throm- bus formed by successive deposition, it will be found to be made up by alternating layers of ordinary blood-clot and of white corpuscles. Thrombi are, therefore, of two kinds, stratified and unstratified. The first steps in the organization of a thrombus consist in a process of con- densation : the liquid disappears, the red globules lose their color, and the mass contracts an intimate adhesion to the intima of the vessel. Vessels are formed by the union and canalization of migrated white corpuscles (Rindfleisch), and the remainder of the thrombus consists of a fine reticulation of fibers and corpuscles, but the corjjuscles have usually disappeared at the expiration of two months. Softening of the clot begins in the oldest part. There is no attempt at organiza- tion, and the delicate reticulation of fibrin breaks up into a uniform granular mass. The red globules lose their coloring matter, and, mixed with the other contents of the thrombus, form a white or yellowish- white fluid having the consistence of cream, and an appearance like "laudable pus," but differing from pus in structure, for on microscopic examination it is seen to be composed of albuminous particles, fat- molecules, and altered blood-globules. While the interior of the thrombus presents this puriform appearance, the exterior may have the brownish-red of the clot, and there may be various shades of color, representing various stages in the process of softening. When the process is complete there remains a puriform-like collection, in which no red globules remain undestroyed, and together with the white are transformed finally into fat-gi*anules. An embolus derived from a thrombus will have the appearance belonging to the age and condition of the latter. The vessel in which it is lodged will be damaged at the point of lodgment, but in front and behind the embolus, will be healthy. The vessel may be completely or only partially obstructed. If com- pletely, coagulation will ensue behind the point of obstruction fonning a thrombus ; if partially, successive depositions of coagulum will occur, and a thrombus will form about the embolus. The bifurcation of arteries is the usual point at which an embolus lodges. Its effects are not limited to the point of lodgment, but include the whole area nour- ished by the vessel, and the wider zone supplied by the branches re- maining permeable. The part receiving blood through the obstructed vessel at once becomes ansemic ; but the neighboring district is the THROMBOSIS AND EMBOLISM. 227 _ seat of an active hypersemia, which is designated collateral hypercBmia. One result of the increased pressure in this hyperaemic area is the rup- ture of small or large vessels and extravasation of blood. If the ves- sel obstructed is small and not a terminal artery, the anastomoses may be sufficient to supply the anoemic district. If, however, the compen- satory circulation is insufficient or absent, the ischaemic part dies — un- dergoes necrobiosis, gangrene, or necrosis. The consequences follow- ing arrest of the circulation by an embolus depend largely on the position, still more on the size, of the obstructed vessel. Dry gangrene is produced by embolic blocking of a vessel of an extremity. In internal organs, especially the brain, centers of softening and fatty transformation of the tissue elements, and hgemorrhagic extravasations in the area of collateral hyperoemia, are results of embolism. Besides the haemorrhagic extravasations, infarctions occur in the parenchyma of those organs supplied with Cohnheim's terminal arteries.* Symptoms. — The position of a thrombus or an embolus exercises a most important influence on the symptoms caused by them. When a thrombus occupies a vein of an extremity, oedema of all the parts be- low is a result, and, if the obstructed vein is adjacent to important nerves, excessive pain, or troubles of motility, will also be present by reason of the pressure of the distended vessel. Gangrene is not a result, since the nutrition of the parts is accomplished, although feebly and impei'fectly, but moist gangrene may be produced if other injuries are superadded — as erysipelas, traumatism, compression, etc. A cure in such a case is in part effected by the collateral circulation, but in a truer sense by the canalization of the thrombus. Notwithstanding the similarity in the symptoms, caused by thrombosis and embolism re- spectively, there is a great difference in the time at which the phe- nomena manifest themselves : the symptoms of autochthonous throm- bosis come on gradually ; of embolism suddenly, with shock (Wagner). Two classes of symptoms arise — affections of nutrition, from the sim- plest disorder up to gangrene, and functional disturbances, proper to the organ affected. These symptoms are not ascertained with the same facility in all situations. In the extremities, every step in the local process is easily followed and interpreted, but in internal embo- lisms only those symptoms due to perversion or suspension of fimction are recognizable. Embolic obstruction of a member is announced by a sudden and often intense pain and a chill, with numbness, loss or diminution of tactile sense, coldness, pallor of the skin, and a feeling of deadness and weight, and paralysis of the muscles ; the pulsations wanting below, while above the obstruction they are full and strong. If embolic blocking of a vein in the brain, there occur defects of speech, hemiplegia, etc. ; if of a pulmonary artery, sudden difficulty of breath- * Wagner, op. cit. " Untersuchungen iiber die embolischen Processe," von Dr. Julius Cohnheim, Hirschwald, pp. 112. Berlin, 1872. 228 DISEASES OF TEE HEART. ing and sense of oppression, with, it may be, intense oppression and anxiety and death. Sudden attacks of amaurosis in puerperal fever, acute rheumatism, and pyaemia, are usually, due to embolism of the central artery of the retina. Those organs not well supplied with nerves, as the liver, kidneys, and mucous membranes, do not offer dis- tinct reactions on embolic blocking of their vessels, and hence the symptoms are obscure.* If the immediate danger of an embolic ob- struction is past, even if the symptoms are very formidable, provided terminal arteries are not obstructed, they may disappear in some hours or days by establishing a collateral circulation. Treatment. — As all the symptoms are due to the obstruction of vessels by a blood-clot, the point in the treatment of special importance is to effect a solution of this obstructing material. Theoretically, ammonia possesses a solvent power, and in its use the author has had most striking results in the case of thromboses and embolisms of the brain. To accomplish the purj^ose in view, ten grains of the carbonate of ammonia may be administered in a tablespoonful of solution of the acetate, three or four times each day. As, however, the action must be slow, the point of contact being small, the remedy must be very persistently employed. The iodide of ammonium may be administered in a solution with the carbonate also, and usually with good results. Other alkalies possess the same power, but to a less extent. The most generally useful is the phosphate of soda, in drachm-doses, three times a day, used for many weeks. As, however, prompt and speedy action is needed to avoid the serious structural alterations which occur so quickly, the ammonia preparations are preferable to any other having the same effects. DISEASES OF THE HEART. INFLAMMATION OF THE PERICARDIUM— PERICARDITIS. Definition. — The term pericarditis means an inflammation of the pericardium. The inflammation may be limited to the parietal or visceral layer, or to a part of either, or it may involve the whole of both surfaces. In the former case, it is partial or circumscribed ; in the latter, general or diffused. The inflammation may also be either acute or chronic. * Ulile and Wagner, op. cit. PERICARDITIS. 229 Causes. — Idiopathic or primary pericarditis may arise from trau- matism or from cold. In those cases supposed to be produced by changes of temperature there is usually, probably, a diathetic condi- tion — as albuminuria — which escapes notice. Secondary pericarditis is moi'e common, and is due to two causes : to an extension of inflam- mation from neighboring parts — pneumonia, left pleurisy, pulmonary tuberculosis, caries of the sternum or ribs, aneurism of the aorta, endo- carditis, etc. ; to the rheumatic dyscrasia. The dependence of peri- carditis on rheumatism has been very differently stated by the different authorities. That in about one third of all the cases this complication arises is the opinion of Bamberger, and is doubtless a close approxi- mation to the truth, but Thompson * says sixteen per cent. The severity of the cases, but not the position of the joints affected, has some influence in determining the frequency of the complication. The first attack is more liable to this complication ; the second attack stands next. In Thompson's forty-three cases of pericarditis, twenty-five happened during the first attack and thirteen during the second. The author has seen three cases in which the pericarditis preceded the joint affection. Usually this complication arises during the period of great- est severity of the disease — during the second week, the favorite days being the ninth and tenth (Thompson). Pericarditis also occurs dur- ing the course of certain eruptive fevers, as scarlatina, variola, in puer- peral fever, in albuminui'ia, scorbutus, etc., but there are no numeri- cal data for an exact statement of the relative frequency. As regards the period of life in which pericarditis happens, there are differences in the two sexes — women being more liable during the period of pu- berty, thirteen to twenty, and men from twenty to thirty, the average being respectively nineteen and twenty-five (Thompson), Men are somewhat more liable to the disease than women, but the difference is slight. Pathological Anatomy. — In the first stage of the inflammation there are two pathological conditions present : an alteration of the tissue, the seat of the inflammation ; and an effusion into the pericardial sac. The inflamed membrane is marked by an arborescence of minute ves- sels, or is of a deep-red color, in consequence of the general stasis^ and contains here and there spots of extravasation from rupture of over-distended vessels. The membrane becomes dull, cloudy, and at first dry, and also swells from interstitial exudation, and its resistance is diminished by the separation of the connective-tissue elements. The stage of hypersemia and suspended secretion is of short duration — ^last- ing from a few hours to twenty-four, the shorter rather than the longer period. Rarely a case occurs in which there is no other than the in- terstitial exudation, no moist exudation on the surface, nor effusion * " St. George's Hospital Reports," vol. iv, p. 31. 230 DISEASES OF THE HEART. into the cavity. Usually, after a variable period of a few hours, the membrane which was dry becomes coated, especially the visceral layer about the origin of the great vessels, with an exudation of fibrinous substance, having, it may be, a thin, pellicular character, or thicker and more consistent, but soon extending over both surfaces. Some- times the exudation is reticulated, sometimes it forms conical or fili- form projections — pineapple heart, cor villosum, cor tomentosum, etc. These peculiar appearances are due largely to the movements of the heart and the friction of the exudation on the two surfaces. When the exudation is sero-fibrinous, more or less straw-colored serum, having flocculi of lymph or masses of fibrinous substance fl.oating in it, is con- tained in the cavity. Instead of being straw-colored the fluid may retain so much of the solid exudation churned up with it as to have a creamy consistence and a yellowish color ; or it may have a reddish tint from a slight admixture of blood, or be composed largely of blood (hsemorrhagic pericarditis). The serous fluid may also have a yellow- ish tint from the presence of leucocytes, or the exudation may have from the beginning a purulent character. The latter is the case in pericarditis occurring during pyaemia, puerperal septicpemia, variola, etc. The IiEemorrhagic exudation occurs in chronic alcoholismus and in scorbutus. There are, therefore, sero-fibrinous, hgemorrhagic, sero- purulent, and purulent exudations. A strictly serous exudation is found in general dropsy, in dropsy of the pericardium, etc., but not in true pericarditis. Effusions may be entirely removed, even those consisting largely of solid exudation. The fibrinous matter breaks up into a granular mass, w^hich gradually becomes fatty ; the cells also undergo a fatty metamorphosis ; the watery part is quickly taken up and the fatty emulsion undergoes slow absorption. A complete restoration of the parts to the normal may ultimately take place, but this is an excep- tional result. It is to be expected only when the exudation is largely serous, or when the fibrinous substance is dej)osited on a small extent of surface and is thin. Usually the watery part of the exudation is taken up ; the migrated white-blood corpuscles in the mass of fibrin- ous exudation assume a fusiform shape, unite end by end, and form canals or blood-vessels, and thus an exudation becomes organized. The epithelium takes part in these changes, by the proliferation of its cells, and the mass of solid exudation is composed not only of fibrinous substance, but migrated leucocytes, and proliferating epithelium, mixed with a basis substance, composed of germinal matter.* Pro- jecting masses of exudation, uniting from the two sides, form bands, which organize by the formation of vessels, and remain j)ermanently. There may be a thin band or bands connecting the visceral and pa- rietal layers, or larger and broader bands which, uniting, form sub- * Rindfleiscb, op. r.it., p. 265. PERICARDITIS. 231 divisions of the sac, or, the two surfaces may be glued together, en- tirely obliterating the cavity of the pericardium. The union may be so perfect that the most careful dissection can not separate them. Calcareous deposits may subsequently form in the exudation, or the whole of it may finally become so completely calcified, by the deposit of lime salts, that the heart is inclosed in an apparently bony case. The adherent pericardium is not unfrequently reported in medical journal literature as a congenital absence of this sac, and the calcifica- tion of an exudation, as the formation of a true bony envelope of the heart. The fluid exudation may persist notwithstanding the forma- tion of neo-membrane and bands of adhesion, and it changes in quan- tity, now increasing while fresh deposits of fibrinous substance is occurring, now diminishing with a temporary amendment ; some- times assuming a hemorrhagic character, but more frequently becom- ing purulent. The more solid and unorganized exudation, crossed here and there by bands of adhesion, assumes a grayish color, and undergoes ultimately a caseous transformation. The muscular tissue of the heart becomes diseased by reason of the proximity of the inflammation — an acute myocarditis — which affects the muscular tissue in contact with the inflamed membrane. The muscular fibers become paler than normal, soften, and are infil- trated with fat-granules, so that the muscular contractility is impaired, and hence, if the lesion extends, the power of the heart will be greatly lessened. The extent of the pericarditis and the duration of the in- flammation have a material influence on the extent of the myocarditis. In hsemorrhagic and purulent exudations, the damage to the heart is greater. The strain on the heart due to the increased exertion re- quired in fever, and the compression of the exudation, interfering with the passage of the blood to the muscular tissue of the heart, also affect the nutrition of the organ, and favor degenerative changes. Endo- carditis may result by an extension of disease from the inflamed pericardium, as has been experimentally and clinically established. In chronic pericarditis the myocarditis persists, the walls yield to the blood-pressure, and the cavities, the right especially, dilate. Symptoms. — When an idiopathic pericarditis comes on, the initial symptoms occurring are those of any acute serous inflammation : malaise, chill, fever, increased respiration, loss of appetite, frequently nausea and vomiting. Pain of a dull, heavy character, or a feeling of soreness, is felt in the chest, but not invariably. Acute pain in the position of the pericardium is experienced only in those cases with pleuritis of the adjacent portion of the pleura, so that the real signifi- cance of any soreness or pain felt is ascertainable only on physi- cal exploration. When pericarditis is secondary to an existing dis- ease, there are no marked disturbances to indicate its onset — no dis- tinctive increase in the temperature and pulse-rate, or in the respiratory 232 DISEASES OF THE HEART. movements, but there may be some praecordial anxiety and oppres- sion, so that, in all cases of diseases in which inflammation of the peri- cardium is liable to occur, systematic physical exploration of the chest should always be practiced. The fever movement in simple idiopathic pericarditis is of the remit- tent type, but in the secondary disease it does not modify that of the existing malady. The state of the circulation varies from a condition of high tension, with full, strong pulse, to great feebleness, low ten- sion, and small, irregular, and unequal pulse. A weak, irregular pulse is characteristic only of cases with considerable effusion, with myo- carditis, or exhausted by the severity and duration of this disease. The rational signs of pericarditis possess but little value ; but the physical signs are highly significant. In the young, a small amount of effu- sion may render the precordial space prominent, but, in adults, only a large accumulation will push out the intercostal spaces sufficiently to produce bulging, unless the lung is shrunken, or there are pleuritic adhesions so situated as to prevent the outward expansion of the peri- cardium. When there is any considerable distention of the sac and anterior bulging, the nipple of the left side is thrown up higher than its fellow of the opposite side. In consequence of the effusion, the sac of the pericardium is enlarged, and the mobility of the heart on changes of position is increased. Hence, on jDalpation, this in- creased mobility is ascertained by the different positions in which the apex-beat can be felt. "When the effusion is suflficient to force the heart to a more horizontal position, the apical impulse is farther out and upward. As the effusion increases, filling the sac, the apical im- pulse becomes weaker and weaker, and is finally no longer felt, as the fluid is interposed between the apex-beat and the chest-wall. When the systole of the heart is weakened by myocarditis, or exhaustion, the apical impulse disaj^pears earlier, especially if there be interposed a thick layer of soft exudation ; on the other hand, the apex-beat will be felt longer when there is hypertrophy of the heart, and may not disappear at all if old adhesions keep the apex against the chest-wall. A change of position, as bending the body forward, may cause the apical impulse to be felt again when it had disappeared on the dorsal decubitus. On palpation, for a brief period may occasionally be felt a vibration of the chest-wall, due to the rubbing of the roughened sur- faces together. To develop this sensation, firm pressure must be made in the intercostal space with the finger-tips. It is exceedingly rare for this friction fremitus to be stronsf enou2:h to excite vibrations of the chest-wall, which may be perceived by the hand laid on the prrecordial space. It is a rough, jarring, rasping sensation, similar to but quite distinct from the frei/u'ssement cataire, or purring tremor, and is not exactly isochronous with the cardiac systole and diastole, although a to-and-fro movement. PERICARDITIS. 233 The area of cardiac dullness is increased Avhen the effusion is suf- ficient in amount. The enlargement of the area of relative dullness is more important in a diagnostic point of view, because there may be no change in the absolute dullness, even when there is considerable effusion. The diminished sonoriety is first perceived at the sternal end of the third and fourth ribs — at the base of the heart. The dull Fig. 16. — Effusion into the Sac of the Pericardium. space has a triangular form, with its apex uppermost and base down- ward — the right line of the triangle extending from the apex at the second rib and sternum, along the right border of the sternum, and even beyond, to the right sixth and seventh ribs and sternum ; the base-line of the triangle passing through the seventh intercostal to the axillary border, and there intersecting the left line. When the effusion is extreme, the epigastrium is pushed outward by the descent of the diaphragm and the left lobe of the liver.- The size of the trian- gular space is enlarged by sitting up and by bending forward. When the apex-beat can still be felt, and the area of dullness extends beyond it, this fact indicates that the sac of the pericardium is greatly dis- tended, and consequently forced beyond the apex, and is therefore an important sign of effusion. A change in the position of the dullness may be slightly effected by changing the decubitus of the patient, the fluid obeying the laws of gravity. The pressure of the lung in the neighborhood of the pericardium is a necessary result of the accumu- lation of fluid ; but this condensation is distinguished from effusion 234 Diseases of the heart. by the vocal fremitus, which is weakened or absent in the latter, but increased or normal in the former. In estimating the results of per- cussion, two sources of error may interfere : the dullness may be more extensive than the amount of the effusion warrants ; it may be less. The first is due to adhesions which have the effect to retract the lung from the pericardium, and to push the heart forward, thus enlarging unduly the area of absolute dullness ; in the other, the lung is attached anteriorly, and the heart lies deeply, and is still further depressed by the weight of the effusion. The pericardial friction murmur is the most significant of the physical signs of pericarditis, and is produced by the rubbing together of the two surfaces roughened by exudations, or by one roughened surface. This hruit makes the impression on the ear of scraping, grating, creaking, churning, and various modifications of these noises. They are, ordinarily, resolvable into three : the creaking of new leather, grating, or scraping. The sound may be partial or general ; it corresponds to the seat of the exudation, and is not confined to the situation of the orifices of the heart, but is heard with the maximum intensity at the third intercostal space on both sides of the sternum. The area over which it is audible depends on the extent of the exudation. The hruit accompanies the heart-sounds, but is not confined to them, and extends into the interval, and may indeed occupy the whole revolution of the cardiac movement. Hence the term '■^ hruit de galops Usually or frequently, the hruit is pre- systolic, systolic, and diastolic — the presystolic corresponding to the auricular systole, and the others to the systole and diastole of the ven- tricles. When there is no effusion (dry pericarditis), there will be usually no rational symptoms of the malady — nothing but fever, and the physical signs of pericardial inflammation. The friction murmur, as well as the friction fremitus, occur early, and are recognized, if at all, within the first two days, and they persist for several days or weeks, according to the progress and amount of the effusion. They may decline in two or three days and disappear, as the effusion fills the sac and separates the two surfaces, so that fric- tion is no longer possible. If the effusion is absorbed, then the hruit will become audible again. When the silence of the hruit is due to adhesions, there will be no return of it when it ceases. With the increase of the effusion the heart - sounds become weaker, and finally are no longer heard in some cases ; but usually they continue to be audible, although very feebly. The character of the pulse, dur- ing pericarditis, has no special quality ; it may be but slightly elevated above the normal ; it may be very much accelerated ; its rhythm may be much altered. At the onset of the inflammation, the pulse may be strong, the tension high ; but this is not maintained, the pulse becom- ing weak, and the arterial tension low from depression of the vital powers and the occurrence of myocarditis. A large effusion exerts a PERICARDITIS. 235 mechanical pressure upon the great vessels within the pericardial sac — the aorta and pulmonaiy artery — and interferes with their proper filling. Also, as the veins can not empty their blood into the auricles fully, they are kept over-distended, and an abnormal fullness of the venous system in general is the result. Stasis of the venous system causes passive congestion of the lungs, bronchial catarrh, difficult breathing, cyanosis, and oedema. The venous congestion occurs in the brain, and is manifested objectively by headache, vertigo, epistaxis, etc. ; in the liver, causing enlargement of the organ and hypera^mia of the portal system ; and in the kidneys, inducing albuminuria. Irrita- tion of the phrenic excites a most distressing hiccough. Difficulty of breathing, cyanosis, feebleness of the heart's action, are also produced by myocarditis, which is really an acute fatty degeneration. The heart's movements are not only feeble, but scarcely distinguishable ; the pulse irregular, intermittent, feeble ; the sounds of the heart are hardly recognizable, and the first sound is often absent ; the tempera- ture falls, the legs become oedematous, and death soon closes the scene. "When severe dyspnoea and cyanosis come on in the course of pericarditis, they are more frequently due to the damage done to the heart's muscle than to the mechanical effects of the effusion. Again, the same symptoms, in a less extreme degree, however, may be due to nervous disturbance — to irritation of the pneumogastric and phrenic. Dysphagia may be caused by pressure of the effusion on the oesopha- gus, and aphonia by pressure on the recurrent laryngeal nerve. Course, Duration, and Termination. — The course of pericarditis is not always upon a uniform plan, and there are peculiarities due to the causes and complications. Those cases arising in the course of puerperal septicsemia, scorbutus, or pyaemia, are shorter in duration, and greatly more fatal than those which are due to the rheumatic di- athesis. The duration is influenced by many circumstances. In sim- ple, uncomplicated cases, terminating in health, the effusion may be absorbed and recovery take place in from ten days to two weeks. When a case tends to recover, the severe symptoms subside, the fever and the difficulty of breathing cease, the appetite returns, and conva- lescence is established. When there is much effusion, and yet the ten- dency is toward health, the area of dullness lessens, the apical impulse returns, the friction murmur and fremitus reajDpear for a short period, the normal sounds are heard again, and, with these evidences of im- pi'ovement afforded by the physical signs, are also the rational symp- toms of cessation of dyspnoea, of fever, and return of appetite. In other cases the improvement is partial ; the rational and physical signs of pericarditis persist, and the subsequent history is that of chronic cardiac troubles. In other cases a fatal termination takes place early — in the scorbutic form with haemorrhage in a few hours after the well- defined symptoms come on ; in cases with large effusion, dyspnoea 236 DISEASES OF THE HEART. delirium, etc., death will occur in a week or ten days ; in cases with myocarditis and syncopal attacks, according to the age and other cir- cumstances, a fatal termination may occur within the first two weeks. According to Thompson, the average duration of rheumatic pericar- ditis in St. George's Hospital is fifteen days. Prognosis. — Simple cases of pericarditis, and rheumatic pericardi- tis, are not often fatal, and a favorable prognosis may be expressed in a very large projDortion. As an intercurrent disease, coming on in the course of certain grave maladies, it is is extremely fatal. Among these may be mentioned scorbutus, pyaemia, puerperal diseases, Bright's disease, some of the eruptive fevers, pneumonia, etc. Diagnosis. — The differentiation of pericarditis from endocarditis, hydropericardium, and left pleurisy, presents some points of difficulty. The separation of the endo- and exo-cardial murmurs is often an affair of extreme nicety. Dropsy of the pericardium is to be distinguished from the inflammatory affection by the absence of fever, local pain, and friction murmur. The character of the fluid in any case is to be determined only by the concomitant circumstances. If the patient is scorbutic, it is probably haemorrhagic ; if a subject of chronic alcohol- ismus, it may be haemorrhagic ; if the accompanying malady is pyae- mia, or a septicaemic process, it is probably purulent ; if rheumatism, it is sero-fibrinous ; if albuminuria, serous. The differentiation of exo- from endo-cardial murmurs is based on the character, quality, seat, and persistence of the sounds. The friction murmur is a sound of rasping, of crackling ; the endocardial murmur is softer, smoother. The friction murmur may be local or general, and has no constant rela- tion to the orifices of the heart ; the endocardial murmur is heard with maximum intensity within certain valve areas. The friction murmur is not regularly isochronous with the valve-sounds, or with the cardiac rhythm ; the endocardial murmurs are usually systolic or disastolic, or coincide with the rhythmic movements of the heart. The friction murmur continues where it began ; the endocardial murmurs are prop- agated in the direction of the blood-current — basal or ajDical. The friction murmur varies from one hour to another in intensity and ex- tent ; the endocardial murmurs remain constant. The friction mur- mur increases with pressure of the stethoscope on the chest-wall ; the endocardial murmurs are not affected by pressure. The friction mur- mur increases in loudness with the upright position and bending for- ward ; the endocardial murmurs are most distinct in the recumbent posture. The friction murmur disappears when the effusion reaches a certain amount, and reappears for a short time when absorption has taken place ; the endocardial murmurs are permanent. The friction- sound of pleuritis is synchronous with the respiration ; the pericardial is synchronous with the cardiac movements, or nearly so ; suspension of respiration arrests the former, but does not affect the latter. When PERICARDITIS. 23Y that portion of the pleura in contact with the pericardium is the seat of inflammation, a friction murmui-, synchronous with the cardiac movements ; in that case the distinction is impossible. In pleuritic effusion, as a rule, the dullness changes with the position of the pa- tient, and in the upright position is over the inferior part of the tho- rax. In pleuritis with effusion, all voice and breath sounds disappear; in pericarditis, they are unaffected, except in so far as the lung is dis- placed by the enlarging pericardium. In hyj^ertrophy of the heart, the action is heaving, and the apical impulse is strong ; in pericardi- tis, with or without effusion, the impulse becomes weaker, and, as the effusion increases, the apical impulse will cease, or at least greatly di- minish in force. In hypertrophy the absolute, in effusion the rela- tive, dullness is increased ; and, as has been pointed out, dullness exists beyond the apex of the heart when the effusion is large. Treatment. — If the initial symptoms are recognized, a full dose of quinia sulphate (3j) should be administered, with a half grain of mor- phia, and the cinchonism should be maintained, by repeated smaller doses, for twenty-four hours or longer. When the evidence of effu- sion exists, there is no longer any indication for the use of quinia, since the inflammatory process has passed beyond control. The next object of treatment, and that which usually engages our attention at once, is the management of the exudation. There can be no question, at present, respecting the influence of ammonia salts in lessening the coagulability of the fibrinogenous substance. The carbonate should be given in solution of the acetate — five grains every two hours — when the exudation is forming, and to procure its disintegration and absorp- tion, thus preventing adhesions. When the initial symptoms make their appearance, if the patient is robust, six to ten leeches should be applied to the epigastric region; they should be allowed to fill and fall off, but the bleeding should not be encouraged. Dry cups may be applied to the same point, if the condition be that of debility. With or without previous abstraction of blood, if the patient is not depressed and the action of the heart feeble, an ice-bag should be applied to the prsecordia during the initial period, but this expedient ceases to be useful when there is much exu- dation, and may be very injurious if the heart is weakened by myocar- ditis. When the time comes for the removal of ice, good results may be expected from the ajjplication of fiying-blisters. As a condition of quietude of the diseased organ is a measure of the highest utility, rem- edies which slow the heart are necessary. Aconite-root tincture and veratrum-viride tincture may be given to quiet the heart before con- siderable damage has been done. When, however, the heart begins to flag, remedies of a dej)ressing kind are not suitable, and then digi- talis becomes extremely serviceable, not only to lessen the work of the heart, but to promote absorption. The infusion is the best form, 238 DISEASES OF THE HEART. and it sliould be given in a tablespoonful-dose every four hours. The absorption of a pericardial effusion may be hastened by the use of jab- orandi, or better, its active principle — pilocarpine — so administered as to act freely on the skin. But jaborandi is too dej^ressing a remedy when the action of the heart is feeble, and the pulse is small and irreg- ular. Stimulant doses of quinia and alcoholic stimulants are very important when the powers are failing and syncopal attacks are occur- ring. Mechanical means are proper when the effusion into the peri- cardial sac is great and does not yield to the remedies proposed. Paracentesis of the pericardium has now been performed many times with success, so that it can no longer be regarded as a doubtful experi- ment. . The hypodermic syringe may be used to ascertain the character of the effusion. The needle, as in the operation for capillary puncture, is inserted close to the border of the sternum, in the fifth intercostal space. The operation of paracentesis is required when the effusion is great, or when it is purulent. If the effusion returns repeatedly, it is safe practice to inject the tincture of iodine ( 3 ij — f iv) to prevent the reaccumulation. If the contents of the sac are purulent, the iodine should be used more freely ( 3 ij of the tincture, 3 ss potassium iodide, and I iv water). To avoid wounding the heart, the jjatient should be recumbent when the puncture is made. The disadvantages of the operation are, that it is rarely curative ; that it has caused a pneumo- pericardium ; that the fluid is quickly replaced, because of the less- ened extravascular pressure ; that haemorrhages take place by rup- ture of the thin-walled vessels of the neo-membrane.* Better results are claimed from the operation of paracentesis when a part of the fluid is drawn at a time, rather than all at once. When there is extreme debility, the patient may not be able to bear the loss of the blood- serum which pours into the sac after the removal of the fluid. It is highly important to maintain the powers of life by suitable alimenta- tion from the beginning. Stimulants should also be moderately ad- ministered at an early period, and be given freely when cardiac failure is threatened. The author has not mentioned the so-called sorbefa- cients, calomel, and iodide of potassium, because the first named has no influence over the inflammation, and is, besides, highly iinfavorable to the process of repair, and the latter is useless, except locally. As the pericardium is a closed sac, and as effusions into it are not affected by diuretics, they have not been considered among the remedies. ADHESIONS OF THE PERICARDroM. Nature. — Adhesions of the two pericardial surfaces are results of pericarditis. They occur in a variety of forms : as narrow bands, as membranif orm partitions, dividing the cavity into several smaller cavi- * Jaccoud, " Pathologie Interne," toI. i, p. 535. ADHESIONS OF THE PERICARDIUM. 239 ties, and sometimes these secondary sacs contain exudation, in the form of a caseous mass, or dark-brown deposits, a product of altered blood. The adhesion may be total, so that after some years no line of union can be made out between the two surfaces. The mass of exudation uniting the surfaces may be converted into an ajDparently bony case enveloping the heart by calcareous deposition. Bands of adhesion may exist externally to the pericardium, and unite this membrane to the neighboring pulmonary pleura, to the pleura costalis in front, to the mediastinum, etc. As has been pointed out in the preceding chapter, an inflammation of the pericardium leads to acute myocarditis — an acute fatty degeneration of the muscular tissue. Hypertrophy and dilatation are among the results of adhesions. Opinions are divided as to the precise part played by the adhesions, but there can be no doubt that atrophy with hyperplasia of the connective tissue are results of the myocarditis, which, in turn, induces dilatation of the cavities. When the cavity of the pericardium is obliterated, and adhesions have been contracted to neighboring parts also, the heart works to great dis- advantage; but the most serious result is the interference with the nu- trition of the organ. On the other hand, there may be entire adhesion of the two pericardial surfaces, and the heart be not at all incommoded. Symptoms. — The disturbances produced by adhesions are mani- fested in rational and physical signs. The propelling power of the heart being diminished, stasis takes place in the right cavities, in the lungs, and venous system generally. There are therefore constantly present bronchial catarrh ; difficulty of breathing ; swollen liver and spleen ; gastro-intestinal catarrh ; urine scanty, high-colored, and albu- minous ; veins full, face cyanosed ; general dropsy. The apical im- pulse is either wanting entirely, or is a mere tremor ; the pulse is rather quick, but low in tension, and the volume varies in different beats. These rational symptoms are chiefly indicative of the degeneration and atrophy which have occurred in the heart -muscle. Other symptoms are caused by adhesions. One of the most important physical signs of pericardial adhesions is a depression with the systole of the heart at the place of the apex-beat. Instead of an elevation of the inter- costal space when the apex of the heart is tilted against it at the time of the systole, there occurs a de^yression, or draioing in of the chest- wall. There may also be, at the left of the sternum, several small de- pressions or " pittings " in the intercostal spaces. These depressions are frequently due to pericardial adhesions of the two surfaces, and to the parietal pleura ; but they may occur independently of this, as has been demonstrated by Friedreich, produced by causes which obstruct the downward movement of the heart toward the left, and the tilting of the apex upward, the lungs at the same time not coming forward sufficiently. A diastolic elevation of the chest-wall is the compensatory sign of the preceding elevation. When the force producing the other 240 DISEASES OF THE HEART. ceases to act, there is a rebound of the chest-wall, which, if not visible to the eye, may be felt on palpation. These two signs are highly sig- nificant, but their absence does not negative the existence of pericardial adhesions. It has already been stated that the area of absolute dull- ness is increased in those cases of adhesions which fix the heart against the chest-wall, and do not permit the organ to fall- back, while at the same time the lung is prevented coming forward. If the heart is so fixed in position by adhesions, and is at the same time hypertrophied, and if the pericardium be adherent to the chest-wall, and to the spine behind, there must, of necessity, be produced the systolic depression. When the diastolic rebound (" diastolic concussion ") occurs, a syn- chronous or diastolic collapse takes place in the cervical veins. Much distended during the systole, they suddenly subside and even disappear during the diastolic rebound, for during this act the chest is expanded and the blood is drawn into the cavity. The importance of pericardial adhesions depends much less on the adhesions than on the changes in the heart-muscle. Adhesion bands connecting the two surfaces may exist without injurious effects. When hypertrophy takes place com- pensation ensues, and the heart is equal to its duties for many years. On the other hand, when the heart-muscle undergoes atrophic degen- eration, its propelling power is insufiicient, venous stasis and dropsy follow, and then a fatal termination is near. The treatment in these cases must be directed to the nutrition of the heart-muscle. Rest must be enjoined ; the appetite and digestion must be improved by bitters, mineral acids, and the ferruginous tonics. The heart must be toned up by digitalis and iron, and by the judicious administration of quinia and morphia — the latter in minute quantity (y^g of a grain). The author has seen the greatest advantage from the use of sulphate of iron (gr. j), sulphate of quinia (gr. ij), sulphate of morphia (gr. ^^), and digitalis (gr. j) in pill-form, three times a day. HYDROPERICARDIUM— DROPSY OF THE PERIOARDroM. Pathogeny. — By hydropericardium is meant an accumulation of water in the sac of the pericardium without the occurrence of inflam- mation. After death, especially from chronic wasting diseases, there will be often found in the sac an ounce or two of fluid, poured out at the time of the death-agony and immediately after. In dropsy, prop- erly speaking, the quantity of fluid may reach to one or two pints. It is a clear, yellowish, or straw-colored serum, usually, but it may present a somewhat turbid appearance from the presence of cast-off epithelium, or a bloody appearance derived from hfematin. This fluid has the composition of the blood-serum, and its alkaline reaction, but does not contain the same relative proportions of its constituents. The albu- men is less than in the blood-serum, and also some of the salts ; but it HYDROPERICARDIUM. 241 contains the fibrinogenous substance which sometimes coagulates when exposed to air. Urea is found in this fluid in renal diseases, and it is stained with bile-pigment in cases of jaundice. The fluid, if large in amount, dilates the sac, and its walls become thinned by the pressure, and often present a sodden appearance when there has been a protracted contact of the fluid with the endothelium. The subserous fat is ab- sorbed by the pressure, and the areolar tissue is infiltrated with fluid. The causes of hydropericardium are twofold : mechanical and dys- crasic. Diseases or neoplasms,* that interfere with the return of blood through the veins, as tumors, obstructive pulmonary disease, emphy- sema, and dyscrasia, such as Bright's disease, cancer, and tuberculosis, are the principal etiological factors. Symptoms. — A small quantity of fluid will not produce sufficient disturbance to cause recognizable symptoms ; a large effusion will be recognized by the rational and physical signs, such as were described under pericarditis, with effusion. There is, of course, no friction mur- mur. The apical impulse becomes more and more feeble as the effu- sion increases, and it ultimately ceases to be felt. The heart-sounds grow more and more feeble, and may disappear entirely. The area of relative dullness greatly increases and extends finally beyond the region of apex-beat, and has the characteristic triangular form of dullness from effusion. The diagnosis of hydropericardium, from the effusion of peri- carditis, rests entirely on the history — the latter being due to inflam- mation, the former not. The prognosis of this malady is serious, not wholly because of the fluid, but on account of the conditions associ- ated with it. The treatment is directed to the removal of the fluid, and consists in the use of eliminants and mechanical means ; purgatives, diaphoretics, and diuretics are employed to procure absorption. Saline purgatives, compound jalap powder, elaterium, are given to diminish blood-pressure and the quantity of fluid ; squill, digitalis, and cream- of -tartar, to excite diuresis ; warm baths and pilocarpine to stimulate the skin. These means may be entirely successful in some few cases in Bright's disease, for example, but will have but little effect in cases of emphysema, tuberculosis of the lungs, and when the effusion is due to the pressure of a tumor. Aspiration is proper when life is threat- ened by the extent of the effusion, but there is danger of exciting peri- carditis and of the admission of air.f HYDROPNEUMOPBRIOARDIUM. — This form of disease differs from the preceding in that air or gas, as well as fluid, is present in the cavity. The fluid, when gas is also present, is composed of some de- composing exudation, of pus, or of blood. The first named is derived * "Transactions of the Pathological Society of London," vol. xxii, p. 123. t Roberts, " Paracentesis of the Pericardium." Philadelphia, 1880. An excellent work. 16 242 DISEASES OF THE HEART. from pericarditis, the result of traumatism, or excited by an ulceration penetrating the cavity from the neighboring parts. The symptoms are physical. The space of absolute dullness is occupied by a tympanitic sound, except at the base, where it is dull from the presence of fluid. Change of the patient's posture alters the position of the dullness. The heart-sounds and the apical impulse are sometimes feeble and may not be perceptible, but are usually loud, splashing, and prominent. A pe- culiar, clanging, metallic character is imparted to the heart-sounds. The friction murmur has a rough, rasping, metallic resonance. Yery remarkable sounds are produced by the churning of the liquid and air together by the heart-movements, and are designated "the water- wheel sounds." The functional disturbances produced by hydropneu- mopericardium are those of pericarditis, and need not therefore be re- capitulated. The prognosis is grave ; yet, of fourteen cases collected by Friedi'eich, only ten proved fatal. It has usually been regarded as more fatal than these figures indicate. It is probable that some of them were examples of the admission of air merely, and were not produced by the gas of decomposition. The treatment is that of peri- carditis. The presence of decomposing materials, or such an excess of gas or fluid as to exercise dangerous compression, justifies the employ- ment of the aspirator, and washing out the sac with an iodine solution. INFLAMMATION OF THE MUSCULAR TISSUE OF THE HEART —MYOCARDITIS. Definition. — The cardiac muscle is subject to attacks of inflamma- tion, as muscular tissue in other situations. The term myocarditis includes several morbid conditions of an analogous kind, but different in seat and also in progress. Causes. — The male sex is more liable than the female. The acute form is more common before than after thirty years of age. Myocar- ditis may occur during intra-uterine life, and then preferably on the right side, setting up important changes. It is supposed that chilling the body, suddenly, when in a warm and perspiring state, will cause this disease ; again, violent muscular exertion is said to have excited inflammation ; but these are very doubtful causes. In fact, nothing is definitely known of the influences setting up such a morbid process in the heart-muscle. As regards the secondary diseases, our information is more definite. It has already been pointed out that myocarditis is a result of pericarditis, the inflammation extending by contiguity of tissue. It results from valvular lesions also, and may be secondary to the acute infectious diseases — as typhoid, pysemia, scarlet fever, etc. Inflammation and abscess may be the result of embolic obstruction of the coronary artery. Pathological Anatomy. — The muscular tissue itself, or its inter- MYOCARDITIS. 243 vening connective tissue, may be the seat of the inflammatory action ; consequently there are two forms — parenchymatous and interstitial. 1l\xq, parenchymatous may occur in two forms ; in isolated patches, or generally diffused. "When a large part of the organ is attacked, there is a marked change in its appearance. The muscular tissue has a reddish color, is puffy in appearance, and the pericardium is spotted with points of ecchymoses, is cloudy, and coated here and there with a delicate exudation. The muscular tissue, on microscopical examina- tion, is found to be cloudy, granular, and swollen, and the striae indis- tinct or absent, or the fibers are broken up into granular fragments, are crowded with fat-granules, and ultimately are replaced by rows of fat-granules. When the change is far advanced, the muscle is brown- ish in color, and almost or quite piilpy in consistence. This change may extend over large parts of the organ, or may be confined to spots or isolated patches, and certain parts of the heart are especially apt to suffer, as the apex of the left ventricle, and, at the base, the posterior wall ; next, the aortic valves adjacent to the septum, then the papil- lary muscle, and, on the right side, the muscular trabeculse. Interstitial myocarditis also occurs in two forms : the suppurative and the sclerotic ; the former being acute, the latter chronic. Suppu- rative interstitial myocarditis usually coincides with the parenchyma- tous ; and, between the muscular elements disintegrating with acute fatty degeneration, is seen more or less extensive dissemination of pus, or distinct and isolated collections, or abscesses. When the suppu- ration is due to emboli, the purulent collections are small, and there are usually several ; when the result of interstitial inflammation, there is usually a single large one. An abscess may rupture outwardly into the sac of the pericardium, or inwardly into the cavity of the heart. If situated in the septum, by the discharge a communication is estab- lished between the two ventricles, or it may cause a rupture of a seg- ment of the semilunar valve, an example of which has fallen under the author's observation. Again, an abscess in the walls discharging into the ventricle, forms a sac which, bulging outwardly under the blood-pressure, becomes an " aneurism of the heart," so called.* The interior of such a sac becomes lined with successive layers of fibrin, ■which protects the cavity from rupture, but only for a brief period. When an abscess discharges into the pericardium, a fatal pericarditis results ; when the purulent matters and shreds of broken-down tissue enter the cavity, they produce the disastrous results of multiple embo- lisms. f Rarely, the pus is absorbed, and a mass of connective tissue *" Transactions of the Pathological Society of London," vol. xix, p. 149 (with plate). f Ibid., vol. XX. " A case of abscess of the heart bursting into the left ventricle." Boy of eleven years had a fall and hurt his shoulder ; had delirium, wakefulness, and fever, and a very rapid pulse, but no cardiac symptoms. Died on thirteenth day. 244 DISEASES OF THE HEART. and a puckered cicatrix remain to indicate the nature of the dis- ease. The chronic interstitial myocarditis is sometimes called sclerosis of the heart, or fibroid degeneration (Legg) of the heart. It consists in a proliferation — an overgrowth — of the connective tissue and an atrophy of the proper muscular elements. There may be small bands of connective tissue stretching between the muscular fibers, or larger, firm bands, or indurated masses, which take the place of muscular tis- sue entirely. These bundles or masses of connective tissue occur in the papillary muscle of the left ventricle and in the walls, but more toward the apex than at the base. Two evils result from the pres- ence of these bands and masses of connective tissue and from the re- sulting muscular atrophy : the propelling power of the heart is re- duced and stasis occurs in the venous system ; the walls yield at those places composed of the connective tissue, and form the so-called "par- tial aneurism of the heart." It is especially at the apex of the left ventricle (eighty-five in eighty-seven cases) that these aneurisms form. They vary in size from a pigeon's to a hen's ^gg, are irregular and divided by partitions and often have diverticula attached, and they contain old deposits of fibrin and recent soft coagula. The walls of these partial aneurisms are composed of the sclerotic material, the en- docardium, and the visceral layer of the pericardium with, it may be, the parietal layer attached.* Symptoms. — The existence of myocarditis can hardly ever be any- thing but a presumption, based on negative rather than positive signs. If maladies are present, as rheumatism, pyaemia, puerperal fever, etc., in the course of which myocarditis may be expected, if the symp- toms of cardiac failure come on suddenly, and if they can not be referred to an endocarditis or pericarditis, then the existence of in- flammation of the heart-substance may be suspected. When this dis- ease occurs as secondary to rheumatic endo- or pericarditis, the patient passes rapidly into that condition of profound adynamia known as the typhoid state. When an abscess discharges its contents into the cavity of the heart, the symptoms of multiple embolisms are produced ; there are repeated violent chills, very high febrile temperature, profuse sweats, icterus, swollen spleen, albuminuria, delirium, or the disturb- ances due to embolism of the cerebral vessels, etc. The yielding of the sclerosed tissue and the formation of the so-called aneurisms are announced by failure of the heart ; the pulse becomes thready, the lips blue, the face anxious, livid, and cyanosed, the respiration em- barrassed, the surface cold, the weakness extreme, death occurring in a short time in syncope. Those cases of myocarditis in which the symptoms of embolism -... * Ponfick, Virchow's " Archiv," Band Iviii, p. 528. FATTY HEART. 245 are wanting, and aneurismal dilatations have not occurred, are char- acterized by the presence of the following signs : The movement of the heart is feeble, and the apical impulse unfelt ; the pulse is small, weak, irregular, and intermittent. The great diminution which has taken place in the propulsive power of the heart manifests itself in stasis, pulmonary engorgement and oedema, cyanosis of the face, swol- len veins, vertigo, delirium, etc. In the so-called chronic partial aneu- rism, there may be no symptoms for a time to indicate the existence of the lesions. We have here the same groups of symptoms, due to the diminished propelling power of the heart, as in the preceding paragraph, when sufficient damage has been done to cause yielding of the cardiac wall. Course, Duration, and Termination. — The course of the acute form of myocarditis is very rapid, and the duration from two or three to eight days, but some of them terminate in a few hours. Death may be due to rupture of the heart, to cerebral emboli, to pulmonary oedema, to paralysis of the heart, etc. Chronic myocarditis pursues a very latent course. The development of the lesions may be slow, and hence the duration may be prolonged, but not indefinitely. Dilata- tion of the cavities, feebleness of action, and stasis, will bring on fatal lesions in a few months, or, at most, a year or two. Treatment. — The treatment must be largely symptomatic, and for parenchymatous carditis is to the last degi'ee inefficient, since the causes are not to be removed. Interstitial inflammation, like the same disease elsewhere, is little influenced by remedies. Minute doses of chloride of gold, or of corrosive chloride of mercury, quiniae, and digitalis, offer the best prospect of improvement. The utmost qui- etude of mind and body must be maintained. A generous diet and means to promote digestion are necessary to improve the quality of the blood. FATTY DEGENERATION OP THE HEART. Definition. — A distinction must be drawn between fatty degenera- tion and fatty substitution : the former implying a change in the struc- ture of the muscular tissue; the latter, a displacement of the muscular tissue, in which atrophy of the muscular elements may take place, by the pressure. Causes. — The nvitrition of the heart is impaired by a variety of causes, intrinsic and extrinsic. Among the intrinsic are pericarditis and myocarditis, which set up an inflammation of the heart-muscle ; diminished blood-supply due to atheroma ; compression, etc., of the coronary arteries ; fat substitution, which, encroaching on the proper tissue of the organ, causes absorption, etc. Among the extrinsic causes are impaired nutrition in general, originating in various ways — cancer, tuberculosis, scrofula, prolonged suppuration, prolonged lac- ^ 246 DISEASES OF THE HEART. tation, etc. Most of the foregoing causes induce atrophy by setting up a fatty degeneration. Anaemia, especially when extreme and long- continued, has a strong tendency to induce this change. This has been demonstrated experimentally by Perl,* and clinically by Ponfick f and others. In the various causes above given it is the condition of anaemia induced by them which is responsible for the changes in the heart's muscular tissue. Infectious diseases, fevers, and certain poi- sons, notably phosphorus and alcohol, bring on fatty degeneration. The same result is produced by the mineral poisons in general, but to a less degree, and some other substances. Fatty deposition sometimes takes place to a dangerous extent in the obese, along the sulcus, and penetrating to the endocardium. Furthermore, in the anaemia of the obese, sometimes a very marked condition — fatty degeneration of the heart-muscle — comes on. Pathological Anatomy. — The change may be general or diffused, or exist in spots and patches. The color becomes yellowish, the tissue soft and easily torn, and on the touch makes, in advanced cases, a dis- tinctly greasy impression. The initial change is in the primitive bun- digs, which become cloudy, granular, and their striae disappear. Minute oil-globules appear, and are soon seen in rows, but they presently coalesce ; large globules are formed, and nothing is then visible in the sarcolemma but a multitude of fat-drops. With this change in the fibrilke of muscle, an oedematous condition of the sub-serous connective tissue occurs, and the nutrient vessels are advanced in calcareous de- generation. The fatty change may occupy the walls of the left ven- tricle, or be confined to isolated patches here and there in the walls of the heart, the papillary muscle, the trabeculae, the septum, etc. In the cases of fatty substitution, the whole heart may be enveloped in a dense layer of fat, which also pushes its way into the muscle, follow- ing the inter-muscular planes and the connective tissue, causing such compression that the muscular fibers undergo atrophy, and are pale, thin, and wanting in contractile power. Symptoms. — Weakening of the heart, produced by fatty change in its muscles, causes the disturbances due to(^f(9lmia of the organs and to venous stasis. The rational are more significant than the physical signs. On palpation, the apical impulse is weak. On percussion, there is nothing distinctive, except an increase of the area of absolute dull- ness, if the organ is enlarged by dilatation of its cavities. As there is venous stasis, and as the right cavities yield more than the left, the area of dullness is increased over the lower end of the sternum to the xiphoid appendix. On auscultation, if there be fatty degeneration of the papillary muscle, a systolic murmur is audible in the mitral area. * " Ueber deu Einfluss der Anamie auf die Ernahrung des Herzmuskels," Virchow's "Archiv," Band lix, p. 39. f Ponfick, "Berliner klin. Woeh.," "Ueber Fetthcrz," Nos. 1 and 2, ISYS. FATTY HEART. 247 The sounds of the heart are dull, confused, almost inaudible, and there is often a failui'e of synchronism in the closure of the valves, causing double sounds. The pulse is small, irregular, intermittent, weak, and easily compressed, and may be very slow, falling to forty, often even as low as twenty ; but this is exceptional. A very formidable symp- tom, which, however, occurs under other circumstances, is a peculiar alteration of the respiratory rhythm, known as the Cheyne-Stokes breathing, in which at intervals the respiration becomes slower and shallower, until finally it seems to cease — is suspended "for some sec- onds, half a minute, for a minute — and then is resumed, slow and shal- low, but gradually attaining its normal amplitude. This may be kept up for some time, then disappear, to occur again. The diminished propul- sive power of the heart, causing anremia of organs, induces character- istic symptoms. Sudden anaemia of the brain, faintness, and actual fainting, often occur on rising up suddenly from a recumbent pos- ture, stooping, turning around quickly, etc. These subjects experi- ence constantly, or nearly so, a sense of fullness and distention about the ensiform cartilage or lower sternum, which is associated with prae- cordial anxiety, and they have attacks of angina pectoris,* They experience difficulty of breathing on slight exertion, and can not ascend elevations or stairways without experiencing great distress. The veins of the neck are habitually distended, and the countenance looks dusky and anxious. The legs become oedematous ; next, the body generally; the liver enlarges, ascites forms, the urine becomes albuminous, etc. Course, Duration, and Termination. — Acute fatty heart, produced by the action of poisons, terminates early ; but the eases due to the ordinary causes proceed more slowly, and may last during several years. Their development is obscure, and there are no pronounced symptoms until those of failing heart come on. The termination is in general dropsy, or death is caused by oedema of the lungs, or takes place suddenly by paralysis of the heart, or by rupture of the organ. Diagnosis. — If the causes of fatty degeneration have existed, and symptoms of cardiac weakness come on .slowly, the existence of fatty heart may be regarded as probable, but the diagnosis is largely the balance of probabilities, and is not to be arrived at by exclusion with certainty. Treatment. — As augemia plays so important a part in the causation of fatty degeneration of the heart, the treatment should be directed to the enrichment of the blood. Iron, manganese, and strychnine (the sulphateg), is an excellent combination. The author has seen good ^ results from the phosphate of iron, quinia, and strychnia, in the form of the elixir. Jaccoud prefers cafi^ein to digitalis as a heart-tonic in these cases. The efficiency of opium, or, better, small doses of mor- * J. Lockhart Clarke, " St. George's Hospital Reports," vol. iv, p. 1. 248 DISEASES OF THE HEART. phia, as a tonic of the heart, is too little understood. Especially in the form of hypodermatic injection is it useful, as demonstrated by Clif- ford Allbutt. Inhalations of oxygen gas, the internal use of cod-liver oil, and faradization of the muscles generally, are expedients of high utility. As the case progresses, symptoms must be treated as they arise. RUPTURE OF THE HEART. Definition. — Under the designation of rupture of the heart is meant the so-called spontaneous rujDture, in contradistinction to rupture by wounds and injuries. Pathogeny and Symptoms. — That rupture shall occur it is necessary I that the walls of the heart be weakened by disease. The most fre- quent cause is fatty degeneration, for, in twenty-four cases, this condi- tion of the muscular tissue was found in nineteen,* Next in impor- tance as a cause is the softening produced by acute myocarditis, espe- cially the suppurative form, or the aneurisms, so called, due to the changes of chronic myocarditis. Diseases of the coronary artery, tumors, echinococci, by destroying muscular tissue, lead to rupture. It is more common in men than in women, and in old age — after sixty years. As to the site of the rupture, statistics show that the left ven- tricle, at or near the apex, next the right ventricle, then the right auricle, are the most usual ; but the preponderance is immensely on the side of the left ventricle — forty-three times in fifty-five cases. There is usually but a single vent, but there may be several, and, as they follow the direction of the muscular bands and the line of least resistance, they are tortuous, somewhat jagged in their margins, and the two orifices are not opposite. The size of the rent varies from an inch to the whole length of the cavity. The pericardial sac contains more or less blood, according to the size of the opening. The rupture may be gradual, a part yielding at a time. Death may take place almost instantaneously. Usually, a groan or a cry is uttered, the face grows deadly pale, the individual falls unconscious, there is some shud- dering, and he is dead. The dying may extend over several days — the patient experiencing the symptoms of angina pectoris several times with intervals of partial relief, death occurring suddenly at last. In such cases, it is assumed that successive portions of the heart-wall yield, or that clots temporarily obstruct the rent. The treatment, when there is time for it, is purely symptomatic. HYPERTROPHY AND DILATATION OF THE HEART. Definition. — By hypertrophy of the heart is meant an increase of size of the organ, because of an addition to its substance. This en- largement takes several directions, as follows : * "Berliner klinische Wochenschrift," IS'ZS, p. 15 ; Ponfick, "Ueber Fettherz." UYPERTROrriY AND DILATATION. 2J.9 Simple hypertrophy means an increase in size without alteration of the cavities ; concentric hy2')ertrophy means increase in thickness of the walls, the cavities becoming smaller ; excentric hypertrophy means increase in the thickness of the walls, the cavities becoming larger. The dilatations of the heart correspond in arrangement as follows: In simple dilatation, the cavities are enlarged while the walls re- main normal ; in active dilatation, which corresponds to excentric hypertrophy, the cavities are enlarged, and the walls are increased in thickness ; in passive dilatation, the cavities are enlarged and the walls are thinner. This is the most usual form. The conditions attendant on hyi^ertrophy and dilatation are, in some respects, the same; so that it is an economy of space, and con- tributes to clearness of conception, to study them together. Causes — Hypertrophy. — Simple hypertrophy, which is by no means common, arises from over-action of the cardiac muscle, without there being any disease of the circulatory apparatus. The over-action is due to the abuse of such stimulants as coffee, tea, tobacco ; to moral emotions and intellectual effort, when excessive ; to repeated muscular fatigue, etc. The hypertrophy resulting in this way is general. Any obstacle to the free circulation of the blood imposes additional work on the heart. Narrowing of the aortic orifice gives the left ventricle more work to do, and hence its muscular fibers undergo hypertrophy ; in the same way, hypertrophy of the right ventricle results from nar- rowing of the pulmonary orifice, of the left auricle, from mitral steno- sis, and of the right auricle, from tricuspid stenosis. These are typical examples of partial hypertrophy. The causes of obstruction in front, inducing hypertrophy of the left ventricle, are several : stenosis and regurgitation at the orifice of the aorta; narrowing of the artery at the duct of Botal ; aneurism, and compression of the vessel by tumors ; atheroma of the arterial system. Hypertrophy of the left auricle re- sults from obstruction and regurgitation at the mitral orifice, especially narrowing of the orifice. Similar causes produce similar effects on the other side. Hypertrophy of the right ventricle is due to narrowing of the pulmonary orifice, to aneurisms, and tumors compressing the artery, to chronic pulmonary diseases which obstruct the circulation, as em- physema, caseous pneumonia, fibroid lung, large pleural accumulations, etc. Hypertrophy results from, or is an attendant on, Bright's disease. Various explanations have been offered of the nature of this relation- ship, but it is clear that, if hypertrophy of the muscular layer of the arterioles exists in front, the heart has increased resistance, which re- quires additional effort to overcome. Hypertrophy is, so to speak, a physiological result of the changes in the arterial system due to age ; for the calcareous deposition in the tunics of the aorta and of the ves- sels generally greatly increases the resistance of the arterial circuit by diminishing the elasticity. 250 DISEASES OF THE HEART. Dilatation. — Simple dilatation of the heart occurs in delicate con- stitutions, es^^ecially of growing youths, subjected to over-exertion. This has been observed in armies on a large scale, and by civil physicians as well.* Maclean f has published observations on this point made in the English service ; Seitz and others in Germany ; but Da Costa was the first to set the subject in its true light, by studies in our hospitals during the late rebellion, and preceded all other investigators in this line. The right ventricle, being much feebler than the left, is more liable to suffer dilatation. This condition results from the increase of pres- sure due to insufficiency of the semilunar and tricuspid valves, and pulmonary lesions w^hich hinder the circulation in the pulmonary capil- laries, such as emphysema, chronic bronchial catarrh, chronic intersti- tial pneumonia, and tubercular and caseous infiltration. On the left side the most frequent cause is aortic obstruction and insufficiency ; but o bstru ction rather than insufficiency is more certain to produce the dilatation. Mitral insufficiency leads to dilatation of the right cavities by maintaining constantly an increased pressure in the pulmonary capillaries. The cavities yield under normal pressure of the blood when altered by disease. Pericarditis and endocarditis affect the con- dition of the muscular tissue, by setting up a myocarditis — a granular degeneration. Myocarditis arises under other circumstances also, and the heart-muscle is weakened, not by this disease only, but by fatty degeneration, fatty substitution, tumors, etc. Pathological Anatomy. — In hypertrophy the change may be con- fined to one part, or the whole organ may be involved. To such enor- mous proportions does the heart attain sometimes as to be called cor hovinum — ox's heart. The walls of the left ventricle may increase to an inch, an inch and a half, or even two inches in thickness, and the walls of the other cavities undergo corresiDonding development. The shape of the heart is altered by hypertrophy. When there is hyper- trophy of the right ventricle, the heart is widened transversely and the apex is blunted ; when the left ventricle is enlarged, the heart is elongated, and, if its cavity is at the same time enlarged, the septum is pressed over into the right ventricle. When both ventricles are enlarged, the heart assumes a globular shape. The position of the hypertrophied heart is more horizontal ; if the left ventricle is the seat of the change, the direction of the organ is to the left and downward. By reason of an increase in weight the heart in the recumbent posture sinks relatively lower, and hence the area of absolute dullness may appear smaller ; in the vertical position the heart descends, pushing the diaphragm .before it, and making the epigastrium more prominent. * Dr. 0. Frautzel, " Ueber die Entstehung von Hypertrophie und Dilatation der Herz- ventrikel durch Kriegsstrapezen," Yirchow's " Archiv," Band Irii, S. 215. f "The British Medical Journal," February 16, 1867. HYPERTROPHY AND DILATATION. 251 In texture, the substance of the heart is firmer than normal, and when divided has sharp edges which remain apart. In color, the tint is brighter and fresher looking than in the healthy state. Subsequently, if fatty change begins in isolated patches, the reddish-brown hue of the muscle will be marked by spots of a faintly yellowish or reddish- yellow color. It seems to be well established that the increase in the muscular tissue of the heart is a true hypertrophy, and not a hyper- plasia, that the existing elements are increased in size, but that no new elements are formed. Dilatation occurs chiefly in the auricles, which may be so stretched that the muscular elements undergo fatty degen- eration, are absorbed and disappear, leaving the endo- and pericardium in contact, or separated by some connective, tissue only. The size to which the auricles may be expanded is enormous. The right ventricle may be much dilated and its walls thinned ; the orifices may be much enlarged, the trabecule wasted, and the valves thinned. The left ven- tricle is rarely dilated merely, but the walls are also hypertrophied. Symptoms — Hypertrophy. — The signs and symptoms of cardiac disease are divisible into two groups — rational^ physical. The rational signs are presumptive, and consist of the functional disturbances which indicate the probable seat of the disease ; the physical signs are de- rived from physical laws and methods, and are positive in their results. As respects the rational symptoms, the first point to be noted is, that those vessels receiving their blood-supply from an hypertrophied ven- tricle obtain more blood and with greater force than in the normal condition, and hence the tension in these vessels is higher ; whereas, the vessels on the other side receive less blood with diminished force, and their tension is lower. When the left ventricle is hypertrophied, the tension is increased in the aortic system and diminished in the pul- monary. The opposite condition obtains when the right ventricle is enlarged, for then the pressure is greater relatively in the pulmonary system and less in the aortic. When both ventricles have imdergone hypertrophy, the tension is increased in the aortic system and in the pulmonary artery. In consequence of the increased distributing power of the left ventricle, the blood-cuiTent is accelerated in the arterial system and communicating capillaries, and, as the pulmonary circuit has also a higher tension and greater celerity, the blood received from the great venous trunks is quickly disposed of, so that the tension falls Fig. 17. — Hypertrophy. in the venous radicles. The final effect of pure hypertrophy is an acceleration in the whole round of the circulation. The pulse is full, firm, and bounding. The ascent line of the sphygmographic trace is 252 DISEASES OF THE HEART. vertical and abrupt, but the summit is rounded and the descent oblique, unless there be regurgitation at the aortic orifice. The face is red and congested ; the nose bleeds easily ; the head feels full, and aches a good deal, especially when any strong muscular effort is made ; there are more or less tinnitus aurium and dizziness. When the arterial walls are weakened by atheromatous degeneration, cerebral haemorrhage may be a result of hypertrophy of the left ventricle ; but the way to rupture is prepared by gradual yielding of the arterial tunics, and the formation of minute aneurismal dilatations knovrn as "miliary aneurisms." The strong beating in the superficial arteries is felt by the patient, and produces a disagreeable roaring and beating in the ears, especially when lying on the left side. The attacks of palpitation are frequent, but their severity is not in proportion to the extent of the hypertrophy, for the action may be very tumultuous when the enlarge- ment is slight, and vice versa. There are pretty constantly felt by the patient a sense of prsecordial anxiety, and, rarely, attacks of pain ex- tending to the shoulder and arm, similar to angina pectoris. A sense of fullness in the chest, of oppression, and sometimes embarrassed breathing are experienced, but the pulmonary symptoms may be due to congestion of the bronchial mucous membrane, supplied as it is by the bronchial arteries, and not from the pulmonary. When the hyper- trophy is confined to the right ventricle, no other lesion existing — an extremely rare condition — the symptoms present will be a sensation of fullness and oppression of the chest — possibly dyspnoea ; oedema and haemorrhage may occur, and the production of interstitial inflammation and possibly other diseases promoted. The foregoing signs of hyper- trophy are presumptive or rational ; the physical signs now to be con- sidered establish the seat and character of the lesion. On ijisj^ection there is to be observed a prominence of the chest, greatest at the junc- tion of the fourth and fifth ribs with the sternum. This has been denied; but, that it is often encountered in hypertrophy occurring in young subjects, the author's experience entitles him to aflirm. When hyper- trophy occurs later in life, the ribs having become rigid, no elevation of the chest-wall can be effected, how powerful soever may be the impulse of the heart. As in hypertrophy, the position of the heart is more horizontal and depressed to the left, on 2yoJpation, the apical im- pulse is felt near to the axillary line, and one, two, and possibly three intercostal spaces lower down, and it is stronger and more widely dif- fused. The force of the impulse is sufficient to raise the hand when placed on the cardiac region, or the head when applied in auscultation, and the whole left thorax may be felt lifted up and carried toward the left. This is entitled the heaving impulse, and is very characteristic of extreme hypertrophy. Instead of the impulse having a heaving character, sometimes it makes the impression of a sudden jar which is immediately arrested. In hypertrophy of the right ventricle the heav- HYPERTROPHY AND DILATATION. 253 ing impulse is felt at the end of the sternum, especially its right border, and in the epigastrium. In the third and fourth intercostal spaces to the right of the sternum, the impulsion of the hypertrophied auricles may sometimes be felt. On percussion, the area of praecordial dullness can be demonstrated. The absolute or superficial dullness is that de- rived by percussion over that portion of the heart uncovered by the lung — a triangular space ; the relative or deep dullness is that obtained by sti'ong percussion over that portion of the heart covered by the lung. The dull space extends from a point internal to the upper border of the second rib at its junction with the sternum, obliquely downward to the left to the apex-beat, thence transversely to the right border of the sternum. This is an irregularly triangular or ovoidal space which returns, on percussion, the forms of dullness mentioned above. The area of absolute dullness is increased by hypertrophy of the heart, if the patient is percussed when erect and inclined slightly forward. The relative dullness is increased more when the patient is recumbent, by the heart sinking backward. In hypertrophy of the left ventricle, the dullness is parallel to the long axis of the heart ; in hypertrophy of the right, the dullness is over the lower extremity of the sternum. When pure hypertrophy is the condition under examination, aus- cultation furnishes no important information. The sounds of the heart are somewhat aifected in their timbre. In hypertrophy of the left ventricle, the first or ventricular sound has a rather metallic quality, and the second sound is strongly " accentuated " ; in hypertrophy of the right, the same facts exist, but the sounds are less intense. At the apex, a peculiar metallic " click " is sometimes heard, and is doubtless due to the vibration in the chest-well, produced by a very strong im- pulse. It is much louder when the stomach is distended with gas. Dilatation. — When dilatation occurs in any of its forms, the propul- sive power of the heart is diminished ; less so, however, in active dila- tation. The result of this is a condition of ischaemia in one set of ves- sels, and of stasis in the other system. Thus, when the left ventricle is dilated, there is a lowering of tension in the aortic system, and an increase of pressure and abnormal fullness of the pulmonary; when the right ventricle is dilated, there are diminution of tension, and ischae- mia of the pulmonary artery, and elevation of pressure with stasis in the peripheral venous system. The ultimate effects of the disturbance in the vascular system are the same when one ventricle is dilated as if both were, for, taking as an example the most common dilatation, that of the right side of the heart, the stasis in the peripheral veins extends to the capillaries, to the arteries, thence to the left side, and vice versa. When, however, dilatation of the right ventricle coincides with hyper- trophy of the left, the excess in power of the one compensates for the deficiency in the contractile energy of the other. The results of dila- tation of all the cavities are these : the vessels receiving blood from 254 DISEASES OF THE HEAET. the heart — efferent vessels — are in a condition of ischsemia, or dimin- ished blood-supply, while the vessels conveying the blood to the heart — afferent vessels — are constantly abnormally full, or in a condition of hypersemia and exaggerated tension. When the right heart is dilated, there are ischgemia of the pulmonary vessels, producing habitual dys- pnoea, insufficient haematosis or aeration of the blood, and stasis in the general venous system. The peripheral veins are turgid with blood, there is cyanosis from deficient aeration, and a constant hyperaemia of the liver, spleen, kidneys, and intestinal canal. Increase of pres- sure in the renal veins causes albuminuria ; in the hepatic veins, jaun- dice and ascites ; in the veins of the extremities, cedema and general dropsy, and thrombosis. The rational symptoms of these functional disturbances are, palpitations of the heart ; frequency and irregu- larity of the pulse ; deficiency in the arterial blood-supply to the brain, and manifest in vertigo, ringing in the ears, attacks of faint- ness or actual syncope, etc. ; deficiency in the blood going to the lungs, and causing cough, dyspnoea, etc. The composition of the blood is impaired by the excess of carbonic acid ; the lessening of the oxidation processes diminishes the production of heat, and hence the general temperature is low ; the vessels themselves, the heart, and the tissues, undergo nutritive changes in consequence of insufficient energy in the process of tissue metamorphosis. A cachectic state, with low- ered vitality of the tissues, so that they ulcerate under the least irri- tation, is the necessary outcome of these changes. There is not only a lowered state of the assimilative functions, but elimination is im- perfectly carried on, and excrementitious materials are retained in the blood — carbonic acid and urea — causing hallucinations, delirium, eclampsia, coma, etc. The ill results of these nutritive alterations are also exhibited in increased damage to the heart-muscle, and conse- quently an exaggeration of the mechanical effects of the dilatation. Inspection furnishes no information of value, except, when dilatation of the right cavities render the valves incompetent, a venous pulse will be visible in the neck. On palpation, the area of cardiac impul- sion is as wide as in hypertrophy, but the apical impulse is feeble, and may not be felt when the patient is recumbent. When there is hyper- trophy of the right heart to compensate for dilatation of the left cavi- ties, the apical impulse will be feeble, while the pulse of the right cavi- ties at the border of the lower sternum will be comparatively strong. On percussion the extent of dullness is made out as in hypertrophy. On auscultation, the sounds are feeble, as a rule ; on the other hand, they may have a more clear and resonant quality. A soft-blowing murmur sometimes takes the place of the first sound. This murmur is situated in the mitral and tricuspid areas, and is due to the insuf- ficiency of the valves to close the auriculo-ventricular orifices. Diagnosis. — Hypertrophy is to be distinguished from dilatation of HYPERTROPHY AND DILATATION. 255 the heart, from pericardial effusions, tumors of the mediastinum, etc. The force of the impulse, the accentuation of the second sound, and the state of the systemic circulation, enable the differentiation to be made from dilatation, and also from effusion ; besides, in the latter, the dull- ness has been preceded by a friction-sound, and, when the effusion comes on, the heart-sounds weaken and disappear. The seat of the dilatation is determined chiefly by the position of the dullness. Hyper- trophy and dilatation are differentiated from tumors in the mediasti- num, by the displacement of the heart occasioned by the latter, and by the persistence of the normal heart-sounds. The pressure of a tumor on the great vessels and impoi'tant nerves introduces into the symp- tomatology of the case new symptoms quite foreign to either hyper- trophy or dilatation. From pleui'itic effusion in the neighborhood, retained by adhesions — the so-called encapsulated — the dullness due to hypertrophy or dilatation may be difficult to separate, but effusions displace the heart without altering the character of its impulse and its. murmurs ; when the pleural effusions are unconfined, the ready dis- tinction consists in the change of the position of the patient, shifting the dullness. Course, Duration, and Termination. — The course of these affections is chronic, but hypertrophy continues much longer than dilatation. Hypertrophy, uncomplicated, exists unchanged for many years, and is important rather on account of the complications which may grow out of it than of itself, yet changes in the heart-substance and in the ves- sels must eventually result. Over-supply of blood to organs leads to nutritive alterations in them. Rupture of vessels may take place, but disease of the arterial tunics is necessary also ; hence the importance of hypertrophy of the heart as a factor in cerebral and in pulmonary hgemorrhage. Dilatation of the cavities is much more rapid in its course and important in its results than hypertroj)hy, but simple and passive dilatations are more serious than the active form. The heart is much weaker, its tissues become diseased, and death may be sudden by pai'alysis or by ruj^ture, or in attacks similar to angina pectoris. The stasis in the circulation, the pulmonary, hepatic, and renal trou- bles, and the general dropsy which result from dilatation, are the usual sequelae, and death ultimately occurs from the combined effect of these disturbances. Prognosis. — The prognosis is necessarily grave, but it should always be guarded. Simple hypertrophy may exist for years, without any apparent interference with function. In dilatation, the hope of any lengthened period of freedom from ill results can not be encouraged. When dropsy appears, it becomes a question of the physical endur- ance largely, for death can not, then, long be delayed. Treatment — Hypertrophy. — When hypertrophy is compensatory or compensated, there is no need of therapeutical measures. It may, 256 DISEASES OF THE HEART. however, be necessary to combat the hypertrophy, or its results in the organism at large, if the force of the heai't and the pressure in the vascular system are so great as to threaten serious consequences. The most direct method is the abstraction of blood, either by venesection or by leeches, and this is allowable in vigorous subjects. Purgatives lower the blood-pressure, especially the saline purgatives, which draw off by the intestinal mucous membrane more or less fluid. They are much less objectionable than bloodletting, are more easily handled, and are more permanent in results. Next to saline purgatives in effi- ciency is the tincture of aconite-root. Tincture of veratrum viride is more powerful, but less easily managed, for its effects are quickly pro- duced and not easily confined within the prescribed limits. The action of the heart may be readily maintained by aconite at a uniform rate, which need not be lower than seventy beats of the pulse per minute. The abnormal fullness of the vascular system may also be lessened by reducing the gross amount of aliment taken in the twenty-four hours. This method will be all the more effective if the rate of waste is en- couraged by the use of potassa salts, which also increase the discharge of the products of waste by the kidneys. The treatment of dilatation must pursue the opposite direction. The general nutrition must be maintained at the highest point, to pro- mote the nutrition of the cardiac muscle. A generous diet, moderate exercise in the open air, the inhalation of oxygen, are important agen- cies to accomplish the objects just mentioned. Bitters to increase the appetite and iron to improve the quality of the blood are strongly in- dicated. To tone up the heart and raise the tension of the vascular system, there is no remedy so efficient as digitalis. It should be given with quinia, which is also an excellent heart-tonic. The most remark- able effects attend the use of minute doses of morphia hypodermati- cally in these cases. When there is extreme dyspnoea, the heart very feeble, the fluid everywhere gaining, the effect of the injection is almost magical. It sometimes happens that the symptoms are too urgent to await the slow action of digitalis, or it may be the stomach will not tolerate the digitalis in any form, then the injection is most opportune — the patient is relieved by it — time is gained for the action of digitalis, or the stomach will bear it better. ENDOCARDITIS — INFLAMMATION OF THE ENDOCARDIUM— PLASTIC ENDOCARDITIS. Definition. — The endocardium is a delicate serous membrane, lining the cavities of the heart and forming its valves. The acute inflam- mation occurs in two distinct forms, which differ so widely as to require separate consideration : plastic, or simple exudative inflam- mation ; ulcerous, or diphtheritic inflammation. The plastic form is ENDOCARDITIS. 25T either acute or chronic, but these differ merely in degree and rate of progress. Causes. — Primary or idiopathic endocarditis, except in the ulcerous form, is extremely rare. Plastic endocarditis is usually a secondary affection : secondary to pleuritis, pneumonia, pericarditis, myocarditis, etc., but, very much more frequently, secondary to acute rheumatism. The relative frequency of endocardial inflammation in acute rheuma- tism, is differently stated by different observers. According to some, one half, others one third, of the cases are complicated by endocarditis, but the real number is, no doubt, lower than one third. The source of error is the occurrence of a soft-blowing murmur in cases of rheuma- tism, due not to inflammation of the endocardium but to the condition of the blood. The more severe the type of rheumatic fever the greater the danger of cardiac complications, but there are numerous exceptions to this rule. The pericardial and endocardial inflammation may pre- cede the joint-troubles. Pathological Anatomy.^The initial lesion is hypertemia, which in- volves the sub-serous connective tissue as well as the membrane itself. The stasis in the vessels induces rupture of the capillaries, here and there, and minute extravasations are thus formed. Migration of white corpuscles, exudation of fibrinogenous and germinal matter, now takes place into the affected membrane, and the cells of the endothelium be- come cloudy, loosen, and undergo proliferation. The membrane, which in health is thin, transparent, and glistening, becomes, as a result of these changes, rough, opaque, and thickened. The roughness of the mem- brane is due, further, to the formation of lamellif orm or conical vegeta- tions, the product of the activity in cell proliferation at particular j)arts, or, according to Rindfleisch, they are composed of an homogeneous fibrinous exudation from the vessels. K the changes in the structure of the membrane do not go beyond this point, it is probable that com- plete restitution may occur. Proceeding from this point the inflam- mation may take the plastic or the ulcerous form. We are now con- cerned with the former only. The exudation on the auriculo-ventricu- lar valves (mitral) is found chiefly at the free border, where the ten- dons are inserted ; on the semi-lunar valves (aortic)* on the lateral border where the segments come in contact, yet the corpora arantii may also be the seat of abundant exudation. The vegetations pro- jecting from the surface of the membrane entangle masses of fibrin whipped out of the blood, which may project from the valves, swing- ing to and fro like a polypoid excrescence. The chordae tendinse may be affected in a manner similar to the valves. Softened by the inflam- matory process, the chordae may give way, permitting a segment to become adherent to a neighboring one. Adhesion of the semi-lunar valves may occur at the side where they are in contact. The adhe- sions undergo organization, and thus the most serious changes are 258 DISEASES OF THE HEART. wrought in the structure and functions of the valves. Also, large masses of fibrin may be entangled in them, and they may be the cause of thrombotic deposits around them. When the inflammatory pro- cess passes to the chronic stage, characteristic changes take place in the exudation : it loses some part of its water, solidifies, and subse- quently contracts. The connective tissue undergoes hyperplasia, espe- cially the connective tissue of the borders of the valves, but the mem- brane, generally of the valves, may be affected by the same change. As a result of the tendency of the new material to contract, the valves become much deformed, thick, and inflexible, and, of course, their functions are correspondingly impaired. Calcareous changes occur in the deposits, and fatty degeneration also takes place. Patches of soft- ening also occur in the valves, the membrane yields, and pouches or aneurisms form, which ultimately give way, and thus a valve is per- forated. This process, occurring at various points, imparts to the valve a sieve-like appearance. Vegetations detached, or bits of ad- herent fibrin cast off, constitute emboli, which, entering the blood-cur- rent, will be deposited in distant parts — on the left side of the brain, in the kidneys, spleen, etc. The orifices of the valves undergo similar changes. The connective-tissue transformations take place, and hence rigidity, deformities, and contraction result. Symptoms. — When endocarditis is idiopathic, which is very rare, its onset is marked by the usual symptoms of an acute febrile or in- flammatory affection. There is a chill, followed by fever, a coated tongue, anorexia, nausea, sometimes vomiting, and general malaise. As it occurs in the course of another disease, the additional disturbance induced by it may altogether escape recognition, and it is only by per- sistent watchfulness, under such circumstances, that it is discovered. This is true of its onset in rheumatism, Bright's disease, the eruptive fevers, etc. On the other hand, the commencement of endocarditis may be manifest by very obvious signs. For example, if during the course of acute rheumatism endocarditis comes on, there will occur an increase in the temperature, the thermometer rising a degree or two, the pulse will become more rapid, and the general condition less favor- able, than before the complication arose. The fever does not pursue a special type, and the pulse exhibits no characteristic quality. The other rational symptoms are equally indefinite. There may or may not be some uneasiness in the region of the heart, some prsecordial opj)ression, and some palpitation. There may occur, also, increased impulsion of the heart, more rapid and tumultuous beating of the ca- rotids, headache, noises in the ears, some dyspnoea, etc. After a time the action of the heart becomes less energetic, the strength of the pulse declines, the function of hgematosis is impaired, and hence the functions generally, especially the cei-ebral, are less energetically per- formed. The physical signs are much more distinctive than the ra- EXDOCAKDITIS. 259 tional ; tlie changes in the valves and at the orifices necessarily modify the character of the murmurs, or add new sounds. The period and position of the murmur are determined by the valve affected and by the time, in the cardiac revolution, when the blood-current passes the affected orifice. In mitral insufiiciency a hridt or murmur is audible with the first sound (systolic) at the apex, and with the second sound (diastolic), or after it (presystolic), if there is obstruction at the mitral orifice. In aortic obstruction the murmur is audible with the first sound (systolic) at the base, and with the second sound (diastolic) if the aortic valves are insufficient. If the lesions occur on the opposite or right side of the heart, which is very rare, the same rules obtain, but the position at which the sounds are heard is different. To hear the sounds at the right auriculo-ventricular orifice, the ear must be placed over the ensiform appendix, and, for the pulmonary valves, at the junc- tion of the third right rib with the sternum. Percussion affords but little information. If there be aortic obstruction, some distention of the heart is occasioned, which increases the area of dullness in the ver- tical direction ; if mitral obstruction, the right cavities will be some- what dilated and the dullness increased in the transverse direction. The facts may be formulated as follows : In acute endocarditis the same physical signs characteristic of chronic valvular diseases of the heart occur suddenly ; and, further, the sudden development of the symptoms of mitral insufficiency is the most characteristic sign of acute endocarditis (Jaccoud). Obstruction or regurgitation at the mitral orifice increases the pressure of the blood in the pulmonary ar- tery, and hence a physical sign of this condition is accentuation of the pulmonary second sound. More or less congestion of the lungs and sta- sis in the venous system are necessary consequences of mitral disease. Course, Duration, and Termination. — The course of acute plastic endocarditis is necessarily brief. The patient either partially recovers by the disease assuming the subacute and chronic phase, or he dies from the immediate consequences and complications. When the case passes from acute to chronic, the fever ceases, compensation takes place, by which the disorders of circulation are obviated for a time, yet the physical signs of valvular mischief continue. Death may result from a gradual weakening, terminating in paralysis of the heart, or heart- clot may form, or a cerebral embolism occur. Pericarditis, myocar- ditis, and pneumonia, may also intervene and take life. That a cure of actual lesions may happen is admitted, but the examples of such a fortunate termination are extremely infrequent. The duration of the acute attack is short ; of the subacute and chronic form, indefinite. Diagnosis. — The differentiation consists in the application of the physical signs. It should not be forgotten that a murmur exists of a soft-blowing character, not due to valvular lesion, and which disap- pears on the subsidence of the acute symptoms. 260 DISEASES OF THE HEART. Prognosis. — The acute form is not very dangerous to life, and hence a favorable prognosis may be expressed. As regards tlie ultimate re- sults of valvular lesions, tbe prognosis is grave. Treatment. — The character of the associated malady and the con- dition of the patient must enter largely into the consideration of reme- dies. As it is a fundamental principle to keep the suffering organ quiet, remedies capable of effecting this are very important — these are, ice and digitalis. An ice-bag should be applied to the precordial region, and a tablespoonf ul of infusion of digitalis given every four hours. Flying-blisters should be applied to the axillary region. In the incipiency, before much damage has been done, there can be no doubt of the great efficacy of the hypodermatic injection of morphia, or the internal administration of morphia and quinine — one quarter grain of morphia and ten grains of quinia every four hours until three or four doses are taken. When considerable exudation has occurred, besides the remedies to quiet the heart, ammonia should be given freely, with the view to exert a solvent action. The best form for adminis- tration is the carbonate (ten grains) in the solution of the acetate (half an ounce) every four hours, or half the quantity every two hours. If there be much depression in the progress of the case, quinia and digitalis should be prescribed in combination. ULCERATIVE ENDOCARDITIS— DIPHTHERITIC ENDOCARDITIS. Definition.— This is a peculiar form of disease, in which ulcerations and dii^htheritic exudations, with colonies of micrococci, develop in the endocardium, followed by septic infection of the blood and mul- tiple embolisms. Causes. — A peculiar state or type of constitution seems necessary to develop this disease. It occurs during the course of some cases of a'cute rheumatism, of puerperal fever, of diphtheria, etc., and now and then this process attacks the valves in cases of chronic plastic endo- carditis, the new material undergoing rapid and destructive ulceration. This disease occurs from puberty to forty years. A depressed condi- tion of the vital forces, due to bad hygienic influences, seems to be very influential in determining the occurrence of this disease in youths. The close analogy between the diphtheritic process and this ulcerous disease of the left heart and the frequent coincidence of the two affec- tions render it highly probable that the diphtheritic poison is the chief if not the only factor in its causation. Pathological Anatomy. — The initial lesions are the same as those described under the head of plastic endocarditis. The lesions are chiefly on the left side of the heart, and attack by preference the anterior flap of the mitral and the semi-lunar valves of the aorta ; next the walls of the appendages to the left auricle, and, lastly, the walls of ENDOCARDITIS. 261 the ventricle. Occasionally the same morbid process occurs on the right side, and, in one reported case, on the tricuspid only,* and its chordte tendinse, which were destroyed. After the initial changes already described, the nuclei of the connective tissue undergo rapid proliferation and form granulations of the surface ; fibrinous depos- its take place, and the whole forms a " felt-like " mass, intimately connected with the tissues beneath. A process of softening then begins in the interior of these masses ; they crumble and fall away, and leave a ragged, irregular ulcer, which is the seat of fresh fibrin- ous deposits. Perforation of the valve may ultimately take place, and the margins of the perforation are rough, ragged, and ulcer- ated ; and they are surrounded by granulations having the same struc- ture as those which have already ulcerated. A distinctive peculiarity of this process is the presence early in the course of formation of the granulations, and in the midst of the proliferating connective- tissue corpuscles, of a finely granular material, the particles having various shapes, strongly refractive of light, and resisting the action of acids and alkalies. These granules, as Virchow was the first to point out, are micrococci, and the granular masses are colonies of micro- cocci. The losses of substance by thinning the valves lead to the for- mation of the so-called valvular aneurisms, and coagula forming in these are thrown off with patches of diseased tissue, when the aneurism gives way. Ulceration of the septum, induced in the same way, leads to communication between the cavities. The particles of ulcerating tissue, of fibrin and blood-clot, and the little masses of micrococci colo- nies thrown off into the blood-current, form multiple embolisms. Two results follow : either there is merely mechanical obstruction of vessels, or an infective process is set up the same as that of the original disease. The spleen, kidneys, and brain, are the organs in which these de- posits take place from the left side of the heart. When the disease is in the right side of the heart, the emboli are swept into the lungs. f As these organs contain the " terminal arteries " of Cohnheim, there will occur hsemorrhagic infarctions and ichorous suppuration. All the organs of the body may, indeed, be the seat of abscesses for embolic deposits. The distribution of infective materials — specific micrococci — sets up a general infection of the blood. Wherever the micrococci are deposited they undergo rapid multiplication, and initiate the same morbid action as at the original source of infection. Numerous are the alterations occurring in various organs in ulcerative endocarditis. The spleen is very much enlarged, whether the seat of infarctions or not ; in the kidneys are abscess formations, and the afferent vessels are blocked with colonies of migrating micrococci ; in the brain there * T. Whipham, M. B., " Transactions of the Pathological Society," vol. xxii, p. 118. f C. J. Eberth, Virchow's " Archiv," Band Ivii, " Ueber diphtherische Endocarditis." 262 DISEASES OF THE HEART. are extravasations, especially of the meninges ; in the lungs, abscesses from emboli ; in the heart, myocarditis and pericarditis ; and in the small intestine, swelling of the patches of Peyer and solitary glands, and ulcerations which differ from those of typhoid, in that they are not confined to the lower extremity of the ilium, are not opposite the insertion of the mesentery, and are not limited to the glands.* Symptoms. — Cases of ulcerative endocarditis differ much in their objective symptoms, but they may be referred to two types : typhoid; pyaemic. In both, the cardiac symptoms are quite masked by the pre- ponderating importance of the systemic state, and hence cases of pri- mary endocarditis are apt to be overlooked. When there is an attack of rheumatism going on, suspicion of cardiac mischief will of course be excited by the sudden occurrence of a violent chill which inaugurates both forms. In the typhoid form succeeding the chill there is con- siderable fever, the range of temperature being rather of the remittent type ; headache, vertigo, and extreme prostration, and sometimes a sense of prsecordial oppression, are then experienced ; the tongue is dry and brownish ; there are nausea and vomiting, and the bowels are con- stipated, or diarrhoea is present. The prostration gains rapidly, and by the fourth day a condition of depression is reached comparable to the second week of typhoid. The resemblance to typhoid is all the greater, since the abdomen is swollen and tympanitic and the spleen is enlarged. Delirium (irritation) soon comes on, to be replaced in a few days by stupor and coma (depression), A severe diarrhoea now succeeds to constipation, if that condition has existed before, and the perplexity of the case may be enhanced by rose-spots and petechias appearing on the abdomen. Presently, the patient lying in a comatose state, the stools and urine are passed involuntarily. The urine has a smoky ap- pearance, and contains more or less blood, and albumen is present. There is usually some bronchial catarrh, with cough and dyspnoea — the latter, however, may be due to blocking of vessels and infarc- tions. On auscultation, a rather loud, systolic murmer is audible, usually with greatest intensity in the mitral area, or with the second sound in the aortic area. The pymmic form begins with a chill, which is a decided rigor, followed by a high fever and sweating. The chills recur sometimes with the regularity of an intermittent fever, but usually very irregularly, as is proper to pyaemia. A condition of profound and increasing adynamia is soon developed. There is often a yellowish hue of the skin ; there may be jaundice, or there may occur petechial or haemorrhagic spots, or a roseola may make its appearance. During the maxima of the temperature curves the heat may attain to 105° Fahr. and the pulse to 140. Dyspnoea and accelerated breathing may indicate pulmonary infarctions and pneumonia ; enlargement of the * Rudolf Maicr, Virchow's " Archiv," Band Ixii, " Ein Fall von primarer Endocar- ditis diphtheritica." ENDOCARDITIS. 263 spleen (infarctions of that organ) ; renal pains, albuminuria and hsema- turia (infarctions of the kidneys) ; and apoplectic attacks and hemi- plegia (infarctions of the brain). Abscesses occur in the joints in a considerable proportion of cases. They are peculiar, in that they form with great rapidity ; are, when at rest, free from pain ; and are not manifest by swelling and changes in the form and appearance of the joint. In some cases there occurs an acute atrophy of the liver, with an intense icterus. Confusion of mind is observed with the onset of the symptoms, then an active delirium, followed in a short time by stupor, coma, and insensibility. Not all the cases conform to one or the other of these types ; some pursue an intermediate course ; others seem to be only aggravated cases of rheumatic fever. There may be no physical signs to warrant the opinion that endocarditis exists; there may be no marked affection of the joints — only vague pains in them, and in the muscles, yet there are maintained a high grade of tempera- ture and a rapid pulse, and the stomach continues much deranged. Course, Duration, and Termination. — The course of ulcerative endo- carditis is very rapid, but the pyaemic form is more quickly fatal. This form rarely continues longer than ten days, and many terminate within a week. On the other hand, the typhoid form may last three or four weeks, or even longer. Death may occur from paralysis of the heart, from heart-clot, from thrombus of the pulmonary artery, from pneu- monia, from cerebral embolisms, etc. Diagnosis. — A typical case of the typhoid or pyaemic form, occur- ring in the course of acute rheumatism, ought to be diagnosticated without difficulty. Generally the symptoms do not indicate the nature of the lesions. Probably ulcerative endocarditis is more frequently confounded with typhoid than any other malady. The differentiation can not be made from the symptoms, but from the history of the case. In typhoid there is slow development, and the grave symptoms do not come on until the first week is passed. The circumstances surrounding the individual and the occurrence of other cases in the neighborhood must be taken into account. Treatment. — Notwithstanding the apparently hopeless condition of the patient affected with ulcerative endocarditis, our efforts should be directed to the use of stimulants and support, and special remedies, as if there were a prospect of cure. As septic materials are circulating- through the blood, the benzoate of ammonium, or salicylic acid, should be administered freely. To effect the solution of blood-clots and fibrin masses, we should keep the blood as highly alkalinized as possible by ammonium carbonate. Quiniae and morphia are the appropriate reme- dies during the first few days; carbonate of ammonia and the benzo- ates, when the endocardium is disintegrating, and alcoholic stimulants and abundant food-supply throughout the whole duration of the case. 264 DISEASES OF THE HEART. DISEASES OF THE VALVES AND OP THE ORIFIOES.— VALVU- LAR LESIONS. Definition. — Under the term " valvular disease " are included those alterations in the structure of the valves themselves, or of the orifices, which render the former incapable of performing their office in the closure of the latter. The lesions may be of two kinds — obstructive, or regurgitant ; that is, the orifice may be so narrowed as to obstruct the passage of the blood, or the valves may be so damaged as to per- mit the blood to regurgitate. The narrowing of an orifice is termed stenosis ; the incompetence of a valve to close the orifice is termed insufficiency ; as aortic stenosis, mitral insufficiency, etc. There are four points at which these lesions may occur : on the left side, at the auriculo-ventricular orifice (mitral), at the aortic orifice (semi-lunar) ; on the right side, at the auriculo-ventricular orifice (tricuspid), at the pulmonary orifice (semi-lunar). Causes. — There seems to be no difference in the liability of the two sexes respectively to the occurrence of valvular diseases. Age exer- cises a very manifest influence in the production of aortic disease, by the development of atheromatous changes, while mitral lesions occur more frequently in youth. Still, the rule is not invariable. Aortic disease may be brought on in early life by overwork and strain of the heart, as was first pointed out by Da Costa. According to Bam- berger, the greatest frequency of mitral disease is from ten to thirty, and of aortic disease from thirty to fifty. The relative proportion of cases fatal from heart-diseases, in the deaths from all causes, is differ- ently stated by different observers, from two per cent, to twenty, but the lowest estimate is probably nearest the truth. The most impor- tant cause is, doubtless, rheumatic endocarditis, which affects all the valves, but greatly more frequently the mitral. The next in impor- tance as a factor is chronic endarteritis, or atheromatous degeneration, which usually affects the aortic orifice. Sy^^hilis is also a cause, but the precise value of its influence in lighting up mischief in the valves is not known, and, as gummata are deposited in the walls of the heart, the lesions of the valves are usually secondary to myocarditis. Lea- red * reports a case supposed to he syphilitic, in which vegetations formed on the aortic valves, the patient having had recently a well- marked constitutional syj^hilis. Rational Signs and Symptoms of Valvular Defects. — When the nor- mal course of the circulation through the heart is disturbed by changes in the orifices and in the valves, certain consequences ensue to the heart itself, and to the organs in general. When stenosis exists at an * Dr. A. H. Leared, " Aortic Yalve-Disease, apparently caused by Syphilis," " Path. Soc. Transactions," vol. xix, p. 94. VALVULAR LESIONS. 265 orifice, the amount of blood passing through is necessarily lessened, with the effect to cause ischajmia and lowered tension in front, and stasis and abnormally high tension behind. The same result follows if the contractions are feeble and the cavity dilated, for then the amount delivered in front is lessened, and accumulation takes place behind. Lesions of the aortic orifice, either obstructive or regurgi- tant, lead to dilatation of the left ventricle, to diminished blood-sup- ply, and lowered tension in the vessels of the aortic system, and to increased pressure and distention in the left auricle and pulmonary veins. Mitral lesions, either obstructive or regurgitant, cause abnor- mal fullness and distention of the left auricle and pulmonary system, and ischsemia and lowered tension in the left ventricle and aortic sys- tem. Again, lesions of the tricuspid orifice induce dilatation of the right auricle and increased pressure in the venae cavse, and ischsemia and lowered pressure in the right ventricle and pulmonary artery. Also, lesions of the pulmonary orifice bring about dilatation of the right ventricle, and elevated tension in the right auricle and vense cavae, and ischsemia and lowered tension in the pulmonary artery. Al- though obstruction and regurgitation of the aortic orifice affect first the aortic system, yet ultimately the dilatation of the left ventricle, and the changes in the auriculo-ventricular orifice will lead to incompe- tence in the mitral and general venous stasis. The same fact is true of mitral stenosis and regurgitation ; the arterial system does not receive its normal supply, and accumulation takes place in the pulmo- nary veins, and next in the right cavities. Obstruction and regurgita- tion on the side of the right heart lead to ischtemia in the pulmonary artery, then of the pulmonary veins, then of the left cavities, and finally of the aortic system, while stasis and high tension obtain in the venous system. The final result of valvular lesions on the circulatory system may be formulated as follows : All valvular lesions bring about, sooner or later, a state of the circulatory organs in which there are ischaemia and lowered tension in the aortic system and stasis and higher tension in the venous system. When compensation takes place, this formulated expression ceases to be applicable. By the term compensation is meant an adaptation of the organs of circulation to the new conditions imposed on them by the valvular lesions. Ste- nosis of an outlet is compensated by dilatation of the cavity and hy- pertrophy of the walls. Thus, in aortic stenosis, some dilatation of the cavity enables the heart to retain the excess in the quantity of the blood, and hypertrophy of the walls enables the left ventricle to de- liver the whole amount into the aorta. In this way the obstruction is compensated, so that the subjects of aortic stenosis are enabled to live in comparative comfort for many years. But the compensation may be easily ruptured or overcome. Any unusual Avork put on the heart, new obstacles inti'oduced by disease in the lungs, or in the heart itself, 266 DISEASES OF THE HEART. may disturb the comj)ensatory relation, and the symptoms of valvular disease be resumed again with renewed force. The slowing of the current, which is a consequence of stenosis, of changes in the heart-muscle, and of stasis at some point in the circuit, has a disastrous effect by the formation of heai-t-clots. Coagula form in various situations : on the walls of the heart, entangled in the tra- becular, or in the auricles. These coagula are found more frequently on the right side, and hence hasmorrhagic infarctions in the lungs are results of valvular disease. A true infarction is possible in those organs only supplied with Cohnheim's terminal arteries. An embo- lus lodged in one of these stops the blood-current, and, the terminal artery having no anastomoses, there can be no collateral circulation ; but in the efferent vein, supplied through a communicating vein by an unobstructed artery, a recurrent movement of the blood takes jjlaee, flows on into the capillaries, then finally into the artery with a rhythmical movement. The result is, the wedge-shaped area sup- l^lied by the obstructed artery becomes deeply injected, and, vessels yielding under the increased pressure, a haemorrhage occurs. Thus is produced the pathological state called " haemorrhagic infarction." If the infarction is large, or if several smaller ones unite, symptoms of disturbance in the pulmonary functions will be induced. There will be dyspnoea, mucous exjjectoration with more or less blood, chilli- ness, and the physical signs of consolidation — dullness on percussion and bronchial voice and breath sounds — the latter, however, recog- nized if the area of infarction be large and situated at or near the periphery. If the pleura is involved there may be pain and fever, but usually the temperature remains rather below than above the nor- mal. In some cases the infarction may be entirely healed, and nothing remain but a cicatrix ; in others, if the embolus be infective, a gan- grenous inflammation may take place ; in others, again, death may occur suddenly from blocking of a considerable vessel. The most usual pulmonary disturbance induced by valvular disease is stasis of the blood, which leads to catarrh of the bronchi, and is accompanied by cough, by mucous expectoration, mucous and sub-mu- cous rales, etc. Very important changes ensue in the intima of the ves- sels, and in the caliber of the capillaries ; the former undergoes an atro- phic change, the latter enlarge and become varicose, and, projecting into the alveoli, narrow the breathing-space, and thus cause dyspnoea. Under the increased pressure, vessels give way and haemorrhage occurs in the alveoli and intervening connective tissue ; and the blood un- dergoing the usual transformation, produces the so-called " red-brown induration." When the stasis has continued for a long time, and is extreme, the pulmonary tissue becomes oedematous. Difficulty of breathing is a necessary result of these conditions. Besides this habitual difficulty of breathing, there are paroxysmal attacks of con- VALVULAR LESIOXS. 267 siderable severity, in which, without any increase in the number of respiratory movements, there is a sense of need of air, accompanied often by pain in the chest, in the shoulder, and extending down the arm. These attacks are more usual in cases of disease at the aortic ostium, due to atheromatous degeneration. In consequence of the slow circulation through the tissues, the blood loses more oxygen and takes up more carbonic acid ; in consequence of the interference with aei'ation caused by the pulmonary changes, the blood contains always more carbonic acid and less oxygen than is normal — hence cyanosis is a symptom in these cases. It exists, in varying degree, from a decided blueness of the whole surface to a faint blueness of the lips only. The condition of over-fullness of the venous system is further seen in the distended state of the superficial veins. The increased tension of the veins is an efficient factor in the production of oedema, the absorption of fluid is hindered from the same cause, and the state of the blood- serum favors outward rather than inward osmosis. The accumulation of fluid in the areolar tissue first occurs in the inferior extremities, and then gradually extends upward. Of the internal cavities, the perito- neum becomes earliest and most abundantly the seat of effusion, be- cause of the changes which take place in the liver in these cases of cardiac disease (see Coxgestion of the Liver). Next to the perito- neum, the left pleural cavity contains the most transudation ; next the sac of the pericardium. The severe pressure on the skin of the legs, which is also filled with serum, leads to inflammation of the skin ; it becomes tense, brawny, and congested, and finally ulcerates, forming a more or less extensive purplish excavation, exuding serum constantly. The ulcer or ulcers thus produced are liable to attacks of erysipelatous inflammation, to sloughing, and to deep-seated, burrowing suppuration. The condition of the blood which contributes to dropsical accumu- lation is produced by several factors. The loss of albumen and salts has the effect to prevent osmosis into the vessels of fluid in the tissues, which therefore accumulates, and the hepatic derangement and chronic gastric catarrh, which interfere very seriously with digestion and the absorption of its products. The aiDj)etite is either wanting or capri- cious ; food distresses the stomach ; the intestines are filled with gas, the result of the decomposition of certain kinds of food ; and diarrhoea, which nothing controls permanently, comes on toward the close. The continued hypersemia of the liver causes that appearance known as "nutmeg-liver," the connective tissue undergoes hyperplasia, and the organ, after a period of enlargement, contracts more or less. This state is often confounded with " cirrhosis," but the morbid process is different. The kidneys are affected by the variations in the tension of the vascular system. As a smaller quantity of blood than normal passes through the tufts of the glomeruli, the amount of urinary water decreases, and hence the urine is scanty in quantity, has a high spe- 268 DISEASES OF THE HEART. cific gravity, deposits abundantly of urates, and finally becomes albu- minous as the tension increases in the venous system. The urine also contains much pigment, but there is rarely any blood present, and there are hyaline casts. The first effect of the persistent venous congestion is enlargement, due to over-production of connective tissue, but in the progress of the case atrophy occurs and the organs become reduced in size, very tough, and dark-purplish in color. These atrophic changes are due to the pressure of the contracting connective tissue and con- sequent wasting of the proper gland elements. During these altera- tions the tubular epithelium becomes granular and ultimately fatty, whUe the basement membrane also undergoes thickening. Infarctions sometimes occur in the kidney during the course of chronic cardiac disease ; they are due to obstruction in the branches of the renal artery by emboli ; they assume the characteristic wedge-shape, with the apex toward the hilus, and they undergo the same changes as in- farctions elsewhere. Very characteristic cerebral symptoms are also produced by car- diac valvular lesions, but they vary in character according to the valves affected. The disturbed state of the intra-cranial circulation thus occa- sioned doubtless leads to nutritive alterations in the walls of the cere- bral vessels. Furthermore, atheromatous change at the aortic orifice will be followed by similar changes in the intra-cranial arteries. Mil- iary aneurisms form when the walls of the small arteries undergo these changes. Rupture and consequent extravasation will then take place readily, because of the variations in tension of the blood-vessels. Em- bolism of the brain is exceedingly common in recent cases of endocar- ditis. Owing to the position of the left carotid and the left middle cerebral, it is pretty certain that an embolus dislodged from the valves of the left side of the heart will be deposited somewhere within the area of distribution of the left middle cerebral artery. Hence the fre- quent association of acute rheumatism, valvular disease of the heart, and right hemij^legia, with aj)hasia. Without causing organic lesions of any kind, very unpleasant and severe symptoms of intra-cranial disturbance are produced by valvular lesions, especially those of the aortic orifice. Xarrowing and obstruction, or regurgitation at the aorta, must necessarily produce anaemia of the brain, with the usual symp- toms of that condition, as sudden faintness, dizziness, tinnitus auriuni, persistent headache, etc. Chorea has long been associated with endo- carditis. According to the well-known theory of Jackson, chorea is due to multiplex capillary embolisms of the corpus striatum, but this view is not generally accepted. In a large proportion — probably in one fourth — chorea is associated with rheumatic endocarditis, but the exact nature of the relation is not now understood. VALVULAR LESIONS. 269 AFFECTIONS OF THE AORTIC VALVES AND ORIFICE.— The alterations which occur in the aortic valves are very numerous, as re- spects the character of the resulting deformity. The segments may be adherent by their lateral planes, leaving a central opening through which only the little finger may protrude. A segment may be torn from its base in part or almost wholly.* This accident may result from a suppurating myocarditis, which so weakens the attachment of the valve that it gives way while in the perfomiance of the ordi- nary functions. Such a degree of shortening and rigidity may ensue that the segments can not successfully approximate, or this change may take place in one or two segments. Besides rigidity and thick- ening, the valves may be deformed by ragged, dentated, and rough- ened margins. The margins of the segments may become thinned and slits form, presenting the appearance known as "fenestrated," or the so-called valvular aneurisms may occur, and, giving way, open- ings are made which render the valve incompetent. Atheromatous changes beginning in the aorta extend downward to the orifices, producing rigidity, narrowing, and deformity. Rough excrescences form and project into the ostium, and so small may it finally become that the smallest finger will barely pass through. The valves also become much altered by calcareous deposits ; they become rigid, roughened, and incompetent. As a result of the changes in the valves and orifices — stenosis and insufficiency — the left ventricle is kept too full and the cavity dilates. The septum between the ventricles is pushed over by the distention, encroaching on the right ventricular cavity ; the auriculo-ventricular orifice is stretched, and the segments of the mitral are drawn on and lengthened. The increased labor im- posed on the muscle of the left ventricle, to propel the blood into the aorta, induces an hypertrophy, and consequently the walls become thicker as the cavity enlarges, although the growth of the walls is not X)ari passu. The papillary muscles are stretched and flattened by the strain of the diastole, and are not hypertrophied. Symptoms of Stenosis, Rational and Physical. — The character of the pulse has high significance. The ostium being small and the ventricle hypertrophied, the pulse is small, slow, and hard. The sphygmo graphic Fig. 18.— Stenosis of Aortic Orifice. tracing exhibits these characters clearly. The ascensional line is rather oblique, the summit rounded, the abscissa low, the descending line ob- lique, and the interval long ; almost the opposite of the tracing in in- sufficiency. The supply of blood to the brain is insufficient, and hence * Dr. Burney-Yeo, "Lancet," December 5, 18Y4, "Clinical Lectures on Rupture of the Aortic Valves." 270 DISEASES OF THE HEART. there are attacks of headache, vertigo, syncope, and the patient may- fall suddenly relaxed, with or without losing consciousness, or there may occur distinctly epileptiform seizures. The diminution in the quantity of blood passing to the brain may be the cause of serious nu- tritive derangements in the organ. The left ventricle undergoes dila- tation and hypertrophy, and, the mitral becoming incompetent, stasis takes place on the venous side. The lungs are kept abnormally full, haemoptysis and infarctions may occur, dyspnoea is paroxysmal, and thei'e may be attacks similar to angina pectoris. In the progress of the case the heart becomes less capable of overcoming the resistance, and then, instead of a hard pulse, it becomes soft and weak. On pal- pation, the apical impulse has the position usual in hypertrophy, but it is much weaker than when there is insufficiency of the valves, and may, indeed, be scarcely perceptible. On percussion, the area of dull- ness is somewhat increased in the long axis, but little transversely, if at all. Auscultation furnishes a rasping, whistling, singing, or musical murmur, according to the character of the obstruction, and it is sys- tolic in time, audible with greatest intensity in the aortic area — at the junction of the right third costal cartilage with the sternum. It may be very loud and audible a short distance from the patient. If there be regurgitation also, a diastolic murmur will be produced. The dias- tolic normal sound will be weak because of the diminished elasticity and imperfect closure of the valve-segments. So long as compensation continues there may be no pronounced symptoms, and the heart may be equal to the ordinary duties required of it. When the comjDensation is ruptured by overwork of the heart, or by the occurrence of disease, then stasis will ensue in the venous system and dropsy will occur. In other cases the amount of obstacle is too great, and the compensation is imperfect ; then the disturbances due to the nature of the lesion will slowly develop. Symptoms of Insufficiency, Rational and Physical. — The pulse has a Fig. 19.— Pulse of Aortic Regurgitation. very different character from that in stenosis. The amplitude of the wave is great, the rise in the beat sudden, its declension rapid. It is known as the "water-hammer" pulse, or as the " Corrigan pulse," from Sir Dominic Corrigan, who described it. The sphygmographic tracing clearly indicates these qualities : the ascent is vertical, the ab- VALVULAR LESIONS. 271 sciss lofty, the descent abrupt, and, if the case is purely one of re- gurgitation without other defect, the descent is not marked by the secondary wave produced by the closure of the valve and the recoil of the current. If there is no stenosis, so strongly is the blood propelled into the arteries that small vessels not before visible pul- sate distinctly. This condition of things produces the pulsation of the retinal vessels which may be recognized by the use of the ophthal- moscope. So long as this valvular defect is compensated by dilatation of the left ventricle, and hypertrophy of the walls — excentric hypertrophy — the objective and subjective symptoms are not very pronounced. There are usually a good deal of headache — the pain pulsating synchronously with the heart-beat — more or less dizziness, and pulsation, and tin- nitus aurium. When associated with atheromatous changes of the intra-cranial vessels, there is great danger of cerebral haemorrhage. When similar changes have occurred in the aorta and coronary artery, attacks of angina pectoris may take place. So long as the compensation continues unruptured, there will be no difficulty in breathing, no stasis in the venous system, no dropsy ; but, if from any cause the compensation becomes unequal, then there will ensue the or- dinary series of phenomena — dyspnoea, cough, enlargement of the liver, congestion of the kidneys, albuminuria, ascites and dropsy. As these j ^ cases may continue for years with the lesions compensated, the prog- 1 , nosis is more favorable than in any other form of organic cardiac dis- \ ease. As soon as the mitral becomes incompetent, dyspnoea begins, the initial symptom, usually, of the widespread disturbance which comes on in the fully developed cases. In aortic insufficiency, there are present the signs of hypertrophy : the area of dullness, especially the absolute dullness, is increased both in the vertical and transverse diameter, as has been already point- ed out in the discussion of hypertrophy of the heart. The murmur proper to aortic insufficiency is a churning, rushing, diastolic murmur, heard at the time and taking the place of the normal murmur, and audible at the aortic area — at the junction of th e Jgft t hird-rib cartilage ' with the sternum. Also, there is usually, independently of stenosis, a systolic murmur heard along the aorta and carotids, produced prob- ably by the movements of the column of blood in the dilated aorta, and by the vibration imparted to the walls of these vessels by the force of the impulsion. This is a rather soft and blowing murmur, not unlike the murmur of anaemia heard in the same situation. It has been shown, further, that a reduplicated sound — systolic and diastolic — is audible in the femoral artery without pressure when there is a marked degree of valvular insufficiency, and it may be developed when there is but little insufficiency, by pressure above and below the steth- oscope. This reduplicated sound should not be confounded with the 272 DISEASES OF THE HEART. hruit which can be produced by pressure of the stethoscope on any artery, and which is a single sound. Affections of the Mitral Valve and Orifice. — More frequently than at the aortic orifice, the changes in the valves are results of endocardi- tis — aplastic or verrucose endocarditis. Atheroma and calcareous depo- sition are not such important factors as in lesions of the aortic orifice. Various changes occur in the segments of the mitral. One may be- come adherent to the ventricular wall ; the two segments may be united, the chordae tendinse of one segment breaking off ; there may be thickening and contraction of each ; the borders of the segments may be ragged, thickened by new tissue, and at the same time con- tracted so as to be quite too small to close the orifice ; there may be perforations of the valves by giving way of the so-called aneurisms or by ulcerations, and lastly the valves may unite, leaving a small central orifice. The margins of the ostium may also be thickened and nar- rowed by inflammatory changes ; there may be calcareous deposits, roughening and obstructing it, or the ostium may be enlarged by dila- tation of the cavity so that the valves, although normal, are unable to close it perfectly. Insufficiency of the mitral may occur alone, but usually stenosis and insufficiency occur together, and stenosis never, probably, without insufficiency. Whether insufficiency or stenosis, the result is, that the left ventricle is inadequately supplied with blood to distribute through the systemic vessels. The left auricle is over-dis- tended, and the tension in the pulmonary veins is high. The walls of the auricle are hypertrophied, and the endocardium is cloudy in con- sequence of nutritive changes. The intima of the pulmonary veins is altered by proliferation of its connective-tissue corpuscles, and by fatty degeneration. The pulmonary veins, the pulmonary artery, the right cavities, and the venae cavas, are kept over-distended and in abnor- mally high tension, because the blood is pumped back through, or can not pass through, the mitral orifice, and there is, therefore, ischemia and low tension in the aortic system. Sjrmptoms of Stenosis, Rational and Physical. — Having unusual work to do to overcome the obstruction in front, the left auricle be- comes hypertrophied. The left ventricle, having less volume of blood to discharge, diminishes in size somewhat, and the aorta also is re- duced in caliber, but this is not invariably the case, for there is often either a normal size of the ventricle or it actually becomes enlarged. For example, in a case of mitral stenosis narrated by Balfour, where the segments were " glued together by their margins," and " the opening ■ was so extremely contracted as only to permit the point of the little finger," it is stated that the " left ventricle is slightly hypertrophied, not dilated." * The chief reason why, under a diminished volume of * " Diseases of the Heart," p. 136. VALVULAR LESIONS. 273 blood, the left ventricle may undergo hypertrophy, is that the contrac- tile energy expended is necessarily increased, because of the obstacles in the circuit. The pulse is small, its tension low, and its rhythm Fig. 20.— Mitral. irregular,* but the irregularity is not constantly present, and is a sign ~^ rather of rupture oJ ..t he compen_satk )n. There are much cough, diffi- culty of breathing, bronchorrhoea, often bloody sputa, sometimes haemorrhage, red-broAvn induration and hemorrhagic infarctions ; dila- tation of the right cavities ; general venous stasis, cyanosis ; enlarge- ment of the liver, ascites ; albuminous urine, and general dropsy. By enlargement and hypertrophy of the left auricle, by dilatation and hypertrophy of the right ventricle, and by the distention of the veins, the stenosis is for a brief period compensated. But the condi- tions present bring about a slow rupture of the compensation, without the introduction of new disturbances. The changes in the muscular tissue of the right heart, the degeneration of the walls of the dilated vessels, and the alterations produced by the congestion of the liver, intestinal canal and kidneys, suffice to bring on the group of disorders above mentioned, which belong to the mitral lesions. The rupture of the compensation is much facilitated by overwork of the heart, by pulmonary diseases, or by intercurrent febrile maladies. On inspec- tion, rather wide diffusion of the apical impulse is perceived, if there be an apical impulse strong enough for recognition. It is rather a widespread undulation than an impulse at a special point. It extends from within the mammillary line to the right border of the sternum and downward to the epigastrium. It may be absent. On palpation the apical impulse is found to be weak and unresisting, and a purring tremor is felt which may be diastolic or presystolic. If there be re- gurgitation, a purring tremor may also be felt synchronous with the systole. Both absolute and relative dullness are increased. The transverse dullness is more increased than the vertical, and extends to the right border of the sternum, even beyond, and over the xiphoid appendix. A murmur is audible in the mitral area, of a rather harsh, grating, or blowing character, and occurring with the diastole and extending on up to the systole. The murmur may be presystolic — that is, occurring just before and extending in to the systole, but there are differences of opinion in respect to the time of this murmur. The murmur is usually heard with greater distinctness when the patient * Balfour, " Diseases of the Heart," "Extreme Irregularity," p. 126. 18 27i DISEASES OF THE HEART. sits upright leaning f orwai-d, or to the left. No murmur may be audi- ble in some cases under any circumstances. Then the rational signs of mitral lesions possess a high degree of significance, and deserve attentive study, and a failure to appreciate their value and overween- ing attention to the physical signs are fruitful sources of error, under these circumstances. While, when present, the murmurs are heard in the mitral area with the greatest distinctness, they are propagated toward the apex, and lost toward the base. In a few cases of steno- sis, another sign is to be heard over the apex, and at the pulmonary area, namely, reduplication of the second sound. Various explana- tions of this phenomenon have been offered, but the most probable is that the aortic and pulmonary valves do not close in the same instant of time, owing to the difference in tension of the aorta and pulmonary artery, the tension of the latter being relatively greater and therefore closing before the former. There is a sharp accentua- tion of the second sound in the pulmonary area, when the reduplication does not occur, owing to the high tension under which the valves are filled and closed. This characteristic of the second sound will disap- pear when the tension of the vessels declines from any cause or when the tricuspid becomes incompetent. Symptoms of Regurgitation or Insuffleiency, Rational and Physical. — So long as the compensation continues, the patient may be compara- tively free from discomfort, but the existence of these circulatory de- rangements leads to pathological changes which effect a rupture of the compensation — e. g., the pulmonary disorders, which are thus brought about, the myocarditis which attacks the walls of the right ventricle, or an intercurrent disease of some kind. Prascordial uneasi- ness, palpitation, cough, and dyspnoea are the first symptoms experi- enced when the compensation is ruptured. The pulse becomes soft, small, rapid, and irregular, and while the sphygmographic trace ex- hibits these features there is nothing distinctive in its form. The Fig. 21. — Mitral Valvular Disease. legs, presently, become oedematous, the cavity of the abdomen fills, the liver is disordered, the urine is loaded with albumen, and the pa- tient ultimately dies drowned in his own fluids. The physical signs are characteristic. As in insufficiency of the mitral, there is more or less, usually considerable hypertrophy of the left ventricle, enlarge- ment of the cavity and thickening of the walls of the left auricle, hy- pertrophy and dilatation of the right ventricle ; the total result is that the heart is much enlarged, and lies lower and deeper than is the nor- mal condition. The area of dullness, absolute and relative, vertical VALVULAR LESIONS. 275 and transverse, is enlarged, and the cardiac impulse diffused. On auscultation a systolic blowing murmur is audible in the mitral area, is propagated toward the apex, and may be most intense at the very extremity of the apex. This systolic bruit may also, when loud and strong, be heard over the whole cardiac area, and posteriorly under the angle of the scapula ; it may take the place of the first sound, or be heard with it. Usually the murmur can be separated from the proper systolic sound, by very carefully raising the head from the stethoscope so that the ear but touches it>. Sometimes the bruit is heard with the greatest intensity in the second intercostal space, external to the left border of the sternum, in the position of the appendix of the left auricle, and because of the regurgitating blood like "the fluid in veins produc- ing sonorous vibrations louder at the point of impingement than at that of origin " (Balfour), This, the explanation of Naunyn, is now gener- ally admitted. If there be obstruction as well as regurgitation at the mitral orifice, there will be, as already set forth, a presystolic murmur, extending up to the systole, or under some circumstances a diastolic murmui-. In regurgitation, as in stenosis, there is marked accentuation of the pulmonary second sound, until, at least, dilatation of the cavity and incompetence of the tricuspid introduce new conditions. The diagnosis of mitral disease must rest on a careful survey of the rational and physical signs. Too strict attention to the physical and neglect of the rational signs are frequent sources of error. Exact localization of the murmurs to the areas to which they belong is most important. The history of the case necessarily enters into the ques- tion of its nature. When the indications afforded by the history of the case and the rational and j)hysical signs coincide, any serious error is hardly possible. AFFECTIONS OF THE TRICUSPID VALVE AND ORIFICE Only once or twice, in one hundred cases of endocarditis, will the right auriculo-ventricular orifice be the seat of mischief, and then in association with similar changes on the other side of the heart, at the mitral orifice. Stenosis of the left auriculo-ventricular orifice and obstructive diseases of the lungs cause distention of the right ventricle and produce that kind of insufficiency which is known as relative insufficiency. Regurgitation takes place through this orifice, because, being enlarged, the valves become unable to close it during the systole. Over-distention of the auricle and hypertrophy result from the regurgitation, and the tension rises in the venae cavse and venous system, while there are ischaemia and diminished tension in the aortic system. The right ventricle also undergoes hypertrophy, because it is filled under the increased pressure of the high tension in the veins and the hypertrophy of the auricle. Regurgitation is often due to changes in structure that are congenital, and stenosis 276 DISEASES OF THE HEART. almost always. Very rarely is stenosis produced by acute endo- carditis, and, when it does occur from this cause, the anatomical changes are precisely those which have been described as taking place on the other side. The results of stenosis are the same as those of regurgitation, and need not, therefore, be repeated ; but stenosis never exists alone, and is always associated with changes on the left side. The pulse is small, weak, but not otherwise altered. A very charac- teristic symptom is the occurrence of a pulsation in the jugular, synchronous- with the cardiac movement. It ought not to be forgotten that waves are caused in the jugular by the respiratory movement — by the expiratory pressure. The true venous pulse does not extend beyond the bulb of the jugular, if the valves of the vein are intact, but by distention they become so, when the venous pulse is perceived along the whole extent of the vessel, extending even to the external jugular. It is synchronous with the contractions of the heart. The pulsation may be double, produced by the contraction of the auricle, and by the beating of the aorta, the vena cava superior lying in close proximity to that vessel. There is a feeble venous pulsation when there is regurgitation at the mitral orifice, a stronger one with coincident in- sufficiency of the tricuspid, and with the latter alone. That this pulsa- tion is produ-ced by the lesions above mentioned, and is not an oscilla- tion in the blood-current caused in the various ways already described, is determined by merely compressing the vessel with the finger, when the following facts will be elicited : If the pulsation be due to the heart-movements (regurgitation), when the vein is compressed at its middle, it will continue below the j^oint of compression and cease above ; if due to the beating of the carotid, it will continue above the point of compression, and cease below. If due to the respiratory movements, the pulsation will be synchronous with those movements ; if to the heart-movements, sychronous with them ; if respiratory, they will cease with the suspension of breathing; and, if cardiac, will continue. There is an equally characteristic venous pulse of the liver, which is felt immediately on the occurrence of the changes on the right side of the heart, because the hejoatic veins are not provided with valves. The pulsation, synchronous with the cardiac movements, may be felt over the whole organ, or be confined to the right lobe. The venous pulsation in the neck may appear and disappear under the variations in the fullness of the right cavities and the force of the ventricular contractions. The hepatic pulsation is affected by effusions in the abdomen, as well as by the state of distention of the vena cava and the hypertrophy of the right ventricle. So long as the valves of the jugular remain intact, the increased tension under which their closure is effected causes a murmur, humming and clacking combined, which is audible in the bulb. The hypertrophy existing chiefly to the right, the area of impulse must be seen to the right, and is rather diffused. VALVULAR LESIONS. 277 Dullness on percussion, due to the enlarged right auricle, can be de- veloped to the right of the sternum from the second to the fourth rib, and the dullness due to the right ventricle, to the base of the sternum, to the xiphoid appendix, and to the central and right portion of the epigastric region. A pulsation produced by the right auricle can be seen and felt sometimes in the right, second intercostal space. On auscultation in the tricuspid area — the lower segment of the ster- num — we hear a blowing murmur, systolic in time, and most intense at the junction of the intercostal space between the fourth and fifth rib and the sternum ; sometimes, most intense over the xiphoid ap- pendix. This is the characteristic murmur, but there are associated with it the valvular mitral murmurs which almost always are present, and are audible with the greatest intensity at the mitral area and toward the apex. These are both systolic, presystolic, and diastolic, as has been pointed out. In the affections of the right auriculo-ventric- xilar orifice, the pulmonary second sound is weak, because of the di- minished tension in the pulmonary artery, unless there is coincident obstruction or regurgitation at the mitral orifice, which causes an accentuation of the pulmonary second sound. The mechanical effect of the lesions on the right side is immediate, and compensation is possible to a very limited extent. Extreme venous stasis soon occurs, with the attendant symptoms of hepatic disturbance, ascites, albumi- nuria, general dropsy. The jjrognosis is therefore unfavorable. The diagnosis is difiicult because of the coexistent mitral lesions, but the lesions of the right auriculo-ventricular orifice are established by the determination of these physical signs: a well-marked, true venous pulsation of the neck ; a systolic murmur, audible with the greatest intensity at the junction of the intercostal space between the fourth and fifth rib with the right border of the sternum, and a weak, pul- monary second sound. AFFECTIONS OF THE PULMONARY VALVES AND ORIFICE.— These may be congenital or acquired. When acquired they are pro- duced by endocarditis, or are due to calcareous deposition and athe- romatous degeneration, but acquired changes are extremely rare. The results of stenosis and insufficiency are the same, and consist of dilata- tion of the cavity and hyperti'ophy, leading to insufficiency of the tricuspid. In insufficiency of the pulmonary valves the resulting con- ditions are the same as in the corresponding change at the aortic ori- fice. The pulmonary artery and its divisions undergo dilatation, the intima becomes the seat of the nutritive changes already described, and lobular pneumonia and haemorrhagic infarctions occur in the lungs. The rational signs are dyspnoea, deficient aeration of the blood and cyanosis, distention of the superficial vessels, dropsy, pal- pitation of the heart, prsecordial oppression, sudden attacks of suffo- 278 DISEASES OF THE HEART. cative feeling, with prsecordial pain and intense anxiety, etc. The physical signs are those of enlargement of the right cavities, a loud diastolic murmur heard with great intensity at the left border of the sternum and the upper margin of the third rib, and propagated toward the middle of the sternum, opposite the fourth rib and downward, and is lost going toward and over the great vessels at the base. There may be also a systolic murmur. These symptoms only occur when the compensation is ruptured, for the hypertrophy of the ventricle walls and the dilatation of the cavity compensate very fully for the mischief done. Stenosis is a more important condition than insufficiency, but it is congenital stenosis with which we have to deal chiefly, the acquired condition being exceedingly rare. In congenital stenosis the changes consist in constriction of the pulmonary artery, unclosed foramen ovale, unclosed ductus Botalli, stricture at the ductus Botalli, with hypertro- phy of the right cavities. The importance of these congenital defects, besides the damage to the heart, consists in the frequent association of these anatomical anomalies with tuberculosis of the lungs. The right ventricle enlarges to a remarkable extent, the walls attaining in thick- ness to the dimensions almost of the left. The result is, there are pres- ent the physical signs of hypertrophy of the right ventricle — an in- creased area of cardiac dullness to the right ; a blowing, systolic mur- mur, audible in the pulmonary area, and propagated not toward the base and great vessels, but somewhat to the left and a little down- ward, the point of greatest intensity being the junction of the third rib, upper border, with the left border of the sternum ; weak or inau- dible second sound. The rational symptoms correspond to the ana- tomical conditions. The compensation effected by dilatation and hy- pertrophy of the right ventricle suffices to maintain a condition of comparative comfort, but unusual physical exercise, obstructive pul- monary diseases, and other causes bring about a rupture of the com- pensation, when there ensue difficulty of breathing, cough, cyanosis that may be very intense, but general dropsy and albuminuria occur only when the right ventricular wall weakens by myocarditis. The duration of these cases of congenital defects in the structure of the heart varies with the degree of deformity and the circumstances in life. The compensation may be so perfect that the heart is equal to the needs of a quiet existence, and comparative comfort may be en- joyed by youths who possess even a considerable degree of cyanosis. But the degree of cyanosis is usually a measure of the success of the efforts at compensation. The subjects of congenital pulmonary stenosis are otherwise imperfect in organization — they are comparatively weak, develop slowly, have soft, flabby muscles, bones do not unite, and the nutrition continues poor. Beside the cyanosis, which is usually most strongly marked in the extremities, they have cold hands and feet, and VALVULAR LESIONS. 279 possess but little endurance of cold, are subject to asthmatic attacks, to giddiness and vertigo, to epileptoid attacks, etc. The duration of life in these congenital cases varies from a few months to twenty or thirty years. Treatment. — In a clinical lecture recently published,* which is marked by that clinical acumen and power of accurate expression char- acteristic of the author, Flint emphasizes the necessity for caution in the expression of opinion to the subjects of cardiac mischief ; the im- portance of recognizing the fact that some murmurs have no patho- logical nor clinical significance ; the good results obtained from the treatment of associated morbid states in cases of undoubted valvular disease ; and, finally, the striking relief derived from the timely use of "digitalis and active hydragogue purgation repeated from time to time." Any one having clinical experience will fully and entirely agree with the distinguished professor in these observations. When the mischief done to the heart is recent, and the newly formed con- nective tissue is contracting, it is highly important, as Fothergill f has pointed out, to give the heart "physiological rest," to enable the dam- age to the valves to be repaired as completely as can be effected. The rest is best secured by maintaining the recumbent posture much of the time during the period of convalescence, by the careful administration of veratrum viride, to keep the revolutions of the heart at about fifty to sijfty per minute, and by iron and a suitable diet to improve the quality of the blood. When compensation is effected and the heart is equal to the obstacles, no medicinal treatment is necessary. Every effort must be directed to the maintenance of the compensation, by quietude of mind and body, and by avoidance of all causes of diseases. Active exercise, climbing mountains, running up stairways, lifting, and every kind of physical exertion involving heart-strain, must be avoided; nevertheless, daily open-air exercise and exposure to sunshine are ne- cessary to maintain health at the proper standard — for, if the blood is impoverished by an in-door life, and the want of appetite and imper- fect sleep, which are necessary results, the rupture of the compensation must then take place. In the natural course of events in valvular af- fections, the nutritive alterations which occur in the tunics of the ves- sels and in the heart-muscles ultimately effect a rupture of the com- pensation. Anaemia not only hastens the pathological processes taking place in the vessels and in the heart, but it actually inaugurates similar changes. It is, therefore, a measure of the highest importance to keep the appetite, digestion, and blood-making process, in the most efficient state. Moderate exercise in the open air daily must be enjoined in these cases, while fatigue and strong exertion of any kind are avoided. * The " Medical News and Abstract," January 1, 1880. f "Diseases of the Heart," second edition. 280 DISEASES OF THE HEART. When the heart is behaving badly in consequence of the anaemic con- dition, the organ is relieved by attention to the nutrition. Unless, therefore, under such circumstances there is plain need of digitalis, it should be avoided, for this agent disturbs the stomach and interferes with digestion. "When, in women especially, the compensation is not ruptured, but great distress is experienced from anaemia or the chlo- rotic state, the indications clearly are not to treat the heart, but those nutritive disturbances on which the functional troubles depend. When such subjects are not relieved by stomachic tonics, iron, and a generous diet, the system of rest, forced feeding, massage, and muscular faradi- zation proposed by Weir Mitchell may be resorted to with advantage. Besides the measures necessary to prevent or overcome anaemia, the dietetic management requires the patient with compensated valve- mischief to avoid such cardiac stimulants as tea, coffee, tobacco, and alcohol in any form, except a little wine allowed at dinner provided it improves digestion. The choice of a suitable chalybeate can be made from a long list of preparations. It is a rule that combinations of iron with a mineral acid are more effective and often better borne than the milder and supposed more easily assimilated citrates, tartrates, and carbonates. German therapeutists much prescribe the ethereal acetated tincture of their pharmacopoeia. The tinctura fei-ri chloridi is, proba- bly, the most generally useful and efficient of the officinal preparations. It should be given always well diluted with water after meals, and should be taken through a glass tube or a straw. An excellent sto- machic tonic is tincture of nux vomica — ten drops to twenty — ter in die and before meals, or the milder tinctures of colomba or gentian may be preferred. A combination of great value in these cases is the elixir of the phosphates of iron, quinia, and strychnia (Aitken). The nutri- tion in cases of compensated valvular lesions often fails slowly, from the gradual congestion of the liver and of the intestinal mucous mem- brane. The digestion is slow and insufficient, the appetite fails, and the absorption of aliment is seriously intef ered with by the hyperaemia and distention of the vessels. Timely recognition of this state and the use of appropriate means will prevent serious trouble. Excellent remedies are iridin and euonymin ; they are stomachic tonics, and, in sufficient quantity, powerfully stimulate the hepatic functions and de- plete the portal system. The treatment should be commenced by free action of the intestines procured by these agents or corresponding ones. Then stomachic tonics, chalybeates, and digestives, as pepsin and lac- topeptine, are indicated. The kidneys should be kept active, and this is best accomplished by the simultaneous but not conjoint use of a chalybeate and a diuretic, as tincture of iron and solution of bitartrate of potassa — the iron to be taken after meals, and the potassa solution to be drunk freely between meals. An excellent method of managing these cases, when a rupture of the compensation is threatened, is to VALVULAR LESIONS. 281 give two or three times a week some efficient doses of iridin or euony- min, and to prescribe iron, quinia, and digitalis in pill-form — a half grain of ferrum redactum, three grains of quinia, and a gi*ain of digi- talis in a pill three times a day. If the stomach is doing fairly good work, the best results may be expected from this combination. The practitioner is usually consulted when the failure of the heart, dyspnoea, cough, anaemia, albuminuria, and beginning dropsy, announce the rup- ture of the compensation. The principles of treatment differ some- what, according to the seat and character of the lesion and the condi- tion of the system. As the ultimate effect of all cases of valvular dis- ease of the heart is to cause ischnemia of the arterial system and stasis of the venous, a general method of therapy may be first developed and the special indications pointed out subsequently. The remedy which, above all others, opposes the condition of the vascular system in val- vular disease of the heart is digitalis. In prescribing this agent there are several points to be carefully considered. Is the digitalis of two years' growth ? Is it English or German ? Is it wild or cultivated ? The second-year plant contains more of the active principle ; the pro- duction of this continent seems inferior to that of English or German sources ; the wild digitalis is more active than the domesticated. For the effect on the circulation and on the kidneys, the officinal infusion is to be preferred to the other preparations, but the infusion is only ser- viceable when it is made from the proper digitalis. It must be given in sufficient quantity to produce its physiological effects — to diminish the number but increase the force of the pulsations ; to raise the tension of the vessels ; to increase the urinary discharge. The higher the tension at the periphery, the more decided the recoil, and consequently the better filled is the coronary artery, which includes a more active and healthy state of nutrition of the cardiac muscle. The higher ten- sion of the vessel means an arrest of the outflow of the serum and more active absorption. When the compensation is ruptured, the digestive organs suffer and the blood-making is inefficient. Excretion by the liver is hindered, and the waste of albumen through the kidneys lessens rapidly the amount of this important constituent in the blood. The poverty of the blood reacts, again, on the circulation through the heart. When, therefore, the necessity for digitalis arises, the demand for iron and bitter tonics (quinia) must be heeded also. Experience has abun- dantly demonstrated that the effects of digitalis are more decided and more lasting when iron and quinia are given at the same time. A tablespoonf ul of the officinal infusion three times a day until the char- acteristic effects are produced, and then twice a day, is the amount usually required and that can be borne. As its action is slow, frequent repetition of the dose may cause serious symptoms. If large doses are taken, and if the pulse is much reduced, the patient should maintain a fixed position — what position soever it may be — and not change it 382 DISEASES OF THE HEART. suddenly. Especially should lie not rise suddenly from the recumbent posture, for under these circumstances the pulse becomes rapid and feeble and the surface cyanosed. When headache, dizziness, disturb- ances of vision, vibration of external objects, and anxiety are produced, the dose must be at once reduced or discontinued. It should also not be forgotten that digitalis continued in large doses aifects the motor power of the heart ultimately, by exhausting the irritability of the ganglia, when the action becomes rapid, weak, and irregular. It is good practice, during the long-continued use of digitalis, to suspend it for a few days at a time. If it can not be borne, cimicifuga may be substituted — a half to a drachm of the fluid extract three times a day, Suflicient attention has not been given to the utility of cimicifuga as a cardiac tonic and substitute for digitalis. Of the mineral tonics, no one is so serviceable as the acetate of lead. When there is much op- pression of breathing, the patient unable to lie down, and becoming exhausted from loss of sleep, no remedy is so valuable as morj)hia hypodermatically. It affords surprising relief to the distressing symp- toms, improves remarkably the driving power of the heart, causes free diaphoresis, and gives time for the action of the other remedies. We owe this important suggestion to Dr. Clifford Allbutt, of England. From the ^^^ to ^ of a grain of morphia, according to the character and susceptibility of the patient, should be given. Next to the remedies for the heart, in importance, are the hydragogue cathartics. The great- est relief is afforded by draining off fluid from the intestinal mucous membrane. Euonymin and iridin have already been mentioned, but more powerful remedies are necessary when there is general dropsy. One of the most useful and efficient of these is the compound jalap powder. As it is important not to interfere with the digestion, this remedy should be administered in the early morning. If not sufii- ciently active, podophyllin may be added, or, this failing, elaterium may be substituted. Free transpiration by the skin should be main- tained. This is best effected by the vapor-bath. The mistake must not be made of attempting to act on the skin and kidneys at the same time. When digitalis is being taken, and bitartrate of potassa or other diuretics, the skin must not be excited at the same time ; on the other hand, free purgation assists the action of diuretics. When digitalis can not be borne by the stomach, it may act quite efiiciently by exter- nal application to the abdomen or back : some leaves inclosed in a muslin bag are steeped in warm water, and kept applied for several hours. When the vapor-bath can not be used, a good substitute is a warm, wet pack covered with blankets. Remarkable benefit has been obtained from the treatment by compressed air, and by the inhalation of oxygen. The compressed-air treatment diminishes the tension in the venous, and elevates it in the aortic system, and also gives relief by contributing to the oxygenation of the blood. Oxygen merely acts HEART-CLOTS. 283 in the latter mode, and often affords great comfort when there are paroxysmal attacks of dyspncea. There are some limitations to the use of digitalis in ruptured compensation with its direful results. It can not be borne at all by some subjects. It is contraindicated in aortic stenosis, and may be dangerous in large doses. When there is mitral insufficiency, as well as aortic stenosis, digitalis may be given, but only in small doses, with a view to its diuretic action. Again, digitalis is of doubtful utility if not positively contraindicated in fatty heart, and consequently in cases of dropsy, from dilatation and insufficiency due to fatty degeneration. HEART-CLOTS. Definition. — By the term heart-dot is meant a mass of fibrin or of coagulated blood found in one or more of the cavities of the heart. They are divisible into three varieties : First, translucent masses of fibrin, soft, yellowish, and full of serum, loosely attached to the chordae tendinse, trabecule, or other projecting parts ; second, large, loose, black coagula occupying the right ventricle or auricle, and ex- tending into the pulmonary artery or vense cavae ; third, coagula of variable size, attached to projecting parts, found in all cavities, but chiefly in the left ventricle, and consisting of coagula containing a puriform -looking fluid in their interior. The first variety is not pathological, is formed during the death-agony or after death, and is found in the subjects of chronic wasting disease. The second va- riety may or may not be pathological, and stand in a genetic relation to the suspension of the cardiac movements. The third variety is always pathological. Causes. — The occurrence of these clots is not affected by sex, but they are more frequent at the middle period than at the extremes of life (Bristowe*). There are two leading factors in their causation — a condition of the blood ; disease of the heart itself. In many diseases the fibrinogenous substance seems to be greatly increased, and thus a state of ready coagulability is induced. If, under these circumstances, the coagulation of the blood is favored by a slow and feeble action of the heart, a slight cause suffices to determine it. The actual deter- mining cause is disease of the heart itself, roughness of some project- ing part, or fibrinous concretion deposited on such rough surface. f Pathological Anatomy. — Clots ai-e found in all the cavities of the heart, but most frequently in the left ventricle and least frequently in the left auricle (Bristowe). They form in by-places, and are entangled in the rough surfaces and inequalities. The appearance of the clots differs according to the circumstances of their formation. Leaving * " Pathological Society's Transactions," vol. xiv, p. 71. f Ibid., cases by Dr. J. W. Ogle. 284: DISEASES OF THE HEART. out of consideration tlie masses of fibrin, which have no pathological import, the two other varieties differ in consequence of the changes wrought by age. The second variety mentioned above consists of a large, black, rather loose venous coagulum, which fills one or the other cavity of the right side and projects into the annexed vessel, which may be completely filled by it. Such a clot, we may suppose, is some- times the cause of death after post-partum haemorrhage, or such as Sir Joseph Fayrer describes * as forming and causing sudden death after surgical operations. After profuse hsemorrhage of this kind, the pro- pelling power of the right ventricle is so feeble that coagulation may readily ensue. The shock of a surgical operation may induce such slowness and weakness as a severe hsemorrhage, and result in the same accident. In the third variety the clot has undergone transformations due to age. It is firm, tough, grayish, yellowish, and brownish in strata, or variously intermingled, and attached to the columnse carnese, chordae tendinse, or other parts. It usually contains in the interior, in a pseudo-cyst, a quantity of thick fluid having a " grumous " or "puriform" appearance, and consisting of the fibrin, red and white corpuscles, undergoing the transformation usual to blood under these circumstances, f These clots are in position for a long time, often. Rarely are they found in a sound heart, and usually the changes of endocarditis have taken place, the coagulation of the blood being in- duced by roughening and exudation of the membrane. Symptoms. — Nothing can be more indefinite than the symptoma- tology of heart-clots. Nevertheless, we may make an attempt to define, from recorded cases and from observation, the character of the dis- turbances of function caused by them. There are two distinct groups of symptoms belonging to the two forms of clot. After post-partum haemorrhage, or after a surgical operation, or during the course of some septic disease, there suddenly comes on an extreme oppression of breathing, wild restlessness, beating about the bed and crying out for air, deep cyanosis, a fluttering heart without pulse at the wrists, which stops in a few minutes ; the patient falls back, the agitation ceases, but then a general convulsion may occur, and all is over, or death occurs quietly without any convulsive movement. In the other variety the symptoms develop more slowly, and may extend over several weeks. The earliest symptoms are irregularity in the heart-movements, indis- tinctness of the murmur s, difficulty of breathing, anxiety, oppression, cyanosis. The action of the heart becomes more and more feeble, the sounds run into each other and are dull and confused, the difficulty of breathing continues, moist rales appear all over the chest from oedema * " The Medical Times and Gazette," vol. i, 1873, p. 58; also "Pathological Society's Transactions," vol. xxvii, p. 70. f Cases by Dr. J. W. Ogle, " Pathological Society's Transactions," vol. xiv, p. 65, et seq. PALPITATION OF THE HEART. 285 of the lungs ; the cyanosis deepens ; dropsy comes on ; stupor passing into unconsciousness, and convulsions end the scene. In most of the cases recorded by Ogle, the urine was albuminous ; there were lesions of the lungs, and effusion into the thoracic cavity. While the recorded symptoms are closely similar to the account given above, the state of the heart as to rhythm and the character of the sounds differ among themselves, and agree in part only with the above description. The duration of these cases ranged from a few days to six weeks, and the symptoms during that time seemed to de- pend on the presence of the clot found j^ost mortem. Treatment. — Notwithstanding the uncertainty which must attend the diagnosis in these cases, which at its best must be a fortunate guess, some details of treatment are necessary. The treatment by frequent small doses of ammonium carbonate offers the best prospect of relief. In the cases which occur suddenly, and immediately extin- guish life, the intra- venous injection of ammonia should be practiced. This method consists in the injection into any vein — in this case, the jugular — of one part of aqua ammonise to two parts of water, by an hy- podermic syringe. Of course, precautions must, be taken to avoid the introduction of air or any foreign body. It has been abundantly demonstrated that this intra-venous injection of ammonia is entirely safe. In the less acute cases, there is a small prospect of success from the persistent use of the ammonia. The action of the heart must be maintained by the judicious use of digitalis and alcoholic stimulants. PALPITATION OF THE HEART. Deflnition. — By the term ^^oXp^^CLt^on of the heart is meant a func- tional disturbance of the organ, characterized by increased rapidity of movement, with more or less irregularity of rhythm. Causes. — The heart possesses a power of independent motion ; but as this motor apparatus is not sufficient to keep up the action of the organ, it receives accessions of force from the great centers. To maintain the movement at a uniform rate, there is a regulator appara- tus, designed to prevent overaction, or " to inhibit." Besides this mech- anism for evolving force, and applying it so as to produce uniform results, the action is affected by the state of the vessels, by the den- sity of the blood, by the movements of the respiratory organs, by the activity of the organic functions in general, and by the functions of ani- mal life. Accordingly, to maintain the action of the heart, there are — 1. A motor apparatus — rhythmically discharging motor ganglia — situ- ated in the substance of the heart. 2. Excitors of activity, branches from the cervical sympathetic, and also from the spinal cord, irritation of which increases the movements of the heart. To regulate the move- ments of the heart, there are — 1. The pneumogastric, irritation of which 286 DISEASES OF THE HEART. may arrest the heart in the diastole. 2. The depressor nerve of Lud- wig, which acts by dilating the blood-vessels. The fibers of the sym- pathetic, dilator, and constrictor, aifect the work of the heart by increasing or lessening the tension at the periphery. When the pe- ripheral vessels are dilated, the work to be done by the heart lessens, and hence the contractions are less numerous and forcible, and vice versa. The mechanism by which the action of the heart is kept at a uni- form rate may be disturbed by a variety of causes : by muscular exercise ; breathing rarefied air, as in the ascent of mountains ; by mechanical interference with the movements of the organ, as thoracic effusions, tumors of the mediastinum, flatulent distention of the stom- ach, atheroma of the arterial system generally, etc. Moral and emo- tional causes, as grief, hope, anxiety, fear, excessive mental effort, etc., increase the action of the heart. Various reflex troubles have the same effect — as affections of the nervous system, reacting on the ner- vous apparatus of the heart — such as uterine disease, gastralgia, worms in the intestinal canal,* etc. The cardiac ganglia are rendered irritable by the excessive use of tea, coffee, tobacco, spirits, etc. The excitor apparatus of the sympathetic may be the seat of a disturbance, as in Grave's disease, etc. Symptoms. — There may or may not be, previous to the attacks of palpitation, any symptom of trouble in the heart. When such prelim- inary symptoms are felt, they consist of a vague sense of uneasiness, prsecordial oppression, or dull pain. There is no fixed period for the attacks, unless excited by some habit or custom, as eating, smoking, etc. ; neither have they any special duration, but may last from a few minutes to some hours, or a day. The attack consists of a rapid and tumultuous beating of the heart ; dyspnoea, anxiety, and an hysterical sense of choking accompany the beating ; the heart seems almost to turn over, to rise up into the throat ; the recumbent posture can not usually be borne, esiDecially lying on the left side, and the sitting pos- ture, leaning somewhat forward, is the most comfortable position ; there are also experienced more or less vertigo, faintness, flashes of light, coldness of the surface with cold sweating and a very weak pulse, or it may be the surface is warm and perspiring, the pulse full and strong. The face may be pale or flushed, but is always expressive of anxiety ; speech is difiicult, or is arrested. The physical explora- tion, if no cardiac lesion exist, is merely negative. The movement, if very rapid, can not be separated into its component parts. Examina- tion must be made, in the interval of the seizures, to ascertain the real condition of the heart. The duration of the attacks, as already stated, * Case of Dr. Cotton ("The British Medical Journal," June, ISG*?), in which the pul- sations were 240 per minute, and ceased on the evacuation of a tape-worm. ARTERITIS. 287 is very variable. The beating may subside in a few minutes, or sev- eral hours may be occupied in returning to the normal. At the con- clusion of the paroxysm, a quantity of pale, limpid urine is usually passed, and there is a strong sense of fatigue and exhaustion, with a tendency to sleep. Treatment. — Prophylaxis is important. The vice, of whatever kind, on w^hich the attacks depend, should be removed. Tea, coffee, and spirit drinking must be given up ; errors of digestion, reflex dis- turbances, and curable diseases must be corrected or cured. The hy- giene of the individual must be carefully investigated, and sources of disturbance be put aside. The general health must be maintained at the highest point of efficiency. In the absence of any explanation of the paroxysms, the presence of a tape-worm may be suspected. For the immediate relief of the paroxysm, there is no remedy so efficient as the hypodermatic injection of morphia. If the surface is pale and the extreme vessels contracted, inhalation of nitrite of amyl (two or three drops) affords prompt relief. The inhalation of ether is also effective. All narcotic agents must be used with caution, because of the certainty, if the attacks are frequent, that the habit of their abuse will be formed. The application of cold, in the form of an ice-bag to the jDrsecordial space, is an effective means of quieting the heart. The galvanic current, from ten to thirty or forty elements, passed through the pneumogastric and cervical ganglia of the sympathetic, often gives great relief. If there is no cardiac disease, chloral is an efficient quiet- ing agent, and the bromides may also be given with good results. DISEASES OF THE BLOOD-VESSELS. ARTERITIS— INFLAMMATION OF THE ARTERIES. Definition. — The acute form of arteritis is uncommon, and is rather a surgical than a medical topic. Chronic arteritis, on the other hand, is not only a common but it is an extremely important disease. It has received various designations, as endarteritis, atheromatous arte- ritis, arterial sclerosis, arteritis deformans, etc., intended to indicate the nature of the change undergone by the vessel. Causes. — It is extremely rare before forty, and frequent after fifty. Men are probably more liable to it than women, but there is slight difference as reo-ards sex. Various cachexise seem to hasten its devel- 288 DISEASES OF -THE BLOOD-VESSELS. opment. A fatty change occurs in the intima during the course of severe and prolonged anaemia. Chronic alcoholism, the poison of lead, gout, rheumatism, syphilis, etc., are supposed to be influential in devel- oping the disease at an early period. Functional strain, in accordance with a well-known law, tends to excite arteritis ; hence its early ap- pearance in the aorta. Sometimes aortitis is derived, by contiguity of tissue, from endocarditis. Pathological Anatomy. — The initial change consists in a prolifera- tion of the connective-tissue corpuscles of the intima ; the young cells crowd the space between the lamellae, and, pushing up the intima, form a projection about a line above the general level. This abun- dant formation of new cells requires an amount of pabulum which can not be supplied, and hence the proliferating cells undergo a fatty de- generation. While this process is going on, a solution of the basis substance (the connective-tissue matrix) takes place.* This change appears to the naked eye as yellowish or yellowish- white opaque spots or patches, distributed through the thickened elevations of the intima, which become soft and friable, and are gradually detached, leaving an abrasion, or "atheromatous ulcer." These abrasions may be coated with masses of fibrin, or blood-clot may form on and adhere to them. Coincidently with the process of fatty metamorphosis, another process, beginning also in the sclerosed intima, develops. This consists in a deposition of calcareous material — the lime salts, chiefly — in the basis substance of the intima, and between the lamellae. Plates of consid- erable size are thus formed in the aorta ; they may be several inches in length, and of a curved shape corresponding to the aortic curve, and may extend over one half, even more, of the circumference of the vessel. Their rough surfaces project through the innermost lamella into the vascular lumen. These two processes very frequently coin- cide. The alterations taking place in chronic arteritis are not confined to the intima, but the media and the adventitia also participate. The unstriped muscular fiber undergoes fatty metamorphosis and calcifica- tion, or disappears by simple atrophy. In advanced cases the adven- titia inflames, becomes infiltrated with cells, or undergoes fibroid degeneration. The results of arteritis are very important ; when the small vessels are affected, their lumen is encroached on and may be entirely obstructed, or a large number affected to a less degree, the amount of blood passing to the district supplied by them will be much reduced, and important nutritive alterations must occur. The changes in the tunics of the vessels especially involve their elasticity, and they become mere rigid cords, through which the blood passes in jets. The loss of the power of elastic recoil exposes them to injury as the blood is driven through, and they slowly dilate or yield in places, forming * Rindfleisch, op. cit., p. 211, d seq. ARTERITIS. 289 sacculi, or are torn outright. The increased resistance to the propulsion of blood, caused by these changes in the arteries, leads to dilatation and hypertrophy of the left ventricle. Named in the order of relative liability to arteritis deformans, are the aorta, the cerebral arteries, the coronary, the arteries of the extremities, and, lastly, the arteries dis- tributed to the organs of vegetative life. Symptoms. — The symptoms are obviously of a very diverse charac- ter when produced. Nothing is more usual than to see men after fifty with extensive atheroma, without a single symptom referable to it. Nevertheless, numerous and important consequences follow arteritis in some situation^, and at certain stages of its development. Arteritis of the aorta, and the cardiac disturbances due to it, and arteritis of the brain, and the structural alterations produced by it, are the same as regards the arterial change, but are widely different in respect to the symptomatology. If the lumen of the aorta is encroached on, especially if very great narrowing takes place at the bifurcation of large arteries, or if extensive arterial districts have undergone sclero- sis, the work of the heart to distribute the blood is so much increased that the organ undergoes hypertrophy. This change is indicated by the heaving impulse, by an extension of the area of cardiac dullness downward and to the left, and by accentuation of the second sound. Murmurs, due to regurgitation or stenosis, or both, may be audible with greatest intensity in the aortic area, when an extension of disease from the aorta to the ■ semilunar valves, or to the endocardium, takes place. Weakening of the heart, dyspnoea, general oedema, may finally occur from degenerative changes in the heart-muscle, the result of atheroma and calcification of the coronary artery. The physical signs, then, of hypertrophy, from the causes above mentioned, must neces- sarily disappear and be supplanted by others when the aortic valves and the cardiac tissues become diseased. Dilatation of the ascending aorta may produce a pulsation in the right second intercostal space that may be mistaken for aneurism, and, if the dilatation be consider- able, some dullness on percussion may be developed in the same posi- tion. The changes of arteritis deformans may be studied clinically in some superficially placed arteries, as the radial and the temporal ; they are rigid, tortuous, irregular in size, and may be rolled under the skin like whip-cord. The tortuosity is increased during the systole, and lessens during the diastole, and the pulse is delayed — firm when the calcification is beginning, but becoming less and less recognizable as the artery degenerates into a calcareous tube. The loss of elasticity of the arterial tunics influences the sphygmographic tracing, which exhibits the same features as in albuminuria — rounded summits, ob- lique descent, without dicrotic or recoil wave. Advanced endarte- ritis leads to disastrous results in the nutrition of peripheral parts — the fingers and toes. In consequence of the diminished supply of 19 290 DISEASES OF THE BLOOD-VESSELS. blood, the sensibility is low, the skin bluish, benumbed, and cold, and the least injury may set up destructive inflammation. A thrombus forming in the principal artery, dry gangrene will follow in the parts below, or in a small vessel of the foot ; a single toe, or several toes, may slough off. Even more serious results follow endarteritis of the internal vessels. Thus, as has been pointed out in the article on gas- tric ulcer, solution of the mucous membrane and the subsequent for- mation of a chronic ulcer may have its origin in disease of an artery and thrombosis. It is a singular fact that, although the arteries of the vegetative organs are the last to be invaded by endarteritis, yet it occasionally happens that a small part of an artery supplying the gastric mucous membrane is the seat of this degeneration, with the disastrous effect above mentioned. But the arteries of the brain are much more widely and early affected by endarteritis than of any ves- sels except the aorta, and indeed this morbid process may begin in the brain. The dilatations of the arterioles and small arteries, known as miliary aneurisms, are the great cause of cerebral haemorrhage ; throm- boses of the capillaries and small arteries induce local softening ; en- darteritis, without interrupting the passage of the blood through the lumen of the vessels, impedes the transference of the nutritive mate- rials to the tissue of the brain, with the result of serious impairment of the nutrition of the organ, and consequent failure of mental power, and the usual objective evidences of cerebral mischief. Course, Duration, and Termination. — The course of endarteritis is influenced by various circumstances. The progress of the change is hastened by the abuse of spirits, and by such cachexias as syphilis, rheumatism, and gout. It is very chronic, and its duration may be measured by years. As has been pointed out, many cases exist with- out causing any disturbance ; others are very important in conse- quence of the lesions invited by arteritis. The termination is a ques- tion of the nature of the secondary lesions, and especially of the changes in the cerebral arteries. There is more danger in those cases occurring at an early period of life. For example, the author has seen life terminated by a small aneurism of the basilar artery, when this was the only spot where endarteritis existed. Treatment. — Although, when the change has once taken place in an artery, nothing can be done to remove it, the author believes that the progress may be, if not arrested, at least retarded by proper treatment. There are three remedies of special importance in this disease : quinia, hypophosphite or lactophosphate of lime, and cod-liver oil. The phosphite or phosphate of lime, and the cod-liver oil, should be given after meals — a teaspoonful of the sirup, of either phosphate or phos- phite, but preferably of lactophosphate of lime, and a teaspoonful of cod-liver oil. They may be given in an emulsion simultaneously, or one may follow the other, and they should be taken without failure ANEURISM OF THE AORTA. 291 for months at a time. Quinia should be given in five-grain doses, morning and evening, on alternate days at various times. Personal habits contributing to arterial degeneration should be discontinued. A syphilitic taint should be corrected, and lead or other poison depos- ited in the tissues should be eliminated. The diet should be composed of nutritious materials, but indigestion ought to be avoided. Daily out- door air and moderate exercise are very necessary hygienic measures. ANEURISM OP THE AORTA. Definition. — An aneurism is a tumor formed of the coats of an artery, and containing blood and fibrin. They are designated cylin- drical, fusiform, or sacciform, according to their shape ; and true if all the layers are engaged, false if one or two form the walls of the sac. A dissecting aneurism is one in which, the intima and media giving way, the blood dissects along underneath the adventitia, and the walls of the sac are composed of this membrane only. A varicose ajieurism is one in which a communication is established with the venae cavae, the innominatse, the right auricle, or the pulmonary artery. The ana- tomical distinctions on which these names are based are important chiefly from the prognostic point of view. Causes. — The aorta is the favorite site of aneurisms, because, in the performance of its functions, it is subjected to great strain. If the left ventricle is hypertrophied, the blood - pressure in the aorta is increased, and the tendency to the formation of aneurism is greater. Powerful muscular effort has the same effect, and hence those who are engaged in occupations requiring the exertion of their utmost strength suffer more from this malady than those having easier pur- suits. Men are more liable to the disease than women, and for the same reason that those who labor hard suffer more. The frequent association of syphilitic infection and aneurism has attracted much attention, but a causal relation has not yet been established. Chronic arteritis is, doubtless, the chief cause ; the tunics of the vessel, weak- ened by the structural alterations, yield more and more under the force of the blood - pressure. To this view, which is generally ac- cepted, is opposed the important fact that, while aneurism is most usual between thirty and forty, atheroma rarely sets in until after forty. On the other hand, it may be alleged that aneurism would be vastly more frequent if the changes in the structure of arteries oc- curred earlier in life ; and, furthermore, in cases of aneurism, the existence of atheromatous degeneration can almost always be ascer- tained. Pathological Anatomy. — In Sibson's* collection of cases of aneu- * Sibson's " Medical Anatomy," London, 1S69 (sec columns 57-60). 292 DISEASES OF THE BLOOD-VESSELS. rism occupying some part of the aorta, 880 in number, 703 were of the thoracic aorta, the others of the abdominal and its branches. Of these, 193 were of the ascending aorta, 87 occurring at the sinuses of Valsalva. This statistical fact is a confirmation of the pathologi- cal law that those parts most subject to strain in the ordinary course of functional work soonest become diseased. Next to the ascending part, comes the arch which was the seat of aneurism in 120, while only 72 were in the descending aorta. As regards the form assumed by the aneurism, two thirds of those affecting the ascending part are examples of the sacculated variety. It is a curious fact that, while aneurisms of either the ascending or transverse aorta are sacculated, those involving both parts of the vessel are cylindrical or fusiform (Sibson). In the descending aorta, the sacculated are about two thirds of the whole number. The direction taken by the aneurism of the ascending aorta is usually to the right of the transverse part, about one half toward the back, the other half to the right and front ; of the descending, to the left and posteriorly. The sac of the aneurism, which in the beginning is composed of the tunics of the vessel, or of the adventitia, is subjected to various pathological influences which alter its character. It is affected by atheroma, by calcification, but is still more changed in structure by attacks of inflammation which unite it to neighboring organs. The author has met with a case in which the proper sac had disappeared, and the walls were made up for the most part of the tissue of the left lung in which it was imbedded. The interior of the sac is altered by successive deposits of fibrin, differing in age, color, and density, and having a distinctly stratified arrangement. The oldest layers are grayish-white, tough, and firmly adherent to the inner surface of the sac, while the recent coagula contain more or less coloring matter, are softer, easily broken up and detached. By the gradual addition of layers of fibrin the sac is ultimately closed, and a cure is effected by the obliteration of the cavity. Sometimes the outermost layers of fibrin undergo calcification ; sometimes an acute inflammation is set up and the sac is destroyed by suppuration. Occasionally blood-clots or masses of fibrin are cast off, with the effect to block the efferent vessel, or some of its tributaries, or, breaking up, are distributed as multiple emboli. The mischief caused by an aneurism is not limited to the sac itself, but involves neighboring organs by pressure, interfering with functions, or inducing inflammation, ulceration, and atrophy. The bronchi, oesophagus, or thoracic duct, may be opened by ulcei-ation, or the vena cava occluded by a thrombus, or invaded by ulceration, thus producing an aneurismal varix, or atrophy of the neighboring lung may be caused by pressure. The ribs, sternum, and vertebrae may be eroded, and the spinal cord compressed. Important nerve-trunks are first irritated by the proximity of the tumor, next inflamed by pres- ANEURISM OF THE AORTA. 293 sure, and ultimately so mixed in the elements of the sac as to disap- pear. If the aneurism occur in the sinuses of Valsalva, the aortic valves become incompetent by reason of changes in the orifice. It had been generally maintained that aneurism of the aorta causes hypertrophy of the heart, but Sir Dominic Corrigan, Professor Axel Key,* of Stockholm, and others, have shown that " aneurism has no tendency to jDroduce enlargement of the heart " (Corrigan) ; and, when hypertrophy coexists with aneurism, there is no causal connection. Tei-mination by rupture is the most common. As regards aneu- risms of the sinuses of Valsalva, about eighty per cent, terminated by rupture ; of the ascending aorta, fifty-seven per cent, ended by rup- ture ; of the transverse, thirty-seven per cent. ; of the descending aorta, seventy-five per cent. (Sibson). Rupture of the ascending aorta occurs into the pericardium (in one half of the cases), into the right auricle, into the lung, into the pleura, into the right bronchus, into the trachea, into the oesophagus, or externally ; of the transverse portion, into the trachea, lungs, cesophagus, pleura, posterior mediastinum, pul- monary artery, or vena cava ; of the descending portion, into the pleura, lungs, etc. Symptoms. — The signs and symptoms of aneurism, as of cardiac diseases, are comprehended in two groups : rational and physical. The rational signs are symptomatic of the functional troubles caused by the aneurism, and, of course, vary somewhat with the position of the new formation. It will conduce to clearness to consider the sub- ject of aneurism of the thoracic aorta and its main branches first, and follow with aneurism of the abdominal aorta and its main branches. Aneurism of the Thoracic Aorta. — The earliest symptom is pain. This may be a fixed pain, almost constant, and felt in one spot under the sternum and in the neighborhood of the aneurism. More fre- quently the pain has a combined lancinating and tensive character, shooting up from the interior of the chest to the neck, to the shoulder, down the arm to the elbow, sometimes to both sides ; or, it is felt in the back and shoots around the chest in the direction of the intercos- tal nerves. At times the attacks of pain are most severe, and demand the use of active anodynes. These pains, which occupy the trajectory of the cervical and brachial plexus, and of the intercostal nerves, ought not to be confounded with attacks simulating closely angina pectoris, which occur when the aneurism is near the heart. These paroxysms consist of praecordial pain and anxiety— pain shooting across the chest, in the precordial region, and to the shoulder, down the arm. Although these attacks are due to the irritation of the nerve-trunks, they affect a different set of nerves, those supplying the heart itself. So constant is this symptom of pain, so severe and persistent, although paroxys- * The "Medical Times and Gazette," June 4, ISTO. 294 DISEASES OF THE BLOOD-VESSELS. mal, that, if it come on in a man of middle age without any explanation, aneurism should be suspected in the absence of more characteristic symp- toms. There is also more or less dyspnoea, paroxysmal rather, in the initial period, a^xl may occur without any apparent cause, from pres- sure on the pneumogastric when there is apt to be nausea associated with it, or to pressure on the phrenic, when there may be hiccough. In the further development of the aneurism, dyspnoea may be pro- duced by pressure on the left primary bronchus, diminishing the air passing to the left lung or on the trachea, or to pressure interfering with the return of blood from the lung, and there may be simultane- ously pressure on the pneumogastric, causing laryngeal symptoms, and on the phrenic, causing paralysis of the diaphragm. When the dysp- noea is due to pressure on the recurrent laryngeal, there will be asso- ciated with it peculiarities of the voice, cough, and breathing. When due to pressure on the trachea, it is somewhat relieved by inclining the head forward ; and in one case, that of a physician seen by the author, a violent suffocative attack was brought on by raising the head erect. In other cases of pressure on either bronchus, relief to the breathing is afforded by turning to the opposite side. When the dyspnoea is due to direct pressure on the lung, there are present fever, profuse expectoration, etc., the signs of phthisis. When the aneurism is at the arch and springs from the inferior segment, pressure on the recurrent laryngeal will produce characteristic symptoms at an early period. If the pressure irritates without destroying the nerve, all of the muscles of the larynx innervated by it will be thrown into a state of spasm, with the effect to modify the voice and cough in a most characteristic manner. While one cord approximates its fellow and vibrates in the normal manner, the other is in a state of rigidity and does not vibrate normally, producing an odd effect on the voice, there being a double tone, one high-pitched and the other lower ; but this vox anserina occurs with both inspiration and expiration. Alteration of the voice is much more common than aphonia. When the paralysis of the vocal cords is double, which is an extremely rare event, the voice is gone and there is aphonia ; but, if, as is usually the case, the paralysis is of the left vocal cord, the voice has a harsh, stridulous character. The cough exhibits the same peculiarities. When the nerve is irritated without being destroyed, the cough is loud, resonant, and metallic — croup-like ; on the other hand, when the nerve is destroyed and the muscles of the larynx paralyzed, the cough is suppressed, wheezy, strid- ulous. By laryngoscopic examination, the explanation of these phe- nomena is afforded in the character of the movements of the arytenoid cartilages and vocal cords. The effect of ii-ritation is seen in the rigid state of one cord, which does not approximate accurately its fellow during phonation, and vibrates imperfectly if at all. When the de- struction of the nerve is effected and paralysis comes on, the paralyzed ANEURISM OF THE AORTA. 295 vocal cord is relaxed, wrinkled, and does not move up to its fellow during phonation, nor does the inspiratory dilatation take place on the paralyzed side. Irritation of the main trunk of the pneumogastric may, as has been pointed out, cause respiratory disturbances, par- oxysms having an asthmatic character, etc., but the peculiarities of voice and speech above mentioned are only produced by lesions of the recurrent laryngeals, and chiefly of the left nerve. Several cases of bilateral paralysis of the larynx have resulted from the pressure on the nerve of one side only. Dr. George Johnson * supposes this to be due to a reflex influence transmitted by the commissural connection be- tween the nuclei of the spinal accessory, and this is most probably the true explanation, although it has been opposed. The state of the pupil has a high degree of clinical importance. If the aneurism irritate the fibers of the sympathetic nerve without destroying them, this fact is signalized by permanent dilatation of the pupil ; but if the nerve-fibers are destroyed, paralysis of the radiating fibers of the iris ensues, and hence contraction of the pupil follows (the thii'd pair unopposed). Usually spasm of the glottis (irritation of the inferior laryngeal) coincides with dilatation of the pupil (irri- tation of the sympathetic) ; but this relation is not invariable, for spasm of the glottis may be present with contracted pupil (Russell). Unilateral sweating of the head and face is a symptom which occurs in a small proportion of cases, and may or may not be coincident with changes in the pupil. The sweating is strictly limited to one side of the head and face, and, although increased by external warmth and exercise, comes on quite independently of external conditions. It is supposed to indicate irritation of the sympathetic, but the real nature of the phenomenon is as yet unknown. As unilateral sweating is pro- duced by a variety of causes, it is of importance in this connection only when it coincides with other and more definite signs. The character of the cough associated with laryngeal troubles has been mentioned. There is also cough when the lungs are involved, and sometimes profuse expectoration. Cough is a symptom of pressure on the trachea or bronchi. Expectoration of blood from a minute com- munication between the sac of the aneurism and trachea is one of the puzzling symptoms, for it may have all the characteristics of an ordi- nary pulmonary haemorrhage. This escape of blood may continue for several weeks by a circuitous channel, before rupture finally occurs. Dysphagia or difficulty of swallowing is produced by the same mechan- ism as the laryngeal spasms : irritation of the pneumogastric is reflected over the motor branches distributed to the oesophagus. This does not continue a permanent disability, but persists for a few hours, then dis- appears, to return again at some uncertain period. Pressure of the * "The British Medical Journal," December 19, 1874. 296 DISEASES OF THE BLOOD-TESSELS. aneurism on the oesopliagus produces a more permanent dysphagia, and, as might be expected, is a more common symjitom in aneurism of the descending aorta than in any other position. According to the statis- tics of Sibson, dysphagia was present in thii-ty-five per cent, of cases of the descending aorta, in thirty-one per cent, of those of the arch, and in only two per cent, of those of the ascending aorta. As the aneurism enlarges, important symptoms are produced by pressure on the great vessels. If the descending cava is obstructed, bilateral cedema of the face and arms follows, or, if the innominata only is compressed, the effusion is limited to the right side or to the left side, according as it is the right or left vein. When the right auricle is im^^inged on, there must ensue cyanosis, general venous stasis, and dropsy ; when the left auricle, pulmonary congestion with its consequences — brown-red indu- rations, haBmorrhagic infarctions, etc. Dilatation of the lymphatic ves- sels will be produced by the pressure of an aneurism occupying the last portion of the arch and the descending aorta. When an aneurismal tumor protrudes at the thoracic wall, the diag- nosis by the physical method becomes much simplified. By palpa- tion, the existence of a tumor, pulsating and swelling with each pulsa- tion, is made out. The first beat is stronger and more prolonged than the second, if there are two, and is a little subsequent to the heart- beat, while it anticipates the radial pulse. The second corresponds to the diastole of the heart, and is the recoil from the closure of the aortic valves, and of course is indistinct or wanting when the aortic valves are incompetent. A double pulsation exists only in the case of recent aneurism, and of the thoracic aorta ; old aneurisms, lined with thick layers of fibrin, or comjjosed of bony tissue, can not be thrown into vibration by the comparatively feeble force of the recoil wave, and abdominal aneurisms lie at too great a distance. Palpa- tion also reveals a peculiar thrill or tremor which is intermittent, or is synchronous with the first beat, and is known as aneurismal thrill. It is obvious that, to feel this, a tumor must be very superficial, and without dense, thick, or bony walls. In the case of aneurisms deeply placed in the thoracic caAdty, these symptoms ascertainable by palpa- tion are wanting. Dullness on percussion is elicited only when the aneurism has attained sufficient size or is in a position to cause the reac- tion, and it exists over a very limited area under any circumstances. The usual jjosition of the dullness is on the right of the sternum, parallel with the second or third rib ; or it is at the sternum, or to the left of the sternum, and posteriorly to the left of the spinal column. This symptom does not afford precise indications, since the dullness of an- eurism does not differ from that caused by any tumor, or by a solid organ, or by a purulent depot. On auscultation we hear in aneurism a systolic and diastolic sound or shock, such as is audible over the ar- tery itself. These sounds correspond to the pulsations, with the excep- ANEURISM OF THE AORTA. 297 tion, however, that a diastolic sound may occur when there is a systolic and not a diastolic pulsation. The mechanism of their production is obvious enough, the systolic sound being due to the vibration of the column of blood propelled into the sac, and the diastolic to the recoil from the shutting of the aortic valves. The second or diastolic sound has a " booming " quality, and is heard the more perfectly the nearer the heart the aneurism is jilaced. When there are cardiac murmurs of stenosis or insufficiency, or peculiarities of accentuation, they are prop- agated to and are audible over the aneurism. The fitness of the expres- sion, that when aneurism is present "two hearts are beating in the chest," is quite obvious ; so close, indeed, is the resemblance that the sounds heard in aneurism were considered by Laennec as cardiac en- tirely. Murmurs also occur in aneurism with, or take the place of, the sounds ; they are formed in or of the sac, and are not propagated from the heart. They are by no means common, and a diastolic mur- mur is greatly less frequent than a systolic. They are produced by some irregularity in the interior of the sac, or by pressure on a neigh- boring vessel, or on an adjacent part of the aorta. A sacculated an- eurism does not, but the other varieties do in some cases, retard the pulse-beat. If it occupy the ascending aorta the pulse will be behind on the whole round of the circulation ; if the transverse portion of the arch and between the arteria innominata and the left subclavian, the pulse of the radial will be retarded ; if the descending aorta, the fem- oral pulse will be delayed. The pulse is also changed in character. If the orifice of the efferent vessel is unobstructed, the normal dicro- tism of the pulse is increased because of the secondary undulation im- parted to the blood-column ; on the other hand, if the efferent vessel is narrow or obstructed, the pulse is small, irregular, and without dicrotism. The symptoms of aortic aneurism vary with the position of the sac in the course of the vessel. In aneurism of the ascending part there are pressure on the right auricle, cyanosis, venous stasis, and dropsy. The aortic valves are usually incompetent, and the murmurs thus pro- duced are audible over the sac. As the tumor develops anteriorly, the pulsation is felt in the second or third right intercostal space at the border of the sternum. When it projects it forms an hemispherical tumor, having, usually, a double pulsation, a reddish and purplish tint, is crossed by enlarged and varicose veins, and presently softens. The radial pulse is retarded equally on both sides, unless compression of the innominate artery occurs. The laryngeal symptoms, so constant in aneurism of the arch, are wanting, but the pupillary phenomena and the unilateral sweating may be present. The trachea and oesophagus are occasionally encroached upon, but the right primary bronchus may be compressed. In about one half of the cases the pulmonary artery and the adjacent right ventricle are impinged on. According to the data 298 DISEASES OF THE BLOOD-VESSELS. of Sibson, aneurisms of the ascending aorta compressed the right lung in thirty-four instances, the left lung in ten, the right bronchus in six, the left bronchus in one, the pulmonary artery in seven, the descending vena cava in sixteen, and the trachea and oesophagus in nine each. In aneurism of the arch there will be oedema of the head and upper ex- tremities ; the pupil will be affected but not invariably ; laryngeal symptoms will be usually present from compression of the left recurrent nerve ; there will be compression of the left primary bronchus, and consequent feeble respiration or collapse of the left lung ; there will be dysphagia from obstruction of the oesophagus sometimes ; attacks of angina pectoris from irritation of cardiac nerves. Referring again to the facts of Sibson, we find in regard to aneurism involving both the ascending and transverse aorta, that there were present dyspnoea in 74 per cent., orthopnoea in 21-5, cough in 47, haemoptysis in 10, stridu- lous breathing or affection of voice in 17, dysphagia in 21*5, the head and neck were swollen in 14 per cent. ; while in aneurism of the trans- verse aorta alone there were present, dyspnoea in 71 per cent., orthop- noea in 20 per cent., cough in 57*5 per cent., hsemoptysis in 19 per cent., inspiration stridulous in 47*5 per cent., dysphagia in 31 per cent., the pulse weaker in one wrist in 26 per cent. As regards the descending part of the arch of the aorta, we find that the vertebrae were eroded in 42 per cent. ; the tumor made pressure on the trachea in 12*5 per cent., on the left primary bronchus in 37'5 per cent., on the oesophagus in 31 per cent., the left lung in 48 per cent, ; dysi^noea occurred in 50 per cent., cough in 46 per cent., the voice affected in 25 per cent., and dysphagia existed in 33 per cent. The important disturbances arising from aneurism in this situation are obviously due to the recurrent laryngeal nerve, left primary bronchus, oesophagus, and trachea, which come into close relation with the vessel at this point. Aneurisms lower down compress the left lung, and cause erosion of the vertebrae in 74 per cent. There is a fixed boring pain about the site of the aneurism in one half the cases ; there is also much pain in the intercostal nerves ; the femoral pulse is retarded ; and, when the spinal canal is invaded, disorders of sensation and of motility occur in the lower limbs, termi- nating in hemiplegia. A case is reported of an aneurism of the arch, dissecting downward between the trachea and oesophagus and bursting into the stomach. The symptoms were orthopnoea, dysphagia, and stricture of the oesophagus, but not of aneurism.* Aneurism of the innominata causes very much the same symptoms as the first part of the arch : a systolic and a diastolic pulsation ; a double sound, synchronous with the cardiac, and audible with the greatest intensity at the junction of the clavicle and sternum ; retar- dation and increased dicrotism of the right radial pulse if undbstiaicted * "Pathological Society's Transactions," vol. xxvii, p. 9Y, report of Dr. Frederick Taylor, ANEURISM OF THE AORTA. 299 at orifice of exit ; pain in the neck and arm ; compression of the de- scending vena cava, and oedema of the head and upper extremities, or there may be compression of the left vena innominata, and consequent oedema of the left side of the head and the left arm. Aneurism of the Abdotnmal Aorta. — The point of election is at or near the coeliac axis. In Dr. Sibson's collection of cases, 177 in num- ber, 131 occurred at this point. Less than one half arise from the an- terior face of the vessel, and consequently the vertebrae are eroded in a large proportion of cases — 55 per cent. The variety of the aneurism is the so-called false, and the form sacculated in 60 per cent., and they attain considerable size, sometimes to a capacity of ten pounds. Aneurism of the abdominal aorta is usually referred to a violent muscular effort — always, in the author's experience. It appears to be less associated with atheromatous degeneration of the arteries than is aneurism of the thoracic aorta. One of the earliest symptoms is pain, felt in the position of the tumor and radiating through the abdomen. As the aneurism is so situated that the semilunar ganglion and the nerves of the solar plexus must be compressed by it, pain is necessarily produced, and, as the nerves radiate from a common center, the pain also radiates, shooting up into the hypochondria and downward to the iliac regions and hypogastrium. These pains are paroxysmal, and may disappear for hours and days ; but the attacks are of extreme severity, and when they subside leave the patient exhausted. The local pain seems to the patient to be in the stomach, and, as this organ is disturbed in function also, the attacks are often confounded with gastralgia. This local pain is more constant than the other, and there is rarely an entire cessation of it, although it may be little more at times than an uneasi- ness. In about one half of the cases the most violent pains occur in the back, and shoot down through the lumbar region into the hips along the course of the sciatic nerves. There is here also a fixed^ boring pain felt opposite the coeliac axis, which is rarely absent. In both situations the pains are aggravated by pressure, by sudden jolt- ing, or bending the body. The pain in front is increased by taking food, especially by distention of the stomach. Distress produced by eating, indigestion, flatulence, and nausea, are early symptoms, due to irritation of the solar plexus. As the pain is brought on by eating, and as pronounced stomach troubles are present in a majority of the cases, it need occasion no surprise that they are often supposed to be entirely stomachal. This mistake is persisted in even when a tumor is present, and the phenomena are then ascribed to cancer of the stomach. This mistake is all the more readily made, since the interference with digestion brings on a cachectic state with wasting, and since jaundice may be caused by pressure on the common duct. The stomachal dis- orders are less pronounced in those aneurisms springing from the pos- terior part of the aorta and making their way posteriorly. According 300 DISEASES OF THE BLOOD-VESSELS. to Sibson, a pulsating tumor was observed in 55 per cent, of the cases. A large tumor may form posteriorly, and produce extensive erosions of the vertebrae, without being ascertained by the most careful palpa- tion. A dislocated kidney, a migrating spleen, a bunch of enlarged lymphatics, may rest on the aorta and receive a pulsation synchronous with the cardiac systole. In applying the method of palpation, to de- termine the nature of a pulsating epigastric tumor, the sources of error just mentioned must be eliminated by putting the patient in such a position that these bodies will fall away from the aorta, when, of course, the pulsation will cease. The aneurismal tumor is situated usually in the epigastrium, a little to the left of the median line. It is a globular, elastic tumor, pulsating with an expansile movement in all directions, and on inspection there will be seen a swell of the whole abdomen with each pulsation. The pulsation of an abdominal aneurism is single, a little later than the cardiac systole, and there is usually a thrill. If pressure is made on the aorta below the aneurism, the sac will be filled with a stronger impulse, and retain its fullness, while the thrill ceases or is less marked. Percussion is of little value. Dullness may be elicit- ed under favorable circumstances, but this affords no indication of the nature of the producing cause. Murmur is present in a considerable proportion of cases. It has a blowing character, is rather soft, and, in time, is a little later than the cardiac systole. When the aneurism springs from the anterior surface of the aorta, the murmur is audible in front, and, when the growth is posterior, audible behind ; rarely is it audible in both situations in the same case. Standing erect arrests the murmur, because, according to Corrigan, of the increased tension in the sac pi'oduced by the superincumbent column of blood. To this statement and explanation must be opposed the important fact that the murmur was audible in the erect and ceased in the recumbent pos- ture in an undoubted case of aneurism. Aneurism of branches of the aorta iare occasionally encountered. An aneurism of the mesenteric artery is a movable tumor which may be confounded with floating kidney.* It differs from the latter in being globular and pulsating. Aneurism of the hepatic artery may cause jaundice, by pressure on the duct, or ascites, by pressure on the portal vein. As they are small in size and deeply placed, aneurisms of the hepatic artery are rarely, if ever, recognized during the life of the individuals affected by them. Course, Duration, and Termination of Aneurisms of the Aorta.— The course of aneurism is much influenced by the condition of organs compressed, and the disturbances of function thus induced. They are essentially chronic, slow in development usually until of sufficient size to compress the organs about them, when symptoms are caused which * Dr. Burney-Yeo communicates a case to the Pathological Society ("Transactions," vol. xxviii, 1877), in which the first part of the artery was affected and not movable. It com- pressed both renal arteries, and caused death by uraemia. ANEUEISM OF THE AORTA. 301 attract attention to them. Not all cases give rise to symptoms that indicate the cause of the disturbances which they produce ;.only the disturbances are recognized and treated as the real malady. Thus, aneurisms deeply placed in the thorax posteriorly, or of the abdominal aorta, high upon between the crura of the diaphragm, or growing toward the lumbar region, may produce no symptoms which can indi- cate the nature of the disease. Even when a tumor of considerable size exists, in the situation most favorable for recognition, grave doubts may be entertained as to its aneurismal character. They may terminate in a variety of modes ; by exhaustion, by pneumonia, by rupture and haemorrhage. Probably the most useful collection of sta- tistics showing the course and terminations of aneurism is that of Sibson, and the author prefers, therefore, to illustrate these points from it. As regards aneurism of the first part of the aorta (sinuses of Valsalva), we find that 80 per cent, terminated by rupture, 45 per cent, into the sac of the pericardium, 13*5 per cent, into the pulmonary artery, 8-5 per cent, into the right auricle, 5 per cent, into the right ventricle, and 5 per cent, into the left ventricle. Aneurism of the ascending aorta " ruptured in 57 per cent. ; externally in 8, into the pericardium in 22, into the pulmonary artery in 4, into the descending vena cava in 5, into the right lung in 5, into the left pleura in 4, " etc. In a series of 25 cases published in the "New York Pathological Transactions," * the termination was by rupture ; and in almost all of the cases death occurred suddenly, but few of them having been diag- nosticated. Aneurisms of the ascending aorta and arch conjointly rup- tured in 37 per cent., into the pericardium in 10, into the vena cava 4, into the trachea 4, etc. Aneurism of the descending part of the arch ruptured in 75 per cent., into the trachea in 4, into the left bron- chus in 16-5, into the left pleura in 23, into the right pleura in 12-5, etc. Aheurism of the abdominal aorta ruptured in 77 per cent., into the peritoneal cavity in 28*5 per cent., into the subperitoneal tissue, in the left hypochondriac region, 22 per cent., etc. Although death is almost immediate when an aneurism ruptures, yet this is not invaria- bly the case. A small opening may exist in the trachea, permitting a little blood to escape from time to time, simulating pulmonary hsem- orrhage, and continuing to discharge in this way until a complete rup- ture occurred at the end of several months. These are called " weep- ing aneurisms." Gairdnerf records a case of this kind in which the opening was blocked by some fibrin, and continued so for four years. An opening externally may discharge slowly, of which notable exam- ples have been published — a free and fatal hasmorrhage being pre- vented usually by a plug of fibrin. As the beginning of an aneurism is very uncertain, it is difficult to state its duration within exact lim- * Tabulated in " Transactions of the London Pathological Society," vol. xxix. f " Clinical Medicine," op. cit. 302 DISEASES OF THE BLOOD-VESSELS. its. They vary exceedingly in duration ; from fifteen days to thirty years are the extremes which have fallen under the author's notice. Much depends on the influences, medicinal and moral, to which the patient is subjected. Some cures are effected. Prognosis. — Aneurism must be regarded as a very grave disease. Under the improved methods of medical treatment now available, more cures are effected than formerly, and the question of treatment must enter largely into prognosis. Under any circumstances, a quali- fied opinion only should be given, for an aneurism that is apparently solidifying may take an unfavorable tui*n, and death be caused by some intercurrent malady. Treatment. — The object of the medical treatment of aneurism is to secure the solidification of the sac. As this has occurred several times spontaneously, without the intervention of art, it is more difl&cult to assign to remedies their exact share in any successful treatment. To obtain coagulation of the blood in the sac and to effect the solidi- fication of the fibrin are the objects before us. If we have to deal with a sacculated aneurism, the closure of the sac can be accomplished without interrupting the current through its proper channel. The importance of this is very obvious in dealing with the aorta, for no collateral circulation is here possible. The difficulty of a case is im- mensely increased from the therapeutical standpoint, when we have to treat a dilated vessel. The treatment by rest, as absolute as can be maintained, is a very old method, and has much to recommend it even now. If the patient maintains a position of recumbency, and moves in that position as little as possible, the action of the heart is slowed and its force lessened, so that the blood in the sac may coagulate. Formerly, the abstraction of blood and an absolute diet were com- bined T^-ith rest in the recumbent posture (Valsalva's plan), but, in the more recent method of Tufnell, only the rest and a restricted diet are considered necessary. The diet of this plan consists of two ounces of liquid and four of solid food morning and evening, and four ounces of liquid and six ounces of solid at mid-day.* In addition to this re- stricted diet, the blood-pressure is reduced by the daily use of laxa- tives. The period of confinement to a recumbent posture is from eight to thirteen weeks. The results obtained by Mr. Tufnell are cer- tainly very satisfactory, for he has reported cases of aneurism of the abdominal aorta solidified in thirty-seven and twenty-one days, and one of popliteal cured in twelve days ; and he affirms that, " if the plan of treatment by position be but steadily and perseveringly car- ried out, a successful issue can (in suitable cases) almost be guaran- teed." In addition to rest, arterial sedatives are sometimes given, with the view to keep the action of the heart still lower than that rate of * " Mcdico-Chii'urgical Transactions," vol. xxxix, 1874, p. 83, et seq. ANEURISM OF THE AORTA. 303 movement attainable by rest merely, according to Tufnell's plan. The arterial sedative employed for this jjurpose is the tincture of veratrum viride, given to bring down and to keep the pulsations about fifty per minute. The author has witnessed successes obtained in this way. Bloodletting is admissible in cases of large aneurism, a rupture being threatened by violent action and plethora. Recently, important re- sults have been obtained by the free administration of the iodide of potassium (gr. xv — 3j) three times a day. It has a remarkable influ- ence over the pain, probably because of its effect in diminishing the tension of the sac, the force of the heart, and the blood-pressure (Bal- four). Besides this, the iodide seems to affect the sac itself. The use of the iodide of potassium may be combined with rest and a lowei'ed diet, but these are only adjuvants, and are not essential to the treat- ment. Langenbeck has called attention to the great value of ergotin as a remedy in aneurism, and has reported some successful cases. It has been used since with advantage. Its employment is based on the action which it exerts on the muscular fiber of the arteries, and there- fore, it is asserted, it can have no effect on the aorta. Those who use this argument forget that ergot slows the heart, and raises the blood- pressure at the periphery by contracting the arterioles — conditions highly favorable to promote coagulation of the blood in the sac. Two to five grains of the so-called ergotin, which is the aqueous extract, should be administered hypoderraatically, simply dissolved in water and filtered. This practice may be continued while the other measures are being cai'ried out, as there is no therapeutical incompatibility. The success which has lately been obtained with barium, based on the experimental research of Boehm, is a beautiful example of the value of such investigations. From 3 ss to 3 j of the liquor barii chloridi, w^ell diluted, may be given three times a day, after meals. The physi- ological effects of this medicine on the vessels suggested its employ- m.ent originally. Acetate of lead also affects the vessels — especially the intima — but there are very obvious objections to its long-contin- ued use. Attempts have been made by direct means to secure the coagulation of blood in the aneurismal sac. These consist in the in- troduction of fine wires, horse-hair, etc., with the intent to supply a foreign body about which the blood will coagulate. Thus far, these attempts have been failures. Another method, of which very confi- dent anticipations were at one time entertained, is the method of elec- trolysis. This consists in the introduction of an insulated needle into the interior of a sac, and the application of a sponge electrode to the exterior, through which a galvanic current is passed. The blood coag- ulates about the needle. Much discussion has resulted as to the pole,, anode or cathode, to be introduced into the sac. As about the posi- tive pole acids, oxygen, etc., collect, a firmer clot is there formed ; while about the negative, hydrogen and the alkalies, producing a 304 DISEASES OF THE RESPIRATORY ORGANS. softer clot. The positive electrode needle is withdrawn with difficulty from the sac, owing to the firmness and adhesiveness of the adherent coagulum, and in making the effort there is danger of hsemorrhage and of setting free multiple emboli. On the other hand, although the clot produced by the negative- needle is less firm, it acts as a nucleus about which denser coagula will form afterward. Although cures have been reported by electrolysis, this method is not so successful as others recommended above. Furthermore, the danger of haemorrhage, of exciting inflammation, of detaching large clots in the circulation, is so great that this plan is not to be commended. Anem'ism of the coronary artery is a rare disease. Crisp * has collected and tabulated twelve cases. They occurred from eleven to seventy-seven years of age, but chiefly after forty, and in subjects exposed to such injury by occupation. They may cause sudden death without symptoms, or there may be suffocative attacks, pain, and pal- pitations. They vary in size from a pea to a walnut, and rupture into the pericardium. This is not the invariable termination, although usual, death being caused in three of Crisp's cases by bronchitis, ex- haustion, and an unknown cause unconnected with the aneurism. DISEASES OF THE RESPIRATORY ORGANS. INFLAMMATION OP THE PLEURA— PLEURITIS. Definition. — JPleuritis, or jy^&urisy, is an inflammation of the pleu- ral membrane. Although not separable by any well-marked signs and symptoms, it is usual to consider two forms, acute and chronic. It may occur as an independent ^pr«?2ar?/ affection, or it may be secondary to some other disease. Causes. — There can be little doubt that many cases arise from ex- posure to cold, especially when a current of cold air is directed against the body in a perspiring state. There is probably a constitutional condition of some kind which determines the seizure, but this state can not be defined. It is more common in early life up to the middle period, but is uncommon in old age. The secondary disease is much more frequently encountered than the pi'imary. It is very frequently associated with pneumonia, by extension of inflammation through con- tiguity of tissue ; often, indeed, the pleuritis is the more important of * "Transactions of the Pathological Society," vol. xxii, p. 108. PLEURITIS. 305 the two affections. It is also associated with catarrhal pneumonia, with bronchitis, pericarditis, embolic pneumonia, pyaemia, abscesses, and other affections of the thoracic organs. It may be excited by caries of a rib, deep-seated (sub-joleural) abscesses, cysts and abscesses of the liver, etc. A dyscrasia may be a cause, when it is said the pleuritis is an intercui'rent malady ; but it is now known that various morbific matters in the blood may excite serous inflammations, of which rheu- matism, gout, Bright's disease, cancer, diabetes, and the eruptive fe- vers may be taken as examples. Pathological Anatomy. — The initial lesion is hypersemia of the sub- serous connective tissue, while red points due to congested vessels are rather thickly scattered over the pleura. Such is the force of the blood- pressure that minute points of extravasation occur on the pleura and in the subserous tissue. The membrane has an arborescent or striated appearance, and is of a reddish or reddish-brown color. The injected portion of the membrane is dull, opaque, and rough ; the epithelium is swollen, cloudy, and granular, and is rapidly cast off, while the ad- herent cells undergo similar changes, and the subserous tissue becomes swollen, infiltrated, and crowded with migrated leucocytes. On the membrane there appears in detached masses, but rather thickly placed, an exudation which makes the surface rough and uneven. Large flakes of exudation may be thrown off, or the membrane may become thickly covered with a more or less heavy coating of fibrinous material. This may also contain a good deal of serous exudation in its meshes, when it presents a gelatinous, felt-like, or spongy appearance. If there be present much liquid, the flakes or masses of fibrin are seen floating in it, or they may be churned up with the serum and form a milky-look- ing fluid. The exudation which thus forms on the surface passes through various changes. It may undergo fatty metamorphosis, be- come emulsionized, and disappear by absorption, leaving the membrane unharmed. Adhesions may form by the gluing together of the op- posed surfaces, the connecting band of exudation undergoing organi- zation. The membranous exudation on the surface may also become organized; large thin-walled vessels develop from the leucocytes, accord- ing to Rindfleisch, and close connections are formed between the neo- membrane and the pleura. Again, broad patches of membranous exuda- tion on the opposing surfaces of the pleura uniting by their margins, a central cavity is thus formed in which there may be serum, sanguino- lent serum, and flakes of exudation, etc., while close adhesions unite the pleural surfaces all around for a greater or less distance. These secondary cavities form at the base, on the lateral wall of the thorax, and between the pleura and pericardium, and, as they retain the effu- sion in a fixed position, give rise to errors of diagnosis. Those are examples of dry pleurisy , in which a very plastic exudation is thrown out on the two surfaces, over a small extent of the membrane, union 20 306 DISEASES OF THE RESPIRATORY ORGANS, taking place, either directly or by a connecting band, there being no other exudation or effusion. It is probable that many of the exam- ples of connecting bands, or adhesions between the pleural surfaces, which are found ^:>os^ mortem, no symptoms having occurred during life, were of this character. Usually, however, in pleuritis, a more or less abundant exudation is poured out. According to the nature of the effusion, the cases of pleurisy are divided into the sero-fibrinous, the purulent, and the hcemorrhagiG. In the sero-fihrinous form there is poured out from the distended vessels a quantity of fluid, straw-colored and having the qualitative composition of blood-serum. This contains floating in it masses of exudation or flakes, leucocytes, lymph, and red-blood corpuscles, which impart to it a more or less milky or sanguinolent character. The fibrinous part of the exudation consists of layers or folds of whitish, grayish, or reddish albuminous and fibrinous material deposited on the pleura. It may be soft, easily separated, or tough and elastic ; and may be readily detached from the membrane, or may adhere with considerable tenacity. When removed, this exudation is found to be closely adherent to a layer beneath, made up of the proliferating con- nective-tissue corpuscles of the basement membrane, together with a plastic matrix. These layers become ultimately closely connected by the growth of the connective-tissue membrane, or the fibrinous exudation may undergo fatty degeneration and be absorbed. The new connective-tissue membrane, built up as above described, is very rich in vessels, and readily unites with the same formation on the op- posing surface of the pleura. The corpuscular elements — leucocytes, lymph-corpuscles, cast-off epithelium, etc, — in the serous fluid may be so abundant as to give it a yellowish or purulent appearance. Hence it may be difiicult to make a distinction between this and the truly purulent form, in which the serum contains such a quantity of pus- corpuscles that it is thick, yellowish, or greenish yellow. The term empyema is applied to a purulent collection in the thoracic cavity. Primary empyema is a very rare event, and, when it does exist, signifies the admission of air or some foreign matter to the cavity. The exuda- tion is at first sero-fibrinous, and becomes purulent, usually not until after the first week. There takes place, under conditions not now understood, a remarkable production of pus-cells — probably by enor- mously rapid proliferation of the leucocytes which have wandered from the vessels. While the serous fluid has an alkaline reaction, the purulent exudation is acid in reaction. Often the color of the exuda- tion is reddish from the presence of red-blood corpuscles in consider- able numbers. But this is not the hcemorrhagic exudation, properly. This consists of blood derived from the newly formed, thin-walled ves- sels of the exudation undergoing organization, A vessel giving way, the blood is poured out (or there is a diapedesis of the red globules) PLEURITIS. 307 between the layers of the exudation and bursts through into the cavity of the pleura, and, mixing with "the serum, forms a bloody fluid. The hcemorrhagic form of pleuritis is usually tubercular in origin, or rather is due to the deposit of miliary tubercle exciting a recurring inflam- mation. An exudation may be ha^morrhagic when the pleuritis occurs in an individual having the haemorrhagic diathesis, or who is the sub- ject of purpura. The evil results of effusions are not limited to the affected mem- brane. When the quantity is suflicient to displace the neighboring organs, various functional disturbances arise from the compression. At first the lung retracts before the effusion, and only suffers by pres- sure when the eft'usion attains a certain volume sufficient to counter- balance its elasticity. As the fluid increases from below upward, the lung at first floats ; but gradually the expansibility declines, less and less air enters, and the organ is finally flattened against the spine about its roots. It then appears as a grayish, bluish, or reddish-gray, rather solid and flattened mass, about the size and shape of the adult hand without the fingers. It contains no air, is bloodless, and may be coated with a membranous exudation, or may be bound down by membranous bands. If adhesions exist, the lung will be compressed in part, or, if the organ is infiltrated by caseous or other deposits, the fluid will act on those parts that yet remain compressible. The fluid may be collected in secondary cavities, and compression be confined to those sit- uations. The blood being forced out of the lung, when the organ is flattened against the spine, distends the right cavities, which may dilate, and fills the sound lung, which may become congested and oedematous. If the effusion occupies the right cavity, the heart is forced toward the left side, the diaphragm is pushed down, enlarging the capacity of the right thorax, and displacing the liver downward ; if the left cavity, the heart is forced over to the right, the diaphragm is pushed down to a less extent than on the right side, enlarging the left thorax, and displacing the spleen downward. The intercostal muscles become in- filtrated, weakened, and, yielding to the pressure, assume a convex instead of a concave shape, the thorax being globular and increased in circumferential and diametrical measurement. If absorption take place and the lung is not adherent, the air will again distend the alveoli, and the thorax assume its normal shape ; if the lung can expand again only in part, under the force of the atmospheric pressure, there will take place a depression of the ribs and distortion of the spine to efface the portion of the cavity which the lung can not fill. When there is present purulent or ichorous exudation in the thorax, the pleura will, if long exposed to its action, undergo necrosis, and a canal may be tunneled through the lung into a bronchus, and through this there may be more or less discharge, and a cure be ultimately effected. Caries of a rib may follow necrosis of a portion of the cos- 308 DISEASES OF THE RESPIKATORY ORGANS. tal pleura, and a fistulous communication be opened up externally, tlie pus draining off, a cure being ultimately effected, or tbe prolonged suppuration may lead to tubercular deposit or to amyloid degeneration of the organs. A fatal peritonitis is in rare instances lighted wp by the passage of ichorous matters through the agency of the lymphatics of the diaphragm. In other cases a fistulous communication is estab- lished, and the pus dissects downward along the psoas muscle, pointing under Poupart's ligament, or opens about the umbilicus, etc. Again, the pus may ulcerate into the mediastinum, into the pericardium, or into the great veins, but these are excessively rare accidents. Chronic j^^^urisi/ differs only in time and extent from the acute form. In ^^^^uritis deformans the exudations are of great thickness and extent, and, by adhesion and subsequent contraction, extensive deformity of the lung may result. The space left between the ribs and the lung will be filled with fluid, and, as the pleura is damaged so that absorption can not take place, encapsulation may hold the fluid months, even years. Often, indeed, the false membrane which has become organized possesses the power of pus-forming (pyogenic mem- brane), fistulous communications are established, and matter is dis- charged for years even. The chest becomes greatly deformed by shrinking, the shoulder depressed, the spine curved, and the heart pushed aside and permanently fixed in its new position. Symptoms. — The symptomatology of pleurisy varies with the form. As dry 2>l&urisy is the simplest form, it will be best to consider it first. This may set in with chilliness, fever, pain in the side, and dyspncea, but more frequently there is little or no fever, no respiratory disturb- ance, only the pain in the side to indicate the nature of the attack. If the former symptoms are present, they do not continue longer than thirty-six to forty-eight hours ; if the latter, the symptoms rarely ne- cessitate confinement to bed. The physical signs of dry pleurisy are as follows : On inspection, the extent of the inspiratory movement is seen to be lessened by the pain — ^is aiTested midway by a sudden start, and the body is curved a little to the affected side to avoid pressure on the inflamed membrane. On percussion, there is no change in the sonority from the noraial minimum, because of the limited movement in insj)iration, and if the pain is slight there will be no change in the normal maximum. On auscultation, the respiration will be feeble on the affected side, because of the pain elicited by the expansion in in- spiration ; and, if the pain is severe, the inspiratory murmur is rather suddenly arrested before completion, but if the pain is slight there will be no change in this respect. During the first two or three days, there will be audible on auscultation a sound due to the rubbing to- gether of the roughened surfaces of the pleura — a friction or to-and- fro ridjibing sound — synchronous with the respiratory movements, and ceasing when they are arrested. If strong and loud, this friction- PLEURITIS. 309 sound produces a vibration of the chest-walls, or fremitus, which is recognizable on palpation. Dry pleurisy terminates in two ways — by resolution, or by adhesion. "When resolution takes place, the pain and fever subside, and the friction murmur gradually lessens, and finally disappears. At the apex, the friction murmur modifies into a leather- creaking sound, persists, and may be confounded with the crackling rales which accompany the first stage of tubercular deposition — a mis- take all the more likely, since pleuritic attacks are invited to the apex by the irritation of tubercle. Dry pleurisy occurs at the side and base of the thorax. This is the origin of the adhesions found after death, consisting of firm, strong bands of connective tissue, and which excited no symptoms that attracted attention. These bands often do serious mischief by limiting the movements of the lung. Acute pleurisy with effusion, the ordinary form, sets in as any other acute inflammation, with chill, general malaise, and fever, with pain in the side ; or there is in other cases, for several days, a daily paroxysm of fever, but without any local symptom for the first few days ; or, again, there are cases in which pain in the side and effusion have preceded the febrile movement. Less often than pneumonia is pleurisy announced by a decided chill ; more frequently there is chilli- ness recurring irregularly for the first few days. The fever which follows is a continued fever, Avith an evening exacerbation, and con- tinues up to the beginning of the effusion, or about eight days, with little variation. If there are rigors occurring every day, although irregularly, and persist, it is probable that the effusion is purulent, or that the pleuritis is tubercular. The type of fever is not peculiar to the disease, and is not therefore diagnostic ; the temperature does not often exceed 104° Fahr., and ranges from 101° to the former point. The pain is usually acute, lancinating, circumscribed, and is increased by breathing, coughing, or abrupt movements of the body. It is felt in the outer and inferior portion of the mammary region, sometimes at the base of the thorax, occasionally in the lumbar and iliac junction, and over a space which may be covered with a finger or two. It is commonly designated "a stitch in the side." Instead of being cir- cumscribed, it may be diffused and ill-defined. The duration of the pain is variable ; it may cease in three or four days ; it may reappear after having ceased for a time ; it may persist throughout the attack, and so long as it is present it affords evidence of the persistence of the inflammation. The severity and tenacity of the pain indicate the vio- lence of the disorder. Dyspnoea is also a prominent symptom in pleuritis. Several factors are concerned. When the pain is severe, the inspiration is suppressed, shallow, and frequent ; hjematosis is ac- cordingly impaired, and respiration is embarrassed from this cause. Fever, by increasing the waste of tissue and the excretion of carbonic acid, augments the necessity for oxygen. When effusion occurs, the 310 DISEASES OF THE RESPIRATORY ORGANS. respiratory field is narrowed, and mechanical difficulties are created by the pressure. The decubitus of the patient is highly characteristic. Before effusion has taken place, the position on the sound side is easier, for, as Traube has pointed out, the blood gravitates from the diseased side, and thus relieves the nerves of pressure ; but, when the effusion begins to compress the lung, the position on the diseased side becomes the easier. When there is extreme pressure, the patient can not lie down, and hence seeks rest in the semi-erect posture. More or less cough is present in pleuritis, and from the beginning. It is a sup- pressed cough, and is arrested in the act of inspiration by the catching pain in the side, and is again suddenly arrested in the explosion on ac- count of the pain given by the shock. When effusion comes on, the cough declines, but when there is considerable effusion cough is in- duced by the attempt to take a full inspiration, or by change of posi- tion. The expectoration consists only of a little frothy mucus, unless bronchitis coexists, which is not unusual. As there are anorexia and more or less interference with digestion in all febrile diseases, the waste of tissue proceeds rapidly — on one side insufficient supply, on the other increased oxidation. Emaciation, loss of strength, with the accompanying depression of the nervous system, are prominent among the objective symptoms in pleuritis. The countenance has an expres- sion of weariness, anxiety, and exhaustion, and may be pale or cya- nosed. The cyanosis is present if there is much orthopnoea ; but there may be more or less pallor, possibly significant of hsemorrhagic pleuritis, especially if it occurred suddenly. The urine is scanty, high- colored, has high specific gravity, and deposits urates abundantly. Although the rational symptoms of pleuritis are very significant, they are not so precise and definite as the physical signs. Having described the former, we will now take up the latter. On inspection, the movements of the affected side are seen to be restricted, to be sud- denly arrested, and with an expression of pain. When effusion is present, an enlargement of the affected side is discerned ; the inter- costal spaces are less concave, are elevated to a level of the ribs, even rise above them, and no movement takes place in respiration, while the healthy side is abnormally active. On palpation, the absence of vocal fremitus is a very important and significant symptom. The fremitus of the voice is lessened as the effusion rises, to be entirely absent when the chest is distended. On the sound side the vocal fremitus is exag- gerated. When the effusion is large, on palpation there maybe fluctu- ation detected in thin subjects ; by tapping one side smartly, a wave traverses the liquid and is felt on the opposite side. The character of Xh^ percussion-wot^ is much affected by the quantity of liquid present. When there is a moderate amount of effusion, the tension of the lung is increased and consequently the note is high-pitched, rather hard, and having a distinct tympanitic quality. The tympanitic and high- PLEUEITIS. 311 pitch quality of the note is pai'ticularly evident on percussion of the infra-clavicular region, while the note becomes deeper and harder over the inferior and dependent parts where the effusion gravitates. So different are the pitch and quality of the percussion-note in the infra-cla- vicular region of the diseased and the healthy side, that, if the examination be carelessly made, the latter region, having none of the tympanitic quali- ty, will appear to be diseased. When the fluid accumulates so that the lung is covered by a layer of fluid, two inches in depth, the percussion-note will be dull all over the chest, except at the sterno-clavicular articulation, where the note will still be high- pitched and tympanitic, although somewhat dull. There will be abso- lute dullness over the whole of the affected side, except j)osteriorly over the root of the lung, when the cavity is full and the lung flattened against the spinal column. Exception should also be made of a jjoint correspond- ing to the junction of the second rib with the sternum, where a tym- panitic note—le bruit de pot /e/e— indeed, is obtained by vibration of the column of air in the primary bronchus and trachea ; but in both situations a high pitch and hard quality are the characteristics, if the lung, is entirely flat provided the percussion be lightly made, so as not to develop the tympanitic quality obtained from the trachea and bron- chus. The value of the percussion-note is increased by the absence or presence of a sense of resistance. When there is fluid in the thorax, the sense of touch receives a different impression from that produced by the normal condition. The diagnosis of effusion in the left thoracic cavity is much facilitated by an attentive examination of the character of the dullness in the left hypochondrium. Owing to the shelving mar- gin of the lung, but especially to the proximity of the stomach and large intestine, the inferior portion of the left lung returns a rather higher pitched and tympanitic note on percussion than the portion above. This space is about two to three inches in width at the lateral border of the chest, narrowing to nothing at either extremity. When fluid forms, the diaphragm descends by pressure, and this space is gradually encroached on, and in the case of large effusion disappears. In the first stage of pleuritis the respiration is jerking, and on the affected side the lung is imperfectly filled with air. On aiiscidtcUion these Fig. 22.— Limited Effusion and much Fibrin- ous Exudation. (Da Costa.) 312 DISEASES OF THE RESPIRATORY ORGANS. characteristics of the breathing are ascertained — inspiration has a catching or jei'king impulse, and hence the inspiratory vesicular mur- mur is feeble, because the lung can not be filled with air. When the membrane becomes rough, a rasping, grating murmur, audible with both insiDU'ation and exjjiration — a to-and-fro friction murmur — is pro- duced ; it is synchronous with the respu-atory movements and ceases when they are arrested. It may be so loud and strong as to produce a friction fremitus, and to be heard away from the chest-wall. It be- comes feeble as the effusion increases, and then disappears, to recur again for a short period after the fluid is absorbed. With the increase of the fluid in the chest, the vesicular murmur becomes more and more feeble and then ceases, and, when it is no longer audible at the base, may be heard above the line of effusion and of dullness. When the lung is compressed but the bronchi are still permeable, and the body of fluid not too great, the breathing has the bronchial character, and has no vesicular quality. When the lung is flattened against the spine, no breathing-sounds of any kind remain. Similarly, hronchial voice, or 'bronchophony, is audible from the still pervious bronchial tubes, as is the bronchial breathing, but this ceases as the correspond- ing breath-sound does, and no voice-sound remains, ^gophony, or goat's voice, is a modification of bronchial voice supposed at one time to be produced by the vibrations of a rather thin stratum of fluid, interposed between the chest- wall and the lung, but it is now regarded as a simple modification of broncophony. With the disappearance of the effusion the lung expands, and there is a gradual diminution of the dullness, until the percussion-note becomes normal and the resistance declines correspondingly. The vocal fremitus is restored in the same order. The voice and breath sounds are at first bronchial, then gradu- ally become vesicular. As the bronchial voice and breath-sounds be- come audible, the friction-sound appears and continues up to the full restoration of the vesicular. Besides the friction to-and-fro sound, there are often heard, after the disappearance of the liquid effusion, coarse, creaking, grating sounds, which appear to be produced by the stretching of bands of adhesion, or the rubbing together of the large masses of solid exudation yet remaining for absorption. The author has witnessed the development and gradual disappearance of these sounds, during many months after recovery. Besides these sounds, rales, rather coarse, sub-mucous, and sub-crepitant, are audible during the process of absorj^tion, and were supposed to be due to changes in the pulmonary parenchyma, but are now known to be produced by the opening up of tubes long compressed. Besides these, rdles are present in cases of acute pleuritis, because of an accompanying bronchitis. Course, Duration, and Termination. — Pleurisy does not pursue a defined course, nor does it terminate in crisis, which is the normal mode for pneumonia, but under favorable circumstances the develop- PLEURITIS. 313 ment is gradual, and the return to health is by slow stages. Begin- ning in some one of the modes described, the fever regularly increases for the first four or five days, and then continues for 'eight or nine days pretty constantly at a uniform height. Then comes the period of effusion, when the temperature falls, the pain subsides, and the dyspnoea diminishes unless there is a large effusion, when the diffi- culty of breathing is proportional to the amount of comj^ression to which the lung is subjected. The length of the time the effusion continues at its maximum varies from one day to five. The absorp- tion may take place quite rapidly at first, but it does not continue at the same rate after the first two or three days. The reason is, prob- ably, because the liquid part of the exudation is more easily disposed of, the solid portion needing to undergo a fatty transformation to fit it for absorption. The rate of absorption is measured by the gradual return of the normal sounds, by the diminution of the dullness, and by the movement of displaced organs to their proper positions. The changes in the condition of the inflamed parts are represented in the improved appearance, better appetite, and increasing strength. A marked change takes place in the urinary secretion, which becomes more abundant, less highly colored, and contains for a brief period cast-off eiDithelium and a trace of albumen. The absorption of the last part of the exudation is exceedingly slow, and months, even a year or two, may elapse before the physical signs indicate complete restoration. The return toward health is often interrupted by fresh attacks of inflammation, by a new outpouring of effusion, by an acces- sion of fever and respiratory disturbance. Additional inflammation of the pleura and of the neo-membranes arrests the process of absorption, depresses the vital forces, and prepares the way to the chronic state, yet it sometimes happens that the new excitement awakens renewed activity in the process of absorption, which goes on more rapidly afterward. If, after the twenty-fifth to the thirtieth day, there is no appreciable diminution in the state of the effusion, the acute stage ends and the chronic begins. It maybe that the effusion remains stationary, and the general condition continues good ; in other cases grave symptoms may arise, the temperature may increase, and in a day or two attain to the maximum of the first two weeks, or pass beyond it ; rigors may occur irregularly, followed by paroxysms of fever and sweats ; the countenance becomes anxious ; the tongue dry ; the depression great — without there being any change in the extent of the effusion or any new complication. This grave change in the condition of the patient is due to the purulent transformation of the exudation. It has already been indicated that the exudation may be purulent from the beginning, and that under these circumstances the symptoms have at the outset the septicaemic character above described. The termination is in resolution; in the chronic form ; in death. The 314 DISEASES OF THE EESPIRATORY ORGANS, average duration of an acute, uncomplicated case is two to four weeks. Death may occur within the first two weeks, in the so-called fulminant form, or, when there is a very extensive sero-fibrinous efi^usion causing fatal syncope, most probably by compression of the great venous trunks, especially of the ascending vena cava, which may be twisted and its lumen obstructed by displacement of the heart. Again, oedema of the sound lung may suddenly ensue as a result of compression of its fellow, and cause death. An early recovery from pleuritis with effusion signifies that the effusion must have been of small extent. Any large inflammatory effusion, especially if the solid portion of it is considerable, must require a long time, months certainly, to dispose of it entirely. Chronic pleurisy is an outcome of the acute disease, or it occurs primarily. It differs from the acute merely in the severity and chro- nicity of the symptoms. The fever is slight, the pain is not severe, but yet extensive changes will take place in the pleura. When the characteristic anatomical alterations have been effected, there will be fever of the septicaemic type. The rational and physical signs are the same as those of the acute form. The duration of the cases varies from two or three months to several years. Attempts at absor2Dtion going on favorably may be stopped by a new inflammation of the pleura, and of the neo-membranes with more effusion. An effusion that has remained stationary for a long time may, unexpectedly, un- dergo absorption by reason of the development of vessels in the new formations. But a cure by absorption is rare ; there are usually incom- plete absorption, retraction and deformity of the chest, and permanent displacement of organs, or an external fistula, occurring spontaneously or resulting from an operation, may produce a favorable result com- paratively. Without the operation of paracentesis, chronic pleurisy usually proves fatal by tuberculosis, by purulent infection, or by pene- tration of the pus into neighboring cavities, etc. Complications. — The inflammation may extend by contiguity, and attack the pericardium — a not uncommon complication. There will occur a fibrino-serous exudation, often of considerable extent. The lung may be involved, but pneumonia is rather a coexisting disease — pleuro-pneumonia — than a complication. It is important to note that the lung on the sound side may be affected by oedema, a complication which adds immensely to the gravity of the case. Not only is the organ oedematous, but it usually presents patches of commencing pneu- monic infiltration. The importance of pleuritis as a cause of phthisis is hardly sufficiently recognized, in inducing tubercular deposit, and by adhesions limiting the movements of the organ, and thus inducing disease. Diagnosis. — The most important difficulties in diagnosis are expe- rienced in the differentiation of pleurisy with effusion from conditions PLEURITIS. 315 in which the hing is solidified or is displaced by tumors, cysts, etc. Pleurisy is distinguished from croiq^oiis jmezimonia by reference to the rational and physical signs. Pleurisy begins by chilliness, which persists for several days — pneumonia by a severe rigor, rarely two ; the pain in pleurisy is a stitch, a lancinating pain, which can be cov- ered by the finger — pneumonia by a sense of soreness and pain much more diffused ; the fever in pleurisy is continuous — in pneumonia there is a distinct crisis or lysis, somewhere from the fifth to the eleventh day ; the duration of pleurisy is indefinite — of pneumonia self -limited ; the expectoration in pleurisy is simply frothy mucus — of pneumonia, rusty or bloody ; in pleurisy the vocal fremitus is absent — in pneumo- nia it is not only present but exaggerated ; in pleurisy there is a fric- tion-sound, no crepitant rale, and the bronchophony is not so well defined — in pneumonia there is no friction-sound, the crepitant rctle is present, and broncophony is loud and clear ; in pleuritis there is more decided dullness, the intercostal spaces are pushed out, the thorax en- larged — in pneumonia the percussion-note is not so flat, the intercostal spaces and the size of the thorax remain normal ; in pleuritis the organs are displaced ; in pneumonia the relation of the organs is un- affected. Finally, the subsequent behavior of pneumonia and pleuritis leaves no room for doubt. An abscess of the liver pushing up the diaphragm, or an echinococcus-cyst growing in the same direction, of suflicient size ,to displace the lung in the same way, will cause the physical signs of an effusion into the thorax, and the diagnosis is pos- sible only by a careful study of the history, which is entirely different in the two affections. A tumor or cyst of the chest will produce dull- ness on percussion, displace organs, and, by compressing the lungs cause the disappearance of the voice and breath sounds. The differen- tiation is to be made by reference to the history of the cases, by the situation of the dullness toward or about the central and superior parts of the chest in tumor — the inferior part of the chest in effusion ; by the general and symmetrical bulging of the chest-walls in effusion, the circumscribed and irregular bulging caused by tumor ; by the absence of vocal fremitus in pleuritis — its exaggeration in cases of tumor. Although the withdi-awal of the fluid is the only certain means of arriving at the nature of the effusion, there are signs by which we may approximate with considerable accuracy to a correct diagnosis. If, during the acute stage, the fever running high, the effusion pouring out rapidly, there suddenly ensue great pallor, weakness, and depressed temperature, followed after some hours by rise of temperature even higher than before, a haemorrhage has probably occurred ; or, if during the chronic stage there are recurrent attacks, and the above-described symptoms occur, the case is not only hemorrhagic, but the underlying morbid process is tuberculosis. If the case is characterized from the be- ginning by repeated rigors, occurring irregularly, and followed by 316 DISEASES OF THE RESPIRATORY ORGANS. paroxysms of intense fever and sweats, the exudation is purulent ; if during the course of an ordinary attack of sero-fibrinous pleuritis, the same septicaemic symptoms arise, the exudation has been transformed into the purulent. Treatment. — The author wishes to protest at the outset against that revival in the belief of the aplastic power of mercury, and the return to its use in the treatment of serous inflammation, which is taking place in Germany, and finds expression in Ziemssen's " Cyclopaedia. " * It has been definitely shown that, during the course of acute mercu- rialismus, an attack of pleuritis or inflammation of some serous mem- brane is apt to occur in consequence of morbific matters circulating in the blood. Unless it be established that this effect of mercury is substitutive, there is no ground for its employment, and certainly the experience of English physicians is opposed to the practice. As soon as the pleuritic inflammation begins, and the pain is a good indication, the patient should receive a full dose of quinia and morj)hia (3 j quinia and gr. ss. morphia for an adult), and the effect of this should be maintained by the repetition of smaller doses (gr. v quinia, ■J gr, morphia) every four hours. If the stomach is irritable, the mor- phia can be administered subcutaneously, or, if the pain is very acute, this mode of administration is more effective than by the mouth. Be- sides the power of morphia to relieve pain, it is an effective remedy in serous inflammation. The combination which was so much employed formerly (calomel and opium) owed its virtues to the opium. If there be much fever — a strong pulse and elevated temperature — and the stomach not irritable, digitalis may be combined with the quinia and morphia — one grain every four hours. If the subject be plethoric, a dozen cups or leeches, drawing six ounces of blood, can be applied with advantage. The old plan of bleeding ad deliquum animi or until the pain ceased was a powerful and certain means of relieving pain which has been rightly abandoned, but the local bloodletting is of service. Mustard-plasters and turpentine-stupes, as hot as can be borne, afford relief. The blood-pressure can be reduced also by active purgatives, of which the salines are best. When the exudation is poured out, a dif- ferent plan will be necessary. The only agents which possess the prop- erty of dissolving an exudation are the alkalies, and the most efiScient of these is ammonia. Carbonate of ammonia can be best given in a solution of the acetate (gr. v — x in 3 ss. — 3 j). They should take the place of the quinia and morphia. Absorption will be much aided by keeping up free outward osmosis through the intestinal mucous mem- brane by saline laxatives. The same process can be carried on through the skin by the use of jaborandi or its alkaloid, pilocarpine. This should be administered once or twice a day, but its action on the heart should * Vol, xiv, p, 685, and elsewhere. PLEURITIS. Sl'^r not be forgotten, and care exercised if there be disj)lacment of this organ, especially if there be a twist in the vena cava. The best mode of administering jaborandi is the hypodermatic injection of its alkaloid, pilocarpine — -g of a grain of any of the salts. As the pouring out of 60 much fluid, the waste of tissue produced by a high temperature, and the interference with assimilation caused by the disordered diges- tion, rapidly impair the vital forces, it is important, by proper food- supply and the judicious use of stimulants, to obviate the asthenia. When, however, a large effusion exists, especially if purulent, it be- comes necessary to remove it by the operation of thoracentesis. Even if absorption may eventually succeed in disposing of the fluid, there is great danger that the lung will not be in a condition to expand again fully, and retraction and deformity of the chest will be the result. If the effusion be purulent, absorption can not take place, and hence thoi'acentesis is indispensable. The question of how early shall thora- centesis be performed has been much discussed. It ought not to be undertaken within a few days after effusion, nor unless the symptoms of compression are urgent while the exudation is going on. It ought not to be performed if the natural powers are equal to the task of re- moving the fluid early enough to save damage to the organs concerned. These rules apply to the sero-fibrinous form of pleuritis. Thoracentesis ought to be performed in the purulent form as soon as the nature of the case is evident, for nothing is to be gained by delay. The point of election when the choice may be made is underneath the infei'ior angle of the scapula, but the needle may be inserted at any place with due regard to the position of the heart and great vessels. As regards the method of procedure, nothing has been added practically to the method of Bowditch (the real inventor of the aspirateur), which con- sists in exhausting the chest by the pump and attached needle. Al- though the admission of air does not seem to be very important, yet it is better to avoid it in cases of the sero-fibrinous, for, if subsequent operations are necessary, the effusion will become more and more pu- rulent. If this is the case, the tincture of iodine or a diluted com- pound solution can be injected with great advantage after removing the fluid (liq. iodinii comp. 3J — aquae 3 iv). This iodine injection is high- ly useful in empyema,* Precautions to avoid air are usually regarded as unnecessary in the case of purulent effusion. In those cases requir- ing repeated tapping, late experience has shown that the best results are obtained by establishing free drainage. If a sufficient opening for the drainage-tube can not be obtained in the intercostal space, exsec- tion of the rib is then necessary. The simplest of these operations should be jDerforraed with antiseptic precautions. If the pus of an empyema undergo decomposition and become foul, the cavity should * A warm solution of chlorate of potassa ( 3 j or 3 ij — j) or of salicylic acid and borax ( 3 j of each to the j), may also be used to wash out the cavity in empyema. 318 DISEASES OF THE RESPIRATORY ORGANS. be freely washed out with antiseptic precautions. Although the ad- mission of air in cases of empyema is not sought to be prevented, nevertheless the air should be deprived of its germs of putrefaction. As death has occurred several times very unexpectedly after the op- eration of thoracentesis, certain precautions are necessary. When the effusion is large, the whole amount should not be withdrawn at once, for the sudden removal of the pressure might induce a quick outpour- ing of fluid, or the great vessels, relieved of pressure, would over-dis- tend the right cavities, or the heart, moving from its position, might cause compression of some of the vessels. Sudden death might very unexpectedly be caused by any of these accidents, notwithstanding the operation of thoracentesis is simple, not painful, and is free from danger. After the removal of the liquid exudation by absorption or by thoracentesis, a quantity of solid and semi-solid remains behind and is very slowly transformed. A succession of flying-blisters, paint- ing with the tincture of iodine, and friction of the affected side with ointment of the red iodide of mercury, are the most effective external or topical applications. The best results are obtained, not from the use of supposed stimulants of the absorbents, but from means to promote the nutrition. The iodide of iron (sirup), cod-liver oil, extract of malt, and a generous diet, the digestion stimulated by bitters and min- eral acids, are the best means for increasing absorj)tion. The amount of fluid taken should be reduced to the mir^jmum ; for, although the restrictions imposed in a " dry diet " may be too rigid for ordinary patients, yet they can submit to a considerable reduction of the fluid. Absorption is promoted by lessening the water of the blood, which can be accomplished by saline laxatives and Jaborandi. The laxatives should not be given so as to interfere with digestion, and a daily dose of jaborandi can be so administered as not to interfere with the appe- tite or exercise. To procure complete distention of the lung, and to promote the oxygenation of the blood, compressed air should be inhaled daily, or a sojourn in an elevated, dry mountain-region should be en- joined. Although we may not agree wath Dr. Leaming, of New York, in the importance of pleuritic exudations as a factor in phthisis, we must admit that they -exercise some influence in initiating the jsrocess of tuberculosis. HYDROTHORAX— DROPSY OF THE CHEST. Definition. — By the term hydrothorax is intended an accumulation of watery fluid in the chest. It differs from pleuritis in the character of the fluid and in the state of the pleura. In pleuritis the effusion is an inflammatory exudation, and the pleura is the seat of an inflamma- tion ; in hydrothorax the fluid transudes — a merely physical process — and the pleura is unaffected except by maceration. HYDROXnORAX. 319 Causes. — The various conditions giving rise to general dropsy will cause hydrotliorax — cai'diac and renal diseases. Local obstruction to the course of the circulation produces pure hydrothorax, i. e., hydro- thorax not a part of a general dropsy. The most important of these local causes are emphysema and sclerosis of the lung, tumors so situ- ated as to compress the vena cava, vena azygos, the right auricle, etc. A general dyscrasia may induce hydrothorax, as Bright's disease, chronic malarial poisoning, etc. The most influential factor is the condition en- titled by the older authors latent pleurisy. In this malady there is a state of the pleural membrane closely allied to pleuritis — to that form known as dry pleurisy ; but instead of a plastic exudation there is an abundant outpouring of serum. Pathological Anatomy. — When the hydrothorax is due to any of the causes producing general dropsy, the effusion is bilateral, but usu- ally more abundant on one side. There will be found associated with the hydrothorax the anatomical changes in the lungs, heart, and kid- neys, proper to the particular form of dropsy. The fluid has a pale sea-green color, is transparent, and frequently coagulates on exposure to air, the coagulation consisting in the formation of an excessively fine reticulation of the minutest fibers. In the case of the so-called latent pleurisy the membrane is thickened, congested, and coated usually with a pellicular exudation, portions of which are, to a greater or less extent, floating in the fluid. The amount of serum present is from half a pint to two or three gallons. The effect of the fluid on the posi- tion of the heart and other organs is precisely the same as in pleuritis. The retraction of the lung and its subsequent compression also take place, as in pleurisy, except that it occurs more regularly. Symptoms. — In latent pleurisy, so called, there is some pain felt in various parts of the chest, but it is not acute and well defined as in pleurisy. It is usually situated in the side, and is a rather dull, ten- sive, heavy pain, or a feeling of soreness. It is increased by a full inspiration, or by coughing, but is not so severe as to interfere with daily duties ; and it is often transient, and makes so little impression on the mind as to be forgotten until attention is directed to it. There is some feverishness toward evening, but not much attention is paid to it, and hence it is usually overlooked. The cough may be rather trou- blesome, especially on lying down, but the expectoration is nothing more than frothy mucus. Often these symptoms pass unnoticed, and the first thing which attracts attention is an increasing difiiculty of breathing. In the cases of hydrothorax pure, without plem-al inflam- mation, there is no fever, nor pain in the side, and the first symptom referable to the thorax is difiiculty of breathing greater than in pleu- risy, because the effusion is on both sides. In latent pleurisy, the left side of the thorax is involved in two thirds of the cases ; consequently the heart is pushed over to the right, and the semilunar space is oblit- 320 DISEASES OF THE RESPIRATORY ORGANS. erated. In hydrotliorax there is no displacement of the organs, be- cause of the effusion on two sides and in the abdominal cavity. The physical signs are much the same in hydro thorax as in pleurisy ; but in .the former there can not be that complete filling of the cavities, and hence there must be a considerable space of both lungs where the voice and breath sounds remain unaffected. Furthermore, in hydrothorax, there being no limitation of the eff usio n by neo-membrane and by ad- hesions, the fluid gravitates with the changes of position, and the area of dullness shifts accordingly. The course, duration, and termination of hydrothorax are those of the disease on which it depends. The formation of a large effusion in the chest adds to the severity of the case, and is not unfrequently a cause of death. This is especially true of dropsy, whether cardiac or renal. The hydrothorax is a source of extreme distress when it may not prove fatal, for the patient is unable to lie down, or to make any muscular effort without experiencing a suffocative attack. The author has witnessed a case of sudden death from hydrothorax in an aneurism of the arch of the aorta which was solidifying. The behavior of latent pleurisy is that of the sero-fibrin- ous form of acute pleurisy, when sufficient fluid has accumulated to produce symptoms by compression. Treatment. — If there is large effusion, delay is unsafe and thora- centesis should be promptly performed. As serum will flow through a fine capillary needle, but little pain and no danger attend the opera- tion of aspiration. If the effusion is not sufficient to produce distress by pressure, the treatment is directed to the condition on which the dropsy depends. The treatment for latent pleurisy is the same as for acute pleurisy with effusion. As the inflammatory symptoms are usu- ally overlooked, the physician is not consulted until the difficulty of breathing comes on, and then the sole question is, aspiration or not. The rules for guidance are the same as those already laid down. PNEUMOTHORAX— HYDROPNEUMOTHORAX. Deflnition. — The presence of air in the cavity of the thorax is cSiWed pneiwiothorax/ of air and fluid, liydropneumotliorax. Causes. — Air or gas of any kind is rarely present in the cavity without liquid, and if air alone should enter an exudation would soon be excited. It is now settled that a serous membrane can not secrete air, and that, therefore, if air be found in the cavity of the pleura, it came there from without, or is a gas the product of decomposition or fer- mentation. Almost always it enters from without by perforation of the pleura, by the lung, or by the wall of the thorax. The most fre- quent mode of entrance of air is the giving way of a superficial cavity of the lung, tubercular or caseous. Very rarely the air passes through a communication made by a gangrene patch, or a hremorrhagic infarc- PNEUMOTHORAX. 321 tion, and still more rarely by the giving way of emphysematous alveoli. Abscesses of the liver ulcerating through the diaphragm may form a secondary purulent collection in the pleural cavity, which may com- municate through the lung with a bronchus, constituting pyopneumo- thorax. One of the modes of termination of a purulent pleuritis is by a fistulous passage to a bronchus, through which air is admitted to the pleura. Suppuration may occur in neighboring organs in a way to involve the pleura and some outlet, as — suppuration of bronchial glands, bursting into the pleura and ulcerating into a bronchus ; ab- scesses of the liver or of the kidney, perforating the diaphragm and the lung, etc. Traumatism is an important factor, pyopneumothorax being caused by penetrating wounds, incised or gunshot, the air enter- ing from without. Pathological Anatomy. — The accumulation of air in a given case is much influenced by the formation of the orifice of communication. If the entrance is easy and the exit difficult, a very large amount of air may accumulate, and very often a sort of valvular arrangement, a fibrinous flap or plug, may exist at the orifice which has this effect. The lung quickly retracts until there is an equilibrium of the pressure; com^Dression is then exerted on it if the orifice is such that the air which entered without obstruction can not escape. The quantity of air which can be contained in the cavity depends on several conditions: on the compressibility of the lung, which may be slight owing to so- lidification by caseous or tubercular deposits ; the degree in which the other organs can be shoved aside ; the amount of liquid present, etc. It is a mixture of gases, not air, usually found in the cavity — of nitro- gen and carbonic acid, and but little oxygen, with some sulphuretted hydrogen if there be unhealthy pus present. If atmospheric air en- ters, the pleura inflames, and sero-purulent, then purulent exudation is poured out. As air contains the bacteria of decomposition, it is probable that their entrance is sufiicient to excite purulent inflammation ; but, as, in pneumohydrothorax, ichorous, ulcerating, or decomposing materials pass in under the usual circumstances, these play a more active part in exciting inflammation than the air and its contained germs. The ex- udation which results from the action of these noxious matters is pu- rulent, often ichorous and bloody. The gas is contained in the space above the liquid, and the lung, having had the air squeezed out of it, lies flattened against the spine, unless old and firm adhesions resist the compressing forces. If there be much fluid, that side of the thorax will be enlarged, the intercostal spaces prominent, the diaphragm de- pressed, the heart pushed aside, etc. In some rare instances adhesions form in a circle between the two pleural surfaces, making a central cavity in which gas and fluid will accumulate to a large extent, a fistu- lous communication having been established with a bronchus. Symptoms. — Pneumothorax is to be studied in connection with the 31 322 DISEASES OF THE RESPIRATORY ORGANS. diseases from which it arises. It may develop insidiously, so that it is discovered only on making physical examination of the chest. Bnt, when a perforation occurs suddenly, pronounced, even formidable, symptoms are at once produced. Perforation may be announced by a condition almost of collapse, a temperature of 97° Fahr., and a small, weak, but very rapid pulse. If the temperature does not descend so low, the pulse is weak and rapid, and the resjjirations are hurried — the former reaching so high as 140, the latter up to 40, even 60. At the same time dyspnoea sets in with orthopnoea, and a severe pain, due either to sudden stretching of the pleura or tearing apart of adhesions. In other cases, for example phthisical subjects, none of these severe symptoms are produced, probably because narrowing of the respiratory field has been going on so long as to prej)are them for this additional discomfort. The decubitus varies, the largest number seeking a posi- tion on the diseased side to permit the freest possible play of the healthy lung ; but a considerable proportion lie upon either side, al- though, when air first entered the cavity, orthopnoea Avas experienced by Fig. 23. — Hydropneumothorax. most of the cases. The dyspnoea is due to several causes — to sudden compression of the lungs and the heart, and to a compensatory conges- tion, often with oedema of the other lung, whence the expiratory force is lessened and the voice weak and trembling. Cyanosis appears if PNEUMOTHORAX. - 323 there is mucli difficulty of breathing, the surface becomes cold and covered with a cold sweat, the tongue is blue and cold, and death soon closes the scene ; or, if life continues, general oedema supervenes from the venous stasis, while the arterial tension is low from ischsemia of the arteries. The lessening of the expiratory force makes the cough weak and ineffectual, and the expectoration diminishes. The low state of the arterial tension affects the urinary secretion, which is dense and red, with traces of albumen. The vocal fremitus may be present, di- minished, or absent, in pneumothorax — present when there are strong bands of adhesion which communicate the vibrations to the chest- walls ; diminished when the lung is not entirely collapsed ; absent when the cavity is distended with gas. On palpation, also, increased resistance will be noted while there is fluid, and increased tension with diminished resistance where there is gas. The percussion-note is char- acterized by its marked tympanitic quality, resonance, and elasticity. The resonance is not limited to the part containing air, but extends downward to the lower margin of the ribs, extinguishing the hepatic dullness in its usual limits, and the semi-lunar space on the left side, and also extends across to the middle of the sternum. A peculiar metallic echo may be developed on strong percussion. Percussion over the fluid produces the usual dull sound which sharply contrasts with the metallic clang of the percussion over air, and the dullness here varies with the position of the patient and follows the gravitation of the liquid. The character of the percussion-note is affected by several cir- cumstances : when thick, false membrane lines the thoracic wall it acts as a damper, and there is much less of the tympanitic and metallic quality ; when an external oj^ening exists, there will be produced the cracked-pot sound. On auscultation, there is no respiratory sound, ex- cept a modified, amphoric, blowing sound. All of the sounds audible in the chest — cough, rales, heart-beat, etc. — take on a distinct metallic quality. The dropping of fluid, or coughing, or movements of the body, produce under these circumstances metallic tinMing. But the most characteristic of the physical signs is succussion — a splashing of the liquid against the walls of the chest, produced by a sudden shake of the body. It is best heard by applying the ear to the chest, and then suddenly shaking the body by the hand placed on the patient's shoulder. The patient often recognizes this sound, and soon learns the best movement to produce it. It is like the splashing of liquid in a half-empty barrel. Course, Duration, and Termination. — The course of pneumothorax is much influenced by the associated lesions and the extent of the pul- monary insufiiciency. If, alreadj'', the respiratory field is much nar- rowed, death may ensue in a few hours or days. Death is more fre- quently produced by the secondary pleuritis and its products, causing slow failure of respiration after some weeks. A cure is not to be ex- 324 . DISEASES OF THE RESPIRATORY ORGANS. pected in cases, the most numerous, due to perforation of a superficially placed cavity. Pneumothorax resulting from an incised wound in a healthy subject may get well after some weeks. A perforation occur- ring in the first stage of phthisis is not so important as one occurring later, and a cure is possible in the former before the constitutional forces are much depressed by the progress of the phthisis. A pneumo- thorax, produced by the discharge of a purulent pleuritis by a bronchus may get well after some months. It may be stated in general that the prognosis of pneumothorax is unfavorable, since very few cases get well even in the modified way of a permanent fistula. Diagnosis. — Pneumohydrothorax may be confounded with the large caverns of phthisis, with dilated bronchi, with emphysema, with pleuritis having limited effusion. Vomicae are confined to the upper part of the lung, have formed slowly without any sudden symp- toms ; they present amphoric sounds and metallic tinkling, rarely suc- cussion ; vocal fremitus is not lessened ; the chest-walls are retracted instead of distended, and the heart is not displaced. In pneumo- hydrothorax, loud, deep, tympanitic percussion-note is obtained all over the affected side ; the symptoms have occurred suddenly, and consist of severe pain, dyspnoea, and orthopncea ; well-marked suc- cussion ; vocal fremitus lessened or absent ; the intercostal spaces bulging instead of retracted ; heart and other organs displaced. Em- physema is bilateral ; the respiratory murmur not absent ; bronchial rales audible all over the chest ; vocal fremitus present. Pneumo- hydrothorax is unilateral ; the respiratory murmur entirely absent, and all voice and breath sounds and rales from the affected side want- ing when the lung is collaj)sed ; vocal fremitus absent. In pleuritis, with effusion, the percussion-note has a tympanitic quality in the infra-clavicular region ; the dullness on percussion changes with the positions of the patient, and corresponds to the height of the liquid; an amphoric murmur is exceptionally audible over the root of the lung and at the summit ; with the increase of the distention of the chest, there is absolute dullness over the whole side ; no metallic tinkling, no succussion. In pneumohydrothorax, the percussion-note has a loud, ringing, tympanitic quality all over the chest, instead of a modified normal at the infra-clavicular region, and this tympanitic note is not supplanted by absolute dullness ; there are metallic tinkling and suc- cussion in perfection. Treatment. — As respects the condition associated with pneumo- thorax and pneumohydrothorax, the treatment is indicated under the head of these maladies, and need not now be discussed. If there are much dyspnoea and danger of acute asphyxia, no time should be lost in making a free opening to permit the exit of air. The pyopneumo- thorax is to be treated by incision and the drainage-tube, and the use of antiseptic injections, of which iodine appears to the author to be PNEUMONIA. 325 the best. The severe pain requires the use of anodynes, unless the free exit of air procured by incision relieves the distress. The con- gestion and oedema of the sound lung may be relieved by ligatures to the thighs, by which a considerable quantity of venous blood can be retained in the lower limbs long enough to bridge over the period of danger. This expedient is preferable to bloodletting, which has been recommended for this purpose. PNEUMONIA— PNEUMONITIS— INFLAMMATION OP THE LUNG. Definition. — Pneumonia, an acute inflammation involving the alveoli of the lungs, is designated by the German writers " croupous pneumo- nia," and by the French writers " fibrinous pneumonia." " Catarrhal pneumonia" differs from the fibrinous or croupous form in the seat and character of the inflammation. It attacks the capillary tubes im- mediately next the alveoli, and is a catarrhal instead of a croupous inflammation. The so-called lobular pneumonia is nothing more than catarrhal pneumonia, the changes in the lobules being secondary to the catarrhal process in the ultimate bronchi. Lobar pneumonia is a fibrinous or croupous pneumonia occupying and confined to a lobe. Pneumonia is also known in common language as " lung-fever," " win- ter-fever," etc. Causes. — There is a growing belief that pneumonia is a constitu- tional disease, like typhoid or relapsing fever. It differs from other inflammations in that it is self -limited, and terminates by crisis. It is a very common disease ; it occurs in all degrees of latitude, under every variety of climate, and at all ages. It is common in infants at the breast, but declines somewhat after the second year until after the second dentition, and is frequently encountered and is very fatal in the old. The masculine sex is most frequently attacked, because men are more exposed than women to those external conditions which tend to produce it. In-door life, a vitiated atmosphere, excesses, especially alcoholic, and bad hygienic influences of every kind which induce de- bility, favor attacks of pneumonia. Certain seasons appear to invite the disease — those parts of the year characterized by humidity and by variability of temperature. In the British Islands winter is the season of greatest prevalence ; on the Continent, spring ; in this country, winter and spring, the former especially — hence the name winter-fever. Occasionally, pneumonia occurs in so many persons in a particular district that it may seem to be epidemic, but there are, probably, sub- tile atmospherical influences at work to produce the disease, which elude our means of observation. It is a common belief that pneumo- nia is caused by exposure to cold, especially to draughts Avhen the body is warm and perspiring. That catarrhal pneumonia is induced in that way no one will dispute, but it is more than doubtful that 326 DISEASES OF THE KESPIRATORY ORGANS. croupous pneumonia is thus caused, unless there exist a predisposition to it, either of a vulnerable constitution or an inherited tendency to pulmonary disease. A phthisical tendency, the author believes, is the chief factor, or that peculiarity in the structure of the pulmonary tis- sue associated with consumption. There are other diathetic states concerned in the production of pneumonia — as gout, rheumatism, dia- betes, the eruptive fevers, especially chronic alcoholism. Pathological Anatomy. — The state of the affected lung in pneumo- nia is usually divided into three stages, following the orignal descrip- tion of Laennec, based on the naked-eye appearances : engorgement; red hepatization ; gray hepitization. The better arrangement, based on the description of Jaccoud,* but modified, is as follows : The stage of liypercBmia, or engorgement ; the stage of exudation (red hepatiza- tion) ; the stage of resolution (degeneration and extrusion of the exu- dation) ; the stage of purulent transformation (gray hepatization). In the stage of hypersemia or engorgement, as now described, there are two distinct and separate acts — the increased blood-supply and the pouring out of an exudation. The lung has a reddish-brown appear- ance, is heavier, floats in water, but sinks lower than the normal lung- tissue, crepitates but little when pressed, and it is no longer elastic, but when an impression is made by the fingers it is retained. On section it presents a pretty uniform brownish-red tint, and it exudes a quantity of blood. On microscopic examination the blood-vessels are found to be distended with blood, and the capillary network surrounding the alveoli is so much enlarged that the alveoli are encroached on by it. f The adjacent portions of the bronchioles are similarly en- gorged, the mucous membrane dark reddish from fullness of the ves- sels. This hypersemia marks the first stage in the inflammatory pro- cess. The next step consists in the pouring out and coagulation of an exudation. There is exuded into the alveoli an albuminous or fibrinous fluid of great viscidity, and with it leucocytes which have wandered from the vessels, and red-blood globules present by diape- desis, and blood by the rupture of distended capillaries. This viscid albuminous fluid is poured out also into the bronchioles and bronchi of the inflamed section, and with it leucocytes and some red coi'puscles. When the surfaces approximate, this adhesive fluid holds them tightly together until the incoming air separates them. In the capillaries of the inflamed area the blood-current is finally stopped, and the corpus- cles are then seen to be closely packed together and flattened at the points of contact. The albuminous or fluid exudation remains fluid for a short time, and then solidifies or coagulates, beginning in the alveoli and extending through the bronchioles outwardly. In coagu- lating it incloses the white and red corpuscles, and fills out the alveolus * " Traite de Pathologie " ; " Interne," vol. ii, p. 45. \ Rindfleiscb, op. cit. PNEUMONIA. 327 or bronchiole, probably expanding somewhat in the act of coagulation. When this process is completed, the inflamed part is solid, entirely without air, and falls immediately to the bottom when placed in a ves- sel of water ; it is also friable, is easily broken up between the fingers, but on section with the knife divides cleanly with well-defined mar- gins. The cut surface pi-esents a reddish color, and is granulated ; this granular appearance being due to the little masses of coagulated exudation filling the cavity of the alveoli. These little masses may with some care be lifted out of the mold in which they are formed and held on the point of a pin. The tissue of the inflamed part, in respect to color, density, and granular appearance, so strongly resembles the cut surface of a section of the liver as to be called by Laennec red hepatization. There are two directions which the inflammatory process may now assume : toward resolution, or return to the normal state ; toward purulent transformation. As the first is the more usual, we describe first the process of resolution. The albuminous material which had solidified undergoes liquefaction, and the pressure is thus removed from the surrounding vessels. The watery parts of the exudation dif- fuse into the vessels, and the solids, together with the cellular ele- ments, undergo a fatty degeneration, and are transformed into an emulsioned mixture without any of the viscidity of the original exu- dation, and capable either of absorption or of extrusion, much of it, doubtless, being expectorated. As the exudation liquefies, air again enters the alveoli, diffusion of oxygen into and of carbonic acid out of the blood is resumed, and the current of the circulation is fully reestablished. The effusion into the connective tissue between the alveoli and bronchioles is finally taken up, and the normal color and density are restored to the inflamed part, but its elasticity continues impaired for a long time. "When the purulent transformation takes place, a change is wrought in the density, color, and constitution of the inflamed area. It has been much discussed whether the epithelium of the alveoli undergoes any change, and contributes, by multiplication of its cells, to the exu- dation in croupous pneumonia, and whether any of the pus-corpuscles which become so abundant during the stage of gray hepatization or purulent transformation originate by proliferation of the epithelial cells. The former is denied by most authorities ; the latter is highly probable ; but the pus-cells are derived chiefly from the wandering white cells by multiplication and division. With the formation of pus-cells a process of fatty degeneration takes place in the albuminous exudation, but the rapid and exuberant formation of pus-cells is the principal event, the tissue being changed in color from the reddish- brown appearance of the red hepatization to the yellowish or grayish- yellow tint of gray hepatization. When such tissue is squeezed a 328 DISEASES OF THE RESPIRATORY ORGANS. little, a quantity of pus exudes, and the whole is easily broken up into a fatty and granular mass. Not all parts of the inflamed area are equally advanced in suppuration, some parts still preserving the red- dish-brown, with here and there a patch of yellow ; and others uni- formly grayish-yellow, and some still advanced beyond this into a yellowish, almost diffluent mass. The stroma of the lungs yet remains intact, notwithstanding the enormous production of pus-cells. In rare cases a portion of the affected tissue proceeds beyond the stage of gray hepatization, or purulent transformation ; the stroma of -the lungs yields, becomes disintegrated, and a small purulent collection is formed. A large abscess may be formed by the coalescence of several smaller ones. The collection may be bounded only by disin- tegrating lung-tissue, or the pus may be inclosed by a limiting mem- brane, or, in other words, become encysted. The author has seen a case of encysted abscess occupying a part of the middle of the right lung, which had existed for several months without symptoms. They may discharge by a bronchus, or into the pleura, or the pus of the encysted abscess may gradually undergo absorption. The termina- tion by gangrene is much more uncommon than that by abscess, and, when it does occur, signifles a most depi'aved state of the tissues. The passage of acute into chronic pneumonia is a comparatively frequent occurrence, when the disease is of diathetic origin, especially in stru- mous subjects, or when a tendency to pulmonary disease exists. When the change to the chronic form takes place, the process of retro- grade metamorphosis of the exudation preparatory to its extrusion is arrested ; the tissue appears comj^act, grayish, with here and there dark patches of j^igment ; the hypergemia has ceased, and the infil- trated liquid is absorbed. In other cases the whole of the inflamed area does not pass over to the chronic stage ; resolution takes place more or less perfectly ; the exudation is disposed of in part, but still portions remain, more or less impairing the functions of the part. In other cases the products of inflammation are transfonned into caseous matter. This change occurs when purulent transformation has taken place. The pus loses the fluid in which the corpuscles float, and these bodies become fatty, and more or less calcareous matter is mixed up ^dth the fat, the ultimate product being a soft solid, looking like and having the consistence of cheese — whence the term caseous matter. It must be stated that this termination to croupous pneumonia is re- garded by the best modern authorities as very uncommon, while it is usual to catarrhal pneumonia. All parts of the lung are not equally susceptible to the pneumonic inflammation. The statistics show that the right lung is affected alone in one half of the cases, and as regards the left nearly twice as often, or, to express the relation more defi- nitely, using the statistics of Juergensen — the right lung was affected in 53*7 per cent., the left lung in 38-23 per cent., both lungs in 8'07 PNEUMONIA. 329 per cent. The inferior lobe of the right lung is the point of election, being the seat of inflammation in three fourths of the cases. There are certain consequences which follow on a pneumonia that ought not to be overlooked. When a considerable part of a lung suddenly ceases to functionate, there must be disturbances set up in its fellow. The obstruction to the pulmonary circulation induces over-distention of the right cavities and the veins, and ischaemia of the arteries. The blood displaced from the inflamed part, and which can not circulate through it, induces hyperaemia and cederaa of the other lung. Symptoms. — There are two modes of onset : in the less frequent there has been a day or two of bronchial catarrh and general malaise, when some chilliness is experienced, pain is felt in the side, and the disease proceeds in its usual way. In the other and more frequent mode, a decided rigor is the* initial symptom — a rigor more severe than in any diseases except malarial fever and pyaemia. Elevation of temperature occurs at once, and by the evening of the first day has reached about 104° Fahr. In infants, instead of chill there may be a violent general convulsion or several of them. The duration of the cold stage is from a quarter of an hour to three or four hours, and dur- ing it the thermometer in the axilla notes some slight elevation of temperature, and in a few hours not only is the external temperature high, but the subjective sense of heat is great. The face is flushed, the eyes injected, there are intense headache, severe pains in the back, and muscular soreness in the members. The pulse is large in volume and strong in tension. There is usually a whitish-coated tongue, the appetite is wanting, and the stomach is nauseated, or there are attacks of A'omiting on the first day. By the end of the first day, or the be- ginning of the second, there are rational symptoms which indicate the chest as the seat of the mischief. Pain in the side is experienced, and difliculty of breathing and cough now come on. The pain in the side varies in severity, and indeed is not always present. If the pleura is involved, the pain is more prompt and more acute ; if the deepest part of the lung, there may be no pain until the inflammation approaches the surface. The pain is most severe when it is first felt, and then it usually declines. The position of the pain is, as a rule, in the right chest, a little below and external to the nipple, but it may be felt in the lumbar region, in the iliac region, and in the shoulder. When pneumonia has attacked the summit of the lung, or as it occurs in the aged, pain may be absent. Coughing, breathing, especially a deep ex- piration, increase the pain. Accompanying the pain, or coming soon after it, is dyspnoea ; the respiratory acts are more frequent and shal- low, reaching as high as thirty or forty per minute, the shallowness being due to the pain caused by full breathing, and by the narrowing of the respiratory field. The flushed, anxious, and somewhat dusky counte- nance, the working of muscles of respiration merely accessory, and 330 DISEASES or THE EESPIEATORY ORGANS. those of the alse of the nose, make up an expression which has been called fades pneumonica. The cough, which appears on the first or second day, is very characteristic ; it is husky, suppressed, and painful. At first there is brought up a little frothy mucus, but on the third day there appear the sputa characteristic of this disease ; thick, viscid material like that which is poured out and coagulates in the alveoli and bronchioles of the lung. The sputum also contains blood-corpus- cles intimately incorporated with the viscid albuminous matter, but in varying proportion of coloring, from a light brick-red to a brownish- black. So tenacious and adhesive is the sputum that it remains adher- ent to the bottom of the vessel if turned over, and if a considerable quantity is collected in a vessel it presents a jelly-like appearance of con- sistency. The blood is not always mixed with the sputa at first, but the peculiar characteristics of the expectoration are in other respects present, the blood appearing in four or five days. In some debilitated subjects — for example, the subjects of chronic alcoholism — the expec- toration is thinner and more abundant, presenting an appearance like prune-juice, whence the name prune-jidce expectoration — an ill-omen. Again, there may be no exjjectoration at all, which is sometimes the case in very adynamic states, and in pneumonia of the apex. There are also present in the sputa casts of the finer bronchi. The sputa should be agitated with water, and the grayish, undissolved particles should be fished out and then be f)ut under the microscope. They are ■^ fibrous in structure, cylindrical, and branching. As has been stated, the maximum temperature is soon at- tained. On the evening of the first day it may reach 104° Fahr. (axil- lary), and for several days it con- tinues at about 103°, 104°, or even 105°, there being a slight morning remission and evening exacerbation. The fever pursues this course with little variation in favorable cases, imtil the period of crisis, when just before the defervescence a rise may take place. This rise in temperature in anticipation of the crisis is usual "but by no means invariable. The pulse during the stage of hyperse- mia is about 100— full, hard, and strong ; but, as consolidation takes place, if extensive or extending widely, a change occurs in the pulse ; it becomes less full, and, when the ischemia of the arterial side has reached the lowest point, the pulse is small, soft, and weak, and the superficial veins are abnormally full and prominent. The skin, during the time of greatest fever, is mordicant, or burning-hot, and is dry or Fig. 24. — Fibrous Tissue in Sputa. (Beale.) PNEUMONIA. 33 1 covered with a warm perspiration. If the skin is relaxed, dusky, cool, and covered with a cold sweat, the condition is unfavorable. If the inflamed area is deeply situated and surrounded by healthy lung-tissue, the reactions produced on palpation and percussion are modified. On palpation the resistance is increased if the inflamed lung is exterior ; not affected, if within. The vocal fremitus is some- what increased. The sonority is diminished when the lung is con- solidated ; it is exaggerated when there is a layer of lung-tissue con- taining air overlying a consolidated area. Again, the sonority is exaggerated, or tympanitic, when in the beginning of the inflammation the lung still contains some air. The sound continues somewhat tym- panitic in quality about the consolidated portion of the lung at the maximum. With the progress of the exudation, and when the periph- eral portion of the lung is involved, there is greatly increased resist- ance, and the percussion-note over the inflamed area is flat, with still something of the tympanitic quality. The vesicular murmur becomes more and more feeble as the air less and less distends the alveoli. AYithin twenty-four to thirty-six hours there is heard, with or at the end of inspiration, a fine crackling sound over the region inflamed — the crepitant rale. This is wrongly said to be pathognomonic, since it occurs in acute tuberculosis, oedema of the lungs, etc. ; but it is highly significant in that it is audible in so few conditions, and occurs in pneumonia over a restricted area. This rale has been compared to the sound produced by rubbing a lock of hair between the fingers in front of the ear, to the burning of some grains of salt on live coals, but it is most perfectly imitated by the crackling made by India-rubber sponge when pressed and allowed to expand in front of the ear. As the sound is produced by the separation of the bronchioles and alveoli, adherent by the viscidity of the albuminous exudation, it is obvious that it can occur only during inspiration. When consolidation takes place, the crepitant rdle ceases, but can be heard in the neighboring parts of the lung undergoing the same process. Again, it becomes audible when the stage of resolution is reached. It is then known as crepitatio redux, but it then differs somewhat in quality, and is coarser and louder. The crepitant rdle in children and old subjects is much like the crepitation redux. This rdle is audible for a brief period only, during the stages of engorgement and exudation ; presently the vesic- ular murmur ceases altogether ; the respiration becomes sibilant, then blowing, and on the third day bronchial breathing and bronchial voice come on. The conductivity of the lung being increased by consolida- tion, the sound produced by the vibration of a column of air in the larger bronchi is communicated directly to the ear — whence the term bronchial breathing. The voice-sounds are communicated with equal distinctness to the ear from the larger bronchi — whence bronchial voice. When the lung-tissue is consolidated, the disease is at its maxi- 332 DISEASES OF THE RESPIRATORY ORGANS. mum ; there may be an extension of the area of inflammation in all directions, but the symptoms continue with uniform intensity for sev- eral days. We must now return to the rational symptoms and follow their development up to the period of crisis. The fever continues pretty uniformly at the point already mentioned, 102°, 103°, 104°, or 105° — there being a morning remission of less than a degree. The pain in the side lessens or ceases altogether. The decubitus is toward the right with the body flexed, so as to relax the muscles of the affected side, and thus take the pressure off ; but the dyspnoea is less, because, the pain having declined, the respiration is free, but there is still some difiiculty in respiration. The cough is more or less troublesome, and the characteristic rusty* expectoration, or the more abundant "prune-juice," is brought up with every effort. Sometimes the ex- pectoration is haemorrhagic, and several ounces may be discharged at a time. The smallness of the pulse and feebleness of the cardiac im- pulsion are due to ischsemia of the arterial side, as has been pointed out ; on the other hand, this state of the circulation may be largely due to depression of the forces. If the area involved in the inflamma- tion is not very large, the pulse may continue full and strong up to the crisis ; if this area is large and extending, then the fullness of the venous system and the emptiness of the arterial will have the effect just stated over the circulatory system ; consequently, the condition of the circulatory system will afford valuable information in respect to the extent of lung-tissue involved in inflammation. A rapid and weak pulse — 120, 130, 140 — irregularities in the rhythm, and unequal filling of the artery, are very ugly symptoms, denoting cardiac failure. Delirium is a result of the diminished arterial supply and the venous stasis of the brain ; there may be merely hallucinations or illusions, or noisy and violent delirium. Mental disturbance is more especially present in the cases of pneumonia occurring in drunkards ; delirium tremens too often masks so completely the pulmonary symptoms that they are overlooked. In such cases, the pneumonia is the disease, and the delirium tremens the symptom or complication, instead of the reverse. The obstruction at the lungs and the consequent venous stasis affect other organs besides the brain. The liver is congested, and jaundice, more or less decided, is present in many cases, whence the name bilious pneumonia. Again, the pneumonia of malarious regions is so often modified by malarial infection that the biliary dis- turbance may be either caused or increased by this influence. Fur- thermore, an accompanying gastro-duodenal catarrh may, by an exten- sion of the catarrhal process to the bile-ducts, set up a catarrhal jaun- dice. All of these influences coinciding, the biliary disturbance may enter largely into the symptomatology and therapeutics of the case. Very rarely a case of pneumonia may be complicated by acute yellow atrophy. The urinary secretion is altered in quantity and in compo- TNEUMONIA. 333 sition ; the quantity is reduced ; the urea and uric acid are increased, and the chlorides are much diminished or disapjDear entirely. The chlorides are diverted to the inflamed pai't and from the urine, so that the return of the chlorides (chloride of sodium chiefly) to the urine signifies the cessation of the inflammation. So sensitive is this indica- tion, that the return of the chlorides to the urine may precede for some hours the physical and rational signs which indicate the begin- ning of resolution. In consequence of the venous stasis, the hyper- semia of the kidneys may induce albuminuria, and the urine may con- tain also cast-off epithelium of the tubules, but the albuminuria is a transient state. It should be noted also that, during albuminuria, pneumonia arises as a complication, and not unfrequently a fatal one. Pneumonia is one of the few diseases terminating by crisis. The critical phenomena consist in a sudden decline of temperature by crisis or lysis, and the occurrence of some sjDecial evacuation, as a large urinary discharge, a profuse diarrhoea, general sweating, an herpetic Day 2 3 4 5 6 7 8 9 10 11 1 2 tor 102° 100° 98° 96° J J X^ ^ V^^l __vp^ _ , Z^ « 4 5 ^ -i 'v / I « / / \ / \ ~X(v-L V v -M tj- -V -y Fig. 25.— Temperature of Uncomplicated Pneumouia of Bight Lung. Termination by Crisis. eruption, or considerable expectoration. The return in a few hours to the normal temperature or below it is the most conspicuous of these phenomena. As has been narrated, just before the defervescence, the temperature may rise higher than it had been, and the aspect of the case appear more formidable ; then the decline begins, and within twelve hours the normal or somewhat below it be reached, or, if by lysis, the descent to normal occupies two or three days. The change thus wrought in the aspect of the patient is most remarkable. The countenance clears up, the difficulty of breathing subsides, the pulse falls to seventy, to sixty, even to forty jser minute, and an herpetic eruption appears on the lips ; appetite returns, the skin is covered with warm perspriation, the urine increases in amount, the chlorides reap- pear, and the patient experiences an internal sense of well-being. The physical are in accord with these rational signs : moist sounds now ap- pear in the bronchical tubes, and the sputa become lighter in color, and 33J: DISEASES OF THE RESPIRATORY ORGANS. an abundant expectoration of grayish-yellow muco-pus takes the place of the rusty sputa ; crepitatio redux, coarser than crepitatio indux^ ap- pears along the outer border of the consolidated area ; bronchophony is succeeded by a softer blowing sound ; the flatness is now dullness, with more of the tympanitic quality, and the vocal fremitus is less decided. Careful examination of the sputa during the stage of resolu- tion will disclose the presence of the fibrinous casts of the finer tubes, already described, and small masses, remains of the coagulated exuda- tion in the air-sacs. The alveoli are gradually opened up to the ad- mission of air, and under favorable circumstances the restoration of the lung is complete in a few days. In some unhealthy subjects, the victims of a diathesis, and sometimes those whose vital forces have been reduced by depressing treatment, repair is incomplete, and the affected part lapses into the chronic state. When the course is not toward crisis and health, there may be abortive attempts at crisis ; there may be some considerable subsidence of the temperature, an illusive appearance of a critical evacuation in the way of an exhausting diarrhoea, for example, but the natural powers are not equal to the effort ; there is no real improvement, the temperature rises even higher Day 4. 5 6 7 8 9 fO II 12 13 14 15 lOS" 106° I '\ -vX -*2 X- t \- '04 ^ i^ t 4 I 115 _, ZO zs L s^2 . j X'^ r \-J X 4 102 ir -«=i?H _4\ I 100° ^ t J5 \ 98" ^=^ L_ _, t^ 7- u i^^ ,96* Fig. 26. — Temperature of Uncomplicated Pneumonia terminating by Lysis. than before, and all of the symptoms develop new severity. The pulse declines in strength and volume and becomes very frequent, the dysp- noea increases, and an adynamic state, in which the tongue is dry, the face cyanosed, the breathing quick and shallow, and the debility great, supervenes. If delirium had existed before, it now, assumes more of the low-muttering character ; if it had not existed before, it is now apt to come on in the form of hallucinations ; there are increas- PNEU^MONIA. 335 ing somnolence and a tendency to coma as the venous stasis and car- bonic-acid poisoning increase, and finally a condition of more or less profound coma ushers in death. Complications. — Pleurisy is a frequent complication, the two dis- eases occurring- together in from ten to twenty per cent. A more acute pain and the usual signs of effusion are the only evidences of the existence of pleuro-pneumonia. The effusion must amount to six ounces to be detected with certainty (Juergensen). If there be exten- sive consolidation, the effusion must be proportionally small. Pleuritis is ascertainable with certainty only if there be sufficient effusion to displace the heart. The existence of pleuritis does not modify the course and behavior of the pneumonia itself, but the situation is ren- dered more grave by the simultaneous development of the two dis- eases. Capillary bronchitis is a very dangerous complication of croup- ous pneumonia, and may so conceal the latter as to appear as a case of catarrhal pneumonia. Emphysema is an occasional complication ; it should be stated, however, that pneumonia is an ordinary mode of ter- mination of emphysema. Pericarditis is more frequently a complica- tion of pleuritis, but it may also occur in the course of pneumonia. Granular degeneration of the heart-muscle occurs in pneumonia when the temperature is persistently high, and is a serious complication. The occurrence of jaundice has been alluded to as a symjjtom, and its mechanism explained. That pneumonia is a disease of great frequency and fatality in malarious regions is undoubted. Rheumatism and gout are also frequently associated with pneumonia, and to these may be added acute alcpholismus. Pneumonia of diathetic origin is severe or not according to the character of the diathesis ; it is very fatal in the alcoholic, but not more so than the uncomplicated malady in the rheu- matic or gouty form. The existence of a typhoid ptieumonia is pretty generally admitted, but on questionable evidence. Pneumonia is an occasional complication of typhoid fever, but it is not a typhoid pneu- monia. This term is applied to a form of pneumonia occurring in the weak and debilitated, and has therefore a specially adynamic character. There is not the fever process which we designate typhoid ; there exists a pneumonia to which a specially adynamic character has been imparted by the depressed state of the vital forces. The term has been so far generalized that, in many places, every severe case of pneumonia is called typhoid pneumonia. Course, Duration, and Termination. — Croupous pneiimonia is a well- defined, self-limited disease, which passes through its several stages with considerable uniformity. The stage of congestion or engorge- ment occupies the first twenty -four to thirty-six hours ; the stage of exudation or red hepatization — that period occupied by the pouring out and coagulation of the exudation — continues up to the crisis, which marks the beginning of the next stage. The crisis in pneumonia 336 DISEASES or THE RESPIRATORY ORGANS. occurs somewhere from tlie fifth to the eleventh day of the disease, so that the exudation stage lasts from two to eleven days. The stage of resolution begins with the phenomena of the crisis, and lasts two to four days till convalescence is established. In rare cases (abortive foi-ms) critical phenomena may occur even earlier than the fifth day. In the largest number the crisis begins on the seventh day, and, accord- ing to Traube, always on the odd days, reckoning from the day of the initial chill, but if we except the seventh day the statement of Traube must be denied. The stage of purulent transformation is not dis- tinctly separated from the stage of exudation or red hepatization, unless the occurrence of an abortive attempt at crisis fixes the period. It begins about the middle of the second week, and continues for several days to a week. The whole course of pneumonia is therefore comprehended within three weeks, but favorable cases may terminate in two weeks. The mortality from pneumonia has been and continues to be a subject of warm discussion on the j)art of those who advocate some special plan of treatment. Accuracy in diagnosis and skill in treatment are such uncertain elements in the statistics of mortality, under different plans of treatment, that but little reliance can be placed on the statistical method as aj)plied to therapeutical questions. According to the most approved of the modern methods, the mortality ranges from five to twenty-five per cent. In determining a fatal re- sult in croupous pneumonia, so much depends on the condition of the individual attacked, or the diathesis with which his system is tinctured, that no comparison of systems of treatment can be accurate that does not take note of them. Death is usually due to collapse — that is, cai-- diae failure, and obtunding of the nervous centers. This state is not necessarily caused by purulent transformation — it may be due to fail- ure of heart, and lungs, and brain, before the end of the stage of red hepatization. Death may be caused by the mere extent of the lesions in the lungs, inducing asphyxia ; these lesions consisting not only of localized pneumonia, but also of collateral hypersemia and cedema. The effects of the pulmonary changes are enhanced by the stasis in the cerebral veins and ischsemia of the arteries, and by car- diac paresis. In subjects extremely delibitated, the tissues in a scor- butic state, the termination may be by gangrene, but this is extremely rare. The formation of an abscess is also rare, but is more common than gangrene. An example of encysted abscess which had been carried many months has been mentioned ; usually the abscess formed during the stage of gray hepatization terminates in a short time by discharge either into the pleural cavity or into a bronchus. The pres- ence of a quantity of the elastic tissue of the lungs in the sputa and the occurrence of repeated rigors and profuse sweats indicate the forma- tion of the abscess. If it become encysted, just as is the case in ab- scess in the liver or in the brain, the acute symptoms subside, the fever PNEUMONIA. 337 falls, the rigors and sweats cease, but yet some unfavorable symptoms continue — there are cough, fever, dry tongue, emaciation, and weak- ness, and the appropriate physical signs. In a variable period the abscess terminates in some of the modes already described. The ter- mination may be in the chronic form. There are then no critical phenomena ; the fever gradually diminishes, but does not cease ; the difficulty of breathing lessens, but there is more or less embarrassment on making any effort ; the cough also continues, and muco-pus and fibrous tissue are expectorated ; the weakness and emaciation do not improve if the decline does not go on, and the physical signs of con- densation of the pulmonary tissue remain. The subsequent behavior is influenced by the local condition and the direction taken by the products of inflammation. There may ensue a gradual liquefaction of the exudation, its softening and extrusion may be effected without much damage to the pulmonary parenchyma, and after some months a cure be effected. On the other hand, the exudation may undergo casea- tion, with the usual history of pulmonary consumption. The caseation of the inflammatory products of croupous pneumonia is held to be doubtful by many, and is not regarded as common. The clinical his- tory is that of caseous pneumonia, and need not be discussed until that subject is reached. Finally, death may be caused by one of the com- plications, as pericarditis. Diagnosis. — Ordinary well-defined cases are recognized without difficulty ; it is the obscure or anomalous forms that occasion mis- take. Pleurisy with effusion is very frequently confounded with pneumonia. They are differentiated by the following points : The onset of pneumonia is sudden, by a rigor, and followed by a high tem- perature — pleurisy begins more gradually, there is chilliness for a day or two, and the rise of temperature is gradual ; in pneumonia, the pain is rather dull, or a feeling of soreness diffused over a considerable space — in pleurisy, a sharp stitch, which can be covered by a finger ; in pneumonia, there is audible, on inspiration only, a crackling sound, the crepitant rale — in pleurisy, the friction-sound, synchronous with the respiratory movements ; in pneumonia, the crepitant rdle is suc- ceeded by bronchophony, which continues — in pleurisy, when the effu- sion partly compresses the lung, a modified bronchophony, but, when the lung collapses, all voice and breath sounds cease ; in pneumonia, the dullness has a tympanitic quality, and is fixed in position — in pleurisy, the dullness is flat, and changes with the gravitation of the fluid ; in pneumonia, the organs retain their position — in pleurisy, the heart is pushed aside and the liver downward by the effusion ; pneumonia is self-limited, and terminates by crisis — these phenomena are wanting in pleurisy, the duration of which is indefinite ; subsequent to the crisis, the behavior of the two diseases is so different that further comparison is unnecessary. Next to pleuritis with effusion, pneu- 22 338 DISEASES OF THE RESPIRATORY ORGANS. monia is confounded with catarrhal pneumonia. They differ in onset — pneumonia sudden, with a rigor, and pain in the side — catarrhal pneumonia with an ordinary bronchitis, and a feeling of soreness rather than pain under the sternum ; pneumonia, as a rule, is unilat- eral, self -limited, terminating by crisis, or ceasing within three weeks — catarrhal pneumonia is bilateral, not limited nor terminating by crisis, and indefinite in duration ; if double, which is rare, pneumonia is limited to a portion of either lung, while catarrhal pneumonia is diffused over both. The differentiation of bronchitis and croupous pneumonia rests upon the same points. In respect to physical signs, the differences are marked : In pneumonia, the vocal fremitus is in- creased, and there is increased resistance on palpation — in bronchitis, the vocal fremitus is unaffected, and there is no change in the resist- ance ; in pneumonia, there is dullness on percussion — in bronchitis, the percussion-note is unaltered ; in pneumonia, on auscultation, there is audible the crepitant rale, which disappears and is replaced by bron- chophony — in bronchitis, there is no crepitant but a sub-crepitant rale, followed, not by bronchophony, but by sub-mucous and mucous rales. The rales in pneumonia or the bronchophony are audible at the seat of inflammation only — in bronchitis, they are diffused over the chest. An uncomplicated pneumonia differs from a pleuro-pneumonia in the following particulars : In pleuro-pneumonia there is more acute pain, a friction murmur as well as a crepitant rale, displacement of the heart and of other organs by the fluid, more absolute dullness on per- cussion, and less of the tympanitic quality to the percussion-note. Cases of pneumonia with cerebral symptoms may be mistaken for meningitis, but this can only happen should the chest not be exam- ined. In pneumonia of the aged, and, in some cases, in subjects of delirium tremens, there may be no cough or other rational symptom to direct attention to the chest. Treatment. — As we have to deal with a self -limited disease, which terminates by crisis between the fifth and the eighth day in sixty per cent, of the cases, and as we possess no specific, it is obviously our duty not to interfere too zealously in natural processes, and prevent, by our injudicious handling, a favorable termination. Furthermore, the so-called expectant jDlan, as pursued by moderns, is greatly more successful than the spoliative plan by bloodletting and tartar emetic, pursued by the physicians of forty years ago. Cautious treatment is all the more necessary, since the diatheses are so largely concerned in the origin, the evolution, and the termination of this disease. The constitutional tendencies, the actual state, and the surrounding cir- cumstances should receive careful attention in deciding on a plan of treatment. A vigorous, healthy subject, free from, constitutional vice, will require and bear a more vigorous handling than a broken-down alcoholic. If seen at the beginning, during the stage of congestion, PNEUMONIA. 339 the author believes that much may be accomplished in an ordinarj'- case by a full dose of quinia and morphia (3j — gr. ss.), the application of cups or leeches, and small and frequently repeated doses of the tinc- ture of aconite-root (two drops every two hours). At the same time a large mustard-poultice should be put on the chest, and removed when the skin is reddened, to obtain its stimulant effect on the vaso-motor nerves within, and the feet should be immersed in a hot mustard foot- bath. When the quinia and morphia have been absorbed, an active purgative should be administered, for this also serves to diminish the abnormal blood-pressure. If the viscid secretion is pouring out in the air-sacs and bronchioles, and coagulating, it is necessary to use some agent which possesses the power to lessen the viscidity and coagula- tion. Hughes Bennett employed the potassa salts (liquor potassse eitratis) or an extemporaneous solution of the bicarbonate, and his results were admirable. Ammonia, originally suggested by Richard- son, has been latterly used more freely than potassa, and, as the author believes, with better results. Probably the most advantageous method of administering it is the solution of the carbonate in liquor ammonii acetatis ( 3 ss. — gr. v to x) every three or four hours. By the German school the muriate is preferred in corresponding doses, but it does not appear to the author to be so useful. The ammonia solution should be continued up to the crisis. As soon as consolidation of the lung is ac- complished, all arterial sedatives of every kind should be discontinued. The tincture of aconite, or the more powerful tincture of veratrum viride, may be given with undoubtedly good effects during the stage of congestion, provided the subject is robust, but they cease to be useful when red hepatization has resulted, for then already arterial ischaemia and over-distention of the veins exist — a state of things which can only be increased by cardiac sedatives. During this stage the temperature is high, and hence the necessity for measures to re- strain it. Assuming that pneumonia is a specific disease, like typhoid, Juergensen * maintains the necessity for the use of antipyretics, among which he places the cold bath first ; and the success of his treatment certainly seems to justify his theory. He demonstrates that there is no danger in putting a pneumonic patient in a bath, and that the re- duction of temperature by it exercises a favorable influence over the progress of the disease. ISText to the bath quinia is most useful as an agent for reducing fever, but it must be given in scruple-doses every four hours until the temperature falls to a proper point, when it may be suspended until the temperature rises again in twenty-four to thirty-six hours. To reduce the temperature, Juergensen regards as so important, that in the absence of the means for a cold bath he sug- gests exposing the patient naked to cold air. If there is much depres- * Ziemssen's " Cyclopfedia," op. cit. 340 DISEASES OF THE RESPIRATORY ORGAN'S. sion during this period (red hepatization), quinia may be given in stimulant doses (three grains every three hours), and alcoholic stimu- lants must be cautiously administered — half an ounce to an ounce of whisky or brandy every three hours. As the period of crasis ap- proaches, the utmost circumspection is necessary ; the sudden defer- vescence and the occurrence of some exhausting discharge may tax too severely the vital powers. Suitable aliment, and appropriate stimulants, carefully administered, may then save life. The author feels it necessary to emphasize the evil effects of car- diac sedatives during the stage of exudation and of coagulation of the exudate. The administration of veratrum viride, digitalis, aconite, and tartar emetic, can only add to the burden of the heart, already laboring in consequence of the stasis on the venous side, and lack of blood on the arterial side. Paralysis of the heart is one of the most imminent dangers, because of this state. It is true that a continued high temperature contributes to bring about paralysis of the heart, but we possess the means of correcting this by the administration of quinia, and by cold baths or the cold wet pack. While arterial and cardiac sedatives are to be avoided at the stage of red hepatization, it is necessary also to avoid the immoderate use of alcoholic stimu- lants. These are needed, and in full doses in inebriates at the period of crisis, and when the stage of purulent transformation is reached there are a rapid and weak pulse, a relaxed and clammy skin, and delirium. Protracted wakefulness and delirium need careful manage- ment. Opium or morphia must be avoided, owing to the state of the pulmonary circulation, and the collateral hypersemia and oedema. Then it is that chloral hydrate serves a most useful purpose ; it pro- cures sleep, quiets delirium, and has a good effect on the exudation. Care must be exercised, for large or frequently repeated doses may cause paralysis of the heart ; fifteen grains at night, with ten more in two or four hours, if the first dose is insufficient, is all that is required usually. Aliment must be carefully administered from the beginning, without waiting for depression to come on. Beef-juice, milk, egg- flip, wine-whey, chicken or mutton broth, etc., should be systematically administered every three hours. In weak subjects, a little wine may be given from the beginning. As already stated, the pneumonia of the inebriate requires alcoholic stimulants from the first symptom — for the delirium accompanying it is due largely to the sudden withdrawal of the supply, or the inability to retain it. Much has been said about the blistering-point in pneumonia. Counter-irritation is useful during the stage of congestion, as already indicated, but a fugitive counter- irritant, as a mustard-plaster, is all that can be properly used. When the crisis occurs, a blister is very useful. During the stage of red hepa- tization, turpentine-stupes, cotton wadding, or a flannel jacket, is use- ful unless the temperature is very high, when they do mischief. Fly- EMBOLIC PNEUMONIA. 34I ing-blisters are serviceable in promoting absorption, when resolution is imperfect and exudations still linger at the site of inflammation. To facilitate absorption in chronic, succeeding to acute pneumonia, the iodide of ammonium is highly beneficial. It may be administered with the iodide of iron, and in conjunction with the hypophosphites. If there are " prune-juice " expectoration, weak pulse, relaxed and sweating skin, turpentine in small doses, or eucalyptol, is extremely useful. During gray hepatization, they may be given for the double purpose of acting on the organ by which they are eliminated, and as cardiac stimulants. EMBOLIC PNEUMONIA— PNEUMONIA FROM EMBOLISM. Definition. — ^j embolic p7ieicmonia is meant an infarction of the lung, due to embolic blocking of a vessel. Causes. — From the right cavities of the heart, or from some part of the venous system, an embolus is dislodged, and, entering the cur- rent of the blood, is deposited in a branch of the pulmonary artery. The circumstances under which clots form in the right cavities of the heart have been set forth elsewhere. Pathological Anatomy.*— The emboli which give rise to embolic pneumonia are of two kinds, simple or non-infective and infective. The former act in a merely mechanical manner by closing the vessels and preventing the pass'age of blood to the parts supplied by them ; the latter not only obstruct vessels like the former, but the infective material contained in them sets up a local infectious process. The size of the embolus, and consequently the capacity of the vessel ob- structed, varies considerably, the resulting infarction being from a pea to a hen's-egg in size. If a simple embolus, the damage is confined to the area occupied by the infarction ; but, if an infective embolus, a sup- purative inflammation arises and an abscess is the result. To the for- mation of an infarction it is necessary that the embolus lodge in a terminal artery of Cohnheim — an artery without anastomoses — for, if the obstructed artery is connected by branches with others, the circu- lation in the obstructed area may be restored through collateral chan- nels. If the obstructed artery be a terminal one, as are those of the outer part of the lung in a restricted sense, the pressure in the veins causes a gradual filling of the obstructed vessels through the capilla- ries. Now, as the walls of these obstructed vessels are not properly nourished by the blood thus in a state of stasis, the blood diffuses through into the surrounding textures, which constitutes the infarction. Such an infarction is not often possible at the root of the lung, for here the anastomoses are too numerous, although they do sometimes occur ; * In the account of this process, Cohnheim's classical work, " Untersuchungen ueber die embolischen Processe," Berlin, 1872, Hirschwald, p. 112, is followed. 342 DISEASES OF THE RESPIRATORY ORGANS. but it is at the periphery that they usually form. As the vessels pro- ceeding from the root of the lung toward the periphery divide dichot- omously, it is obvious that, when an embolus obstructs one, the result- ing infarction must be wedge-shaped — the base of the wedge being toward the periphery of the lung, or outwardly. If a section be made through an infarction, its outline will be seen rather sharply defined, its color of a deep blood-red, and it will exude blood on slight pressure. If it has been formed for some time, its structure is denser from an infiltration of the alveoli, whence it presents a granular appearance ; it is dark-brownish in color, is drier, and exudes but little blood, and is very friable, easily breaking up into a pulverulent mass. The bronchi contain a frothy, bloody fluid. The tissue of the lung about the in- farction becomes hyperaemic and (Edematous. The pleura overlying it is deeply congested, or it may be inflamed and coated with a firmly adherent albuminous exudation, while the cavity contains more or less bloody serum. The infarction undergoes various changes ; the blood is gradually transformed, becomes fatty, and is absorbed, although patches of altered hsematin remain ; the proper tissue of the lung undergoes atrophy, the connective tissue multiplies, and in this way a cure is effected, the lung being rendered useless to the extent of the infarction. In other cases an embolic abscess is produced, the embolus being infective ; but it does not have a wedge-shape ; it is globular, and presents the appearance of an ordinary purulent collection. In rare cases an infarction becomes gangrenous. Infarctions are found more frequently in the right lung. Symptoms. — As the embolus proceeds most frequently from the right side of the heart, the clinical history is that of some cardiac dis- ease ; but it may be produced in some distant part of the venous sys- tem under circumstances which favor thrombosis. The prominence and urgency of the symptoms will depend on the size of the infarction. If it be small in extent, there may be no disturbance ; even if quite large, the symptoms may be masked by the coexistent disease. If a large branch of the pulmonary artery be suddenly closed, there will be acute dyspnoea of extreme severity, the patient will gasp for breath, become deeply cyanosed in a few minutes, and, may be, die at once. Sudden difficulty of breathing is the most significant symptom at the time of lodgment of the embolus, especially if there is nothing in the condition of the heart to account for the dyspnoea. Fever comes on some days after the obstruction, but the rise of temperature is not very great. There may be chills, but they are not constant, except in the case of pyaemia. Bloody expectoration appears in a few days after the initial dyspnoea, and is usually inconsiderable in quantity. Besides blood, there is a viscid mucus which is the body of the sputa, and, as it adheres rather tenaciously, a good deal of coughing is necessary to bring it up. Pain begins with the implication of the pleura, and has CATARRHAL PXEUMOXIA. 343 the usual characteristics of pleuritic pain : it is acute and lancinating, and is increased by the movements of respiration. There are present the usual physical signs of consolidated lung — dullness on percussion, bronchial voice, and bronchial breathing. There may be a friction- sound due to the pleuritis, and also the evidences of effusion into the pleural cavity. It is obvious that the diagnosis of embolic pneumonia is difficult and uncertain. The sudden occurrence of dyspnoea, followed by bloody expectoration continuing eight or ten days, and the evi- dences of consolidation, are the only symptoms to indicate the real nature of the malady. If the history furnished the source of the em- bolus, the diagnosis would be proportionally facilitated. The prog- nosis is generally unfavorable, notwithstanding small infarctions may get well. There is no plan of treatment which can affect a mechanical condition of this kind, unless ammonia may dissolve an embolus. This should be tried. CATARRHAL PNEUMONIA. Definition. — Various terms have been applied to this disease, as capillary hroncliitis, lobular pneumonia, hroncho-pneumonia, etc. As right views with regard to it are necessary to a proper conception of pulmonary consumption, it is discussed here somewhat in advance of its proper position. By the term catarrhal pneumonia is meant a catarrhal inflammation involving the bronchioles and alveoli. It may be acute or chronic. Causes. — Catarrhal pneumonia may be an extension downward of a catarrhal process beginning in the bronchial tubes. It is jDrobable that a catarrhal inflammation never begins, under any circumstances, in the alveoli. Typical examples of this disease occur during certain of the exanthemata, notably measles and whooping-cough. It is inti- mately associated with certain diatheses, as rickets and scrofula, and with structural alterations of the heart and lungs, as mitral lesions and emphysema. It is frequent in early life and in old age, and is less so at the period of greatest bodily vigor. Bad hygienic influences as to dress, habitations, humidity, and exposure, favor its development. Cli- mate is an important factor, and the period of most extreme variations is the period of greatest prevalence of this disease. Symptoms. — The acute form is the type ; the chronic differs from' it merely in duration and severity of the symptoms. The initial symptoms are chilliness followed by fever, soreness of the chest, chiefly beneath the sternum, cough, and expectoration of a frothy mucus, and some difficulty of breathing. These symptoms in the acute form of the disease quickly develop into the more serious and characteristic proper to catarrh of the finer bronchial tubes. An abundant secretion, poured out all along the bronchial tree, must greatly affect the functions of the lungs. The breathing soon becomes rapid. 344 DISEASES OF THE EESPIRATORY ORGANS. superficial, and labored, the accessory muscles of respiration are brought into play, and the ala3 of the nose work quickly and continuously ; the face is at first flushed and rather animated, and the eyes have a glaring- expression, but the lips soon become bluish and cyanosis spreads over the face. The cough in the first onset is rather loud and bronchial, but, as the finer tubes become involved, it has more of a stridulous, husky character, and is often suppressed and partial because the difii- culty of breathing is too great to permit the necessary expansion of the chest. The cough is also painful, and in children is attended with moans and crying, and they make attempts to restrain it because of the soreness in the chest. The fever soon rises to the maximum of 104° to 105°, and is nearly continuous, there being a slight morning remission. As the difiiculty of breathing develops, there is increasing restlessness, never a moment of quiet, the struggle for breath and the search for an easier position being incessant. At first there are brief snatches of uneasy sleep, but, as the dyspnoea increases, a state of somnolence comes on which gradually deepens into coma, so profound at length that cough is suppressed. This somnolence is due to the deficient aeration of the blood and the accumulation of carbonic acid. Finally, the blood becomes wholly venous. Then the flush disappears fi'om the face and is replaced by a death-like pallor, the cyanosis deep- ens about the lips, blue spots appear on the cheeks, and the superficial veins grow into thick black cords. The struggle for breath continu- ing, while the carbonic- acid poisoning increases, the most frantic but largely automatic efforts are made to remove supposed obstructions, and the patient, a child, may tear its skin about the neck and face with its nails, in the vain effort to remove them. On inspection, the cervi- cal and other muscles auxiliary are seen actively engaged, and a deep depression of the abdomen from retraction of the lower ribs is made with every strong inspiration. On palpation, the vocal fremitus will be unaffected during the first few days, but, when the lobules have collapsed in considerable numbers, the physical conditions are changed, and the vocal fremitus will then be increased. On auscultation, rales are abundant all over the chest ; they consist of sub-crepitant rales, which are somewhat coarser and louder than the crepitant, and are audible with both inspiration and expiration. With these also occur mucous and sub-mucous rales, produced in the larger tubes. The respiratory murmur becomes more and more feeble as the condition of atelectasis is produced ; and, when a number of lobules are thus affected, over them the respiratory murmur ceases to be audible, a blowing sound is substituted, and this passes into bronchial breathing and bronchophony as the pulmonary tissue becomes consolidated. On percussion there is no change until the atelectasis occurs ; the sonority is diminished as the lobules collapse, until dullness is reached ; but the dullness has much of the tympanitic quality, owing to the jjroximity of CATARRHAL PNEUMONIA. 345 unobstructed alveoli. In making percussion in children, it is important to strike lightly, otherwise the primary bronchi and trachea will be thrown into vibration. The pulse-rate does not always correspond to the range of temperature ; it is usually higher. The pulse ranges from 140 to 200 or more in children, while in the aged it may be but little accelerated. Protracted high temperature may induce changes — parenchymatous degeneration of the cardiac muscle. If, therefore, during the course of this disease the pulse becomes feeble, irregular, and very rapid, the condition of the heart is one to arouse great solici- tude. The appetite is poor, vomiting often occurs, and dian-hoea is by no means infrequent. The embarrassment to breathing caused by the act of eating and swallowing induces young children to avoid eat- ing solid food, although they will often drink greedily. Cerebral symptoms are present to a greater or less extent in all cases : there may be headache, hallucinations, muscular twitchings, even convul- sions, and the coma of carbonic-acid poisoning. So closely do the nervous symptoms belonging to catarrhal pneumonia simulate those of tubercular meningitis that it may be exceedingly difficult to diagnos- ticate between them. In the chronic or, rather, subacute form of catarrhal pneumonia the development is slow, the fever of moderate intensity, and the difficulty of breathing not pronounced. If there has been an attack of acute bronchitis, or of whooping-cough with more or less extensive bronchitis, when the catarrhal pneumonia de- velops, the cough subsides, but the depression of the vital forces, the cyanosis, and the extreme emaciation, indicate the growth of the more serious lesions. When these cases tend toward a fatal termination, the grave symptoms just mentioned increase, and carbonic-acid poisoning comes on, death occurring in more or less profound coma. Some cases pursue a different course ; after a protracted subacute period in which the pulmonary lesions begin, an acute attack arises, and then the sub- sequent behavior is that of an ordinary acute case, death occurring in coma. When they tend to recovery, there is a gradual improvement in all the symptoms : the cyanosis diminishes, the dyspnoea lessens, the appetite improves, and gradually the general health is in part re- stored, the lungs imperfectly repaired. Pathological Anatomy. — The changes involve the bronchial tubes and the lungs. The mucous membrane is the seat of an hypersemia from the larynx down, but it increases in severity downward, reaching the maximum at the most dependent part of the lungs. The vessels are so deeply injected that the mucous membrane is a dark red, and at various points there are extravasations. The finer tubes are filled with a quantity of yellowish, creamy, purulent fluid. On section of the lung, drops of this exudation, escaping from the tubes, look just like pus escaping from a small abscess, especially if the divided tube has undergone dilatation — a change which takes place in the more pro- 3i6 DISEASES OF THE EESPIRATORT ORGANS. tracted cases. This pus is probably made up of the young cells de- rived by multiplijcation of the epitheliuin, but especially of the lymphoid cells which migrate from the vessels, and are found in the sub-mucous connective tissue, in the alveoli, and in the bronchioles. There are two opinions now entertained in respect to the cellular elements which crowd the alveoli, and as to the part taken by the j)avement epithelium. Among others, Rindfleisch maintains that these cells are produced by the multiplication of the epithelium, and derived in part from the pro- liferation of the lymphoid cells ; others, again, notably Buhl, deny the participation of the epithelium, and maintain that the products of the catarrhal inflammation are drawn into the alveoli by a species of suc- tion. Besides the changes in the mucous membrane, the bronchial tubes and intervening connective tissue take part. The bronchioles undergo dilatation if they have been long subjected to the inflamma- tion, and the connective tissue undergoes hyperplasia, attaining to very considerable development. The formation of the very viscid exudation which takes place at the beginning of the process and the swelling of the mucous membrane are important elements in the col- lapse of the lobules (atelectasis) which is a conspicuous result in the sum of pathological changes. The collapse of the lobules takes place before the alveoli which form them are crowded with the products of the catarrhal inflammation. The mechanism of the collai^se is about as follows : In the strong efforts in coughing or in expiration, or both, the air is forced out through the swollen tubes ; and, when the air has passed, the surfaces are brought into contact, and are made to adhere tenaciously. All of the residual air is gradually expelled in this way ; but, in the efforts at inspiration, the force is insufficient to separate the adherent surfaces, and, as the pressure is immediately increased in the adjacent lobules, the collapsed lobule is also compressed. The collapsed lobules are easily recognized by their appearance, which is of a dark- blue or purplish-blue color ; they are much firmer, do not crepitate, because they contain no air, and exude but little blood on section. The extent to which this process is carried varies in different cases. It begins in the most dependent part of the lungs, and advances for- ward and upward, involving much, sometimes the whole, of the lower lobe. In some chronic cases the process takes place chiefly in the upper lobes. Collapse of some lobules, the pressure continuing the same, necessarily involves the dilatation of others, and in this way emphysema results, the anterior portions of the lungs being affected chiefly. Attacks of catarrhal pneumonia in eai'ly life, imperfect repair only taking place, have much to do with the subsequent development of emphysema. After the lobules have collapsed, for a short period they continue permeable to air and may be inflated. The change in color and density which occurs when the collapse is effected is often mis- taken for inflammation — whence the term " lobular pneumonia." If CATARRHAL PNEUMONIA. 347 the collapse continue, an inflammatory j^rocess is set up, similar to but not identical with that of croupous pneumonia, for it never becomes granular. The inflamed part becomes more solid, is of a dark-brown color, which terminates in grayish red ; it begins in the center of the lobules and spreads outwardly ; neighboring lobules affected in the same way coalesce, until ultimately a whole lobe may be involved. Then it presents to the eye, when the process is completed, a bluish- gray appearance ; on section it is found to be homogeneous, very firm, and tough. Before this final stage is completed it is very friable. The purulent matter in the bonchi and the catarrhal products in the alveoli undergo the cheesy transformation. The subsequent history is that of " caseous pneumonia." Those portions of the pleura in con- tact with the inflamed lobules become hyperferaic, inflame, an exuda- tion is poured out, and adhesions form, or effusion takes place in the thoracic cavity. Not every case tends to death, or to the chronic changes above described. Partial recovery ensues in a considerable number, complete recovery in but few. When the collapsed lobules inflame, unless there be but few, restoration seems hardly possible even in the sense of a partly useless lung. If the lobules are capable of being distended again with air, and the catarrhal inflammation sub- sides in the bronchioles and alveoli, a cure is then possible. The purulent contents of the bronchi are brought up by coughing, and swallowed or expectorated ; the watery portion of the exudation in the alveoli is absorbed ; the cells disintegrate, become granular and fatty, and are ultimately absorbed — thus restoring the alveoli to the admission of air. The fluid and the cells of the intervening connec- tive tissue pass through the same process, and thus the injured part is restored, except that its elasticity continues impaired for a long time. Complications and SequelSB. — The complications are really parts of the malady in its entirety. Bronchitis is always present, and laryngitis frequently. Pleuritis is a necessary result when the peripheral portion of the lung is involved. The sequelae are very important. As was indicated under the head of pathological anatomy, there are two dis- eases which result from catarrhal pneumonia — emphysema and caseous pneumonia. The former is a result of the atelectasis or collapse of the lobules ; the latter is an outcome of the changes in the catarrhal prod- ucts which crowd the alveoli, in the bronchi themselves, and in the in- tervening connective tissue. In the account to be presently given of these diseases, the course of development from one to the other will be set forth. Course, Duration, and Termination. — The course of catarrhal pneu- monia is from a catarrh of the larger tubes to a catarrh involving the ultimate bronchioles, and probably the alveoli. There are two prin- cipal phases in the subsequent course : the development of the catar- rhal process ; the collapse of the lobules, and the transformations which 348 DISEASES OF THE RESPIRATOEY ORGANS. they undergo. Restoration may occur by a retrograde change in the catarrhal products and by absorption, and the collapsed lobules may be again expanded. Often the restoration is partial, and the lung may remain contracted and atrophied at the site of the collapsed lobules. In still other cases the bronchial tubes are dilated, the connective tissue undergoes hyperplasia and thickening, the catarrhal products become caseous, and the collapsed lobules slowly inflame. It is obvious that the duration of such a malady must be subject to great variations. The simplest case of catarrhal pneumonia can hardly be concluded in a less time than two or three weeks. In fatal cases, death may occur in a day or two or within a week. In rapidly fatal cases death is due to such a blocking of the bronchioles that the blood can not be aerated, death occurring in deep coma from carbonic-acid poisoning. In chronic cases death occurs in two modes : by an acute exacerbation ; by grad- ual failure of the vital power, by the changes of catarrhal pneumonia, or the results of chronic inflammation in the collapsed lobules. In a large proportion of cases of catarrhal pneumonia in which recovery takes place, there is not a complete restoration, and hence the produc- tion of emphysema in after-years. Prognosis. — About one half of the cases of catarrhal pneumonia prove fatal. The prognosis must be guarded, not only as respects im- mediate mortality, but the future prospects of such patients. The more acute the attack the greater the danger of a fatal result, for acuteness in the attack means the collapse of many lobules. The younger the subject the more dangerous an acute attack is, or indeed any attack of catarrhal pneumonia. Diatheses play an important part in the prognosis, for scrofulous and rachitic subjects are less able to bear up under the inflammation. The prognosis is also much influ- enced by the bodily state, for the less the power of resistance the more severe the disease. Diagnosis. — Catarrhal pneumonia may be confounded with bron- chitis, croupous pneumonia, acute tuberculosis, and cedema of the lungs. From simple bronchitis, capillary bronchitis is separated by the size of the moist rales, by the dyspnoea in the one, its absence in the other ; by the signs of consolidation of the lung-tissue in the one, by the absence of such consolidation * in the other ; and, finally, by the subsequent history so different in the two diseases. Croupous pneumonia is unilateral, or, when bilateral, limited to a certain area ; catarrhal pneumonia is bilateral and diffused over both lungs. Besides the difference in the physical signs recapitulated under the head of croupous pneumonia, there is the remarkable difference in the behavior, one being a self-limited disease, the other having no fixed duration. Acute tuberculosis at its onset is characterized by the presence of a capillary bronchitis, so that a differentiation is possible only by a study of the clinical history and course of the two affections. (Edema of the CATARRHAL PNEUMONIA. 349 lungs is accompanied by similar symptoms as regards the dyspnoea and the physical signs ; but oedema is not a feverish state, and it is accom- panied by albuminuria or some evident cause. Treatment. — The chief source of danger in catarrhal pneumonia is the universal presence of a viscid secretion, which interferes with the entrance of air and thus prevents proper oxygenation of the blood, and causes collapse of the lobules, indirectly. The agents most useful to diminish the viscidity and favor the excretion of the exudation are the preparations of ammonia. The author has obtained the best results from the carbonate (three to six grains) and the iodide of ammonia (four to eight grains) in solution every two hours. The muriate has been much prescribed for the same purpose, but the iodide and carbon- ate are more efficient. These should be perseveringly administered. If the symptoms are subacute, the oil of turpentine, eucalyptol, and copaiba are very active in checking the formation and favoring the extrusion of the exudation in the tubes. Of these, probably copaiba is the best, as it may be more energetically pushed than the others. These stim- ulating expectorants, as they are called, owe their efficacy chiefly to the fact that the volatile oil which they contain is eliminated by the lungs and acts locally. They may be used in the acute cases also, after the subsidence of the most acute symptoms, and at the same time that the ammonia preparations are administered. If there be excessive dyspnoea, notwithstanding the use of these remedies, the accumulated muco-pus must be dislodged by emetics. Apomorphia is the most efficient of the emetics, and can be administered in the way to secure the best effects — by hypodermatic injection. Great care must be exercised in the use of this remedy, since occasionally pro- found narcotism is produced by it, probably due to the presence of morphia. The author has used the subsulphate of mercury, with most excellent effect, as an emetic in catarrhal pneumonia. Although this is a poisonous substance, no danger need be apprehended from it, since it comes up with the vomited matters. It can be given in from two to four grains at a dose, rubbed up with some sugar. Besides its emetic action, the subsulphate seems to have the power to check the formation of the muco-pus. The repetition of the emetic depends on the state of the case — every few hours it may be administered if the dyspnoea and the cyanosis require it. The immediate result of the emetic action ought to be an improvement in the difficulty of breath- ing and lessening of the cyanosis. If the fever is great and the arte- rial tension high, good results are obtained from the combined use of tincture of aconite-root and tincture of belladonna — two drops of the former and four drops of the latter to a child of two years, every two hours. Continued high temperature demands the use of quinine and digitalis. To a child of two years, five grains of quinia and one fourth of a grain of digitalis can be given morning, noon, and even- 350 DISEASES OF THE RESPIRATORY ORGANS. ing, until the temperature and pulse are brought within proper limits, when they should be administered at longer intervals. As this dis- ease makes enormous demands on the vital resources, the strength should be maintained by suitable nutrients from the beginning. Al- coholic stimulants are not only borne well, but they are extremely serviceable, and seem to have power to check the exudation. Inhala- tions are highly useful. The air of the apartment should be kept moist by steam ; but, besides this, by means of the atomizer, there should be directed into the fauces a spray of solution of common salt, ammonium chloride, or potassio chlorate. If the spray can not be borne directly into the fauces, at least the atmosphere about the patient should be saturated with it. In the subacute and chronic cases, excellent results are obtained from the persistent use of the iodide of ammonium, conjoined -with the administration of the hypo- phosphites and lactophosphate of lime. Counter-irritation is use- ful in both acute and chronic cases. During the acute stage mus- tard-plasters and flying-blisters are serviceable, but the mistake should not be made of applying deeply acting and jDrolonged counter-irri- tants, lest the irritability of the organic nervous system be exhausted, and the lesions within promoted. Turpentine-stupes, warm, are gen- erally the most useful application. The tincture of iodine is adajDted rather to the subacute and chronic than to the acute form. Among the occasional expedients employed in the treatment of catarrhal pneumonia is the inhalation of oxygen. This gives great relief to the dyspnoea, although it does not modify the morbid process in any way, and the relief is temporary. The author knows of no case in which the inhalations were continued for some time in such cases. The in- halation of turpentine-vapor might be carried on by disengaging the vapor in the ajDartment occupied by the patient. A local action of some value might thus be obtained, since it is apparent that the effect of this agent at the point of elimination is the chief source of its utility Avhen administered by the stomach. PHTHISIS PULMONALIS— PULMONARY CONSUMPTION. Preliminary. — Three forms of pulmonary consumption are now ad- mitted to exist : caseous phthisis ; tubercular phthisis ; fibroid phthisis. As these forms present differences at all points, it will conduce to clear- ness of conception to treat of the varieties separately. 1. CASEOUS PHTHISIS. Definition. — Caseous phthisis is that form of pulmonary consumption characterized by the caseation, or cheesy degeneration, of inflammatory products in the lungs, and the subsequent softening and extrusion of the PHTHISIS PULMONALIS. 351 caseous matter, with greater or less destruction of the pulmonary tissue. Etiology. — The chief factor in the etiology of caseous i^hthisis is catarrhal pneumonia, especially of the apex, although it may be in any part of the lung. There must, however, be bodily conditions which favor the transformation of the catarrhal products into caseous, since only a portion of the cases of catarrhal pneumonia undergo such trans- formation. These bodily conditions are a strumous constitution, or a state of lowered health, produced by the operation of various evil hygienic influences. The strumous or scrofulous diathesis is charac- terized by these peculiarities : a tendency to protracted suppuration and the production of a watery and ichorous pus, from slight injuries, and having little or no disposition to terminate, but rather to con- tinue ; and the occurrence of glandular enlargements. When in such a type of constitution a catarrhal process is set up in a part of the lungs, the products of such process, instead of undergoing resolution or some form of organization, caseate or become transformed into caseous material. We have in this fact an explanation of the frequent association of measles and consumption. Some of the cases affected to the same extent with catarrhal pneumonia get well, because there is no underlying constitutional state to invite other diseases ; some pass into caseous pneumonia and phthisis, because they are tainted with the strumous diathesis ; in a small number acute miliary tubercu- losis develops. A strumous diathesis, not inherited, may be gradually acquired under the influence of bad hygiene — as living in a dark, damp, and foul habitation, wath insuflicient and improper food, and exhausted by overwork, anxiety, etc. If such influences are not suifi- cient to develop the strumous diathesis, at least they cause a bodily state in which caseation readily takes place in the imflammatory prod- ucts of catarrhal pneumonia. Caseous phthisis is comparatively com- mon in early life, because at this period measles, whooping-cough, and catarrhal pneumonia frequently occur. It may happen at any period, but is more common up to thirty-five than subsequently. As regards sex, the liability to this form of phthisis, it seems to the author, is greater in the female. Pathological Anatomy. — In the description of the pulmonary lesions of catarrhal pneumonia, it was shown that the alveoli of the lungs are crowded with cells, and that the bronchioles are filled with yellowish muco-pus. The part which the epithelium of the alveoli takes in these changes is disputed. According to Rindfleisch * this pavement epithelium undergoes desquamation and other changes. "The cells first become looser, their attached surfaces are covered with a thick layer of finely granular protoplasm, at the same time in each cell the * Zicmssen's " Cj-clopsedia," vol. v, p. 666. 352 DISEASES OF THE RESPIRATORY ORGANS. nucleus, whicli was before hardly visible, becomes swollen and is seg- mented. Thus are formed large granular epithelial cells, with rounded, polygonal contours, and containing one or more nuclei." According to Buhl, the alveoli not containing a mucous membrane can not un- dergo the catarrhal process, and, therefore, the cells which so crowd the alveoli must be drawn or sucked into them. Besides the cellu- '# *^^kii "^ Fie. 27.— Caseous Pneumonia. (Thierfelder.) lar elements filling the bronchioles and alveoli, an enormous infil- tration of cells takes place into the intervening connective tissue — "many of them with two nuclei, nearly all with several surfaces, flat- tened." When this infiltration of cells has reached the point of dis- tending the septa between the alveoli, the vessels are so compressed that the circulation in them is suspended. Hyperplasia of the connec- tive tissue, although denied by Rindfleisch, does take place according to other investigators, and, in contracting, considerable shrinkage oc- curs, and a dense homogeneous mass results, made up of the distended alveoli, the infiltrated septa, the bronchioles dilated and filled with muco-pus and the contracting connective tissue, and is now in a condi- tion preparatory to the cheesy transformation. The caseous change consists in absorption of the watery parts, the fatty degeneration of the cellular elements, and granular disintegration of the fibrinous ma- terial, so that ultimately a soft solid is produced, yellowish in color, and having the appearance of cheese. In the mass are inclosed all the pul- monary elements — the acini, the bronchioles, the vessels, etc. " These nodules are surrounded by atelectatic, oedematous, or gelatinous paren- chyma in the preliminary stage of desquamative [catarrhal] pneumo- nia." The position of the catarrhal pneumonia resulting in the, changes described is usually at the apex, but precisely the same alterations occur in other jjai'ts. They may result from a general catarrhal bron- PHTHISIS PULMONALIS. - 353 chitis which has subsided elsewhere, but usually the disease is of the subacute form already described in the previous section, and limited, as it has a great tendency to be, to the apices or to an apex. Sometimes a whole lobe, a whole lung (phthisis florida), becomes infiltrated, and undergoes the cheesy degeneration. The softening in these cheesy nod- ules or masses begins in the center, and consists at first of a central cavity and softened canals extending from the center to the periphery. According to Rindfleisch, the cheesy masses in the lumina of the bronchi are the first to soften, while that in the peribronchial and perivascular spaces resists the softening process for some time. The force exerted in respiration, the dilatation of the bronchi, and the contraction of the parenchyma of the lungs, are the agencies which procure extrusion of the detritus. Larger cavities are formed by the breaking down of the divisions between smaller ones. The shape, size, conformation, and appearance of cavities vary with their age. The admission of air sets up putrefactive changes, and, instead of an odorless, softened caseous matter, it is now foul, greenish, or grumous matter. When this is mixed with the sputa, elastic fibers are detected in it, and the yellowish-gray solid particles, which are so characteristic a feature of the expectoration. At first, the iiaterior of the cavity is irregular, rough, and is more or less full of disintegrating pulmonary tissue and projecting caseous material ; but, when all this is discharged, it is smooth, and lined with a connective-tissue membrane, which furnishes a quantity of purif orm fluid. If accumulation of the purulent contents of the cavity takes place, putrid decomposition occurs, and the pus becomes fetid. Haemorrhage may be produced by erosion of a branch of the pulmonary artery. This accident would be much more common, if it were not that the vessels are early closed and cease to be pervious. In rare cases the mischief is confined to one or a few localities. Extrusion of the caseous matter occurs, there is no extension of the morbid process to neighboring tissue, contraction of the cavity takes place, and ulti- mately a mass of rather loose connective tissue remains to mark the site of the disease. This is the only mode of cure possible. Symptoms.— Caseous phthisis does not conform to one mode of onset. As respects the initial symptoms, there are three types— the chronic, the subacute, and the acute, or phthisis florida. In the chronic form, the onset is so gradual that the first symptoms can not be fixed on with certainty. A susceptibility to colds has been observed, and gradually a persistent cough and expectoration of muco-pus are com- plained of. Each severe cold is accompanied by chilliness, some fever, pains in the chest, loss of appetite, and a troublesome cough. During- an attack of this kind there may be bloody expectoration, or a mouth- ful or two of coagulated blood may be brought up, or there may be a smart pulmonary hfemorrhage. After such an attack it is observed that the " cold" does not get well ; that the cough and expectoration per^ 23 354: DISEASES OF THE RESPIRATORY ORGANS. sist, that there are a daily morning chilliness, an evening fever, and a sweat some time during the night. A considerable loss of flesh is now observed, and there are great weakness and a feeling of exhaustion on slight exertion ; the appetite is poor, digestion is feeble, and, if a fe- male, the catamenia are becoming scanty. In the subacute variety the onset is not so gradual. There is a history of a severe cold, with pain in the chest, a considerable fever, a troublesome cough, and abundant expectoration. The attack is severe enough to require confinement to bed for a few days, and, although after a week or two some improve- ment slowly takes place, and the patient gets about again, the symptoms continue ; there are fever, some sweating at night, a persistent cough, Day 17 18 19 20 21 22 23 24 25 26 27 28 29 30 3! 32 33 106" in/D -s f ^ \ - \ - ^ I -Mvr \ -\-A \--k K-K—P^-,'- l *- K ^ '-i^M S *- M ^^ '°2 A K ^ ^-i t ^ i ¥ ^ / V H H ^K_iil^^^t;li^t \> \/ i/ » - V im^ , ^ ^ fOO ^J ^ y 98' _ _ _ _-_ _ Fig. 28. — Temperatui-e of Catarrhal Pneumonia becoming caseous — Phthisis Florida. pains in the chest, expectoration at first of frothy mucus, then of muco- pus ; emaciation goes on and the strength does not improve ; the appetite is indifferent. In a portion of these cases, after the catarrhal products have become caseous, there is a period of comparative repose, in which all the symptoms appear less severe. The cough lessens, the fever declines, the appetite improves, and a notable gain in flesh may ensue. Under such circumstances the patient, and physician also, may feel greatly encouraged ; but none of the physical signs indicating consolidation of the caseous area change their significance, and the symptoms of imiDrovement prove delusive. Presently the process of softening begins (after some weeks, even many months), and with the softening, destruction of the pulmonary parenchyma and the forma- tion of cavities. Caseous phthisis may come on in an apparently healthy individual — it may be in a robust subject, of a full habit. In a few months a marked decline in strength, flesh, and activity has oc- curred — all dating from the time of the acute cold (catarrhal pneu- monia), since which the symptoms of pulmonary trouble have persisted. In the acute variety or phthisis florida, the whole course of the disease is run in a few weeks. It begins as a catarrhal pneumonia, involving almost the whole of one or parts of two lungs. It commences rather abruptly, with chilliness, fever, cough, pain in the chest, and rapid loss PHTHISIS PULMONALIS. 355 of strength. The temperature runs very high during the exacerbations, to 104°, 105° Fahr., or even higher, and there are considerable remis- sions and profuse and exhausting sweats. Owing to the sudden ob- struction of so much of the breathing-space, there is marked dyspnoea. The cough is very troublesome, preventing sleep, and the expectoratioo is profuse, purulent in character, and often streaked with blood or bloody, but has not the rusty appearance of the sputa of croupous pneumonia. The body emaciates rapidily, the strength is soon utterly gone, and the appetite is entirely absent. The symptoms increase in intensity, so that in the course of a few weeks or months the case ter- minates in death. Rarely a remission in all the symptoms takes place, an improvement in the local and general condition follows, and there- after the case pursues a more chronic form. In these cases of 2yhthisis florida, a large part of on^ lung or parts of the two lungs are occu- pied with the catarrhal pneumonia, and the products of the inflamma- tion undergo caseous degeneration, so that after death a lung may be a mass of cheesy deposit. 2. TUBEROULAK PHTHISIS. Definition. — ^Tubercular phthisis is that form of pulmonary con- sumption characterized by the deposit of tubercle ; by the changes due to such deposit, its softening and extrusion, and the less or greater destruction of the proper tissue of the lungs consequent on these pro- cesses. Tubercular deposit in these cases, if not limited to, is chiefly in the lung, and the disease of the lung-tissue quite overshadows that of any other organ. Acute tuberculosis is a general deposit of the miliary tubercle, accompanied by symptoms of universal disturbance of the functions of the body. As it is a general and not a local dis- ease, it is more appropriately considered with constitutional diseases. Etiology. — That tubercular consumption is an inherited malady, is held by most authorities. Although, by some leaders of modern medical thought, a certain peculiar " vulnerability of constitution " is transmitted and not the disposition to phthisis, the fact is undoubted that, when tuberculosis exists in a family line, it appears from one generation to anothei-. This disposition to consumption is closely associated with scrofula or struma. In early life struma manifests itself by glandular enlargements, a tendency to protracted suppuration, and the development, under iri'itative conditions, of tubercle. After puberty, the tendency of the strumous constitution is to tubercular deposit in the lungs. One of the factors in determining tuberculosis of the lungs is a badly formed thorax. The position at the apex, the favorite seat of tubercular deposit, may be due to the imperfect respi- ration at this point, owing to its position and conformation. All the conditions which dej)ress the bodily forces favor the growth and 356 DISEASES OF THE RESPIRATORY ORGANS. deposit of tubercle. Confined and foul air, excess of humidity, and rapid variations of temperature, are very influential elements in the sum of causes. Living and sleeping in badly ventilated apartments impair the quality of the blood, and invite disease to the lungs. A direct relation has been ascertained to exist between the amount of consumption in a given locality and the humidity of the air. Bow- ditch first ascertained this for Massachusetts, and the same fact was also shown in England. Variability of climate and rapid and extreme atmosphei'ical vicissitudes have a most injurious effect on those hav- ing a tubercular diathesis. Elevation and dryness are as conspicu- ously beneficial as the opposite conditions are hurtful to those having a phthisical tendency.* The absence of sunlight, by contributing to Fig. 29. — Miliary Tuberculosis. (Thierfelder.) anaemia, also favors the development of tuberculosis. Improper and insufficient food is an influential factor. The repugnance to fat, which is so often manifested by the phthisical, is unfortunate, since it is so necessary as a force-furnishing food. " Is phthisis communicable ? " is a question which can not now be answered, but which seems supported by many affirmative examples. The first experiments with the inocu- * See Lombard, "Traitc de Climatologie Medicale," etc., tome iv, Paris, Baillifere et fil3, 1880, p. 404, dseq. PHTHISIS PULMONALIS. 357 lation of tubercle, by Villemin, apparently proved its specificity, but subsequent researches have shown that it has no more infective prop- erty than other animal matter. The frequent examples of apparent communication of the disease between husband and wife, w^hen an he- reditary tendency had been proved not to exist, have awakened strong suspicions of the possibility of communication. That tuberculosis may result from other thoracic diseases is now a well-established fact ; it is secondary to catarrhal (caseous) pneumonia, to chronic bronchitis, hsemoptysis, and pleurisy. Pathological Anatomy. — The miliary tubercle is a grayish-white, translucent, and semi-solid granulation, about the size of a millet-seed, composed of a reticulum, with cells, giant-cells, and nuclei, the cells resembling white-blood corpuscles except that they are smaller, and the giant-cells having many nuclei. The reticulum is an extremely delicate network, inclosing the cells in its meshes, the giant-cells being placed nearly at the center of the granulation. It is this gray miliary tubercle which is deposited in the lungs, and constitutes pul- monary tuberculosis. According to Rindfleisch, tubercle takes its origin from the connective-tissue cells of the blood and lymph vessels, and the first deposits occur at the point where the bronchioles unite wath the acini. (A group of acini communicating with a bronchus is a lobule.) A whitish nodule — a tubercle granulation — is thus formed around the termination of the bronchiole in the acini, in the angle at their point of junction, the deposit being in the connective tissue. The nutrient vessels are included in the granulation, and their adven- titia become swollen and infiltrated. It is this development of tubercle in the connective-tissue cells of the adventitia that weakens the vessel, and which may finally cause a rupture and hasmorrhage. So many vessels at the apex are occluded by the mass of the deposits, that the pressure in the remaining vessels is much increased. When the walls of the vessels are infiltrated, rupture occurs the earlier by reason of th^ increased pressure from the cause just named. Tubercular deposi- tion also takes place abundantly in the bronchioles, not only those in immediate relation to the lobules, but for some distance beyond. The lymphatics distributed to the mucous membrane are infiltrated, and next those of the peribronchial space, so that all around the alveoli and bronchioles are thickly placed masses of tubercle granulations. The intervening connective tissue is also densely infiltrated. With the deposit of tubercle, there are associated the results of inflammation excited by the presence of these granulations. According to Rind- fleisch, a desquamative pneumonia plays an important part in the subse- quent changes. The cheesy transformation of the products of catarrhal pneumonia, atelectasis, bronchial dilatation, assist materially in enlarg- ing the area of structural changes. The masses of miliary tubercle, in a variable period after their deposition, and often within a few weeks. 358 DISEASES OF THE RESPIRATORY ORGANS. undergo a cheesy transformation, by Tvhicli they are brought into close resemblance to the cheesy products of caseous pnuemonia. It is a process of fatty degeneration, beginning in the central portion of each nodule. In acute tuberculosis, to be studied hereafter, the gray granu- lation is disseminated throughout both lungs. In the pulmonary tuber- culosis, the deposits occur chiefly in the superior lobes, and are often limited to'the apex, but are A^ery rarely indeed confined to one lung, and, when this is the case, the left is more often attacked than the right. When the process of cheesy transformation is completed, the resulting mass is opaque, yellowish, and has the friability of cheese. The infiltra- tion of all the parts, ultimately, of which the parenchyma of the lungs is composed, the closure of the vessels and entire arrest of the nutritive supply, and the compression exerted by the contracting connective tis- sue, necessarily cause a necrosis of the pulmonary elements. When the stage of softening comes on, the products, although having a puri- form appearance, are not purulent. Inflammation and suppuration are excited in the tissues, with the necessary result of disintegration. On the surface of the mucous membrane the destruction of the tissue in and about the site of the tubercle granulations is an ulceration ; in the mass of disease in the body of the lung the destruction of tissue pro- duces a cavity. The fluid matter resulting from the softening of the yellow tubercle is homogeneous, of the consistence of cream, and hav- ing a greenish-yellow or grayish color. Mixed with it are necrosed pulmonary elements, solid particles of a yellowish color, and the whole is contained in a small cavity, surrounded by masses of cheesy tubercle. The softening proceeds from the center to the periphery, and in its progress the pulmonary elements are disintegrated with it. When discharge of a cavern takes place by the ulceration opening a bronchus, or, according to Rindfleisch, by the tubercular ulceration of a bronchus, the elastic fibrous tissue may be recognized in the sputa. Large cav- erns are formed by the breaking down of the intervening septa and the coalescence of smaller ones. The increase in the area of destructive ulceration is greatly promoted by the attacks of catarrhal (desquama- tive) pneumonia, which induce softening and dilatation of the bronchi, collapse of lobules (atelectasis), catarrhal products, that fill the alveoli and bronchi, and there caseate. Cavities are produced under these circumstances by the softening and extrusion of the caseous masses as described under the head of caseous phthisis. In this case the tubercle granulation is the exciting cause of the catarrhal pneumonia ; in the former the products of catan-hal pneumonia undergo the caseous change in consequence of a peculiar "invulnerability" of the constitution, without which the catan-hal products would pass through the ordinary changes. Dilatation of the bronchi, or bronchiectasis, plays an impor- tant part. In catarrhal pneumonia, the walls of the bronchi yield in consequence of an extension of the inflammatory process to them, and. PHTHISIS PULMONALIS. 359 as the existence of dyspnoea renders greater inspiratory efforts neces- sary, and as the area for the admission of air is much reduced, obvi- ously the intcrbronchial pressure is raised, so that greater force is ex- erted against the weakened tubes. According to Rindfleisch, the walls of some cavities are in j^art formed by dilated bronchi. Cavities, still extending, have no proper boundary, and are surrounded by tubercle and caseous masses undergoing softening, and by detritus of the lung- tissue. Others are lined by a connective-tissue membrane, which con- tinuously pours out a puriform matter of a greenish-yellow, often hav- ing a foul odor by reason of decomjjosition from the presence of air. When the cavity is recently formed, not only are its sides ragged and uneven, but large bands traverse it, remains of pulmonary tissue not destroyed. Other organs besides the lungs are affected. The jo/ewroj is usually the seat of a chronic inflammation ; it may take the form of a dry pleurisy, and close adhesions form universally, so that the cavity is obliterated ; or the adhesions may be local and partial when they are chiefly at the apex ; or a neo-membrane is formed, and both the pleura and the new membrane may become tuberculous. Extensive effusion may be formed in consequence of the rupture of a cavity and the escape of its contents, when a pyopneumothorax results. A cavity perforated and firm adhesions having formed, the pleura may ulcerate and dis- charge take place through the thoracic parietes, a fistula remaining. The hronchial glands enlarge by hyperplasia of their contents, which un- dergo caseation. They may be dry and cheesy, or suppurate and dis- charge, the pus finding an exit by the trachea, or by a bronchus, or by the (Esophagus. In infants and children, enlarged bronchial glands may compress the trachea or bronchi, or the pneumogastric, and thus give rise to suffocative attacks. It may be well to mention that the late Dr. Fuller, of London, had secondary pyaemic abscesses of the brain, fi-om suppurating bronchial glands. The larynx always suffers from some morbid change in pulmonary tuberculosis. From simple hy- persemia up to extensive tubercular ulcerations, destroying the epiglottis, vocal cords, etc., there are numerous gradations in the severity of the lesions. Tubercular ulcerations also occur in the oesophagus, stomach, and intestines, but the point of greatest development of the ulceration is the lower part of the ilium and the large intestine. The tubercular troubles of the intestinal canal are found in two stages : the initial de- posit, and the softening and destruction of tissue or ulceration. The peritoneum is granulated, and chronic lesions of the peritoneum coin- cide with the formation of ulcers in the intestine. The liver is usually in an advanced stage of fatty degeneration, but in rare instances the change is that of amyloid disease. In the kidney, the amyloid degen- eration is more common than the fatty. Tubercular ulcerations are often found all along the urinary tract. Symptoms. — There is a peculiar type of constitution, as a rule, asso- 360 DISEASES OF THE RESPIRATORY ORGANS. ciated with tuberculous phthisis, which, being present, may serve to excite suspicions, at least, in obscure and doubtful cases. These pecu- liarities are observed in growing youths and young men, and may be described as follows : They are tall and rather thin ; the neck is long and small ; the thorax flat, narrow, and having but little expansile mobility ; the muscles, especially of the chest and neck, are thin and poorly developed ; the intercostal spaces are wide ; the hair is fine, the eyelashes long ; the eyes are large and bright, the sclerotic glistening ; the skin is transparent and thin, the color quickly changes, and the veins are blue and distinct ; the fingers are long and tapering, but their extremities are incurved or club-shaped. These subjects possess certain moral and mental characteristics also : they are impressionable, the dis- position is variable ; they are fond of activity, but fatigue easily ; oth- ers are more phlegmatic, speak slowly, and differ in complexion, being dark, with thick, muddy skins. When these peculiarities of constitu- tion coexist, with an hereditary tendency to phthisis, they possess a high degree of significance. In such subjects, a cough, losing flesh and strength, with a red line along the margin of the gum, are strongly in- dicative of the onset of phthisis, even when the physical signs may not be jjositive. A large proportion of the cases begin by loss of appetite, indigestion, decline in weight, without cough or any symptom referable to the lung. In women these symptoms are accompanied by disorders of menstruation. Again, an attack of haemoptysis may be the first .symptom. Most usually, the onset of the disease is characterized by a short, dry cough, which is rather more troublesome at night, preventing sleep, some shortness of breath, pains in the chest, either wandering or fixed in the position of an intercostal nerve, or a sharp stitch indica- tive of pleurisy, some nocturnal perspiration, confined at first to the neck -and face, decline in flesh and strength, poor appetite, and often, more or less diarrhoea. At this period, too, some alteration of the voice is beginning to be perceptible and bronchial haemorrhage occurs. The progress of the case is more rapid if the fever now appears. This may be an early symptom ; it may be postponed until the period of soften- ing. The action of the heart is excitable and is accelerated by slight causes from the very beginning, and the pulse is soft and compressible, the tension of the vessels being low. The usual type of fever in the beginning is the quotidian. There is a daily morning remission, an evening exacerbation terminating in a sweat — the so-called hectic fever. The type maybe double quotidian — two paroxyms of fever each day — the first in the morning, the second at night. The range of temperature at this period is not great, the minima about 98° Fahr., the maxima 102° Fahr. The range of fever-heat is an important indication of the degree in which the morbid processes are proceeding, especially those involving the lungs. In illustration of this may be mentioned phthisis Jlorida, in which the highest temperature of this disease is attained, PHTHISIS PULMONALTS. 361 because of the immense extent of the caseous deposits undergoing soft- ening and extrusion. As the case proceeds, all of the rational signs become aggravated. The appetite is almost gone ; in severe parox- ysms of coughing, in the last straining effort to dislodge the sputa, vomiting is excited, an accident very apt to occur after meals. The diarrhoea also increases, and becomes very difficult to restrain. The cough, also, grows more troublesome and painful, the expectoration more abundant, and the voice harsh and husky. Difficulty of swallow- ing comes on in consequence of ulceration of the epiglottis, and some- times the attempts at swallowing are embarrassed by the dropping of particles of food and drink into the glottis, exciting violent suffocative attacks. The expectoration assumes a different character at various periods. At first there is brought up, often with a great deal of effort, some frothy mucous ; after a time the sputa become purulent or muco- purulent, greenish or greenish-yellow in color, without air, and without viscidity, unless there is a complication of pneumonia, when the sputa will have a grayish, vitreous, adhesive charactei', and may also present a slightly rusty aspect from the admixture of blood, or may be simply streaked with blood. These adhesive sputa may be seen in large muco- pus expectorations, as isolated particles. The sputa often have a stri- ated apj^earance, at one time supposed to have much significance, but now known to be produced by the diminution of the cellular elements and the presence of deformed and atrophied cells and of granules — changes of a degenerative kind due simply to retention in the lung. The most significant element in the sputa is the presence of elastic fibers of the pulmonary tissue. These bodies are most easily detected by boiling the sputa in a solution of caustic soda in distilled water (18 — 100) according to the method of Fen wick.* The next ^'^."^t^f^j/'^^'^'i^^ change in the sputa is the char- '^^ a"" c* ^ ^ ^^ " " ^~ ' acteristic impressed on them by formation in small cavities. They then consist of two parts, a frothy muco-pus from the bronchi, and i^lated, globular, compact masses without air, of ".'S^^^^^ oC?^©^^o'^l^ "^-^ ^ "^ "^ a greenish or grayish color; j„j.B,j._Fragineni,oi Lung-Tissue anu ^^puta. (.Beaie.; when allowed to stand, the for- mer rises, and the latter sinks to the bottom, and, if put in water, sinks quickly. The quantity of expectoration varies ; in the begin- ning, because then it is derived from a bronchial catarrh ; afterward according to the extent of the cheesy masses undergoing softening, the size of the resulting cavities, and the degree in which bronchiec- tasis exists, When there is a large cavity, quantities of little more * Op. cit. 362 DISEASES OF THE KESPIRATORY ORGANS. than pus are expectorated. When the patient lies in a position to per- mit accumulation to take place, the expectoration may be suspended, but, when the position is changed, the pus is discharged in a stream. Sputa streaked with blood and -rusty sputa have already been alluded to ; but expectoration of blood, or haemoptysis, is a different affair. Ac- cording to some, phthisis may be due to pulmonary haemorrhage. This notion arose from the clinical fact that hsemoptysis is sometimes the first symptom of the disease, and after its occurrence there is an imme- diate development of the symptoms. The presence of blood-clot is supposed to excite an irritation which has for its ultimate effect the formation of tubercle. The most generally accepted view is, that haem- orrhage is merely a symptom, and a symptom that may occur at any period. If we accept Rindfleisch's demonstration, that the formation of tubercle begins in the connective-tissue cells of the adventitia of the vessels, there can be no difficulty in comprehending the early appear- ance of haemorrhage in the course of phthisis. At any subsequent period, the extension of the area of tubercle formation may be accom- panied by haemorrhage. Again, haemorrhage, and often of large size, may be due to the erosion of an unclosed vessel in the process of de- struction, ending in the formation of a cavity. The amount of blood 'lost varies from a drachm or two to several pounds. The blood is bright colored, more or less aerated, and comes up with coughing ; but a sudden large haemorrhage may pour up in a stream and be ejected by the nose as well as mouth. A considerable part of the blood may be swallowed, and subsequently vomited, and, as it is then acted on by the gastric juice, presents the appearance of haematemesis ; but the history of the case, the rational and physical signs of pulmonary dis- ease and the absence of stomachal disease will afford the data for a correct diagnosis. After the haemorrhage has taken place, and the flow is arrested, for some days clots of small size and blackish in color are expectorated. Occasionally there are indications of the approach of a haemorrhage, the significance of which the sufferers from them soon learn : these are a feeling of warmth in the chest, oppression of breathing, excited action of the heart, and a rather sweetish and saltish taste in the mouth. Usually, nothing in the nature of a warn- ing of the approaching haemorrhage is observed. When the blood- taste is experienced, the mouth should be examined, for the gums may be the source of the haemorrhage. Bleeding from the posterior nares may also be confusing, as there may be a coincident cough, A pul- monary haemorrhage may be vicarious of the menstrual flow, and it may be determined by the sudden arrest of haemorrhoidal bleeding. PHTHISIS PULMOIS'ALIS. 363 3. FIBROID PHTHISIS. Definition. — By this term is intended a form of consumjDtion char- acterized by hyperplasia of the connective tissue of the lung and atrophy and degeneration of its pi'oper structure. In this resj^ect the disease corresponds to fibroid liver, fibroid kidney, etc. ; but the changes do not begin in and are not limited to the connective tissue. Bronchial inflammation, bronchiectasis, and bronchorrhoea, are among the initial changes, the jDulmonary tissue being involved subsequently. Ultimately tubercular deposits occur, and the lesions produced by these are added to those already existing in the connective tissue and the bronchi. Etiology. — Heredity is concerned to the extent that the type of pulmonary tissue favorable to the development of this disease is trans- mitted. It is a disease of mature life, after the middle period, and is extremely rare before thirty. Next to heredity, chronic bronchitis is the most influential factor. The causes of chronic bronchitis are, therefore, indirectly the causes of fibroid phthisis. Pathological Anatomy. — The mucous membrane of the bronchi is of a dark red in the more recently inflamed parts, of a slate-color in the older, traversed by dilated vessels, its glands much thickened and elevated above the general surface. The sub-mucous connective tissue is thickened, the muscular layer hypertrophied at first, but in the fur- ther progress of the case the whole tube is softened and dilated. These dilatations may be fusiform or sacculated. The latter predominate, and are often mistaken for cavities, the resemblance being the more striking if the dilatation contains an accumulation of pus. The atro- phic changes in the walls of the bronchi are not the only factors con- cerned in producing dilatation. The force of the expiration in cough- ing, the contraction of the adjacent connective tissue, and of pleural adhesions, are also concerned. From the bronchi the inflammation slowly extends to the peribronchial, perivascular, and interlobular con- nective tissue. An hyperplasia of its constituent elements takes place, with the result to compress the vessels, the acini, and the bronchioles. The contraction of the newly formed connective tissue, by cutting off the blood-supply and encroaching on the neighboring parts of the pul- monary tissue, causes an atrophy. Some of the lobules collapse (ate- lectasis) ; all within the affected area contain less blood, and are nar- rowed by pressure. The collapsed lobules undergo the changes already described. In the progress of these cases catarrhal pneumonia ulti- mately plays a part ; the cheesy masses which form soften, producing cavities. The protracted suppuration finally invites tubercular deposit. So that the cases of fibroid phthisis, although differing in their rate of progress and in the greater importance of the sclerosis to the other morbid processes, nevertheless are brought into close relation to the 364 DISEASES OF THE KESPIRATORY ORGAN'S. Other forms of phthisis. A considerable increase of the connective tissue of the lungs occurs in chronic tubercular phthisis ; the longer the duration of the disease, in fact, the greater is the development attained by it. The walls of the cavities are composed of a dense layer of connective tissue, closely united to the same tissue of the lung. In caseous pneumonia there is less production of connective tissue, be- cause of the rapid progress. In a fibroid lung the cavities do not attain to great dimensions ; they appear as interspaces in the dense tra- becule. When these intervening portions of the condensed tissue are divided, they are ascertained to be exceedingly firm, of a grayish or slate color, containing here and there patches of brown pigment, and possess but little vascularity. The early compression and closure of the vessels is a source of mischief to the heart. The pulmonary circu- lation being obstructed over a considerable portion of the lung, the right cavities yield to the increasing pressure and dilate. There is, therefore, a stasis of the venous circulation ; the liver enlarges, and ascites is produced ; the kidneys are congested, and albumen is present in the mine. These complications develop toward the close of the malady. Symptoms. — Fibroid phthisis is the most chronic form of the dis- ease ; its early history is that of bronchial catarrh ; and it is not until after months, even years, that, extension taking place to the lungs, the progress becomes more rapid. For months there is merely a dry cough, not very troublesome, but persistent. The expectoration is slight, and is nothing but mucus. The appetite is but little impaired, and the weight and strength are not materially reduced. During the fall, winter, and spring months the symptoms increase in severity ; the cough becomes more troublesome, and the expectoration more abun- dant and having the apjDearance of muco-pus. The symptoms amelio- rate during the warm months, but to increase again with the changeable weather of "winter. After two or three years of tliis alternation, there is less and less improvement in the warm months, but the symptoms of catarrh continue throughout the year. Fever comes on toward even- ing, the temperature at first rising to 100° Fahr. The appetite lessens, digestion becomes poor, and the body-weight progressively declines. The cough is harassing and prevents sleep ; the expectoration be- comes more profuse and entirely purulent ; and the food now and then comes up in the attempt to clear the larynx and fauces. Some difficulty of breathing is experienced ; the pulse is small and weak ; the skin is warm toward eA'ening, while slight chilliness is felt in the morning, and sweating occurs during the night. As the disease ad- Tances, the temperature reaches 101° and 102° in the evening, but it does not attain to the altitude reached in caseous or tubercular phthisis. When the bronchi dilate, the expectoration becomes profuse, especially in the morning — a cupful or more may be brought up in an hour or PHTHISIS PULMONALIS. 365 two. Fragments of fibrous tissue only appear in it when cavities are forming. At this period there may be one or more haemorrhages. Detritus of caseous matter, softening, is found in the sputa only at this later period. The onset of tuberculosis is announced by increase of dyspnoea, rise of the temperature, alterations in the voice, and diarrhcea. The development of the connective tissue and the com- pression of the vessels lead to dilatation of the right cavities of the heart, stasis of the venous system, and congestion of the liver and kidneys, OEdema of the feet and ankles is first observed ; then swell- ing of the legs and scrotum, and ascites appear. Physical Signs of Phthisis. — There are no points of difference as respects the physical signs of phthisis ; hence the three forms may be considered together. The abnormality in the development of the chest, which is observed in phthisical subjects, has been already described. In the movements Fig. 31.— Cavities; one partly filled, one empty. (Da Costa.) of the ribs during expansion in inspiration, deficiency may be observed to exist on the diseased side. On jpalpation, increase of the vocal fre- mitus exists over consolidated lung and over cavities, and is diminished or wanting over effusion in the pleural cavity. The percussion-note has great variety. All shades of dullness exist. If the consolidation is not complete and some air still enters the diseased area, the note is high-pitched, but with a somewhat tympanitic quality ; but if the tissue is entirely without air, then the note is high-pitched and hard in qual- ity. The change in sonority may be unilateral or double, but if double 366 DISEASES OF THE RESPIRATORY ORGANS. it is not necessarily symmetrical ; it may be infra-clavicular on one side, infra-spinous on the other. The dullness may be due to various causes — to a pleuritic effusion, to pneumonic consolidation, or to a tumor or cyst. The extension of the area of dullness and the increase in hard- ness or the disappearance of the tympanitic quality may indicate the increase of the tubercular or caseous deposition. The change in the sonority of the lung is most usually at the apex, but it may be iii any situation. During the process of softening and extrusion there is no change in the character of the percussion-note until excavations have formed ; even then there will be no change, unless the cavity be large and near the surface. The percussion-note may present a nearly nor- mal sonority or it may be exaggerated over a cavity ; it may have a metallic clang, or amphoric quality ; it may, if the cavity communi- cate with a bronchus, have the cracked-pot sound {bruit de ^jot fele). The last is produced by strong percussion^ the vilbrations occurring in the walls of the cavity and in the column of air in the bronchus, A cavity in which pus has accumulated may furnish a dull sound ; when emptied, the amphoric sound will return. On auscultation the sounds audible will present great variety. The vesicular murmur will be unimpaired in those parts free from disease ; it will be feeble or in- distinct if many bronchioles are obstructed ; it will be rude or blow- ing if the bronchioles are narrowed ; inspiration will be jerking and expiration prolonged and blowing if the lung has lost its elasticity from any cause. These signs are much less significant when they occur on the right than when they occur on the left side (infra-clavicu- lar regions) ; in the former situation, they are, so to speak, normal. Next to these modifications in the resj^iratory murmurs are certain adventitious sounds, or rales. The earliest of these audible in the in- fra-clavicular region usually is a fine, dry, crackling sound (sub -crepi- tant) appearing at the end of inspiration, and sometimes requiring a deep and full inspiration to develop it. This rale may be temporary, when it has but little significance. The extension of the inflammation to the larger bronchi induces more abundant secretions, and the sub-crepitant rale becomes a distinctly moist sound, and audible over a larger area, and coarser sounds also moist — mucous rales — are mixed with them. With these rales changes in the respiratory sounds take place : inspiration has a distinct blowing character which approxi- mates to and ultimately does become bronchophonic — i. e., the sound of the movement of the air in the bronchial tubes and of the voice are communicated to the ear directly, the solidified lung acting as a good conductor, the respiratory or vesicular murmur having disappeared. These are the sounds of consolidation, and of softening up to exti'u- sion. When cavities form, new sounds become audible, but it is not always easy to differentiate between bronchophony and amphoric and cavernous blowing, the signs of a cavity. Amphoric blowing and PHTHISIS PULMONALIS. 367 amphoric voice are signs of a cavity, if correctly interpreted ; the cav- ernous sounds produced in a large cavity with thin walls are more sig- nificant. To these must be added metallic tinkling, which is heard in perfection in hydropneumothorax and under similar conditions when the cavity is large. Course, Duration, and Terminafcion. — The course of phthisis is much influenced by its form. Phthisis florida, or acute caseous phthisis, runs its course in a few months, and not often with intermis- sions, although it does sometimes intermit, and then pursue a more chronic course. Its usual course is continuous — a large pai't of one or of both lungs may be occluded, softening occurs, and high fever with rapid emaciation soon exhausts the powers of life. The usual type of caseous phthisis is chronic ; there are repeated bronchial attacks and gradually increasing consolidation, the interval between the attacks being characterized by varying degrees of improvement, but with a general tendency toward decline. In many, it is true, under judicious management, the catarrhal process is arrested, absorption of the case- ous matter takes place in part, the rest is extruded, with more or less destruction of tissue ; cicatricial tissue supplies the place, contraction ensues, with subsequent retraction of the chest-wall, and thus, in a limited sense, a cure is effected. In other cases the course is less marked by intermissions, the caseous deposits are extensive, and there are haemorrhages, fever, emaciation — the symptoms continuing until death. While the duration of the former type may be two, three, and as much as five years, or during the ordinary duration of life, the latter do not often extend two years. The tuberculous form, also pursues two different courses : one chronic, developing slowly, lasting two years or more ; the other more rapid, the whole course being termi- nated within a year. The degree in which broncho-pneumonia, atelec- tasis, and dilatation of the bronchioles occur, the extension of the tuber- culosis to the larnyx and intestinal canal, and the number and severity of the haemorrhages, are important factors in bringing about a fatal re- sult. So long as the tubercular deposit is limited to the lung, is slight in extent, there is a jDossibility of recovery by extrusion, shrinking of the lung, and retraction of the ribs. The most chronic of all the forms of phthisis is the fibroid. The course of this may occupy sev- eral years, indeed an ordinary lifetime, and prove fatal at last. Of all the forms, it offers the best prospect of a cure, if the changes are not too extensive. The initial period, terminating in a bronchiectasis, may occupy a number of years ; at first, for several years, there is winter cough only, the warm season being free, or nearly so ; when the con- nective tissue of the lung is invaded the progress is more rapid, for then atelectasis and caseation enter as elements into the destructive changes. Finally, tuberculosis is ingrafted into the morbid process, which then advances more rapidly, because not only the lungs, but the 368 DISEASES OF THE RESPIRATORY ORGANS. larynx and intestinal canal, become diseased ; the range of temperature rises higher, and emaciation proceeds at an accelerated pace. Phthisis is the great enemy of the human race, since nearly two sevenths of the deaths from all causes are due to this disease. But a few years ago, a cure of any case was regarded as hopeless ; but within recent times the improvements in our knowledge of the local conditions and in the means of treatment have led to better results, and cures are now not uncommon. Diagnosis. — The diagnosis of phthisis can not be doubtful after the initial period. Incij)ient phthisis may be confounded with atonic dyspepsia. A cough may be present in atonic dyspepsia — the so-called stomach-cough. The natural differences in the sonority and the res- piration of the right and left infra-clavicular regions may materially contribute to the error. Attention to this, and to the fact that there is no point of irritation about the air-passages to account for the exist- ence of a cough, will settle the doubts. More frequently, in malarious regions, is hectic fever confounded with intermittent, since in the lat- ter there is usually some cough. This mistake is made when the pul- monary disease is quite advanced, so that the error is either from ignorance or carelessness. In j)hthisis, independently of the physical signs, the fever has been preceded by a period of cough, and loss of flesh and strength, whereas in intermittent these symptoms have fol- lowed the access of fever ; in phthisis there is not, in intermittent there is, an enlarged spleen ; in j)hthisis the hectic is not arrested by large doses of quinine ; in intermittent the fever is arrested and con- valescence is at once established. A careful study of the physical signs ought at once decide the question. Laryngeal symptoms are often so pronounced in the beginning as to obscure the pulmonary affection. Indeed, the disease in the lungs is referred by some to the larynx, to which it is regarded as strictly secondary. This error has arisen from the fact that considerable infiltration of the lung may exist without seriously imj3airing its sonority, or changing or modifying the vesicular murmur. When tubercular deposits occur in the larynx, the tone and quality of the voice are quickly affected, so that the lat- ter may seem to be the only seat of tubercular deposit. Although, to determine this question, time may be necessary, the coexistence of pulmonary disease ought to be suspected, because of the relation known to obtain between them. The most important diagnostic ques- tion relates to the difference between caseous and tuberculous phthisis. The sections devoted to these two forms have indicated the clinical and pathological differences ; nevertheless, it will be useful to state briefly the points which serve to distinguish them. Tubercular phthisis is distinctly hereditary ; caseous i^hthisis is not hereditary, but occurs in the scrofulous. Tubercular phthisis occurs at all ages ; caseous, from youth to middle age. Tubercular phthisis occurs insidiously PHTHISIS PULMOXALIS. 369 with catarrh of the bronchi and larynx ; caseous results from acute inflammations of the bronchi and lungs. Tubercular phthisis is more often than the caseous a cause of pulmonary haemorrhage. In tuber- cular phthisis the lesions are apt to be on both sides ; in caseous, on one side. In tuberculosis of the lung, tubercle may be widely dissem- inated without any striking physical signs ; in caseous phthisis the caseous deposits produce very pronounced physical symptoms. The laryngeal symptoms are much more common in tubercular than in caseous phthisis. The progress in tuberculous phthisis is moi-e rapid and the mortality greater than in caseous. Fibroid phthisis is distin- guished from the other forms by its slow progress, by the long period of bronchial troubles before the pulmonary lesions begin, by the merely purulent expectoration, without fibrous tissue, until late in the prog- ress of the case, and by bronchial dilatation long before the cavities by excavation form. Treatment. — When a phthisical tendency exists, prophylaxis be- comes highly important. Although not often consulted, physicians should discourage, directly and indirectly, the marriage of the phthisi- cal. Children inheriting the dyscrasia should have a careful physical training, substantial food, warm clothing, and exercise in the open air without exposure. They should be guarded against attacks of bron- chial catarrh, of measles, and whooping-cough, for in these diseases the seeds are sown of future mischief. As humidity is such an im- portant factor in the etiology of phthisis, and as dryness and elevation are climatic conditions of the greatest utility, if possible, the growing child should be separated from the one and placed in the other. Sing- ing should be encouraged, since that tends directly to improve the nu- trition of the lung, especially of the apex. Cold bathing should be practiced every morning to diminish the susceptibility to cold. Ca- tarrhal attacks occurring should receive prompt attention, and any lingering remnant of local morbid action should be carefully removed. The tendency to such attacks and the removal of the effects produced by them are equally controlled by the iodides (iodide of iron) and cod- liver oil. As phthisis is preeminently a wasting disease, it is highly important to put the organs concerned in nutrition into the highest state of efficiency. In tubercular and fibroid phthisis, among the ear- liest symptoms are stomach disorders, poor appetite, atonic or acid indigestion, and especially repugnance to the fatty elements of food. The mineral acids, with a bitter, such as tincture of nux vomica, are especially serviceable. If there be acid eructations, pyrosis, and heart- burn, the mineral acids, especially nitro-muriatic (ten to fifteen drops, well diluted, ter in die), should be administered before meals ; but, if the condition be atonic indigestion, the acid should be given after meals. The nux-vomica tincture should be given before meals — fifteen drops in water. The aliment should consist of easily digested articles of diet, 24 370 DISEASES OF THE RESPIRATORY ORGANS. and the stomach should not be overloaded under any circumstances. It should never he forgotten that it is not the quantity swallowed, but digested and assimilated, which contributes to the nourishment of the body. There are certain tonics to the stomach which stimulate the organ to more efficient work, that are very beneficial in promoting the nutrition of the body. These are, besides the bitters and mineral acids mentioned above, small doses of arsenic and silver, and alcohol. Arsenic is deserving of special commendation — in incipient phthisis, to promote the appetite and favor tissue-forming, while it corrects the disordered state of the stomach mucous membrane, and as a remedy for chronic tuberculosis and fibroid lung. The author must impress on his read- ers that arsenic must be given in small doses, as it is to be continued for a long period (two drops three times a day). The oxide of silver performs much the same office, but its administration must be brief, because of the danger of coloring the skin (Argyria). Small doses of alcohol after meals (half an ounce for adults) are highly useful to pro- mote appetite and tissue-formation. Physicians should not encour- age the dangerous notion that whisky is antidotal to phthisis. Fibroid phthisis appears to be produced by chronic alcoholism. Large quan- tities of alcoholic fluids impair the function of digestion, and lessen tissue-forming ; hence the amount named — certainly not more than twice as much — should not be exceeded. The utility of cod-liver oil in incipient phthisis is very great. As the power to digest fats is con- fined within narrow limits, and as the ability to dispose of them is relatively less in consumption, the dose of cod-liver oil should be pre- scribed accordingly, from a tea- to a tablespoonful — a teaspoonful the usual dose. All in excess of the capacity to digest passes unchanged, and may be seen floating on the evacuations. The utility of cod-liver oil consists in the fact that it is a fat, having a special digestibility, owing to its containing bile elements, and is therefore peculiarly fitted to form the "molecular basis of the chyle." It is not useful in cases of phthisis florida, or in caseous phthisis characterized by large de- posits, high fever, and diarrhoea. In incipient phthisis its utility is very great, and only less so in chronic tuberculosis and fibroid phthisis. In what form soever it may be given, it is better to prescribe it with a little ether (tti, xx — 3 j), because of the action of the ether in pro- moting the flow of pancreatic fluid — a fact demonstrated by Bernard, and confirmed by clinical observation. Cod-liver oil may be given in the form of emulsion with the lactophosphate of lime, the compound hypophosphites, and the compound phosphates. The simultaneous administration of these remedies is good practice, and the emulsion may be allowed, if the quality of the cod-liver oil is good, but it should not be overlooked that an inferior oil may be disguised in an emulsion of this kind. The lactophosphate of lime, if well prepared, is a most valuable agent in the treatment of incipient and the more chronic PHTHISIS PULMONAtlS. 371 cases of phthisis. The hypophosphites, although not deserving the encomiums first pronounced on them as remedies for consumption, are vahiable agents to promote the constructive metamorphosis. It is doubtful whether the hypophosphites present any advantages over the phosphates, because of their chemical instability and rapid conver- sion into the phosphates. The lactophosphate of lime has the special advantage that it is a soluble combination of an agent very important to the construction of tissue. The last-named remedy may be given in a dose of a tea- to a dessertspoonful of the sirup three times a day, after meals. It is good practice to give it with cod-liver oil, but not in an emulsion, for reasons already stated, unless the emulsion is pre- pared extemporaneously from unquestionable materials. If caseous or tubercular deposits have formed, we have a new problem for solu- tion. Do we possess means to procure softening, absorption, and extrusion ? The author has seen such good results from the salts of ammonia that he believes this question may, with some important limitations, be answered in the affirmative. A combination of the carbonate and iodide of ammonium seems to procure the best results — five to ten grains of the carbonate and the same quantity of the iodide in solution in water. If the stomach is irritable, the dose must be small. As a rule, five grains of each remedy four times a day is better than a larger dose less often. This combination should be resorted to when the vesicular murmur is assuming a blowing character and the sonority is diminishing, and it should be continued for several weeks, for months, if improvement is manifest under its use. Some of the chief symptoms require remedies to restrain them in proper limits, as cough, fever, sweats, haemorrhage, laryngeal symp- toms, and diarrhoea. These we consider in turn. If cough is very dis- tressing, some relief becomes necessary, and the constant temptation is to resort to anodynes. Gargling the throat with a solution of bromide of potassium, applying a mixture of chloral and camphor by means of a camel's-hair brush to the fauces, the atomization of a solution of morphia, are expedients temporarily beneficial. Fothergill's prescrip- tion of hydrobromic acid (diluted) and spirit of chloroform sometimes acts well, but is often inefficient. Of the principles contained in opium, codeia is the least objectionable ; it causes less disturbance of the diges- tive organs, and has more effect on cough. A combination of codeia, atropia, and strychnia is highly efficient as a remedy for cough, for night-sweats, and reflex vomiting. Picrotoxine allays the vomiting which accompanies the cough almost as efficiently as strychnia, and has at the same time decided anhydrotic effect. A resolute patient may suppress cough to a very great extent by an effort of the will. The irritable feeling in the fauces may be allayed by a bit of gum- arabic or candy, or a troche. The officinal troche of liquorice and 372 DISEASES OF THE RESPIRATORY ORGANS. opium, or of morpliia and ipecac,* may be employed in this way ad- Tantageouslv. In the treatment of the fever of phthisis, the first and most important remedy is rest. Under a mistaken notion of the value of exercise, phthisical subjects, haying a high fever, attempt an active out-door life. A very considerable increase of the normal increment of fever takes place when exercise is attempted, and a corresponding diminution when repose is enforced. As a high range of temperature is most injurious, it is necessary to reduce it as much as possible. The most effective antipyretic is quinia, but to reduce the fever it must be given in sufficient doses. Twenty grains on alternate mornings will usuallv reduce the temperature several degrees and keep it within the proper limits. Digitalis is too nauseating to be used with advantage, and salicvlic acid is more unpleasant in all respects and less efficient than quinia. The most powerfxd anhydrotic which we possess is atro- pia. For an adult about -gL. of a grain at bed-hour usually suf- fices ; but, as atropia seems to have a special action on the lungs in caseous pneumonia, it is better to give it in smaller doses (ytw ^^ roir grain) three times a day. Under its use there is often a remarkable improvement in the condition of the patient, not due solely to the arrest of the night-sweats, but to some special property. The com- bination before referred to is a suitable form for the administration of atropia — with codeia and picrotoxine. Sometimes remarkably good results follow the use of pilocarpine, but it is far from being uniformly successful. If atropia fails, pilocarpine should be tried. Oxide of zinc, with belladonna extract, sometimes does well. Sponging the body with hot water, or vinegar and water, is a domestic remedy, which is refresh- ing. The treatment of haemorrhage will be referred to again, and its consideration is therefore postponed. Remedies for the laryngeal symptoms can be applied directly, the hand being guided by the mir- ror, titrate of silver, carbolic acid, and iodoform are the medicaments most frequently applied directly. Atomization is, however, the more useful and generally employed. Common salt, potassic chloric, am- monium chloride, tannic acid, and tar- water are the remedies most fre- quently used in this way. To this statement must now be excepted benzoate of soda, which is being employed in the most extraordinary fashion. Already, soon after the announcement of its curative power in consumption, comes the statement that there is but little truth in the first reports. The remedies above mentioned are dissolved in water, or in glycerine and water, for example, gr. ij of tannin to the ounce of water, and then atomized, the patient receiAT-ng the spray in the fauces. Obviously, caustic and corrosive remedies are not adapted to such purposes. The diarrhcea of phthisis is most difficult of control, and for obvious reasons — the tubercular deposit and the subsequent * Trochisci glycrrrhizae et opii, each troche contains -^g grain of opium ; trocliisci morphia et ipecacuanhae, each troche contains -^ grain of morphia and -jV ipecac. HJSMOPTYSIS. 373 ulcerations. Opium and acetate of lead, opium and tannin, opium and sulphuric acid, opium and arsenite of potassa, are among the principal remedies. Extract of logwood is highly esteemed by many English practitioners. The author has had better results from Fowler's solution and the tincture of opium than any other remedies (2 gtt. — 10 gtt.) except aromatic sulphuric acid and laudanum (15 gtt. — 10 gtt.). In the treatment of the diarrhoea frequent changes are necessary. A remedy that succeeds for a time will not continue to do so, and hence the resources of the physician are often severely tried. The requisites of a climate for pulmonary invalids have been briefly stated ; they are dryness and elevation. The health resorts which offer these requisites in the highest perfection are the best. Those of North Carolina, South Carolina, Georgia, the Rocky Mountain regions, California, New Mex- ico, offer every variety. No change of climate, however, can be bene- ficial as a rule, after cavitiefe have been formed, unless of slight extent. It is in incipient phthisis that a change to a climate dry, bracing, and elevated, really exerts a curative influence. H.E3M0PTYSIS— BRONCHO-PULMONARY HEMORRHAGE. Definition. — The word haemoptysis, which means " spitting of blood," does not indicate the source of the haemorrhage. Broncho- pulmonary. h(Bm,orrhage is a correct designation, for this expresses both the nature of the accident and the position of the disease. Bron- chial haemorrhage occurs from some part of the bronchi ; pulmonary haemorrhage consists of two forms — pulm,onary infarction / pulmo- nary apoplexy — a hasmorrhage arising from embolic blocking of a branch of the pulmonary artery, the tissues of the lung being dis- placed merely in the former, but broken up in the latter. Causes. — Pulmonary haemorrhage is infrequent at the extremes of life, and is most common from youth up to middle life. It occurs in either sex in about the same ratio. An infarction presents a character- istic appearance of a wedge-shaped portion of the lung infiltrated with blood, and situated at the periphery of the lung, with the base of the wedge outwardly. Infarction is almost always associated with heart disease, in which heart-clots are formed on the right side, and emboli being detached pass into and obstruct a branch of the pul- monary artery. To cause an infarction, the artery obstructed must be a "terminal artery" in the sense intended by Cohnheim* — that is, an artery without anastomoses, and dividing only into the final capil- laries. When such a vessel is obstructed, the blood-current is arrested both in front and behind the point of obstruction, in the capillaries and veins, until they are joined by others. Then commences a back- ward current into the capillaries of the occluded vessel, and into the * " Untersuchungen ueber die embolischen Processe," Berlin, 1872, p. 74. 374 DISEASES OF THE RESPIRATORY ORGANS. vessel itself, until they are thoroughly distended with red-blood cor- puscles, and hence appear to the eye as a red spot having a wedge- shape. In another form of infarction, a diseased vessel giving way, the blood enters a bronchus, and is drawn up into the lobules, distend- ing them. This differs from the other form in appearance ; it is less dark in color, is irregular in outline, and is shaded off into the sur- rounding normal tint. Pulmonary apoplexy is a haemorrhage which breaks up and infil- trates the lung, and is usually due to traumatism, to gunshot injuries and contusion, to the rupture of aneurisms, to gangrene, etc. - Bron- chial haemorrhage arises from primary and secondary causes. The primary causes are of an irritative kind, and induce congestion : pro- longed exertion of the voice, mechanical straining, inhalation of irri- tating gases and fumes, etc. An abnormal weakness of the vessel- wall inherited ; that state of the circulation which exists in the subjects of hsemophilia, the so-called "bleeders" ; the condition of the vessels in young subjects of the sti'unaous type, are factors in the production of i)ronchial haemorrhage. The most important of the causes is tuber- culosis. As has been stated elsewhere, the initial change in the devel- oj)ment of tubercle is a proliferation of the connective-tissue corpuscles of the adventitia ; and, although the multiplication is chiefly outwardly, the media and intima are weakened. Haemorrhage may therefore be an early symptom of tubercular deposit. In the extension of the tuber- cular deposit a vessel may be invaded at any time. A large haemor- rhage may result from the opening of a vessel by erosion in the pro- cess of softening and formation of cavities, or by the development of an aneurism on a vessel in the wall of a cavity. The vessels still per- vious are subjected to a much greater pressure by reason of the closure of so many, and hence this increase in the vascular pressure enters into the question of haemorrhage. The suppression of an habitual discharge has long been supposed to cause pulmonary haemorrhage, but this is no longer admitted. The menstrual flow may take place vicariously by the bronchial mucous membrane, as it does by various channels. A substitution is very different from a vicarious haemorrhage. Pathological Anatomy. — Haemorrhage may be caused by a diape- desis of red-blood globules, and hence no solution of continuity can be detected under such circumstances. Even when there has been a con- siderable haemorrhage, the source of it may elude the most painstaking investigations. If the examination is made immediately after a haem- orrhage, there will be found both fluid and coagulated blood, drawn up into the bronchioles and alveoli, and through the larger tubes. In consequence of violent struggles for breath, in the case of large haem- orrhage, the inspiratory efforts draw up a good deal of blood into the lungs, distending them, so that they overlap the heart and do not col- lapse. They present a mottled appearance, because of the filling of HiEMOPTYSIS. 375 many alveoli with blood. The mucous membrane of the bronchi may be congested or reddened by jDatches of extravasation, or of a dull-red by imbibition of blood, or uniformly pale from anaemia, according to the causes producing it and the source of the haemorrhage. The in- farction presents a most characteristic appearance : it is wedge-shaped, with the base outward, and is, when small, just under the pleura ; when large, nearer the root of the lung. Infarctions vary in size, from a pigeon's to a hen's egg, or may even occupy a half or nearly the whole of a lobe. They are found more frequently in the inferior part of the lower lobe. If under and next the pleura, they appear as dark-blue masses, projecting somewhat above the general surface of the lung, which just about the infarction is pale and exsanguine, while the pleura is roughened by exudation, and confined to the infarction. Some- times effusion occurs in the pleural cavity, which contains flocculi of membranous exudation, and is red by admixture with blood. When a section is made through an infarction, it appears as a dark, reddish- blue, well-defined mass, from which some dark, reddish-brown liquid and granular matter may be pressed. Fibrinous exudation, distending some of the alveoli, gives to the otherwise smooth surface a granular aspect. At first firm and elastic, the infarction soon becomes friable. The surrounding pulmonary tissue is more or less hypersemic and cedematous. An infarction may undergo several kinds of change : the blood may disintegrate, the fibrin become granular and fatty, and the corpuscles break up into fat-granules ; absorption may take place in part, extrusion in part, and recovery ensue, the elasticity of the lung remaining impaired to some extent. Recovery may ensue in part only : the lobules collapsing and inflammation occurring in the con- nective tissue, a brownish-red indurated mass remains ; or, after an imperfect absorption of the blood and inflammatory exudation, the remaining reddish, pulpy mass solidifies by infiltration with calcareous salts, or, merely inclosed by a limiting membrane, a cyst remains — a process only resembling hsematoma of the dura mater. Or, again, inflammation may result in suppuration, an abscess forming ; or, finally, the whole may become gangrenous. Pulmonary apoplexy not unfre- quently forms a blood-mass of considerable size, the blood breaking up the pulmonary elements and diffusing into the surrounding parts, in part coagulating. If next the pleura, this membrane may be per- forated, and the blood, entering the cavity, produce a hsemothorax. Symptoms. — It is but rarely that a hemorrhage occurs in full health without the least intimation of its approach. In this way may the onset of pulmonary disease be announced. Usually there is a sense of heat and oppression of the chest, which those recognize who have experienced former attacks, or there may be general vascular full- ness, headache, vertigo, palpitation of the heart, a quick, strong pulse, etc. The signs of pulmonary disease precede the haemorrhage, in 3Y6 DISEASES OF THE RESPIKATORY ORGANS. a majority of cases, rather than succeed to it. At the moment the attack is experienced, there are a sudden cough, a warm feeling under the sternum, and a mouthful of fluid, tasting both saltish and sweet- isli, comes up. Cough now succeeds cough, and with each effort a teaspoonful or more of blood, somewhat frothy, or, if in large quan- tity, bright — red blood and somewhat darker clots, are discharged. Even with a small amount of blood, the moral effect of the blood-spit- ting is so great that much depression, paleness of the face, and a weak pulse result. If the loss be great, there will come on the subjective sensations of fainting, and actual syncope will happen. If the hgemor- rhage is great, the blood will come up with a sudden gush, spurting from the nose as well as the mouth. If a fatal haemorrhage, the blood will pour out of the mouth and nose, there will be gurgling in the fauces, frantic efforts at respiration, a deadly pallor will overspread the face, and, with a general convulsion in which the breathing ceases, all is over, but the heart will beat for a minute longer. The expectora- tion of blood does not cease with the arrest of the haemorrhage ; for some days subsequently dark-brownish coagula will be brought up, with some rather viscid mucus. The source of the haemorrhage may not unfrequently be determined by the moist rales heard in the bronchi. The signs and symptoms of infarction have already been mentioned under the head of embolic pneumonia, so that it is necessary only to mention that, when an infarction of sufficient size is formed, the symp- toms are sudden dyspnoea and the physical signs of consolidation. Course, Duration, and Termination. — There are great variations in the amount and duration of pulmonary haemorrhage. The whole course may be concluded in a few hours. The expectoration may go on during several days, from a tea- to a tablespoonful being spat up each time, and the haemorrhage in the aggregate amounting to several pounds, causing great depression and a tedious convalescence. In other cases, there may be a number of large haemorrhages, occurring after an interval of several days, the arrest being due to syncope, and the hcsmorrhage recurring when sufficient blood has been made to pro- duce it. Such cases may continue for several weeks, the system being much reduced and the convalescence very protracted. In cases of haemorrhage with infarction there will follow a period of inflammatory reaction, the expectoration will continue bloody for a week or ten days, and, if the area of tissue involved is small, recovery will ensue, and convalescence will be established in about ten days. The reader is referred to embolic pneumonia for further details in respect to this group of cases. An ordinary croupous pneumonia may be accom- panied by considerable haemorrhage, which occurs with the initial hyperaemia, when the pneumonic process r:ay be confounded with the results of haemorrhage. The debility caused by pulmonary haemorrhage is quite disproportioned to the actual loss. A few tea- HEMOPTYSIS. 3Y7 spoonfuls may induce fainting and an unexpected degree of anaemia. Any considerable loss will be followed by pallor, weakness, breathless- ness on slight exertion, palpitation, etc., and the restoration of the blood will require several weeks or months. The moral effect of the haemorrhage and the association of ideas connected with the bleeding are in part responsible for the depression, but more is due to the fact that, in most cases, the system is already enfeebled by a dyscrasia. To this important element is also due the prolonged condition of anaemia — the slow reproduction of the red-blood corpuscles. Diagnosis. — In every case of doubt, the mouth, fauces, and nares should be carefully examined. Is it vicarious haemorrhage ? The patient is a female, the haemorrhage occurs at the menstrual epoch, and takes the place of the menses, or nearly so, and no untoward re- sults are experienced, nor does any evidence of pulmonary disease exist. In many of these supposed vicarious haemorrhages it will be found that the subjects are of the phthisical type, and that, if the physical signs are wanting, there are suspicious rational symptoms. In these cases, it usually happens that the menstrual flow does not return, and that phthisis rapidly develops. Haemoptysis is to be dif- ferentiated from haematemesis. In the latter, the blood is black, con- tains no air, has an acid reaction, is mixed with articles of food, and is vomited ; in the former, the blood is bright red, contains air, has an alkaline reaction, and is coughed up, while there is no nausea. If the blood of pulmonary haemorrhage is swallowed, it will present the characteristics of blood derived directly from the stomach, but the distinction is then made by observing that some of the blood is coughed up, and has the ordinary character of blood derived from the lungs. It should be noted that blood swallowed may pass away with the stools. Haemoptysis is accompanied by rales in the chest, and preceded in the largest number of cases by symptoms referable to the chest ; haematemesis by symptoms referable to the stomach. Prognosis. — It is very rare indeed for the life to be put in jeop- ardy by a pulmonary haemorrhage. If the patient is much reduced, a severe haemorrhage may materially hasten a fatal result. Haemor- rhage proceeding from a cavity is more unfavorable than a bronchial haemorrhage, for the vessel may bleed again and again, since any co- agulum, which in other situations might close it, will here be readily detached. The prognosis must be guarded when the subject of the haemorrhage is much reduced and the quantity lost is considerable. In a case of supposed vicarious haemorrhage, the probability of a rapid development of the pulmonary lesion should not be forgotten. Treatment. — The management of cases of haemoptysis includes the treatment of the haemorrhage and of the conditions on which the haemorrhage depends. If the subject be a plethoric one, and there is niuch oppression from fullness of the vascular system, bloodletting 378 DISEASES OF THE EESPIRATORY ORGANS. may be practiced, either venesection to eight ounces, or a dozen leeches. These are, it must be admitted, rare cases. The most effective remedy is the hypodermatic injection of ergotin. Often, the most severe bleed- ing will be at once arrested, when other means of treatment had been employed in vain. Fluid extract of ergot may be given internally, combined, if desirable, with digitalis and opium — ^with digitalis if the action of the heart is rapid and excited, and with opium if there is a troublesome cough. Ipecac is, next to ergotin, one of the most efficient haemostatics. Its utility has been disputed on theoretical grounds, but not by those who are practically acquainted with its real advantages. Ipecac produces an exsanguine condition of the lung, and arrests haem- orrhage also, by the enfeebling effect of nausea on the heart. It is even successful in stopping post-partmn haemorrhage. Besides its haemostatic effect, the advantage of its use consists in mechanically clearing the alveoli of retained clots. Ipecac should not be prescribed in those cases of haemorrhage from a cavity, the difficulty of keeping a, clot in the position necessary to close the vessel being already great. The most suitable form for the use of ipecac is the fluid extract, which may be combined with ergotin, digitalis, and opium if desirable. Tinc- ture of veratrum viride may be used with great advantage to keep down the action of the heart. Ice has a similar effect to these dynamical haemostatics ; it slows the heart and contracts the arterioles. It should be applied to the chest, especially to the nape of the neck. The alter- nate application of heat and cold is usually more effective than the continuous cold. A sponge dipped in hot water can be applied first, then an ice-bag, and so on alternating — the heat remaining in contact but a few minutes, while the cold is kept applied the rest of the time. Absolute rest is an agent of the same kind. The patient should main- tain a recumbent posture, and not exert a muscle if he can exercise such restraint. All emotional disturbances should be avoided as well. There are remedies called astringents which are supposed to possess haemostatic powers, such as tannic and gallic acids, acetate of lead, alum, and the mineral acids, especially sulphuric. These are decidedly inferior to the remedies above named, yet they are freely used, espe- cially the acetate of lead in combination with opium. That they are serviceable, an immense experience confirms, but they do not deserve the very great confidence reposed in them by many practitioners. In cases of debility, characterized by relaxation of tissue, or in examples of the hsemorrhagic diathesis, or in cases of purpura, oil of turpentine is highly useful. Inhalations, by the atomizer, or spray douche, of a solution of Monsel's salt (subsulphate of iron) or the chloride of iron, will sometimes arrest a violent haemorrhage at once. This undoubted fact is all the more difficult of explanation, since but little, very little, of the iron salt can pass the chink of the glottis, and none of it can reach the point of disease in the lung. Tannin in solution may be em- HJEMOPTYSIS. 379 ployed in the same way, but the iron spray is distinctly better. In administering iron spray great care must be exercised to protect the teeth and the clothing, which may be permanently stained, A mouth- ful of common salt is a domestic remedy, which may be used until more efficient means are available. Counter-irritants are serviceable. A mustard-plaster or a flying-blister is sufficiently active, or a turpentine liniment, the latter being useful also because of its vapor. Good re- sults may be obtained by inhalation of the vapor of turpentine disen- gaged for this purpose in those cases appropriate for its internal ad- ministration. If the hsemorrhage has shown a disposition to recur, the recumbent position, quietude of mind, and the remedies employed to check it, if not objectionable, should be continued until all possibility of danger has passed. HYPEREMIA AND CEDEMA OF THE LUNGS. Definition. — IIyper(Mmia signifies an abnormal increase in the blood- supply, which may be active or passive. (Edema is usually a conse- quence of hypersemia, but it may be due to causes producing general cedema. The term signifies the presence of serous fluid in the alveoli, the intervening connective tissue, the perivascular lymph-spaces, etc. Causes. — There may be an increase in the amount of blood going to the lungs, the result of increased pressure in the arterial system, from greater force of the heart's contractions, or from narrowing of the arterial field elsewhere, throwing an additional quantity on the lung. Undue exercise of the vocal apparatus in speaking or singing, the inhalation of cold, or very warm air, or the sudden transition from one extreme of temperature to the other, and the inhalation of irritat- ing gases or vapors, are causes determining congestion of the lungs under favoring circumstances. The form and character of the chest and the existence of a constitutional vice or dyscrasia are necessary to bring about the results from the operation of such causes, especially the type of chest and the bodily conformation of phthisical subjects. The ingestion of cold drinks, the body in a warm and perspiring state, will sometimes induce extreme congestion of the lungs. The sudden impact of cold air or cold water on the surface will more surely pro- duce the same result, since a larger surface of the capillaries is made to contract, forcing the blood within. One part of the lung, the seat of a disease obstructing the circulation in it, will necessarily throw on another part an excess in its supply ; pneumonia, atelectasis, and obstruc- tion in some branches of the pulmonary artery, are examples. Pas- sive congestion is produced by causes interfering with the return of blood from the lung ; mitral stenosis and insufficiency, aortic stenosis and insufficiency, and obstructive lesions maintaining venous stasis, are examples. A weak heart may produce the same result by insufficiency 380 DISEASES OF THE RESPIRATORY ORGANS. in propulsive power, and hypostatic congestion results from such a state of adynamia that the blood simply obeys the force of gravity. (Edema is a result of congestion, whether active or passive, or a local effect of the causes producing a genei'al dropsy. Pathological Anatomy. — When the lung is congested it is heavier, contains less air and more blood, and crepitates less than is normal. The color is darker and redder ; on section it is found to contain more fluid in the interstices, more blood flows out from the divided vessels, and the bronchi are injected and filled with a sanguinolent, frothy serum. In chronic cases the congestion is considerable, the color of the affected portions is dark red, almost blackish red ; the interstitial connective tissue is distended with serum, the capillaries are so swol- len as to compress the alveoli, almost or quite obliterating the cavity, and numerous extravasations are found through the parenchyma. So firm and dark becomes the tissue of the lung as to resemble the appear- ance of the spleen, whence the term splenization to characterize this condition. In the dependent portions of the lungs of the very adynam- ic or of aged persons confined to a recumbent position, a serous fluid, having considerable viscidity, exudes, giving to the lung on section a somewhat granular aspect, whence the term hypostatic pneumonia. In oedema there is a serous infiltration into the interstitial connective tissue and in the alveoli, which may be sufficient to distend the lung and afford pitting on pressure. On section of the lung under these circumstances, a quantity of serum flows out ; the serum is reddish when there is much congestion associated with the oedema. When oedema of the lung coexists with general dropsy, the fluid that exudes is colorless, and the tissue of the lung is pale. The dependent and inferior portions of the lungs first become oedematous ; thence it spreads to the superior and anterior portions as the fluid increases in amount. As a result of congestion of the passive kind, due to disease of the mitral valve, the lungs generally become denser, more resistant, and are much increased in size. The color, externally, varies from a red- dish-yellow to a brown, and on section its texture is found to be firm, to crepitate but little, to exude blood very freely, and not only blood, but, on pressure, to exude a yellowish or brownish fluid. While the general color of the divided surface is yellowish-red or brownish-yel- low, there are spots interspersed having a brownish almost blackish color — whence the designation brown induration. Some of these brown spots are very dense, and sink in water. Symptoms. — A sudden and complete congestion of both lungs may be a cause of sudden death. Between this extreme and a simple uni- lateral congestion of slight extent, there are numerous gradations in the severity of the seizures. In the mildest cases there occur a sense of internal heat, oppression of the chest, some slight difficulty of breath- ing, a flushed face, a strong, full pulse, beating of the carotids, and in- HYPERJJMIA AND (EDEMA OF THE LUXG. 381 jection and brilliancy of the eyes. When the congestion is sufficient to cause universal oedema of the alveoli, the symptoms are formidable. There are great difficulty and extreme rapidity of breathing, a strong sense of oppression, intense anxiety, rapid and violent action of the heart, beating carotids and pulsation in the temples, headache and fullness of the head, a flushed face, a hasty and troubled cough, and expectoration of a frothy liquid which may be tinted with blood. On percussion the resonance of the lungs is but little altered — slightly diminished, with a tympanitic quality. The vesicular murmur is supplanted by sub-crepitant and mucous rales, which are very abun- dant and very loud. If the alveoli are filled with fluid, the sonority will be still more diminished, and the respiration will have a blowing character approaching bronchophony. If the alveoli are filled to that degree that the oxygen can not reach the blood, accumulation of car- bonic acid must take place, and hence there will be blue lips, a livid face, headache, etc. When this condition is reached, there will be still greater anxiety and oppression, the breathing will be shallow and ex- ceedingly hurried, the pulse will decline in volume, and at length will be merely thready and intermittent, the surface of the body will be cold and covered with a clammy sweat, the fingers will be blue and cold, and with the accumulation of carbonic acid there will be in- creasing somnolence, replacing the extreme restlessness, deepening into coma. With the increasing stupor there will be less and less effort at cough and expulsion of the fluid accumulating in the bronchi, and an increasing difficulty of breathing from this cause. In the cases of passive congestion of the lungs, due to cardiac disease, there are difficulty of breathing, cough and oppression, constantly present, and paroxysms of extreme dyspnoea, in which the patient labors for breath, the face is cyanosed, the extremities cold and blue, the skin cold and covered with a clammy sweat, the pulse, small, weak, and irregular, the jugulars swollen, the mind clouded, etc. The severity of these attacks will be greatly increased if oedema come on suddenly ; but if the oedema is gradual in forming, the difficulties of breathing will be slowly augmented, and carbonic-acid poisoning will also be slowly de- veloped. The physical signs in cases of hypostatic congestion will indicate the existence of bilateral lesions if the decubitus is dorsal ; or unilateral, if the decubitus is to one side. The sonority is diminished, or dullness with a tympanitic quality exists. On auscultation, the ve- sicular murmur will be weak, or supplanted by moist rales. The dif- ficulty of breathing which arises during chronic Bright's disease is due to oedema of the bronchial mucous membrane — an interstitial oedema and swelling of the terminal bronchi. Course, Duration, and Termination. — An acute congestion of the lungs may pass through its whole course and prove fatal within a few hours. The usual duration is from three to five days, and the termi- 382 Diseases of the respiratory organs. nation 'may be by resolution, occasionally by lisemorrhage, and rarely by inflammation or pneumonia. The passive form associated with cardiac disease develops slowly, and is subjected to great variations ; to periods of improvement under appropriate treatment ; then exacer- bations. Acute oedema may come on, and prove quickly fatal in acute, or chronic kidney affections. Diagnosis. — Active congestion is to be distinguished from the stage of engorgement in pneumonia. The points of difference are : in congestion there are no chill, no pain in the side, and not the range of temperature of pneumonia. The subsequent course separates the two diseases more widely. CEdema occurring during hyperemia is announced by dyspnoea, by the auscultatory signs of the presence of fluid in the terminal bronchi, and by the expectoration of a frothy, serous, and reddish fluid. The hypersemia of a passive kind produced by valvular lesions is accompanied by rational and physical signs, which make the diagnosis merely a question of the recognition of these signs. Treatment. — Active congestion in a plethoric subject may demand bloodletting, if not by venesection, by the application of cups or leeches to the chest. A ligature to the thighs applied merely firmly enough to retain the blood in the superficial veins is a useful expedi- ent when the abstraction of blood may seem to be necessary. Coun- ter-irritation in the form of a large mustard-plaster should be applied to the chest, and the feet should be put in a hot foot-bath. As the removal of the fluid in the alveoli and terminal bronchi is of the utmost necessity, an active emetic should be prescribed ; of these apomorphia subcutaneously is probably the best, and next, the sub- sulphate of mercury. Stimulant expectorants should be prescribed to procure the expulsion of the fluid by expectoration. Squill, senega, and serpentaria are appropriate remedies for this purpose. To dimin- ish the viscidity of the fluid, and thus secure its easy expulsion, the iodides, especially the iodide of ammonium, are highly serviceable. The iodide and carbonate of ammonium in sirup of senega is an excellent combination to secure the rapid and easy extrusion of the fluid pres- ent. In the oedema of cardiac disease and renal dropsy, digitalis and squill are very important remedies. If the blood is much impover- ished, iron is indicated, especially the iodide of iron, which is a rapidly acting and an efiicient chalybeate. When there is hypostatic conges- tion, changes in the position of the patient are very necessary, and the propulsive power of the heart must be increased by stimulants, quinine, and small doses of opium. In the cases of brown induration, the iodide and carbonate of ammonium should be persistently used together, with means to increase the energy of the heart, such as tur- pentine, eucalyptol, and alcoholic stimulants. ATELECTASIS. 383 ATELECTASIS. " Definition. — This term means a collapse of the lobules, so that the cavity disappears and the walls approximate. Congenital atelectasis is the state in which the lungs are before being dilated with air (foetal lung). Causes. — The congenital condition is simply a failure to distend the alveoli. The whole lung may be in such a state, or only a part of it, in a premature child, or one so weak at full term as to be unable to expand the lungs fully, and hence some of the lobules or alveoli remain in a state of atelectasis. The acquired atelectasis is the col- lapse of lobules that have been expanded. A terminal bronchus may be closed against the admission of air by a plug of mucus which, act- ing like a ball-valve, permits the exit, but not the entrance, of air, so that gradually all the residual air is expelled, and then the sides approximate, and the cavity is closed — in other words, it has col- lapsed. This result is the more apt to occur in the case of feeble, ill-nourished, and ill-developed children, who are attacked with such troubles as measles, whooping-cough, etc. Collapse of lobules — of a large part of a lung, indeed — may be induced by pressure on a bron- chus, of an aneurism, of enlarged bronchial glands, tumors, etc. The air remaining in lobules, to which the access of air is cut off, is gradually absorbed by the blood. Direct pressure may also cause atelectasis — such direct pressure as is made by hydrothorax, empy- ema, hydropericardium, aneurisms, tumors of the thorax, and effu- sions in the peritoneal cavity, sufficient to push up the diaphragm. Pathological Anatomy. — Seen from without, those portions of the lung in the atelectatic condition have a bluish-red color, or grayish, and are depressed somewhat below the general surface of the organ. These parts have a greater density than the healthy tissue, and, as they do not contain air, do not crepitate on pressure, and they are tough and not easily broken up. When divided, but little blood flows out, nor do they contain any kind of fluid, and appear smooth instead of granular. When inflated with air, as freshly atelectatic lung can be, an immediate change in color ensues, the lobules become pink, and crepitate on pressure as normal lung. If, however, they contin- ued collapsed, changes of a nutritional kind ensue, and, after a time, dilatation can not be effected. When congenital, this condition is found to exist in the posterior and inferior parts of the lungs, in the apices and anterior borders, and may be limited to individual lobules, or a considerable part of a lobe may be affected. When atelectasis is acquired, usually isolated lobules, or small groups of lobules, are thus affected, they are more or less thickly disseminated through both lungs, and the superficial portions are first attacked, the deeper parts subse- quently. This acquired atelectasis differs from the other in that the 384 DISEASES OF THE RESPIRATORY ORGANS. collapsed parts contain more blood and serum, and hence there is a marked difference in appearance of the affected and surrounding surfaces, since the latter are distended with air, and paler ; are, in fact, in the condition of vicarious emphysema. The pleura is usu- ally normal ; it may be somewhat congested and thickened. The situation of the collapsed lobules is due to the position of the com- pressing force. If the force of the compression has not been suffi- cient to drive all the blood and air out, it is then said to be carnified ; if all blood and air are excluded, the color is grayish, and the tex- ture is firm. Symptoms. — In congenital atelectasis, symptoms are produced only in the event that a considerable number of lobules are collapsed, when the chief sign is imperfect respiration. The thorax has but little am- plitude of movement, the breathing is rapid but superficial, and the voice is nothing more than a husky whisper. So rapid is the breath- ing, and urgent the need of air, that a child so affected nurses with diflaculty, or not at all. The supply of oxygen being inadequate, car- bonic acid accumulates ; the lips are blue, the extremities blue and cold, and very feeble, and there are drowsiness, muscular twitchings, and possibly convulsions and paralysis. In the acquired form, the collapse of the lobules is preceded by bronchitis of the finer tubes. When the atelectasis occurs, the difficulty of breathing increases, there is corresponding frequency, and the movements of the two sides may be unequal if there be a limitation to one lung. In inspiration, instead of expansion of the chest in all directions, there is retraction of the intercostal spaces, and of the inferior ribs, due to the fact that the lungs can not be expanded. The significance of the physical signs will depend on the extent to which the atelectasis has proceeded. If isolated lobules only collapse here and there, and the adjacent lobules are dilated (vicarious emphysema), there will be no appreciable change in the sonority. If, however, a group may be collapsed of consider- able extent, there will be dullness, but the note will have somewhat the tympanitic quality. The changes on auscultation will depend equally on the amount of tissue in the condition of collapse. The re- spiratory murmur will be replaced by bronchial sounds if there are a large number of lobules atelectatic. These sounds will also change with the alterations in the affected parts — an increase of the collapse will enlarge the area of dullness ; improvement in the local condition and the reentrance of air will reproduce the vesicular murmur. As very pronounced lesions are associated with the atelectasis, obviously the symptomatology will be very much influenced by them. An im- portant complication arises from the collapse of lobules ; the pulmo- nary circulation is obstructed, the blood accumulates on the right side, the cavities dilate, the venous system is abnormally full, and the ar- terial system is ischsemic. The results of this state of things are, there ATELECTASIS. 335 are venous stasis and oedema, the pulse is small, the urine scanty and high-colored, and the skin pale and relaxed. Course, Duration, and Termination. — The course of atelectasis is that of the malady associated with it. The congenital form, if limited in extent and not associated with a patulous condition of the foramen ovale, may get well. If, however, it is extensive, and especially if the cardiac anomaly exist, life will continue feebly for a short period, and death occur, frequently in convulsions. The acquired condition, when associated with capillary bronchitis and catarrhal pneumonia, pursues two directions : imperfect recovery with damaged lungs, these organs becoming emphysematous ; caseous pneumonia and phthisis. The du- ration, therefore, becomes indefinite, and the termination that of the associated disease. Acute cases terminating fatally rarely continue longer than one week. Diagnosis. — Atelectasis is to be distinguished from bronchitis, pneumonia, and effusions in the thorax. As atelectasis is usually as- sociated with bronchitis, the distinction will rest on the evidences of consolidation of the lung, which are not present in bronchitis. There are no real differences between atelectasis and catarrhal pneumonia, since atelectasis occurs more or less in the former ; hence the distinc- tion must rest on the course and behavior, on the locality, and the difficulty of breathing with retraction of the ribs, which occurs in atelectasis and not in catarrhal pneumonia. From croupous pneumo- nia atelectasis is distinguished by these symptoms, which are peculiar to pneumonia : localized pain, initial chill, high temperature, crepitant rdles, crisis — and do not occur in atelectasis. Treatment. — In the congenital disease, the child should be made to cry vigorously, or the lungs should be well expanded by an efficient and careful inflation with condensed air — an ordinary -fire bellows will suffice. The chest should be irritated with mustard and tincture of iodine, the great delicacy of an infant's skin being regarded. Re- spiratory stimulants are very useful. Belladonna stands first, next arsenic. Suitable nourishment must be given, and stimulants should also be freely but carefully administered. In the treatment of the acquired disease, the accompanying bronchitis is the point to which attention must be directed. The author has witnessed such important results- from the use of iodide and carbonate of ammonium, that he must repeat his recommendation of them. They should be given in small doses frequently repeated. By increasing the flow of serum and lessening the viscidity of the tough secretion which occludes the ter- minal bronchi, the access of air is again secured to the alveoli. Stim- ulants to the respiratory function are equally necessary as in the con- genital form. Belladonna, or, preferably, atropia {-^-^ grain ter m die), turpentine, eucalyptol, copaiba, are very valuable remedies for this purpose. If the symptoms are urgent, emetics must be used to 25 386 DISEASES OF THE EESPIRATORY ORGANS. - clear the tubes, of which the most effective are apomorphia, subsul- phate of mercury, and ipecac. If the strength is reduced, or if the disorder has occurred in a strumous or rachitic subject, quinia, arsenic, iron (syrup, ferri iodidi, 3 j t&'H' in die), and cod-liver oil, are very ne- cessary and useful. Inhalations of compressed air should be prac- ticed as soon as the condition of the patient will warrant it. Inhalations of turpentine-fumes and of the vapor of iodine are very efficient appli- cations to remove lingering bronchial lesions. EMPHYSEMA OF THE LUNGS. Definition. — As eynphysema means an infiltration of the connective tissue with air, certain adjectives are necessary to define the position. Pulmonary emphysema is the form of disease meant here. A general emphysema of the connective tissue of the body is produced when a fractured rib, puncturing the lung, permits the air to pass through the injured pleura into the connective tissue. The subject has been much confused by the variety of terms employed in explanation of the char- acteristics of the disease. There are two varieties, as regards the part of the lung affected : the vesicular and the interlobular ; the former meaning alveolar emphysema, the latter meaning the presence of air in the space between the lobules of the lungs and underneath the pul- monary pleura, whence the terms interlobular em,physema, sub-pleural emphyse'ina. When the disease occurs as an idiopathic and indepen- dent malady, it is known as substantive emphysem,a ; when developed because of another malady, as, for example, the dilatation of the alveoli which occurs because of atelectasis, it is known as vicarious emphy- sema. Causes. — There is a type of lung, transmitted by heredity, which is peculiarly liable to emphysema. The alveoli are relatively too large and their walls thin ; the connective tissue too largely devel- oped ; the vascular supply is insufficient ; the chest is deep, and the heart lies lower than is normal ; and the muscles of respiration are thin and rather weak. Males are more liable than females, because more exposed to the conditions exciting the malady. It is said, but this statement must be regarded as doubtful, that musicians blowing wind- instruments are apt to suffer from it. Various injuries and diseases of the chest which limit the movements of the lungs, as curvature of the spine, pleural adhesions, hydrothorax, tumors, etc., are supposed to produce it. Vicarious emphysema is especially due to attacks of capillary bronchitis and atelectasis in youth and early manhood, or succeeds to whooping-cough and measles for the same reason that bronchitis has led to collapse of lobules, and consequent emphysema of those not collapsed. All of the causes and conditions producing capillary bronchitis are therefore concerned in the production of em- EMPHYSEMA OF THE LUNGS. 387 physema. Interlobular and sub-pleural emphysema are caused by rup- ture of acini, usually by such mechanical violence as severe coughing, but there is necessary to this result probably a weakness of the part yielding to such force. Various theories have been proposed to ac- count for the production of emphysema : they may be referred to two groups — inspiratory and expii-atory. As, however, nutritive disturb- ances exist in many cases, emphysema is produced in them by causes which would not affect healthy lungs. This form or type of structure, which is distinctly hereditary, has been referred to above. In addi- tion to these changes, Freund explains the production of emphysema by a theory which supposes the thorax to be in a condition of fixed dilatation by alterations in the costal cartilages. Although this state of the thorax may sometimes be a cause of emphysema, it can not be so frequently. That structural changes are important factors in the production of emphysema is certainly true ; but that the respiratory acts of inspiration and expiration have also much influence can not be doubted. A certain proportion of cases of vicarious emphysema are produced on Williams's theory of negative inspiratory pressure ; that is, the alveoli appended to unobstructed bronchi dilate in consequence of the increased pressure due to the obstruction and disuse of many tubes. If there exist an hereditary change in the structure of the alveoli, this increased pressure causes them to yield permanently and lose their elasticity. If the inspiratory pressure is thus increased, i. e., by the obstruction to many bronchi throwing a larger volume of air and higher pressure on those admitting air freely, and the expiratory pressure is lessened, there will occur emphysema by atrophy of the alveolar tissue — the theory of ISTiemeyer. A large proportion of cases are produced undoubtedly hj forced expiration. In the act of cough- ing, the glottis being closed, the expiratory pressure is certainly very great, and all the more in the unobstructed lobules, because so many are closed and are in the atelectatic state, throwing the whole force of expiration on a less number of lobules. The result is that the alveoli yield in those parts of the chest not protected by bony walls, at the apex, and toward the root, at the anterior border, in those situations where the emphysematous condition is most decided. Pathological Anatomy. — Enlargement of the lungs is not always found as expected ; adhesions may prevent the anterior borders coming forward to the median line, or the lungs may be actually smaller than normal by the collapse of many lobules, the occurrence of interstitial pneumonia, and the contraction of the connective tissue. On the other hand, the lungs may fill up the thorax, cover the prsecordial space, depress the heart, and lengthen the thorax to the seventh rib by depression of the diaphragm. When the emphysematous lungs are removed from the thorax they do not collapse, and remain full, especially if the bronchi are swollen and filled with viscid mucus. 388 DISEASES OF THE RESPIRATORY ORGANS. which will prevent the egress of air. The situation of the emphy- sematous portions will depend on the form. In those cases due to heightened expii-atory pressure, the force is expended on the apex and anterior border, and hence here will be found the characteristic changes. In vicarious emphysema, due especially to broncho-pneumo- nia, the altered portions will exist more widely — at the apex, the ante- rior border, and along the diaphragm, or they may be very irregularly distributed about the atelectatic points. The appearance of a lung affected with emphysema is peculiar : it is of a pale-red color, the en- larged lobules are little sacs or bladders, not larger than from the size of a pin's-head up to that of a pea, but by the breaking down of the septa between them a number may coalesce, forming a bladder the size of a walnut. When pressure is made, the elasticity of the lung is found to be so much impaired that the pits made disappear slowly or not at all. The tissue of the lung is also very dry and anaemic, and but little fluid of any kind exudes from it on section ; but there is much pigment deposited in small, localized collections, and traversing the atrophied tissue in lines, the remains of blood-vessels. On micro- scopical examination, the walls of the acini are found to be exceed- ingly thin and attenuated, the septa broken down so that the remains of them merely project into the infundibular area, or disappear en- tirely.* In some specimens, the intervening connective tissue becomes hypertrophied, so that the walls of the vesicles appear much thick- ened. In the progress of the atrophic change, the septa between the lobules breaking down, a number of acini are thus converted into a large one. The blood-vessels are from the beginning obstructed, the red corpuscles pass out by diapedesis, and, collected in groups, form the masses of pigment already mentioned, or the blood-globules re- tained by the arrest of the current and obliteration of the vessels in front form a fine tracery of pigment. The continued pressure sets up a rapid degeneration of the vessel- walls, and they ultimately disap- pear by absorption, whence it happens that the tissue is dry and blood- less. The obstruction to the pulmonary circulation is ultimately so great that the pulmonary artery and right cavities become greatly distended. Finally, the muscular tissue of the heart undergoes de- generation, granular and fatty. The distention of the veins leads to widespread venous stasis — nutmeg-liver, congested kidneys, and albu- minuria, gastro-intestinal hyperaemia and catarrh, passive congestion of the brain, etc. Symptoms. — The usual history of cases of emphysema is the occur- rence of attacks of capillary bronchitis, catarrhal pneumonia, or at least of severe bronchitis at some period in childhood, after which there exists a great susceptibility to colds and frequent attacks of * Thierf elder, " Pathologische Histologie," 1. Lieferung, Tafel vi. EMPHYSEMA OF THE LUNGS. 389 severe catarrh with difficulty of breathing. After puberty the diffi- culty of breathing is found to be more decided ; bronchial catarrh is not then a matter of cold weather and attacks of acute cold, but is constantly present. In other cases, after whooping-cough, or measles, a troublesome cough, bronchial catarrh, and shortness of breath come on, and steadily increase. If such attacks have occurred in youth, by the time of puberty the emphysema is pronounced, and the chest has assumed the peculiar " barrel-shape," characteristic of this disease. In still another group of cases, the onset is gradual, and the emphysema is the outgrowth of years of bronchial catarrh, the fully developed emphysema not being attained until the middle or after period of life. In which mode soever emphysema manifests itself, the diffi- culty of breathing is the most pronounced symptom. In all attempts at active exercise, mounting stairways, ascending heights, etc., the breathing is embarrassed. Even before the patient is conscious of his pulmonary defects in this direction, a good observer will note the fre- quency and imperfect expansion of the thorax. The shortness of breathing is dependent on several factors : the diminution in the num- ber of capillaries has an effect in this way by the lessening, which the loss of vessels involves, of the oxygenation of the blood, so that in- creasing frequency of respiration is compensatory of this deficiency. Again, depression of the diaphragm renders additional efforts on the part of the inspiratory muscles necessary, and hence this adds to the difficulty of carrying on respiration. More important than these is the loss of the elasticity of the lung, which requires that the muscles of expiration shall take up the labor of expelling the air, which they accomplish slowly and with great effort. This expiratory insuffi- ciency involves another difficulty — the residual air in the acini is not displaced, and hence can not furnish oxygen to the blood. The con- currence of these several factors produces the most obvious objective symptom in emphysema — the embarrassed respiration. Both inspira- tion and expiration are embarrassed ; all the muscles, auxiliary as well as ordinary, are engaged in inspiration and expiration, but the move- ments of the chest are very slight notwithstanding the labor, and a constant and distressing sense of the need of air is experienced ; the cervical muscles are rigid and prominent, the head erect and forward to permit the easy entrance of air and to facilitate the action of the muscles ; the shoulders elevated ; the veins of the neck enlarged and dilated, and the face more or less cyanosed. A peculiar configuration of the chest is brought about by emphysema, which has existed for some time in young subjects. The chest becomes round ; the inter- costal spaces wider ; the vertical diameter elongated. As the emphy- sema may be limited to one part, the changes in the shape of the chest will correspond. The departure from the normal consists in a circumscribed prominence more frequently on the left than the right 390 DISEASES OF THE RESPIRATORY ORGAXS. side ; above the clavicle, or between the clavicle and nipple, or, during coughing, the lung pushes the parietes of the chest forward at these points, producing a soft, elastic, and resonant swelling. The physical signs are very instructive. On inspection, the character of the respira- tion, the movements of the accessory muscles, and the extremely small excursions of the thorax in breathing are readily ascertained. On pal- pation, the vocal fremitus is diminished, the apical impulse is feeble, and the epigastric pulsations are increased. The heart is found to lie lower down than in the normal thorax, and the liver is also pushed lower, both due to the enlargement of the lungs in the vertical diam- eter. On percussion, the sonority is increased over all the emphysema- tous portions, and, when the whole lung is involved, extends dowm to the seventh or eighth rib in front, and behind to the twelfth rib in extreme cases. The hepatic dullness may not begin until the inferior margin of the ribs is reached, and even when hypertrophy exists the area of cardiac dullness is much narrowed and may not exist at all when the emphysema is extreme. On auscultation over all parts re- turning a resonant percussion-note, the vesicular murmur is weakened, and may entirely disappear over the lungs ; and the bronchial sounds, which are audible at the root of the lungs posteriorly in the normal state, may also disappear. In other cases, the vesicular murmur, whether enfeebled or not, is changed in character ; on inspiration it becomes rough, rude, sibilant or crackling, due to the entrance of air into the dilated and inelastic lobules, and expiration is prolonged and rough from the same cause. Expiration is usually inaudible, but an expiratory sound may be due to an accompanying bronchitis, to nar- rowing of the bronchioles by swelling of the mucous membrane, whence the sound has a rather sibilant character. The accompanying bronchitis, which is usually quite extensive, produces various moist sounds — sub-crepitant, mucous, and sub-mucoas rctles, which are not necessary to emphysema. The sounds of the heart audible in the mitral and aortic area are in emphysema less distinct than in the nor- mal state, while in the pulmonary and tricuspid area they are well defined, the pulmonary second sound being sharply accentuated. Course, Duration, and Termination. — Emphysema is an essentially chronic malady. Beginning often years before any great difficulty of breathing is manifest, it pursues a course which iii its mildest form may continue during an ordinary lifetime. The least extensive cases may continue with little interference in the duties of life for many years, but the case is far different with those examples of emphy- sema occupying a large part of both lungs. In a pronounced case, beginning in one of the modes already described, there are constant difficulty of breathing, and cough and expectoration due to an, attend- ant bronchitis. On taking a bronchial cold, to which they are ex- tremely liable, or on making some sudden muscular effort, the diffi- EMPHYSEMA OF THE LUXGS. 391 culty of breathing is greatly increased, they labor to get breath, are blue in the face, sweating with their exertions, and unable to lie down. After some hours, or a day or two, the paroxysm subsides, and they are back again in the former condition, except each attack increases a little the existing mischief, the breathing is a little more embarrassed, and there are more cough and expectoration. The paroxysms of asth- matic difficulty of breathing increase in number and frequency, until after some years there is no period of partial relief. Meanwhile, the obstacles to the pulmonary circulation increase : dilatation of the right cavities of the heart and stasis in the venous system occur ; the liver swells with venous hypersemia ; the gastro-intestinal mucous mem- bi-ane also is hypersemic, and is affected with catarrh ; the liver is congested, and the urine becomes albuminous. General dropsy now comes on, fluid accumulates in the peritoneal cavity also, but to a less extent in the pleura. The presence of fluid in the two cavities adds to the difficulty of respiration, and now the patient can get breath only as he sits up, leaning somewhat forward. This position increases the accumulation of fluid in the legs, which become blue, cold, and very painful ; the skin yields, blisters form, and, giving way, an ulcer is established from which serum continuously exudes. Such is the course of a well-defined case. Although all are not so severe, yet when emphysema occurs in an adult it is a permanent condition. It is probable that a slight amount of emphysema in a child may get well, but usually the first changes in childhood are the initial of a long series, and continue. Death may be due to the rupture of some of the dilated cells and the formation of an extensive interlobular and sub- pleural emphysema. The termination is often by some intercurrent disease, as catarrhal or croupous pneumonia, cerebral haemorrhage, or paralysis of the heart. Notwithstanding the unpromising nature of the disease, all do not proceed regularly from bad to worse. Periods of improvement may take place, and the difficulty of breathing almost disappears, to return again, however, on the occurrence of a bronchial attack or some other disturbance. The cases are, as a rule, more se- vere in winter than in summer. Diagnosis. — The diseases with which emphysema may be con- founded are bronchitis, bronchial asthma, catarrhal pneumonia, pneu- mothorax, aneurism of the arch of the aorta, and cardiac diseases, with spasmodic difficulty of breathing. From bronchitis, it is distinguished by the presence of those signs characteristic of emphysema, as diffi- culty of breathing, increased sonority of the chest, changes in the shape and size of the thorax, and by the disturbances of the circula- tion and dropsy ; from bronchial or spasmodic asthma, by the fact that in the latter there are no alterations of the chest, and the diffi- culty of breathing is occasional and spasmodic entirely ; from catar- rhal pneumonia, by the history, by the localization of the affection, by 392 DISEASES OF THE RESPIRATORY ORGANS. the changes in the chest, and by the subsequent course ; from pneu- mothorax, by these considerations : pneumothorax is sudden, almost always unilateral, the chest much distended, the intercostal spaces prominent, the heart is displaced to the other side, succussion is pres- ent if there is fluid, which is usually the case. In aneurism there is dullness instead of increased sonority over the site of the aneurism, and no change elsewhere, and the difficulty of breathing is due to pa- ralysis of the vocal cord, which may be seen, and to pressure on nerve- trunks. In heart-disease the area of dullness is not only present but usually increased, and the apex-beat is normal or increased, while the form of the chest and the sonority are not affected. Treatment. — As we have to deal with an incurable disease, our treatment must be largely palliative. For the asthmatic attacks there is no remedy so efficient as the subcutaneous injection of morphia and atropia {^ morphia and yl^ atropia). Care must be exercised lest the morphia-habit be formed, as it is apt to be under these circumstances, and hence the injections should always be practiced by the physi- cian, and reserved for occasions of great distress. A single injec- tion may arrest a paroxysm, but the dose may be repeated as neces- sary, rarely more frequently than once in six hours. Next to the injection of morphia, most relief is afforded by full doses of iodide of potassium alone, or combined with the bromide. From fifteen to twenty grains of the iodide, and forty grains of the bromide, every two, three, or four hours, according to the urgency, may be prescribed. Chloral, which affords great relief, is very unsafe in old cases with dilated right cavities ; if given under any circumstances, it should be combined with morphia and atropia to prevent the depressing effect on the heart. A combination of morphia, chloral, and atropia is an ex- ceedingly serviceable combination for the relief of the difficult breath- ing. Besides these agents, narcotic fumigation may be practiced. Pastils of belladonna, stramonium, tobacco, opium, eucalyptus, etc., may be burned, and the fumes inhaled. Such pastils are always much used by these sufferers, since they procure in this way ready and considerable relief. As the accompanying bronchitis is an important element in these cases, measures are necessary to relieve it. The best results are obtained from copaiba, turpentine, and eucalyptol, given in conjunction with the iodide of ammonium. Excellent results are ob- tained from the combined administration of iodide of ammonium and arsenic, continued for some time. It is well known that arsenic increases the depth and volume of the respiration and promotes the nutrition of the lung, and the iodide is an effective remedy for the bronchitis. In these facts we have an explanation of the utility of the combination. When the bronchial secretions are insufficient, small doses of tartrate of antimony are very useful, and give great relief. Just that quantity which induces a little sqeamishness, and no more, is the quantity re- EMPHYSEMA OF THE LUNGS. 393 quired for this purpose. Atropia is a remedy of great power, and has an influence over the lung, increasing the respiration and promoting the nutrition of the organ. It may distress if there is a lack of bron- chial secretion, but usually the opposite state obtains, and consequently atropia can be given, as it ought to be, under these circumstances, in small doses twice a day for a long period. Of all the means hitherto proposed for the relief of emphysema, nothing has approached com- pressed air in effectiveness. Indeed, this is the only scientific remedy which has as yet been brought forward for the treatment of emphy- sema. The chamber into which air is pumped until a pressure of one and a half to two atmospheres is obtained is the best arrangement, but unfortunately they are available but in a few places. The port- able apparatus of Waldenburg is convenient, easily managed, and pro- duces good results. The object of compressed air is to relieve the breathing by supplying more oxygen, and it effects an equalization of the blood in the two systems by redistributing the pressure. By re- tarding the breathing and the action of the heart, the contractions are firmer, and the cavities are better emptied. The improved condition of the blood, the result of a better supply of oxygen and increased excretion of carbonic acid, induces a better state of digestion and as- similation. By breathing compressed air, the pressure is transferred from the venous to the arterial system, and while the amount of blood on the right side is diminished, on the left it is increased. The good effects of breathing compressed air are enhanced by expiration into rarefied air, which of course has the effect to draw the blood into the lungs. " Expiration into rarefied air is the specific mechanical anti- dote to emphysema." * The inhalation of compressed air or of oxy- gen may be used as a palliative to relieve the attacks of spasmodic difficulty of breathing. The treatment of the dropsy requires a nice adjustment of means to the object. Much can be accomplished by acting on the skin and kid- neys. If the heart will bear it, pilocarpine may be employed to act on the skin. Hydragogue cathartics can be given at the same time, of which the pulv. jalapse comp, is best. A teaspoonful or two should be taken in the early morning, and pilocarpine in the afternoon. If the desired results can not be thus attained, free diuresis may be attempted while the hydragogue is also administered. Basham's mixture is an excellent combination, containing as it does a chalybeate with a saline. Niemeyer's prescription of vinegar of squill, with bicarbonate of potas- sa — thus forming acetate of potassa — is a good diuretic. There is no more certain diuretic than bitartrate of potassa, and it may be com- bined with infusion of juniper and squill. A weak solution of cream of tartar may be drunk ad libitum. Infusion of digitalis may also be * "Die pneumatische Behandlung," etc., Dr. L. Waldenburg, Hirschwald, Berlin, 1875, p. 302. 39J: DISEASES OF THE RESPIRATORY ORGANS. given ; but as so much obstruction exists in the lung, and as there is also ischfemia of the arterial system, its use is doubtful. GANGRENE OF THE LUNG. Definition. — Gangrene is the same morbid process, whether occur- rincj in the luns: or elsewhere. Gangrene of the lung, therefore, means the death and decomposition of a greater or less portion of the lung- tissue. Causes. — Sex exercises an important influence, since somewhat more than two thirds of the cases occur in men. Although it may occur at any age, it is more common from puberty to middle life, "A lowered condition of the yital forces, such as is jjroduced by abject poverty and its attendant miseries, seems necessary to the result. Interruptions to the blood-supplv, as elsewhere, may induce gangrene. Thus it occurs in cases of pneumonia, hemorrhagic infarctions, catarrhal pneumonia, etc. ; but a depressed bodily state is necessary, such as exists in di-unk- ards who are ill fed and exposed to cold and wet. Gangrene may be due to the so-called blood-diseases — as typhus, diabetes, small-pox, measles, etc. — but a low state of the tissues or a depressing cachexia must coincide, the lung becoming the seat of the morbid process be- cause invited by a local malady, such as pneumonia. The deposit in the lung of septic and decomposing materials, as septic or infective emboli, will set up a destructive inflammation terminatmg in gangrene. Putrefactive decomposition in the neighborhood of the lungs, the penetration of the organ by cancer-masses, or the lodgment of foreign bodies, may give rise to a gangrenous inflammation. Lastly, gangrene may be due to traumatism, or to penetrating wounds of the chest. Pathological Anatomy. — Gangrene may attack any part of the lung, but the upper lobe is more often the seat of it than the inferior. It occiirs iu two forms, of circumscribed, of diffused — the former being well defined and strictly limited, the other not separated by any defined border, but spreading into the surrounding limg-tissue. The circum- scribed form attacks by preference the outer portion of the lung, and may or may not include the plem-a. There may be several of the gan- grenous spots, which vary in size from a pea to an orange, or even larger, and they occur rather more frequently in the right lung. The borders are clearly marked, the surrounding tissue being hepatized or cedematous. According to the time at which the masses are examined, they are firm, dry, almost black or soft, difliuent, greenish, or brown- ish, decomposing and offensive masses traversed by large vessels not destroyed, and by bronchi, opened by ulceration, through which the liquid and softened debris are discharging. Gradually sloughing off after evacuation by the bronchi, there may be an attempt at repair, the spread of the decomposition being prevented by the formation of GANGRENE OF THE LUNG. 395 a dense, tough, and rather hyperjemic connective-tissue membrane. A complete recovery can only occur when the gangrenous mass is small and communicates with a small bronchus. The membrane lining the cavity, formed as just described, pours out a quantity of ichorous pus, which serves to spread the morbid process. When the cavity is small enough to close and heal, granulations are thrown out, the walls ap- proximate, and healing takes place, a cicatrix remaining. The ichor- ous pus poured out from the so-called pyogenic membrane sets up a destructive inflammation of the bronchial mucous membrane, which softens and is detached, and excites attacks in the dependent parts of the lungs of broncho-pneumonia, which pursue the same course. If situated at the periphery of the lung the softening may involve the pleura, and the decomposing materials be discharged into the pleural cavity, exciting a violent pleuritis and a pyopneumothorax, if a bron- chus is at the same time opened. It is a remarkable fact that a limit- ing pleuritis may confine the inflammation to a small extent of the membrane, perforation of the thorax ultimately ensue, with a termina- tion in recovery. In a few cases the pus has dissected downward along the sheath of the psoas muscle and opened externally at the groin. The diffused form may, as has been shown, arise from the circum- scribed by an extension of the morbid process through the distribution of the ichorous pus from a gangrene cavity. But the diffused form usually has its origin in an inflammation proceeding from a gangrenous cavity, or from a case of purulent infiltration of pneumonia. The tis- sue affected with the gangrenous inflammation rapidly breaks up into shreds of decomposing materials, infiltrated with a brownish or black- ish fetid fluid, and the morbid process spreads into the surrounding tissue, hepatized and oedematous, without any defined boundary. In a short time much of the upper lobe may be in a gangrenous state, and the whole of it, indeed, may be involved. In both forms the spread of the gangrene may be too rapid to permit the vessels to be closed, and hence there may be formidable or fatal hemorrhage. Metastatic abscesses may form in various organs, from infective emboli proceed- ing from the veins of the gangrenous parts. Symptoms. — Gangrene of the lung being usually a secondary dis- ease, the symptoms proper to the gangrene are obscured by the as- sociated malady ; and there are great variations at different periods. Before communication is established with a bronchus, when the diag- nosis is rendered certain by the character of the expectorated matters, the only symptoms are, a sudden depression of the powers of life, changes in the character of the existing fever, and a very high range of temperature. The symptoms become characteristic only when the sputa contain the materials of the gangrenous decomposition. The sputum is a sanguinolent, sanious, or sero-mucus fluid, of brownish dark- green, or even blackish tint, having a horribly fetid odor, compounded 396 DISEASES OF THE RESPIRATORY ORGANS. of decomposing animal matter and faeces, and so sickening that the patient himself as well as those about him is nauseated by it. That the odor is due to foul gases is evident from the fact that the breath on forced expiration is full of the odor, and the sputa allowed to stand cease after a time to have the smell. The odor may precede the ex- pectoration, and may disappear for a time, to reappear again. The sputa on standing separate into three distinct layers : the uppermost, frothy, of a dark, greenish-yellow color, is composed of muco-pus chiefly; the middle layer is sero-albuminous and translucent; the lowest layer contains a sediment, greenish or brownish in color, with yellow or brownish flakes and masses of decomposing lung-tissue. Again, the sputa may be made up largely of black blood, in a decomposing state (Hertz). Chemically, the sputa have an alkaline reaction, and contain valerianic acid, the fat acids, leucin and tyrosin, triple phos- phate, and other products of decomposition. During the process of development of the gangrene, the symptoms indicate the existence of a grave disorder. TJie elevation of temperature may be very consider- able, but the thermal line is that of septicaemia : irregular chills, high fever, and profuse sweats. The complexion is fawn-color, livid, the expression anxious, the face sunken, the skin relaxed, the pulse quick and feeble, and the respirations are hurried and catching. There is usually severe pain in the side, and the decubitus is toward and on the affected side. There is an incessant and very painful suppressed cough. Copious pulmonary haemorrhage may and usually does take place, started by the coughing. The fetid expectoration is apt to be swal- lowed, and excites by its presence nausea, vomiting, and diarrhoea, but the absorption of putrid matters and the congestion of the portal circu- lation will also cause watery and fetid stools. The operation of these causes rapidly exhausts the vital powers, and the patient lapses into a condition of profound adynamia. The physical signs are such as per- tain to changes in the density of the pulmonary tissue. On percussion, the sonority of the chest is lessened in proportion to the extent of the solidification, but, as there is more or less pulmonary tissue still pervious to air about the gangrenous portions, the dullness has somewhat the tympanitic quality. On auscultation, coarse rdles, mucous and sub- mucous, are audible, and there are bronchial breath and bronchial voice. After the softening and extrusion of the gangrenous portions, the physical signs will correspond, and the symptoms of a cavity will be present. Course, Duration, and Termination. — The course of the disease is so largely affected by the morbid condition on which it is ingrafted that no defined plan can be laid down. The circumscribed form is slower in development, and the symptoms are less formidable, than the diffused, and its duration is therefore longer. In those cases which tend to cure by the extrusion of the gangrenous mass through a bronchus, or by GANGRENE OF THE LUNG. 397 establishing a fistulous communication externally, the duration is pro- tracted, and not to be expressed with definiteness, because so much depends on the vital resources, and on the size of the gangrenous patch. The cases of partial recovery in which there is a cavity lined by a pyogenic membrane continue for months ; but every now and then fresh inflammation arises, more tissue is destroyed, until death finally ensues. The usual termination is in death, after two or three or even six weeks of the circumscribed form, and in a week or two of the dif- fused form. Certain accidents may occur which will materially abbre- viate either, as haemorrhage, perforation of the pleura, etc. The causes of death are various — pleuritis, peritonitis, hasmorrhage, exhaustion, etc. Perforation of the pleura may cause death by the intermediation of pyopneumothorax, sudden distention of the cavity, severe dyspnoea, and collapse ; or it may cause a fistulous communication, emphysema of the connective tissue, and exhaustion, the fistula discharging ichorous serum and the foul-smelling products of gangrenous decomposition. Perforation of the diaphragm and purulent peritonitis may be a cause of death. The prognosis is, of course, exceedingly grave. Diagnosis. — It must be obvious that a diagnosis of gangrene of the lung is not possible when the mass affected does not communicate with a bronchus. Fetor of the breath is, of course, the first indication, but this is not pathognomonic by any means. As the pus in cavities and of dilated bronchi may by decomposition become fetid, and as bits of decomposing lung-tissue are cast off in the sputa, fetor of the sputa as a means of diagnosis must be accepted with limitations. The diag- nosis, under these circumstances, must rest largely with the clinical history, the severity of the symptoms, and the duration. Those familiar with the character of the odor in gangrene will recognize its penetrat- ing power and intensity, as compared with the much feebler odor in putrid bronchitis and in bronchiectasis. All of the symptoms in gan- grene of the lung are much more active and severe than are those of bronchitis. In gangrene, further, there are present the physical signs of pulmonary disease, which are absent in bronchitis. The differentia- tion of fetid sputa from a cavity in phthisis, from gangrene, is more difficult, but the greater intensity of the odor in the latter and the ap- pearance and composition of the sputa will serve to distinguish between them ; but, as cavities are present, the history and behavior of the two maladies must be taken into consideration. Treatment. — To maintain the powers of life by the free administra- tion of spirits, small doses of opium and quinia, and such aliment as beef-juice, egg-nog, etc., is the leading indication, to which all specific treatment must be subordinated. Excellent results have been obtained from turpentine (gtt. v) every two hours ; but still more from eucalyp- tol, which has been very much extolled recently. Eucaly'ptol is most easily taken in perls (tti, v), but it can be made tolerable in an emul- 398 DISEASES OF THE RESPIRATORY ORGANS. sion. Benzoic acid, thymol, and carbolic acid, especially the last named, are very useful in correcting fetor, and also play the part of antiseptics, being eliminated largely by the lungs. Acetate of lead is the remedy most approved by Traube. Inhalations should be prac- ticed with those remedies, such as iodine, which may diffuse by vola- tilization, and with oxygen, which relieves the dyspnoea and improves the blood. Iodine, or the tincture, may • be vaporized by a gentle warmth, and the fumes gradually introduced into the air the patient is breathing. The benzoate of soda, or of ammonia, should be intro- duced into the lungs by atomization, in as large quantity as possible. CARCINOMA OF THE LUNG. Pathogeny. — Cancer of the lung is usually secondary, and very often succeeds to cancer of the breast removed by amputation. It may be primary, but rarely so. While cancer of the lung as a second- ary disease is more common in women, primary cancer of the lung is more common in men. It is a disease of advanced life, and is extreme- ly rare before forty ; nevertheless, a case has occurred at twenty-five. The form of cancer which attacks the lungs is usually the soft and rapidly growing variety known as encephaloid, and it occurs in two forms — in a distinct body or mass, and diffused through the tissue of the lung. In either case it presents the appearance of a yellowish- white, homogeneous, rather firm material, looking like brain-tissue which had been somewhat hardened — hence the name. When a mass is divided, a quantity of whitish, albuminous-looking fluid may be pressed out, and this fluid is called cancer-juice. Sometimes this can- cer-juice may be found in cyst-like nodules, or in delicate canals, whit- ish in appearance, accompanying the lymph-canals. Cancer may occur in any part of the lung ; when primary, in about two thirds of the cases in one lung, and when secondary in both, usually. The right lung is more frequently the seat of cancer, in so large a proportion as two to one. The distribution of cancer varies. In the primary form it occurs in nodules, from a pea to an orange in size, or there may be a great number of the smallest nodules, or a diffused infiltration involv- ing a part or the whole of a lobe, even of two lobes. When it forms a distinct tumor of considerable size, the neighboring parts may be compressed : the lung may atrophy from pressure ; the bronchi may be encroached on and closed, or the cancer elements may enter and fill them ; blood-vessels may be impinged on, their lumen obliterated, or they may ulcerate and haemorrhage result. The bronchi, trachea, and great vessels may be so far obstructed as to interfere with their func- tions respectively. The bronchial, tracheal, cervical, and, axillary glands may "be enlarged from simple adenitis, or from cancerous infil- tration. The pleura is usually invaded ; there may be an effusion into CARCINOMA OF THE LUNG. 399 the cavity, or adhesions unite the two surfaces, and the cancer elements may make their way to the surface as nodules, or in thin plates. A large cancerous mass may displace organs, push the heart aside, and force the liver and spleen downward. Symptoms. — When the cancer forms a tumor, the symptoms pro- duced by it are dullness over the place occupied, increase of the vo- cal fremitus, and bronchial voice and breath sounds over the dull area. These sounds may have the cavernous character if the cancer-mass surrounds, without compressing, a large bronchus. Also, a large artery, impinged on by the tumor, will give forth a distinct systolic bruit, which may be mistaken for aneurismal hriiit, unless it is recognized that there is but one center of pulsation (the heart) in the chest. If the growth be so situated as to press on a lai-ge vein, there will be pres- ent oedema of the head and face, or of one side; if it press on the recur- rent laryngeal, spasm of the glottis, a peculiar cough (croupy), and dif- ficult breathing, or, if the pressure be long continued, paralysis with its usual consequences, will result ; if other nerve-trunks are impinged on, there will be deep-seated pains in the thorax, often of an excru- ciating kind, and there may be paroxysms simulating angina pectoris. The symptoms become more complex and difficult of interpretation, in cases of diffused or disseminated cancer. There are present the signs of consolidated lung-tissue on one or both sides. There are no adven- titious sounds, but the respiration has a rather blowing character in some situations; in others, that of bronchial voice and bronchial breath. The diagnosis rests on these facts : all acute diseases are excluded, as this is comparatively slow in development and is free from fever ; it can not be chronic pneumonia, as there is no localization of the deposits; from tuberculosis it is separated by the absence of fine crackling, and by the fever-movement ; and, lastly, some indurated glands may be found in the neck or axilla, and possibly the traces of a former opera- tion. There will be some difficulty of breathing if the deposits are extensive, and a dry, hard cough ; but there may occur, finally, rusty- colored, semi-transparent, gelatinous expectoration. The difficulty of breathing depends on different conditions from those which obtain in the other form. In this case, the degree in which the air-space is en- croached upon determines the amount of dyspnoea ; in the other, com- pression of bronchi, or trachea, or displacement of the lung, affects the breathing. The character of the cough is very different, according as it is due to deposits in the lungs, to pressure on a bronchus, to irrita- tion of the recurrent laryngeal, or pneumogastric nerves, etc. Besides the symptoms produced by and due to the presence of the cancer in the lungs, there is soon developed the cancerous cachexia, which is manifested by the following symptoms : progressive emaciation, weak- ness and sense of fatigue, a weak, small pulse, a peculiar earthy or fawn-color tint of the skin, pearly sclerotic, anorexia, oedema of the 400 DISEASES OF THE RESPIRATORY ORGANS. ankles, etc. The rate of decline due to the cancer deposits is acceler- ated by the harassing cough, the dyspnoea, the dysphagia, and the pain. As the cancer extends, all of the rational symptoms increase in severity, and the physical signs more clearly indicate the diffusion of the cancer elements through the lungs, or the enlargement of the tumor. Treatment. — This must be directed by the symptomatic indications. Anodynes to relieve pain and support for the increasing weakness are the measures necessary. HYDATIDS OP THE LUNGS— ECHINOCOOCI. Definition. — Hydatids found in the lungs are the intermediate or larval condition of the taenia echinococcus — the tape-worm of the dog — and are therefore designated echinococci. The cysticercus cellu- losus, the larval state of the tmnia soliuin, is very rarely, if ever, found in the lungs. Echinococci migrate from the intestines and take up their abode in the lungs. Each cyst contains the embryo — the scolex with its four suckers, and row of booklets, inverted and contained within its cyst. Dermoid cysts are rarely found in the thorax, but they should not be confounded with echinococci. Pathological Anatomy. — Hydatid cysts usually exist in the paren- chyma of the lungs, but sometimes develop in the cavity of the pleura, or they may be present in both at the same time. They are found in the inferior lobe, and chiefly on the right side. Often, the intra-tho- racic cyst is a solitary hydatid, which fills the cavity, distending and enlarging the chest on that side, pushing out and widening the inter- costal spaces, compressing the lung against the root and the spinal col- umn, and forcing the heart downward or to one side, and depressing the liver or spleen. If the cyst is large, the pleural surfaces may be united and the cavity obliterated. Adhesions are often formed to a bronchus, which may be perforated and a cure effected by discharg- ing the parasite by expectoration. The cavity which remains con- tracts and cicatrizes. In other cases the parasite is not discharged, but sets up an inflammatory induration about it, which excites fever, cough, and expectoration, that ultimately exhaust the patient unless carried off by some intercurrent affection. Rarely do hydatids come into relation with the vessels of the thorax, but a vessel may be in- vaded, with results determined by its size. Habershon * reports a case of a youth of seventeen in whom repeated haemorrhages occurred, from an opening into a branch of the pulmonary vein, produced by " ulcera- tion at the seat of the hydatid cyst." In this case tubercular disease followed the troubles due to the hydatids. Sometimes the cysts attain * " Guy's Hospital Reports," third series, vol. xviii, 18'72-"73, p. 3*73. HYDATIDS OF THE LUNGS. 401 sufficient volume to cause death by suffocation. In other cases death is produced by atrophy of the inferior lobes of the lungs. In a larger number of cases, pneumonia and gangrene of the lung, induced by the presence and pressure of the hydatids, are the cause of death. The length of time hydatids continue in the lungs is measured by years. The ordinary duration is two to four years. Symptoms. — The cysts must attain a sufficient size to interfere with function before symptoms are produced. More frequently than in other situations, hydatids of the lungs give rise to pains which may be felt in the back, in the side, or in the epigastrium. The pain is severe, persistent, and is somewhat paroxysmal, and its situation may indicate the seat of the mischief. The decubitus is on the back or on the af- fected side. The most marked as well as the most constant symptom is dyspnoea, which is always present in a moderate degree unless the cyst is very voluminous, and there occur also violent paroxysms, in which the breathing is suffocative. The cough is dry, or accom- panied with a little expectoration, unless the cyst communicate with a bronchus, when the cough is incessant and the expectoration enormous, consisting of a serous liquid or earthy and calcareous masses, filled with the debris of hydatids. Sometimes the expectoration is fetid, from gangrene, or bloody. Small hydatids of the volume of a pigeon's-egg may be expected, but usually fragments and booklets. The expectora- tion takes place at intervals sometimes of weeks or months ; then a great mass may come up, almost suffocating the patient. The physical signs will depend largely on the volume attained by the cysts, their number and situation. There may be seen, on inspec- tion, an enlargement of the affected side, dilatation of the intercostal spaces, and displacement of the heart or of the liver, or of both. Fluc- tuation or the purring tremor will be felt only if the cysts are protruding through the chest-walls, and if a number of daughter-vesicles are con- tained within the parent-cyst. On percussion, there will be dullness according to the space occupied, and increase of resistance, commencing below the clavicle, over the inferior lobe. The vocal fremitus is diminished. The vesicular murmur is absent, replaced by bronchial voice and bronchial breath. Egophony may be audible. The signs of a cavity will be present when the cysts are expectorated. Course, Duration, and Termination. — The origin and early develop- ment of echinococci of the lung necessarily escape detection. It is only when they are large enough to interfere with neighboring parts that symptoms are produced. The whole course is usually completed within four years, sometimes earlier, if the opportunity for free discharge ex- ists by an opening into a bronchus. In forty cases of which Davaine * has given an account, there were fifteen recoveries and twenty-five * " Traite des Entozoaires," op. cit., whose account I have closely followed in this subject. 26 -1-02 DISEASES or THE RESPIRATORY ORGANS. deaths, the termination by expectoration of the hydatids occurring in twelve cases. Of the twenty-five fatal cases, twelve or thirteen occu- pied the inferior lobe, and five or six the upper lobe. In another col- lection of cases quoted by Davaine, of sixty-two terminating, in recov- ery forty-five recovered by the expectoration of the cysts, and seven by puncture of the chest, expectoration also occurring. The propor- tion of cures to cases in the last-mentioned- collection was sixty-two to eighty-two. The termination by death is therefore more common than recovery. Death is due to a variety of causes — to exhaustion from profuse purulent expectoration, hectic and marasmus, to tuberculosis, to hasmorrhage, to gangrene, to pleuritis, etc. Diagnosis. — There are no well-marked distinctions between hydatid cysts and pleuritic effusion, as regards the physical signs, but they dif- fer widely in history. Pleuritis begins by a violent pain in the side, chill and fever, the effusion following in a short time. Echinococci very slowly develop, and the symptoms of effusion are not produced until after many months. Puncture and examination of the fluid for the characteristic booklets may be required, to determine the question at issue. When expectoration of echinococci or of fragments takes place, there can be no doubt left. Treatment. — When the existence of hydatid cysts is ascertained, there should, if possible, be made a free opening to permit their evacu- ation. Puncture and withdrawal of fluid will arrest their growth, but, as decomposition, suppuration, even gangrene may result, the ex- trusion of the cysts should be procured, if possible. CATARRH OF THE BRONCHIAL TUBES— ACUTE BRONCHITIS- CAPILLARY BRONCHITIS. Definition. — The term bronchitis is limited to a catarrhal inflamma- tion involving the bronchial tubes, of a caliber above the terminal tubes. Catarrhal inflammation of these terminal tubes, or bronchioles, is desig- nated capillary bronchitis, and if associated with atelectasis is then known as catarrhal pneumonia or broncho-pneumonia. If the trachea is at the same time affected with the bronchial tubes, the disease is named tracheo-bronchitis. If the inflammation is general over the whole tube, it is called diffuse bronchitis ; if limited to a part, circum- scribed bronchitis. According to the rate of progress, it is acute or chronic, but the difference is slight. Causes.— Bronchitis is very dependent on climatic conditions. A humid, changeable, and cold climate favors it, while dryness, uniform- ity, and warmth of climate have the opposite effect. More than any other single factor does humidity influence and promote the occurrence of bronchitis. Those seasons of the year characterized by the most rapid alternations of temperature, by cold and damp winds, and by ex- ACUTE BRONCHITIS. 403 cess of humidity, are especially liable to produce bronchitis. All depressing hygienic influences, unsuitable clothing, exposure to damp, cold air — especially when the body is warm and perspiring — are influ- ential factors. In a lowered state of the general health from any cause, the bronchial mucous membrane is more susceptible to evil influences. Bronchitis occurs in greater ratio in men, because they are more ex- posed to the conditions producing it. Age has an unquestionable in- fluence. The extremes of life are more susceptible, but in infancy bronchitis is more frequent than in old age, but from different causes. The inhalation of irritating gases and vapors and the dust of various occupations will excite inflammation and catarrh. Among the causes must be placed minute organisms, the pollen of plants, which excite local irritation of the respiratory tract, and epidemics of catarrhal dis- eases. Valvular affections of the heart, which maintain congestion of the lungs and bronchi, necessarily induce a catarrhal state of the bron- chial mucous membrane. Pathological Anatomy. — The initial factor in inflammation of the bronchial mucous membrane is hyperaemia, or increased blood-supply, the whole surface marked by a fine arborescent or punctif orm redness, or spots or limited areas only are thus affected. The depth of color depends on the period and intensity of the disease — recent and severe inflammation causing deep redness, and passive inflammation a dark- red, even purplish injection. It is hardly ever the case that the entire bronchial tract is invaded by the redness, but portions of the trachea, a considerable part of the primary and some portions of the second and third divisions of the bronchi. In old cases the redness disappears and is replaced by a grayish, ashy hue, with relatively numerous enlarged and tortuous vessels showing through. Nutritive changes in the epi- thelium, overgrowth of the glands, and proliferation of the connective- tissue cells of the submucosa, increase the thickness of the mucous membrane. The cartilaginous rings also undergo important changes, and the peribronchial connective tissue is the seat of an active hyper- plasia. The new connective-tissue elements displace the cartilage. The secretion of the mucous membrane is changed in character ; at first the sudden hypersemia suspends the production of mucus and the membrane is dry ; the next step consists in an increased production of mucus, soon followed by purulent elements, which rapidly prepon- derate, giving the expectoration a yellowish color. The amount of secretion varies in different cases : when it is deficient, the case is known as dry catarrh ; when pus is copiously discharged, it receives the name of hronchorrhoea. The extension of bronchitis to the alveoli of the lungs and the collapse of lobules constitute catarrhal pneumo- nia. Emphysema may also result, especially the vicarious emphysema, and when the atelectatic condition happens to many lobules. The bronchial glands frequently participate in the inflammation, become 404 DISEASES OF THE RESPIRATORY ORGANS. hypersemic, swollen, -and filled with secretion, or the gland elements undergo hyperplasia and ultimately the cheesy transformation. Symptoms. — There may be catarrh of the upper air-passages, and at the same time there is experienced a raw and sore sensation under the sternum, and a dry, harsh, and rather ringing cough, which awak- ens jjain, and has often a suppressed character because of the pain. At first the cough is dry, corresponding to the dry stage of the mucous inflammation, and is most troublesome in the evening. There are also m.uch muscular soreness and a sense of fatigue, but no other symptoms of illness. In other cases there may be some feyerishness, headache, and anorexia. The cough, which was dry, now brings up some mu- cus, at first only after repeated coughing, but in a short time easily and abundantly, and the expectoration at last has an entirely purulent character, and comes up in globular masses. The fever now disap- pears, the pain and soreness cease, the cough is easy and less frequent, the appetite is restored, and the return to health is completed in a few days. Such is the course of a simple acute bronchitis (a cold on the chest), which terminates in recovery in about sixteen days. In such a case the changes in the mucous membrane, we may suppose, consist in hypersemia and swelling, with increased secretion of the glands and more or less destruction of the epithelium. The more severe cases of bronchitis come on with muscular soreness, headache, chilliness, and fever. There is not a single violent chill marking the onset of the disease, but a succession of chills in which there is merely some chil- liness felt several times during the course of the day, and having no influence on the fever, which has an exacerbation in the evening and a remission in the morning, or a complete intermission. Sometimes the febrile movement exists without there being any other symptoms for several days, but the more usual onset is the simultaneous appearance of chest symptoms. There is a sensation of heat and stufiing under the sternum ; cough, which is accompanied by soreness within the chest, now comes on, and it is dry, harsh, ringing. The frequency and force of the coughing make the diaphragm and chest-muscles sore, and now and then the stomach is emptied in a violent paroxysm. In a few days — usually from three to five — the dryness of the mucous membrane ceases, and abundant secretion of mucus now takes place, and there is brought up frothy mucus, which day by day assumes more of a puru- lent character. The fever now declines somewhat, but frequently a gastro-intestinal catarrh is lighted up and diarrhoea supervenes. This is apt to be the case with children, in whom the nausea, vomiting, and diarrhoea assume an important position. The coincident development of bronchial and gastro-intestinal catarrh produces a complexus of symptoms to which the term catarrhal fever has been applied. In bronchitis the sonority of the chest is not altered from the normal. During the dry stage the swelling of the mucous membrane narrows ACUTE BRONCHITIS. 405 somewhat the lumen of the bronchial tubes, but there is no secretion to produce a new sound. The passage of air through narrowed tubes modifies the vibrations, and hence the terms sibilant and sonorous rdles, audible at this stage, both with Inspiration and expiration. When secretion of mucus, muco-pus, and pus succeeds to the dryness, the rdles are said to be moist. Those are suh-crepitant w^hich are produced in the smaller tubes, and mucous and sub-mucous formed in the larger tubes. The largest sounds, or gurgling, are produced only in ca\dties, or that which is equivalent, dilated bronchi. The sub-crepitant is more distinct in inspiration, but all of these rdles are audible both in inspi- ration and expiration. Moist sounds are modified by coughing and expectoration — may, indeed, be caused to disappear by them. The usual termination of these cases of bronchitis is in resolution. The fever ceases, the tongue cleans, the appetite improves, the cough sub- sides, the expectoration is copious, easy, and purulent, but the amount declines rapidly. Certain types of subjects manifest a great suscep- tibility to attacks of bronchial catarrh, and the effects do not cease. This is the case in the dyscrasire, and when the catarrh is due to car- diac disease there can only be a temporary subsidence in the severity of the symptoms. In those debilitated by constitutional causes, or in subjects of the strumous type, the acute attack passes into the chronic form. Acute bronchitis, by an extension of the inflammation to the finest tubes, becomes capillary bronchitis. This is often the case in whooping-cough, and in the eruptive fevers — notably in measles. In those debilitated by previous illness, in the old, and in infants, capil- lary bronchitis is a most serious malady. A sudden increase in the temperature and a marked difficulty of breathing announce the onset of this disease when it arises as just indicated. So difficult is the breathing that the patient calls into use the auxiliary muscles of respi- ration ; unable to lie down, he sits, inclined forward, the arms resting on some support, struggling to get breath, and the respirations, shallow and incomplete, reaching in an adult to forty, in infants to eighty per minute. The difficulty of breathing is incessant ; although, now and then dislodging some mucus by coughing or vomiting, there is a tem- porary alleviation of the distress. At first the respirations, although hurried and oppressed, are normal ; but, when the air can not enter, the lungs are not expanded, and the diaphragm is not depressed, the inferior part of the chest and the epigastrium are drawn in with each inspira- tion instead of being elevated, while the upper portion of the chest re- mains immovable. At first the face is red, the eye bright, and the skin hot with the unwonted effort, but as the air fails to reach the lungs the blood is not oxygenated, the face becomes pale, the veins enlarged, and the countenance has an increasing duskiness from the accumulation of carbonic acid in the blood. The restlessness and anxiety yield to an increasing stupor, and the approaching cardiac 406 DISEASES OF THE RESPIRATORY ORGANS. failure is announced by rapidity and feebleness of the pulse. When no efforts succeed in removing the obstruction to the entrance of air, death takes place in four or five days, but the duration is longer if by vomiting or other means the access of air is secured, even for a brief period, to the alveoli of the lungs. When a favorable termination is about to take place, the dyspnoea becomes less urgent, the pulse im- proves in volume and lessens in rate, the fever diminishes, the expec- toration is less viscid and comes up more abundantly, and ten or twelve days from the onset convalescence is fairly inaugurated. More or less simple bronchitis may persist for weeks longer. The physical signs are similar to those of bronchitis, except the differences due to the volume of the tubes attacked. Besides the coarser sounds of bronchitis, the dominating rale is the sub-crepitant, audible all over the chest. As in capillary bronchitis collapse of lobules takes place, the physical signs of atelectasis are superadded. These have already been sufficiently discussed. Course, Duration, and Termination. — Simple bronchitis usually ter- minates in resolution in about ten to fifteen days. In children the course may be more protracted, and the symptoms more severe, if complicated by gastro-intestinal troubles. The termination may be in the chronic form of the disease. There may be an extension of the morbid action from the larger to the finest bronchial tubes. Capillary bronchitis pursues a more rapid course, and may terminate in four or five days, but it usually continues up to the ninth, even twelfth day. The mortality from capillary bronchitis is large, because of the occur- rence of atelectasis and broncho-pneumonia or catarrhal pneumonia. Diagnosis. — Acute bronchitis is to be differentiated from catarrhal pneumonia and croupous pneumonia. Bronchitis pursues a much milder course, is of shorter duration, and is greatly less dangerous to life. While the moist sounds are the same in the two diseases, the sub-crepi- tant rale preponderates in catarrhal pneumonia, and in the latter the vesicular murmur is replaced by blowing or bronchial breathing and bronchial voice. Bronchitis commences by chilliness persisting for several days — pneumonia by a distinct and severe rigor ; in bronchitis there is fever of moderate height — in pneumonia, the range of temper- ature is very high ; in bronchitis, the fever declines gradually — in pneumonia, there is a sudden defervescence ; in bronchitis, the sputa consist of muco-pus and pus — in pneumonia, of a peculiar viscid mate- rial stained with blood ; in bronchitis, there are moist sounds, with sub- crepitant rale — in pneumonia, there is crepitant rale ; in bronchitis, there are no sounds indicating pulmonary lesions — in pneumonia, there are bronchial breathing, bronchial voice, etc. Bronchitis of the larger is to be distinguished from bronchitis of the smaller tubes, by the dyspnoea, by the fineness of the sounds, and the greater danger to life. The onset of catarrhal pneumonia from bronchitis is announced by CHRONIC BROXCHITIS. 407 the increased difficulty of breathing, the rise of temperature, and the diminishing sonority of the chest over the affected parts, with the auscultatory phenomena of consolidation. Treatment. — The simplest means suffice for an uncomplicated case of acute bronchial catarrh. The combination of tartar emetic (gr. -^) and morphia (gr. Jj) in some sii-up of lactucarium, or in water, a mustard-plaster to the chest, and confinement to bed, will afford satis- factory relief. In children, sirup of ipecac, sirup of tolu, and paregoric usually suffice. If there is much fever, and the pulse active, tincture of aconite-root (gt. j) should be added to the ipecac and paregoric. When the acute symptoms have subsided, the stimulant expectorants should be used — acetum scillae, sirup of senega, and sirup of tolu, for example. When the bronchitis is severe, there is high fever, and the inflammation seems disposed to invade the finer tubes, and especially if the finer tubes are invaded, tartar emetic in sufficient quantity to produce a little nausea, morphia in very small doses, and the tincture of aconite, are highly serviceable. The more the finer tubes are in- vaded, the greater the need of ammonia, carbonate or chloride, and the iodide. Should there be much obstruction, emetics of subsulphate of mercury or of apomorphia must be employed to tide over the emer- gency, and then the iodide and carbonate of ammonia, in small doses, should be given frequently. Should the temperature rise high and continue so, antipyretics, as cold baths and quinia, more especially the latter, must be administered. A temjaerature requiring antipyretics may be attained when a simple bronchitis becomes a capillary bron- chitis or broncho-pneumonia. A persistently high temperature greatly increases the danger of cardiac failure. If there be indications of such failure, ammonia carbonate and alcoholic stimulants must be freely but judiciously administered. The diminution in the supply of oxygen and the accumulation of carbonic acid are important sources of danger in capillary bronchitis. The timely use of emetics, by giving at least temporary admission of air, will postpone the period of stupor from carbonic-acid narcosis. When bronchitis in children assumes the aspect of catarrhal fever, the remedies employed must be different in charac- ter. Nauseants, emetics, and irritants must be discontinued if they have been used. Paregoric, with some carbonate of ammonia, in sirup of tolu, is a good prescription in these cases. In all cases of the differ- ent forms of acute catarrh of the bronchial tubes, alimentation is important, but especially so in those cases accompanied by gastro- intestinal disorder. CHRONIC BRONCHITIS— CHRONIC BRONCHIAL CATARRH. Definition. — By this term is meant an inflammation beginning in the mucous membrane of the bronchial tubes, chronic in type, and in- 408 DISEASES OF THE RESPIRATORY ORGANS. volving not only the mucous membrane, but the substance of the tubes and the peribronchial connective tissue. Causes. — Chronic bronchitis but rarely succeeds to a pronounced acute attack. Usually the early symjDtoms escape recognition, or the chronic form is a resultant of not one but numerous acute attacks. This malady is always associated with obstructive lesions of the heart or lungs. It accompanies or is a local development of the dyscrasiae, as rickets, scrofula, Bright's disease, and of the infectious diseases. The tendency to it may be inherited, or rather a type of mucous mem- brane disposed to such changes may be transmitted. Pathological Anatomy. — The mucous membrane is brownish in color, or has a steel-gray color. In other examples, owing to the develop- ment of vascular loops, it has a bright-red color. The follicles of the mucous membrane are swollen and enlarged by hypertrophic thicken- ing of the connective tissue, and by accumulation of their contents. The connective tissue, especially of the posterior part of the tubes, and the peribronchial connective tissue, become greatly thickened ; the cartilages are invaded and much weakened. Under the strain of cough- ing, especially if there be at the same time firm pleuritic adhesions, the bronchi yield and dilate. The dilatations are cylindrical, fusiform, and sacculated. In cylindrical dilatations the tube or tubes are uni- formly enlarged throughout ; in the fusiform variety the enlargement has a spindle-shape, and in the sacculated there is a lateral protrusion forming a sac or a cavity. To these might also be added the monili- form, in which there is an enlargement of one part, then the tube is normal, then again an enlargement, so that the normal portions by com- parison with the dilated seem to be contracted. The secretions in chronic bronchitis differ greatly from the normal. Fragments of the detached epithelium, mucus, and pus-corpuscles, are the morphotic elements, the purulent being very largely in excess. Usually the secretion is very abundant, greenish-yellow in color, and sometimes fetid. When the secretion consists of young cells and mu- cus corpuscles and granules, it is called mucous catarrh ; when the cel- lular elements are not present, and the secretion is viscid, colorless, without odor, and resembling white of ^q^g, it is called pituitous catarrh or hronchorrhoea ; if the secretion is scanty, tough, rather glistening, semi-transparent, and occurs in defined, globular masses, it is entitled dry catarrh. Whenever the secretion is retained and undergoes decora- position, as is apt to be the case when the tubes are dilated, especially in the saccular form, it is known as fetid hronchitis, the fetor being chiefly due to the fat acids. Sjrmptoins. — If there be no complications, chronic bronchitis is not attended by fever. When it occurs with disease of the heart, Bright's disease, or other dyscrasiae, the clinical features are those of the origi- nal malady, bronchitis being one only of the morbid complexus. As a CHRONIC BRONCHITIS. 409 substantive affection succeeding to acute attacks, it is slow of develop- ment. There are observed, for some years, autumnal and winter seiz- ures of bronchitis, which cease with the warmer and more stable weather of the summer. It may be a number of years before the bronchitis becomes constant, which indicates the existence of perma- nent changes in the tubes. In the so-called dry catarrh there is but little expectoration, and that is brought up with difficulty, and after repeated and most distressing paroxysms of coughing. Next to cough- ing the most important symptom is dyspnoea, due to the viscidity of the exudation, to the swelling of the mucous membrane, and the impli- cation of the finer tubes. The difficulty of breathing is not consider- able when at rest, but exertion at once develops it, and it is accom- panied by more or less wheezing. Owing to the impaired elasticity of the lung and the dilatation of the tubes, the upper part of the thorax is kept in the position of maximum inspiration, and the expiration is prolonged and difficult. The result is, that the supply of oxygen is insufficient for the depuration of the blood, and cyanosis appears, the face becomes congested, the lips and mucous membrane bluish, and the supei-ficial veins enlarged. The pulmonary circulation is hindered by reason of these conditions, venous stasis ensues, and oedema slowly develops about the ankles. The habitual difficulty of breathing is now and then varied by attacks which have an asthmatic character, excited by the inhalation of dust, remaining in a crowded apartment, taking cold, and especially by an attack of acute bronchitis with profuse secretion (humid asthma). These seizures are not very protracted, and terminate after some hours by an abundant discharge of mucus. The cases of chronic bronchitis characterized by profuse expectoration dif- fer from the preceding type in several respects — in a more abundant expectoration, in a less troublesome cough, and in less habitual difficulty of breathing. In these cases of so-called humid bronchitis there are occasional paroxysms of dyspnoea, due to extension of the morbid process to the smaller tubes, causing difficulty of breathing by swell- ing of the mucous membrane, by accumulation of secretion, etc. With or without such paroxysms, the chief troubles arise from the cough, which is most annoying at night or in the early morning, and an abundant expectoration. The sputa consist of muco-pus, or of a semi-transparent, albuminous, viscid fluid (bronchorrhoea), or of a green- ish-yellow pus, and the variations represent differences in the local changes already designated. Percussion reveals no change in the noi-- mal sonority of the lungs in uncomplicated cases. If emphysema, or broncho-pneumonia, or fibroid phthisis have occurred, there will be changes in sonority, but these diseases are not in question. In dry bronchitis, on auscultation sibilant and sonorous rales of every variety will be heard ; in humid bronchitis, mucous and sub-mucous, and sub- crepitant rales will be abundant according to the amount of secretion 410 DISEASES OF THE RESPIRATORY ORGANS. present in the tubes. The vesicular murmur may be entirely displaced by the loud oodles, especially the more nearly the lesions approach to the acini. Dilatation of the tubes impresses some special characters on the rational and physical signs. The expectoration is very abun- dant and often has a butyric and fetid odor, and is sometimes, as in the morning, expectorated in a great mass, due to the emptying of a sac- culated dilatation of a bronchus. This expectoration, when collected, differs from that of phthisis in being homogeneous and of a greenish- yellow color. Haemorrhage from a dilated bronchus is a very mislead- ing symptom ; it may occur gradually and continue for some time, there being considerable loss in the aggregate. The blood coming from a dilatation is fluid, dark, and does not clot, and it may be mixed with the contents of the sac. The physical signs of dilated bronchi are practically the same as those of a cavity formed in other ways, but the distinction may be made by the history of the case and by the situation of the dilatation. Course, Duration, and Termination. — Chronic bronchitis pursues an essentially chronic course, but it is diversified by variations in the intensity of the symptoms, by remissions and intermissions. These intermissions are only possible in the early period ; after a time the symptoms persist. Chronic bronchitis may continue during a lifetime, and death be caused by some other disease. Recovery may ensue in the milder cases, and is more likely to occur in young than in old sub- jects. Severe cases of bronchitis lead to the jDroduction of other mal- adies. The long-existing purulent exudation in the tubes, interstitial pneumonia having been produced by the extension of the peribron- chial connective-tissue inflammation, excites tubercular deposition. Fibroid phthisis is usually, probably always, produced in this way, chronic bronchitis initiating the series of morbid changes. Emphy- sema is a result of dry catarrh, for in this case the chronic inflamma- tion is seated in the finer bronchi, the secretion is highly viscid, the membrane much swollen — conditions most favorable to collapse of lobules and emphysema. Hypertroi^hy and dilatation of the right cavity, venous stasis, and general (Edema are also results of chronic bronchitis, and in this way a considerable proportion terminate. The disturbed circulation in the lungs and the venous stasis cause conges- tion of the liver and of the kidneys, and death may be due to the maladies thus created. Diagnosis. — The same considerations govern the diagnosis of chron- ic as of acute bronchitis. The disease with which chronic bronchi- tis is most apt to be confounded is phthisis. The difficulty of sepa- rating chronic bronchitis with sacciform dilatation from phthisis with cavities is very great. The differentiation must rest on the history of the cases, the evidence of pulmonary lesions outside of the cavity, to be discovered in jDhthisis and not in bronchitis, and CHRONIC BRONCHITIS. 411 in examination of the sputa, those of phthisis containing elastic fibrous tissue, etc. Treatment. — The indications of treatment vary somewhat with the form. In dry bronchitis, full doses of iodide of potassium, or prefer- ably iodide of ammonium (ten to twenty grains), every three hours when the difficulty of breathing is great, are very effective. For the interval between the asthmatic paroxysms, the best results are obtained by a combination of iodide of ammonia and arsenic, with a balsamic expectorant, as eucalyptol, turpentine, copaiba, cubebs, etc. The per- sistent use of these remedies will often accomplish important results, and will in all cases afford relief, if not cure. When there is profuse expectoration, quinia with atropia, and codeia, to quiet cough, and the balsams, are the most efficient remedies. If the expectoration is fetid, the free internal use of quinia, eucalyptol, and turpentine, is to be com- mended, and inhalations of the vapor of turpentine and of iodine, or atomization of benzoate of sodium, carbolic or salicylic acid, or thymol, may be practiced. Of these remedies applied by atomization, carbolic acid is most efficient. In all cases of chronic bronchitis with consider- able expectoration, much good results from the persistent use of the now well-known phosphate of ii'on, quinia, and strychnia. The lacto- phosphate of lime is also highly useful, probably because of the waste of this important material under these circumstances of profuse sup- puration. Arsenic is highly useful when the secretion is not abundant, as in dry bronchitis. It may be combined with the iodides, or with the sirup of the lactophosphate of lime. The hypophosphites, as well as the compound phosphates, are useful when there is waste by sup- puration. Alcohol has the power to diminish suppuration and to arrest fermentative processes, and is therefore useful in chronic bronchitis. Whisky is the best alcoholic in such cases. It may be taken with cod- liver oil, the two forming a nutrient of much value — a teaspoonful of cod-liver oil and a tablespoonful of whisky after meals. A generous supply of nutritrous aliment is, of course, highly necessary. As taking cold is the principal cause of attacks of catarrh (employ- ing that terra to indicate the nature of the influences causing catarrh), it is highly important to avoid this accident by suitable clothing, by good air, and by favorable hygienic surroundings. If a cold should occur, the patient ought to receive at once an efficient dose of quinia and morphia (gr. xv — gr. ss.). As a humid, variable climate, characterized by cold winds and extremes of temperature, is very unfavorable, a change to a mild, equable, and dry climate should be advised. PSEUDO-MEMBRANOUS OR CROUPOUS BRONCHITIS. Definition. — Croupous bronchitis is an inflammation of the bron- chial mucous membrane, characterized by the exudation of a false 412 DISEASES OF THE RESPIRATORY ORGANS. membrane. It corresponds to croupous enteritis and to laryngeal croup. It may be acute or chronic. Causes. — The ordinary causes of bronchitis excite this form appar- ently, but nothing is known of the conditions which give this direc- tion to the products of inflammation. The cases occur usually in youthful subjects, from six to forty * years of age, and in those who have been subject to attacks of bronchial catarrh. A depressed state of the body, and possibly an inherited tendency, are also causes. Ac- cording to Riegel, pulmonary haemorrhage sometimes precedes, accord- ing to Street succeeds to attacks of croupous bronchitis. Morbid Anatomy. — There are two forms of the croupous process in the bronchial tubes — the diffused and the circumscribed : the former are so designated because the exudation extends from the trachea through all the divisions of the bronchi ; the latter, because confined to certain tubes. The mucous membrane has been found both intensely injected and pale ; the epithelium intact, or entirely removed over the whole extent of the surface covered by the exudation. Sometimes cili- ated and cylindrical epithelium has been found embraced in the casts ; in other cases none has been found. These contradictory observa- tions are due to the fact that the examinations were made at differ- ent stages of the disease. Indeed, displacement of the epithelium is not a necessary part of the process of membrane formation. It is most probable that an albuminous solution is poured out, and white corpuscles migrate, the whole consolidating. It may happen that some epithelial cells are embraced, but this is not necessary. The tubular casts form an outline of the tubes in which they were produced. They may be rolled up into a ball, or expelled in fragments, or as a whole. The author has had a case in which a complete cast of one bronchus and all of its subdivisions was expelled entire. The casts differ much in thickness and length. Those coming from the upper tubes are shorter and straighter, and terminate in fine prolongations ; those from the lower tubes are longer, and gradually divide into smaller casts. They are not solid usually, at least the larger casts are not, and contain in their interior mucus and air. They have a lamellated structure, and the lamellae have a concentric arrangement (Riegel) f. The casts are elastic and compact, and bear a good deal of strain. They are whitish or yellowish-white in color, and consist of a "hyaline base- ment substance," J sometimes fibrillated, as was the case in the author's observation. Symptoms. — There are two forms — as regards the clinical features — the acute and chronic. The acute attacks begin as an ordinary acute * Dr. Street's case — a man aged thirty -nine, " American Journal of Medical Sciences," January, 1880, p. 149. f Ziemssen's " Cyclopaedia," vol. iv. \ "Report of Cases of Fibrinous Bronchitis," by Dr. Glasgow. CROUPOUS BRONCHITIS. 413 bronchitis, with chilliness, fever, general malaise, a troublesome cough, soreness of the chest, and oppression. These symptoms continue for several days, when more formidable troubles are manifested by an in- creasing dyspnoea, " livid, swollen countenance," * high fever, rapid pulse, a dry, harsh, and resonant cough, anxiety, and sometimes haemop- tysis. There may be no preliminary symptoms of acute bronchitis merely, but the disease set in at once by severe difficulty of breathing, preceded by a rigor, and accompanied by high fever. At first the ex- pectoration is that of bronchitis, but in a few days the characteristic casts are brought up with a good deal of coughing and straining. There may be then immediate relief afforded, the dyspnoea subsiding and the cough becoming much less severe. In the course of a few hours, or a day or two, there may be a recurrence of the severe dyspnoea and the straining cough, and more casts will then be discharged. More or less haemorrhage may occur, or masses of bloody mucus may be expecto- rated. In the chronic form of croupous bronchitis, there is usually a history of chronic bronchial catarrh, or of some form of pulmonary dis- ease. During the course of such disease, acute bronchial symptoms come on, fever, dyspnoea, and a most severe straining cough, cyanosis, anxiety, etc., during which casts of the tubes are expectorated. Then the symptoms subside, and afterward only those symptoms pertaining to the chronic malady are experienced, until there occurs a return of the paroxysms. In some cases, during a long time — a year — there may be discharged every few days casts ; in other cases the attacks may occur two or three times a year.f When the attacks happen at longer inter- vals, the symptoms are apparently more acute and severe. Course, Duration, and Termination. — The acute cases run their course in a few days. The fatal cases may terminate within the first week, as early as the fourth day, and none continue longer than two weeks. About one half of the cases terminate fatally. In the fatal cases the casts either remain in situ or are in part discharged, or are reproduced. The cyanosis rapidly deepens, carbonic-acid poisoning supervenes, the dyspnoea augments, and the patient dies asphyxiated. The chronic form pursues a different course. The attacks recur from time to time, during the prolonged existence of a chronic bronchitis, and a fatal result is reached in an acute attack with symptoms of as- phyxia, or by the changes belonging to the associated malady. Other cases are connected with phthisis, emphysema, etc., and pursue a simi- lar course, death occurring usually in an acute suffocative attack. Diagnosis. — Until the characteristic casts have been discharged, it will be impossible to distinguish these attacks from those of capillary bronchitis. As there are no symptoms of laryngeal stenosis, bronchial will be readily separated from laryngeal croup. A careful considera- * " Transactions of tbe Pathological Society," vol. xi, p. 23. f Ibid., p. 24. 414 DISEASES OF THE RESPIRATORY ORGANS. tion of the history of the case will prevent this disease being con- founded with a foreign body in the air-passages, the symptoms being much the same in both. It is to be distinguished from catarrhal pneumonia by the changes in the sonority of the lungs caused by the latter, but a suspension of judgment will be necessary until the casts are expectorated in those cases of croupous bronchitis occurring in the course of chronic pulmonary affections. Prognosis. — Opinions must be expressed with caution in any case of the acute type, as fifty per cent, prove fatal. In chronic cases the prognosis is grave, because in so many of them lesions exist, which must eventually destroy life. The prognosis is favorable, however, in the chronic cases without complications, as recovery takes place in a majority of them. The prognosis is rendered grave by these indica- tions : severe dyspnoea, cyanosis, stupor, high fever, great extent of the surface affected in the lungs, the extremes of age, little vigor of constitution, and bad hygienic surroundings. Treatment. — ^As the extreme urgency of the symptoms depends largely on the obstruction by the false membrane preventing the access of air, the first requisite is to dislodge and remove this obsti'uction. Active emesis is the most effective means for immediate result, and the most efficient emetic is apomorphia, which should be injected hypoder- matically. Kext to this is the subsulphate of mercury, which acts promptly without j^roducing depression. Tartar emetic is too depress- ing, but it may be employed in the absence of the other agents. Sul- phate of zinc is safe and effective. The repetition of the emetic is determined by the dyspnoea and cyanosis. Softening the false mem- brane by inhalation of the vapor of water, especially of lime-water, is highly serviceable. Merely disengaging steam in the apartment is useful, but the utility of the application is greatly enhanced by the addition of lime. The domestic method of producing vapor and ato- mizing lime is an excellent plan. This consists in slaking freshly- burned lime, the patient inhaling the vapor as it arises. Lime-water may be atomized in the ordinary way. Such softening and solvent applications should precede the emetic. Great good has been accomplished in these cases by the adminis- tration of the iodides, with alkalies. The author strongly urges the use of the iodide and carbonate of ammonia, in small doses every hour or two. It is highly important to prevent a recurrence of the seizures. Remedies having a direct effect on the bronchial mucous membrane, because eliminated by it in part, at least, afford the best prospect of relief. These remedies are the iodides, the balsams and oils, as copaiba, turpentine, eucalyptol, etc., which should be perseveringly administered for a long time. The effect of these remedies is aided by arsenic, which should also be given persistently. The complications of croupous bron- chitis should be treated in accordance with the requirements of each case. STENOSIS OF THE BRONCHI. 415 STENOSIS OF THE TRACHEA AND BRONCHI. Definition. — By stenosis is meant a narrowing or contraction of the trachea or bronchi, produced by obstruction within and by pressure from without. Causes. — The trachea or the bronchi are narrowed by interior ob- structions and by exterior pressure. In the second group are in- cluded enlarged thyroid or goitre ; swollen lymphatic glands at the hilus of the lungs and the bifurcation of the trachea ; aneurism of the arch of the aorta, especially of the concave and posterior arch ; tumors, abscesses, etc., of the mediastinum ; and cancer of the lung. In the first group are cicatrices, indurations, and adhesions ; neo- plasms or new formations ; inflammation and thickening of the walls, etc. Symptoms. — So far as the symptoms are concerned, the cause of the obstruction is of little moment. The most obvious symptom of stenosis is difficulty of breathing, but not the kind of difficulty pro- duced by emphysema, capillary bronchitis, etc., which is expiratory, whereas that due to this disorder is inspiratory. When there is great difficulty, all of the accessory muscles of respiration are brought into action to fill the lungs, but expiration is easy and unobstructed. Not- withstanding the strong efforts put forth to fill the lungs, this is not accomplished, and hence more or less rarefaction of the air in the lungs takes place, so that on inspiration, instead of expanding, certain parts of the chest are drawn in, viz., the lower part of the sternum and the inferior ribs. The movements of the larynx are very slight in tracheal and bronchial stenosis, and very fi-ee in stenosis of the larynx. A peculiar whistling, wheezing, crowing, or musical note is produced by stenosis, and the sound of expiration is higher in pitch than that of inspiration. If the obstruction is sufficiently high up in the tra- chea, the vibration in the column of air may be transmitted to the walls of the organ, producing a defined thrill. The voice is weak and muffled, because of the interruption in the passage of air to the vocal cords. The vesicular murmur is also weakened, obscured by the tra- cheal or bronchial sounds, or absent. This change may exist in one lung only, if a bronchus is obstructed. If the stenosis is in one bron- chus only, the movements of the corresponding side of the thorax are les- sened ; the vesicular murmur is diminished, obscured or abolished, and there are loud whistling, sonorous, and wheezing sounds, with more or less thrill, while the sonority of the corresponding lung is undiminished. The healthy lung having an increased amount of work to do, there is more or less expansion, the movements are also greater, and the dia- phragm is pushed down somewhat. A laryngoscopic examination separates laryngeal from tracheal stenosis, and imder favorable circum- stances indicates the position and character of the latter. The ration- 416 DISEASES OF THE EESPIRATORY ORGANS. al symptoms are those of difficulty of breathing and obstruction to the entrance of air. The face is anxious, the alae of the nose work, the skin is covered with a sweat, and there is constantly present a sense of the need of air. Besides this constant difficulty of breathing, the severity of which depends on the amount of the stenosis, there now and then occur acute exacerbations of dyspnoea, due either to a fresh catarrh, to a sudden increase of the compressing force, but especially to an asthmatic attack. The ordinary rate of difficulty of breathing may continue uniform for a long period ; but toward the end suffo- cative attacks come on, which are at first separated by considerable intervals of time, but become nearer gradually, and life is ended by them, or by an intercurrent pneumonia. Course, Duration, and Termination. — The clinical history is usually divided into three stages : the first consists of the disturbance pro duced by the growth of the obstruction ; the second, the period of difficulty of breathing and the other symptoms due to the completed obstructing cause, which may continue for a long time ; the third, consisting of the final suffocative attacks. The duration is protracted, and can not be expressed in definite numbers. The ultimate termina- tion of a large proportion is death ; many cases may continue for years without apparently interfering with health, but these are exceptional cases. Cerebral symptoms — coma — may appear toward the end. Death may be caused by pneumonia, oedema of the lungs, etc. Sometimes death occurs suddenly without the warning afforded by severe dysp- noea, caused by the rupture of an aneurism, of an abscess, or rarely without any apparent cause. Treatment. — The therapeutical management is concerned with the cause of the stenosis, and need not, therefore, be considered here. ASTHMA. Definition. — This term has been applied to various morbid states, characterized by spasmodic difficulty of breathing, but it should be restricted to an independent, substantive affection occurring paroxys- mally, without any morbid alteration of the breathing organs, and con- sisting in acute dyspncea, lasting some hours, and terminating in health. It is appropriately divided into the idiopathic and syrapto- matic. Causes. — Various theories of asthma have been proposed. With- out occupying space with details, it will suffice to state that asthma is a neurosis of the breathing apparatus, and like other neuroses arises from sources of disturbances in the nervous system, central and peripheral. Like other neuroses, the conditions of the nervous system necessary to its development may be inherited. Nothing is more com- mon than the occurrence of this malady in different generations and ASTHMA. 417 branches of a family — the author has known of many examples. Asthma alternates with other nervous affections — with hemicrania, epilepsy, and angina pectoris. Asthma also alternates with affections of the skin — with urticaria, for example ; and succeeds to eruptions of the skin, of the herpetic kind (Waldenburg). The pressure of enlarged lymjDhatics on the pneumogastric nerve has excited attacks. Various peripheral irritations induce asthmatic seizures. Evil intelligence, the association of ideas as connected with particular localities, and other moral causes, will excite attacks. Curious examjjles are related in regard to the influence of local associations : thus attacks occur on one floor of a house, and not another ; on one side of a street, and not the other, etc. Distention of the stomach, indigestion, and flatulence, nasal polypi, certain odors, dust of a peculiar kind, pollen of plants, etc., will excite attacks. The mechanism is plain. In the case of intestinal irritation, the end-organs of the pneumogas- tric are acted on, the impression is communicated to the pneumogas- tric nucleus, and reflected over the bronchial and pulmonary branches of the vagus. In the case of affections of the nasal mucous mem- brane, the filaments of the fifth nerve receive the impression, and, as the nucleus of the fifth and of the pneumogastric lie in close juxta- position, and are intimately associated in function, disturbance in the one is easily and quickly transferred to the other. Of this rela- tion numerous examples exist. Asthma is more common in men than in women : according to Hyde Salter, of one hundred and fifty-three asthmatics tabulated by him, one hundred and two were men, and fifty-one were women. The disproportion is greater in advanced life. Asthma is common in childhood and up to middle age, but occurs at all ages. It is rather more common among the well-to-do classes. Surroundings have but little influence, unless a predisposition exists. Change of locality has a remarkable influence on asthma, but the con- ditions of climate which prove favorable are most diverse. Some do better in the heart of a great city, others on a dry and elevated pla- teau, others in a humid valley. Mental and moral influences are more potent than mere climatic peculiarities. Pathogeny. — As asthma is a neurosis, there are no anatomical changes peculiar or essential to it. There are, it is true, morbid states associated with, but are not necessary to it. Bronchial catarrh is often found, also emphysema, but these are sequelse or results, rather than a part of the disease. During the existence of the asthmatic paroxysm, an intense congestion has been seen on laryngoscopic examination. There are, at present, two dominant theories of the pathogeny of the , asthmatic seizures ; the theory of tonic spasm of the diaphragm, pro- pounded by Wintrich ; the theory of spasm of the bronchial muscles, which is the oldest theory, but has the support of Salter, "Williams, and Trousseau, and is now sustained by the remarkable investigation of 27 418 DISEASES OF THE EESPIRATORY ORGANS. Professor Paul Bert. The new theory of Leyden * has attracted at- tention by its singularity. He finds in the expectoration brownish cells undergoing granular degeneration, between which are colorless, extremely small but pointed, octahedral crystals, some readily visible, others requiring immersion lenses to find them. These crystals have been examined by Salkowski,f with the result to show that they must be composed of a material analogous to mucin. Leyden supposes the asthmatic paroxysm to be determined by a reflex spasm of the muscles of the bronchial tubes, induced by the irritation of the terminal fila- ments of the vagus by these minute crystals. A more recent and the latest theory is that of Weber (Riegel I ), which supposes the conciir- rence of a number of factors in causing asthma, such as bronchial spasm, catarrh of the tubes, tonic spasm of the diaphragm, cardiac lesions, etc., which is, in fact, a combination of the previous theories, and is, probably, the nearest approach to a true hypothesis in that it adopts all the presumed causes. Symptoms. — The first attack is sudden, but the succeeding attacks are preceded by prodromes, the significance of which presently be- comes apparent to the sufferer. These prodromes are usually acute coryza, some bronchial irritation, headache, and general malaise; or the preliminary symptoms may be those of indigestion — acidity, pyro- sis, flatulence, hiccough, sneezing, etc. The first attack is nocturnal. The victim, after some uneasy sleep, is suddenly aroused by an intense anguish in his chest ; he is stuffed up and struggles for air, jumps from the bed and rushes to the window, or he sits up, leaning forward on his arms, and uses all his strength in the effort to get more air. The breathing is accompanied with loud wheezing, the face becomes flushed and at the same time cyanosed, and is bathed in perspiration, the eyes stare, the eyeballs protrude, and the muscles of the neck start prominently up, as they are called on to aid in the effort to get air. The difficulty of breathing soon reaches a point that the inspiration is nothing but a gasp, the lips become pallid, the cyanosis deepens, and it appears to the patient that every minute must be his last. After some minutes or hours the respiration becomes a little easier, more air enters the lungs, the cyanosis subsides, and gradually the paroxysm ceases. Eructations of gas give great relief as the breathing becomes easy, and the bronchial tubes pour out an abundant mucus secretion, the expectoration of which also contributes to the ease of respiration now rapidly increasing. A free urinary discharge also takes place, the urine being pale, and of low specific gravity. The patient, exhausted with the violence of his efforts to get air, sinks into a profound sleep, and is bathed in perspiration. The whole duration of an attack rarely * Virchow's " Archiv," vol. liv, p. 324, " Zur Kenntniss dcs Bronchial-Asthma." t Ibid., p. 844. ■\. /icmssen's " Cyclopa3dia," vol. iv. ASTHMA. 419 exceeds six hours, and may, indeed, be no more than one hour. On the following day there are experienced muscular soreness, languor, and debility, but all unpleasant feelings subside and disappear in twenty-four hours, and a normal condition is maintained until the next attack. Instead of a single paroxysm there may be only slight remis- sions, and one attack succeed to another, with exacerbations, so that the patient can not lie down at all, can take but little food, and is, after some days of suffering, utterly exhausted. The attacks are not exclu- sively nocturnal, but do sometimes occur during the day. A diurnal attack must be the rule in those cases brought on by the inhalation of some kinds of dust, gas, or vapor, as from powdered ipecac, etc. On percussion, the sonority of the thorax is increased in the vertical , diameter from one to two inches, and also transversely, and does not f change either on inspiration or expiration. The percussion-note is ' highly resonant all over both lungs, and has somewhat the tympanitic quality. The "bandbox-tone," by which it is described by Bam- berger, is eminently characteristic. The vesicular murmur is either absent or greatly enfeebled, or obscured by the loud, wheezing, whis- tling, sibilant sounds. During expiration the sibilant, sonorous, whis- tling, cooing, sighing sounds are more pronounced and of longer dura- tion. Toward the close of an attack moist sounds occur. The expla- nation of the physical signs present in an attack of asthma is afforded in the condition of the chest. The diaphragm is depressed below its ordinary position by tonic contraction ; the chest, which assumes a dis- tended, globular shape, is fixed in the position of forced inspiration. The lungs are filled with air, but it is residual air, and is not renewed ; and, notwithstanding the effort put foi'th by the patient, the little air which can be introduced only adds to the distention. Expiration is prolonged, laborious, wheezing, and much more so than inspiration. Spasm of the muscular fibers of the bronchi is perhaps only one ele- ment in the obstruction to the expiration of air ; tonic contraction of the diaphragm contributes not a little to the result. The fullness of the cephalic veins and the cyanosis and lividity of the face are due to the contraction of the cervical muscles preventing the return of blood, and to deficient oxygenation of the blood. While the face is flushed and the head hot, the feet are cold. The sputa are wanting in the beginning, but appear abundantly at the close of the paroxysm ; they are frothy, grayish-white, or reddish-white if mixed with blood, and consist of mucus corpuscles, cylindrical and ciliated epithelium, and peculiar " yellowish-green clumps " in which are imbedded Leyden's crystals. Course, Duration, and Termination. — Asthma is an essentially chronic disease, not incompatible with long life, and with good, even vigorous health, during the intervals between the seizures. The par- oxysms last from two to six hours, but sometimes they persist for days. Of itself, asthma is never fatal to life, but changes in the or- 420 DISEASES OF THE RESPIRATORY ORGANS. ganism are gradually effected by the disturbance in the respiratory function, which may cause death. Emphysema, dilated right cavities, dropsy, or cerebral haemorrhage, may be brought on by the long-contin- ued operation of the cause. Much depends on the number of the par- oxysms. There may be very few or very many. They may be mild at first, and become more severe, or they may commence and persist with the greatest severity. They may disappear suddenly, and never occur again. According to the behavior of the disease will vary the sequelge. Asthma may also occur as a complication of some existing disease — as, for example, emphysema, chronic bronchitis, etc. Diagnosis. — It is not possible to mistake asthma when the history is known. The first attack may be confounded with oedema of the glottis or spasm, paralysis of the vocal cords, and stenosis of the trachea. Laryngoscopic examination may serve to differentiate at once, by Tecognition of the lesion. The most important means of determining, besides the history and the direct exploration of the larynx and trachea, is the character of the dyspnoea. In laryngeal or tracheal obstruction, the dyspnoea is inspiratory, in asthma it is expiratory. In cedema of the glottis, while inspiration is difficult, expiration is easy and unob- structed ; with inspiration there is a loud sibilant or crowing noise, and expiration is silent. Treatment. — To relieve the paroxysm is the most pressing duty. There is no medication so effective as the hypodermatic injection of morphia (from -^^ gr. to ^ gr.). An efficient dose of chloral hydrate is often equally effective (3 j — 3 ss.). As soon as the patient comes un- der the influence of either remedy, the difficulty of breathing begins to subside. The best results are obtained from a combination of the two remedies — morphia hypodermatically and chloral by the stomach — but in smaller quantity than when administered separately. Nitx'ite of amyl (by inhalation, three to five minims) sometimes affords relief, but its action is uncertain, and when it fails to relieve it may occasion ex- treme distress. In many cases iodide of potassium, in full doses, will arrest the paroxysms very remarkably. From fifteen to twenty grains, every two, three, or four hours, are usually required. It is better prac- tice to give iodide with bromide of potassium, and to each dose of the solution may also be added a drop or two of Fowler's solution of ar- senic. This combination is to be commended, especially in the cases which persist for some days. Much relief is affoi-ded by fumes of stra- monium and other narcotics ; old asthmatics often depend on fumi- gation to the exclusion of all other remedies. Pastils, or cigarettes containing leaves of belladonna, stramonium, tobacco, grindelia, and poppy, in equal portions, steeped in a saturated solution of niter and dried, are, after ignition, inhaled, as they ai'ise, or a mass of the leaves is ignited in a small apartment which may be filled with the fumes. There are a great many proprietary pastils sold, but, under what name ASTHMA. 421 soever they appear, the composition, with unimportant differences, is about as stated above. Belladonna-leaves saturated with nitre afford as good results, usually, as the more complicated pastils. Simple niter-paper gives ease for a time. The new California remedy, grin- delia robusta, has undoubtedly great power to arrest a paroxysm of asthma. Three to live grains of the extract or the fluid extract ( 3 ss.) can be given every hour or two. Grindelia is often useful as a fumi- gant. The debility caused by asthmatic paroxysms is best removed by quinia and iron, the former in considerable doses. This practice is especially to be commended when the paroxysms recur frequently. To prevent a return of the attacks, arsenic is very useful, and is most effective in combination with the iodides. In debilitated subjects, quinia, arsenic, and belladonna may be given steadily for some weeks or months, as the case may be. Asthma, like other neuroses, is capri- cious in its behavior toward remedies. The remedy succeeding at one time may fail utterly at another time, so that the treatment must be varied accordingly. Hence it is necessary to be fertile of resources in the treatment of this disease. Besides the methods of treatment already mentioned which are most approved, there are others less desirable which should receive some notice. Nauseants, as ipecac, tar- tar emetic, and lobelia, afford relief by inducing relaxation consequent on the nausea. When there is much catarrh, or the attack of asthma is due to an acute catarrh, good results are obtained by small doses of tartar emetic {^^ gr.) with morphia (jV)- ^ ^^w drops of wine of ipi- cac (five to ten) every five minutes, until some nausea is experienced, may lessen the oppression remarkably. During the paroxysm, nause- ant doses of lobelia (m xv. — 3 ss. of the fluid extract) are very effective in stopping the dyspnoea. Besides the very disagreeable effects of the remedies of this group, in producing nausea and depression, there is such debility caused by them that days are necessary to recover the usual stamina. The application of ammonia to the posterior wall of the pharynx is practiced by the French, but this practice is strongly condemned by Jaccoud. He, however, permits the application of ammonia by im- pregnating the air of the apartment. The inhalation of oxygen and of compressed air relieves the breathing somewhat, but ether and chloro- form are much more effective. Indeed, the former should always be given a trial. In the treatment of asthma thei'e is no point of greater importance than careful regulation of the diet. Hyde Salter much insists on this, and the author has had abundant confirmatory observation. The diet should be light and easily digestible, and as little bulky as possible. It should consist, therefore, chiefly of animal food, and to this may be added a little fruit and a few of the succulent vegetables, but starchy and saccharine substances and milk should be excluded. In this pro- 422 DISEASES OF THE EESPIRATORY ORGANS. hibition bread is included, as it is particularly apt to disagree. Articles of diet that are fried, pastry, cakes, and sirup, etc., are highly objec- tionable. Meats should be broiled or roasted. Boiled meats and soups are improper. There should be as little fluid drunk at meals as pos- sible, but a little black coffee may be allowed at breakfast. DISEASES OF THE LARYNX— ACUTE CATARRH OP THE LAR- YNX— LARYNGITIS. Definition. — By acute catarrh of the larynx is intended an inflam- mation involving the mucous membrane — a catarrhal inflammation. There is also a chronic form of the disease — chronic inflammation. Causes. — The mucous membrane of the larynx is in a position to be quickly and easily affected by external agents of a gaseous or aeriform kind — such as ammoniacal gas, chlorine, tobacco-fumes, etc. Very fine solid particles may be carried in the air in sufficient quantity to excite an irritation of the laryngeal mucous membrane. But the organ is more frequently affected by the condition of the atmosphere itself. The long-continued inspiration of air contaminated by respiration is very apt indeed to cause congestion of the mucous membrane, espe- cially when to this is added the sudden contact of cold air. Too pro- longed exertion of the voice may also excite a catarrhal inflammation, especially when the exertion is made in the open air. " Taking cold " is a fruitful cause of laryngitis. There may be an extension of trouble from the pharynx and from the face (erysipelas). Influenza may ex- tend to the mucous membrane of the larynx. Inflammation of the larynx is not an infrequent complication in the course of the infectious diseases. Climate has an unquestionable influence ; humid, cold, and variable climates increase the disposition to affections of the larynx, while warm and equable climates lessen the tendency to these diseases. Affections of the larynx occur at all ages, and both sexes are equally liable in proportion to their exposure to the causes. Pathological Anatomy. — In the mildest cases there is a transient hypersemia of the mucous membrane — in certain situations — over the arytenoid cartilages, the ventricular bands, the posterior ends of the vocal cords, and the space between the arytenoid cartilages. In more severe cases there is a good deal of swelling as well as injection of the ventricular bands, the epiglottis, the ary-epiglottidean folds, and the inter- arytenoid space, etc. The color in severe cases, instead of being reddish, is a dark, reddish-brown. Symptoms. — In the mildest cases there is no constitutional disturb- ance. The local symptoms consist in heat, rawness, and tickling, re- ferred to the larynx and pharynx. When the thyroid cartilages are pressed, unusual soreness, irritation, and severe pain are experienced. There are also present dryness, and a feeling of a foreign body stick- LARYNGITIS. 423 ing in the throat. Swallowing causes pain by the upward movement of the larynx, and by the pressure of the bolus on the larynx as it de- scends to the stomach. In the more severe cases the onset of the dis- ease is announced by some chilliness and general malaise, followed by moderate fever, anorexia, etc., for several days. Cough occurs at once, and it is noisy, harsh, hoarse, or toneless ; or, in children especially, has a ringing, sonorous, so-called " croupy " character. The cough is dry, and produces a sensation in the larynx as of scratching over a raw surface ; but in a short time secretion is poured out, and then the cough has a loose character. At first some frothy mucus is expecto- rated ; it may be streaked with blood occasionally, but in the rare hseraorrhagic form pure blood may be expectorated. The sputa, soon assume the appearance of muco-pus, the pus elements predominating ; and it contains also cast-off ciliated ei^ithelium, young cells, etc. At first the voice is thick, and becomes hoarse on talking ; but as the case progresses the hoarseness deepens, and at length there is aphonia. Dyspnoea rarely occurs to adults in simple mucous laryngitis, but in children spasm of the glottis may come on, when there is extreme dyspnoea in brief paroxysms. But, as this disorder will be discussed in a separate section, its consideration as a symptom of laryngitis is postponed. A sense of oppression and need of air is caused if there be much swelling of the vocal cords or ventricular bands in the case of adults — a condition of things not apt to occur unless there be some effusion into the sub-mucous connective tissue. Besides hoarseness, which may end in aphonia, there may be various alterations in the tone of the voice, high pitch or low pitch, and its timbre may be subjected to corresponding variations. The peculiarities of voice are due to swelling of the mucous membrane, variations in tension of the vocal cords, and the condition of the muscles moving the arytenoid cartilages. The tone of voice is hoarse and rough from swelling of the cords, discordant from the difference in the rate of vibrations of the two cords, high-pitched if the tension in the cords is great, low- pitched if the tension is low ; or there is a double tone, now high, now low, if the cords vibrate with opposite tension. On laryngoscopic examination the state of the mucous membrane, of the vocal cords, ventricular bands, etc., can be made out, and the changes described verified. Course, Duration, and Termination. — Acute laryngitis passes through its course in a week, if mild ; but the more severe cases may occupy three weeks to a month. Mild as well as severe cases may continue indefinitely by repeated relapses, and at last assume the chronic form. Under some circumstances a simple laryngitis may assume formidable proportions by the extension to the sub-mucous connective tissue. Treatment. — Confinement to bed for the more severe cases, and to a uniformly but not too highly warmed apartment for the milder cases, 4,24: DISEASES OF THE RESPIRATORY ORGANS. is essential. The air of the apartment should be kept moist by the vapor of water disengaged in it. For the relief of the inflamed mu- cous membrane, tincture of aconite-root — one drop for a child and two drops for an adult every two hours — is highly efficient. If there be much cough, and especially if the cough have the " croupy " character, two to five drops of the deodorized tincture of opium and one or two drops of fluid extract of ipecac may be given together. Application by spray douche of a solution of morphia to the throat is an excellent means of relieving cough, but is not so generally available as the inter- nal administration. A very minute quantity of tartar emetic, with paregoric and sirup of lactucarium, is also an efficient combination. A hot or cold pack should be wrapped about the throat after a brief application of mustard ; and, if the case is just beginning, the feet should be placed in a mustard foot-bath. If there be a tendency to spasm of the glottis, bromides should be used. Bromide of potassium may be given with any of the combinations above mentioned. Prophylaxis is very important in the case of those who have fre- quent attacks, especially if a phthisical tendency exists. They should wear flannels and protect the feet against dampness, while at the same time they should avoid warm wraj^pings, especially furs about the throat. The tendency to take cold may be obviated by a daily morn- ing cold sponge-bath, and by keeping up the general health. During a variable season, taking cold may be prevented by the daily morning administration of five to ten grains of quinia, and the access of an impending attack may be prevented by a full dose of quinia and mor- phia (15 grs. — gr. i-i). CHRONIC LARYNGITIS— CHRONIC CATARRH OP THE LARYNX. Definition. — Chronic laryngitis is an inflammation of the mucous membrane, less active in type than, but the same in mode as, the acute inflammation. Causes. — The chronic form of catarrhal inflammation of the larynx arises under the same conditions as the acute form, or it succeeds to an acute, or is a result of repeated acute inflammation. Tobacco- smoking, spirit-drinking, and careless use of the vocal organs in speak- ing, reading aloud, or singing, are all influential causes, the most impor- tant, in fact, in our day. The middle period of life and the male sex are predisposing causes. Pathological Anatomy. — The changes described as occurring in the acute form are the initial lesions in the chronic, except that in the lat- ter the color is deeper red or brownish, the mucosa is more swollen, and the submucosa as well as the mucosa is thickened and indurated. Swelling of the inter-arytenoid fold of mucous membrane and of the ventricular bands (false vocal cords) occurs to the degree that the LAEYNGITIS. 425 movements of the arytenoid cartilages are interfered with, and conse- quently of the vocal cords also. The ej)iglottis is likewise swollen and thickened, and marked by enlarged and varicose veins. The vocal cords themselves are injected, and their margins roughened. The follicles of the mucous membrane are enlarged by accumulation of their contents in part, but much more by hyperplasia of the surround- ing connective tissue. The enlarged follicles or glands, more or less thickly distributed over the surface, give to the mucous membrane a granular appearance. Very rarely hyperplasia of the connective tis- sue underlying the vocal cords takes place ; the new tissue contracts, and deformity, with stenosis, is the ultimate result. Symptoms. — Various uneasy sensations are felt in the larynx — a sense of heat, and an irritation compounded of itching and scratching of a tender surface ; this leads to hawking and clearing the throat as if some obstruction were present. Exj)osure to cold air increases these sensations, but still more irritating is prolonged talking, especially in the open air, leading to frequent swallowing of saliva. The voice is husky, and becomes so much so by talking that frequent efforts to clear the throat are necessary. The voice becomes hoarse, rasi^ing, and deep, or it is high-pitched, and unexpectedly drojDS into falsetto. As much effort is necessary to get out the sounds, these patients ac- quire a straining tone and manner, and now and then, amid husky and hoarse, almost toneless sounds, they utter a more distinct and intelligible sound, giving an eccentric and variegated expression to the conversa- tion. The effort required makes talking very fatiguing. In the morn- ing the most severe paroxysms of coughing and straining are experi- enced ; the secretion accumulates during the night, and it is detached with difficulty, so that much coughing, hawking, and straining are necessary. The secretion is in the aggregate not considerable, and consists of a tenacious mucus, with some pus-corpuscles. Course, Duration, and Termination. — It is a very chronic malady and is subject to exacerbations and remissions. Care in the manage- ment of the organ, and of the general health, rest, and appropriate treatment, bring relief, but abuse of the organ, irregularities of life, and the absence of all treatment, will restore the diseased state to full ac- tivity. Years may be passed in this way, the general health mean- while not suffering from the laryngeal disease. Cures may be effected in favorable cases, if proper treatment is carried out faithfully for a sufficient period of time, but the difficulties in the treatment, the self- denial to be practiced, and the duration of the case, should not be con- cealed from the patient. Treatment. — Any effective treatment must include local apj)lica- tions, directed by the laryngeal mirror and by spray. As there is a large extent of surface involved, and as the increased blood-supply is the leading pathological factor, the application of medicated spray may 426 DISEASES OF THE RESPIRATORY ORGAXS. be sufficient of itself. A great number of medicinal agents are so em- ployed — a solution of tannin (gr. v — § j), of sulphate or acetate of zinc (gr. j — | j), of chlorate of potassium (gr. v — 3 j), of bromide of potassium (gr. x — 3 j), of nitrate of silver, with cai'e (gr. j — 3 j), and of morj)hia sulphate if there is much irritability. Solution of nitrate of silver is applied by the brush directly to the interior of the larynx. Ziemssen recommends in inveterate cases the solid nitrate, which is applied by the caustic-holder directly. Such external applications as the tincture of iodine, the ointment of the red iodide of mercury, etc., are serviceable as counter-irritants. The larynx must be kept at rest as long as practicable. Taking cold, sudden changes of temperature, exposure to draughts, must be avoided. The general health must be maintained by a suitable mode of life. Change from a variable to a more equable, and from a humid and cold to a warm and dry climate, will often have a most favorable effect on the case. GSDEMA OF THE GLOTTIS— INFILTRATION OF THE LARYNX. Definition. — (Edema of the glottis means a serous effusion into the sub-mucous connective tissue. The disease or condition intended by this term is an obstruction to breathing produced by an infiltration of the larynx by any kind of fluid. Causes. — An inflammation of the mucosa may extend to the sub- mucosa, and cause oedema. A deep-seated phlegmon of the neck, or of the tonsil and the base of the tongue, may involve the larynx by the diffusion of the pus under the mucous membrane. An inflamma- tion of the cartilages or of the perichondrium may result in a similar purulent infiltration. Erysipelas of the face, typhoid fever, or scarla- tina, may be unexpectedly terminated by a sudden effusion into the sub-mucous connective tissue. During the course of Bright's disease, oedema of the glottis may occur, or this may be the first symptom of the malady to attract attention. Pathological Anatomy. — The oedema exists in those parts containing the most abundant and loose connective tissue — in the ary-epiglottic folds, the glosso-epiglottic ligament, at the base of the epiglottis, and in the inter-arytenoid space. When the inferior or true vocal cords are inflamed (one or both), the cord changes its color, and instead of appearing white, glistening, and brilliant, is dull, grayish-red, or violet- red, in patches, the vessels enlarged and varicose. When oedema exists without inflammatory changes, the sub-mucous connective tissue of the ventricular bands especially, and of the folds mentioned above, IS distended with a serous fluid, and has the translucent appearance of a fish's swimming-bladder. The ventricular bands project forward, almost meeting in the median line, and shutting from view above the vocal cords. The epiglottis sub-mucous tissue may also be distended LARYNGITIS. 427 in the same manner, giving to that organ the same .pellucid and semi- transparent appearance. If the swelling be due to purulent infiltra- tion, the epiglottis, the aryteno-epiglottidean folds, and the ventricular bands, will be swollen, and present a deeply congested, reddish-brown or violet tint, with here and there spots of a yellowish hue. A very considerable collection of pus may form when the base of the tongue, or the loose connective tissue beneath the tonsils, and the tissues of the larynx are simultaneously involved. A serous infiltration sufficient to cause fatal oedema has disappeared in the death-agony, or immediately after, leaving but small traces of the mischief to account for the for- midable symptoms. Symptonis. — Infiltration of the larynx, succeeding either to some inflammatory process in the neighborhood or of the larynx itself, or com- ing on in the course of some constitutional malady, adds its special features to the symptoms of the preexisting disease. These are a sen- sation of distress or actual pain in the pharynx and larynx ; painful dysphagia ; dyspnoea ; or paroxysms of a suffocative character. The sensations referable to the larynx consist of constant oppression as if a foreign body were wedged in the organ, and more or less severe sore- ness and pain shooting through the whole area occupied by the purulent infiltration, if that be the cause of the symptoms. There may be in attempts to swallow only a sense of soreness or of obstruction, but in the case of inflammation and swelling there will be acute pain. The feel- ing of the presence of a foreign body and the accumulation of saliva incite the act of swallowing, which is the more painful the more fre- quently it is repeated. When there is extensive infiltration, swallow- ing may become impossible, and then the saliva is permitted to dribble from the mouth. At first the cough is dry, rather harsh, and somewhat resonant, but as the swelling proceeds it becomes stridulous and sup- pressed. The peculiar difficulty in inspiration is the most character- istic symptom. At first a slight sense of stuffing of the larynx and huskiness of the voice are experienced, but the sensation of stuffing grows tighter, and the inspiration becomes prolonged and with a very obvious effort. A hissing, stridulous, somewhat snoring noise accom- panies the inspiration, but expiration is easy and noiseless. As the inspiration increases in difficulty, all of the muscles needed to expand the chest, and the accessory muscles of inspiration also, are brought into play. The inspiration is difficult, because, in drawing in the air, the swollen mucous folds are brought together in the center, and the more strongly the effort is made the more tightly the folds are approximated— for, the cartilages of the larynx keeping the lower cavity open, where a partial vacuum is created by the expansion of the chest, the incoming air pushes the mobile folds of swollen mucous membrane before it, and hence, the more powerful the attempts at inspiration, the more tightly the folds are wedged into the narrow 428 DISEASES OF THE RESPIRATORY ORGANS. space. Exph-ation also becomes difficult when the swollen folds be- come immovably distended, and fixed in more or less close apposition. When this occurs, expiration becomes stridulous, whistling, crowing, and difficult, but not usually in the same degree as inspiration. In the more formidable cases, the obstacles to the entrance of air may become extreme in a short time, the patient dying asphyxiated. In many other cases the group of symptoms just mentioned are varied by attacks of suffocative breathing produced by spasm of the muscles of the larynx. Excited by cough, by attempts at swallowing, or the accumulation of secretion, etc., on a sudden the breathing is arrested, the face gets blue, the eyes start from the head, there are wild gasping, a terrified expression, and death seems imminent. Death may occur in such an attack. Consciousness may be lost, and then the breathing may be resumed ; again, in other cases — but usually the paroxysms do not proceed so far as unconsciousness — air enters the lungs, and the ordinary difficulty of breathing goes on as before. The existence of the obstruction can usually be made out by carefully passing the index- finger over the base of the tongue, when the swollen epiglottis and aryteno-epiglottidean folds may be felt. It is generally impracticable to use the laryngeal mirror when the case is well advanced, but, earlier, valuable information may be gained by its use. Course, Duration, and Termination. — The most acute cases are those occurring during the course of some infectious malady, as typhoid. The effusion takes place in a few hours, and the patient expires in a short time, asphyxiated. Such may be the course in cases of scarlatina also. In the more chronic kinds of laryngeal disease, if oedema occur, the progress of obstruction is slower ; there may be days passed be- tween the first attack of spasmodic dyspnoea and the fatal result from, the asphyxia of oedema. The duration of infiltration of the larynx varies from a few houi's to several days. Diagnosis. — From the difficult breathing produced by capillary bronchitis, emphysema, and asthma, that of infiltration of the larynx is distinguished by the important characteristic of difficulty in inspi- ration, whereas in the former the difficulty is iti exjyiration. The aid afforded by digital exploration and by the mirror, when practicable, will enable a diagnosis to be made at once. Passing the index-finger carefully over the base of the tongue, the swollen glosso-epiglottic folds, etc., can be felt. Croup, or laryngismus stridulus, foreign bodies, polypi of the larynx, and aneurisms of the aorta involving the recurrent laryngeal nerve, may produce symptoms similar to oedema. The attacks of pseudo-croup come on suddenly, occur at night, are quickly relieved, and between the paroxysms there is no trouble of any kind. The presence of foreign bodies and polypi is determined by the use of the laryngeal mirror, and by the difference in the rational symptoms. The history of the case, the sudden occurrence of suffo- LARYXGITIS. 429 cative attacks after the accidental inhalation of some foreign body, and the coming on or cessation of difficult breathing according to the position of the object, are characteristics differing from those due to oedema. The symptoms produced by laryngeal polypus are of slow development, but the mirror enables a view to be had of the growth, revealing a condition of the larynx very different from that of oedema. Treatment. — To open the trachea is necessary if suffocation is im- minent, but, before resorting to such a severe measure, scarification of the swollen membrane should be practiced, according to the method of Dr. Gurdon Buck, of New York. A scalpel wrapped, but leaving the point free, is passed over the tongue, guided by the finger, and when the swollen parts are reached the cutting edge is turned against them, and free scarifications are practiced. If pus is reached, a free incision is necessary to evacuate it. In the case of purulent infiltration the act of vomiting may, happily, effect a rupture of the depot. Vomit- ing, for this purpose, is best induced by the hy^^o dermatic injection of apomorphia, since swallowing becomes so difficult in these cases. When the infiltration is serous, absorption may be effected by the free salivary and cutaneoiis discharge induced by pilocarpus. The author has had no experience in this particular use of the agent, but he ven- tures to express the belief that great relief will result from it. It is probable, if nothing else be accomplished, that pilocarpus will relieve the swelling of the sublingual and cervical glands. As the effusion is forming, full doses of quinia should be given before the pilocarpus, and subsequently to support the vital powers reduced by the loss of fluid. Quinia, in full doses, is more distinctly serviceable when the infiltrat- ing material is pus. If the onset of the disease is inflammatory, and the effusion into the submucosa is the result, tincture of aconite-root should be freely administered, and quinia should also be given to pre- vent migration of the white corpuscles. As this disease very rapidly depresses the vital powers, it is important to supply the system with nutritious aliment from the beginning. The careful administration of stimulants is also necessary. If swallowing becomes very difficult and but little aliment enters the stomach, the amount taken should be sup- plemented by "rectal alimentation." Defibrinated blood should be in- jected into the rectum, and nutrient enemata should also be employed. SPASM OF THE GLOTTIS— PSEUDO-CROUP— liARYNGISMUS STRIDULUS. Definition. — Spasm of the glottis is a term applied to spasm of the muscles of the larynx, innervated by the recurrent or inferior laryngeal nerves. The mechanism consists in an irritation of the terminal fila- ments of the pneumogastric, in the mucous membrane of the larynx. 430 DISEASES OF THE RESPIRATORY ORGANS. the transmission of this irritation to the pneumogastric nucleus, and its reflection over the motor nerves supplying the laryngeal muscles. Symptoms and Pathogeny. — Spasm of the glottis is never the initial symptom. For the first day or two, the child suffers from a simple acute catarrh. There may be slight feverishness, but not high fever; there is more or less nasal catarrh ; the eyes are apt to be injected; the throat is redder than normal ; the voice is a little hoarse, and there is some cough — in fact, the symptoms are those of an acute cold. Toward evening the voice may get hoarser, and the cough assume a more ringing tone. But in the night the child awakes rather suddenly, coughing in the brassy, metallic, resonant tone which is called " croupy." Every strong inspiration is accompanied by a loud, crowing stridor, and on crying each inspiration has the same character, the expirations being wheezy and somewhat stridulous. This peculiarity of the inspi- ration is due to sudden and high tension of the vocal cords, they being approximated, and consequently narrowing the chink through which the air passes. So difficult is the entrance of air, that the accessory muscles of respiration are brought into use, the alse of the nose work convulsively, the face and lips are somewhat bluish, the countenance is anxious, and the inferior portion of the chest is drawn in instead of being expanded during inspiration. Such is an ordinary case of pseudo- croup. Undoubtedly, there are examples of the disease in which the point of irritation is the stomach. An indigestible supper, or some improper article eaten during the evening, may set up an irritation of the end-organs of the pneumogastric, which may be reflected over the laryngeal motor nerves, producing the symptoms of laryngismus strid- ulus. In which mode soever produced, spasm of the- glottis quickly subsides under appropriate treatment, and in an hour or two after be- ing awakened by the oppression the child is usually sufficiently relieved to become drowsy, barking in its sleep, occasionally, until the morning. This experience may be repeated on the following night, and indeed for several nights. When this recurrence of the paroxysms takes place, the case awakens renewed anxiety, lest an exudation may be forming in the larynx. If the paroxysms recur for two nights, there will be attacks during the day also. The author has observed a few cases in which the spasms continued for several days ; without being violent at any time, the cough had always the " croupy " character, and a strong inspiration developed stridor. Course, Duration, and Termination. — The simplest cases consist of a mild acute catarrh, inducing a nocturnal attack of spasm of the glottis, which terminates in an hour or two. The catarrh soon subsides, and there is no return of the spasm of the glottis until succeeding attacks of catarrh renew the disturbance in the nervous apparatus of the larynx. As only certain children, though by no means a small proportion, suffer, there is probably a peculiar mobility of the nervous system necessary. CROUP. 431 As the mobility of the nervous system is much more pronounced in children than in adults, we have in this an explanation of the fact that spasm of the glottis is a disease of early life, and rarely occurs after twelve. Although a malady of little importance, spasm of the glottis accompanies some of the most serious diseases. Thus it occurs during the course of true croup, diphtheria, oedema of the glottis, etc., and may be the immediate cause of death ; and in all cases adds materially to the difficulties, by the frequent spasms in the laryngeal muscles. As it usually occurs in children, arising in a reflex disturbance, having its origin in an acute catarrh, or an acute indigestion, it always ends in recovery. There are occasional (rather rare) cases in which the catarrh terminates in cedema of the glottis. Diagnosis. — The manner of its occurrence and the promptness of the cure sufficiently indicate the nature of pseudo-croup without the laryngeal mirror. Treatment. — Formerly, every case of the disease was subjected to a severe ordeal, and, when bloodletting and tartar emetic were aban- doned, emesis was still persevered in. Ko perturbating agents of this kind are really necessary. A few drops of the fluid extract of ipecac, given every twenty minutes until nausea is produced, will relieve if a cold wet pack about the neck has failed. From five to twenty grains of the bromide of potassium will usually succeed, and will be more ef- fective if some chloral is added. From ten minims to 3 j of paregoric often arrests the paroxysms. A minute dose of pilocarpine nitrate or muriate {j\ to ^ grain) will stop the spasms usually when diaphoresis begins. As it is so mild a disease, the simplest means will suffice to cure an attack. Children accustomed to the attacks should receive prophylactic treatment. A daily morning cold bath to diminish the sus- ceptibility to colds, the sirup of the iodide of iron, or the lactophos- phate of lime, to promote the body nutrition, suitable clothing, and out- door occupation, are the most approved means to prevent a recurrence of the seizures. CROUPOUS LARYNGITIS— TRUE CROUP. Definition. — The preponderance of authority is in favor of that view that the so-called membranous croup is only laryngeal diphtheria. The author is one of those who maintain that croiq)Ous laryngitis, or membranous croup, is an independent, substantive disease ; that we have a croupous laryngitis as we have a croupous bronchitis and a croupous enteritis. The author believes that this disease is distinct and separate from diphtheria, for the following reasons : it occupies the larynx exclusively, is a purely local affection, the exudation is on and not in the mucous membrane, and that systemic poisoning, or sec- ondary septicsemic and infective embolic processes never result from it. Causes. — Croup is a disease of childhood, and very rarely occurs 432 DISEASES OF THE RESPIRATORY ORGANS. later than the second dentition, and attacks male children by prefer- ence, in the proportion of three to two. It is not merely the ill-fed children of the poor, or the inheritors of scrofula and rickets, who are chiefly attacked, but the vigorous and well-nourished are more liable. It is certain that heredity has an important influence in its causation, in that certain families are especially liable to destructive visitations, and others, living under similar conditions, escape. Notwithstanding the prevalent opinion that humidity, coldness, and variability of cli- mate favor the development and spread of croup, we find that Lombard says " he has sought in vain to discover any difference in the develop- ment of this disease as regards climate, latitude, and altitude."* It seems, nevertheless, well established, that humidity favors its occur- rence, and that more cases occur in winter and spring than in summer. That true croup prevails as an epidemic is highly improbable, but, as diphtheria does, the error, if it exist, has arisen by confounding the diseases, A croupous laryngitis sometimes arises during the course of the acute infectious diseases, as measles, scarlatina, small-pox, etc., but of measles especially. This may be a diphtheritic process superadded to an existing lesion, but is more probably a mere croupous inflamma- tion. Pathological Anatomy. — The initial hypersemia is of an intense character ; the mucous membrane is swollen, has a deep-red color, is marked by an exceedingly fine but diffused arborescent injection, and here and there by minute ecchymoses, and the sub-mucous connective tissue is more or less (Edematous. In the progress of the case the red- ness subsides to a large extent, but the membrane continues somewhat thickened for some time longer. Soon after the hyperaemia attains its maximum, there appears on the surface of the inflamed mucous mem- brane a grayish, semi-transparent pellicle, which soon becomes thicker, grayish-white, yellowish, or brownish — an opaque false membrane. At various places the false membrane differs in coherence, density, and adhesiveness : here, several lines in thickness, uniform in structure, and firmly attached to the mucosa ; there, in flakes or patches, loosely at- tached to the surface beneath. The false membrame is found on the vocal cords throughout their whole extent usually, spread over the ven- ti'icles, and attached to the inner surface of the epiglottis. There may be none found i^ost mortem, it is alleged ; but probably in these ex- amples there was an error of diagnosis. Successive deposits — two or three — may occur ; the first exuded is softened by the serum which transudes, as does the albumen, and is mechanically detached in the act of coughing. As expectorated it usually appears in the form of grayish- white shreds or casts, several lines in thickness, and tolerably tough. Sometimes a cast of the trachea and tubes of considerable extent is * "Traite de Climatologie Medicale," etc., tome iv, Paris, 1880, p. 401. CROUP. 433 tlirowTi off, but this is exceptional. On microscopic examination, the false membrane is found to be composed of a fine network of fibrillae, holding in their interstices leucocytes, and chemically of an albumi- nous nature, or of fibrin. Soon after the false membrane fonns on the epithelial surface of the mucosa, a process of detachment begins, bv the accumulation of serum, having suspended in it muco-pus, cast-off epithelial cells, blood-corpuscles, etc. The mucous membrane, when the exudation is detached, is found to be unaffected, except the hypersemia, and the imbibition of fluid affecting the epithelial cells. In this ab- sence of direct implication of the epithelium lies the distinction be- tween croup and diphtheria, for in the latter the false membrane is closely united to, and is probably developed from, the cells of the epi- thelium, as E. Wagner has apparently shown. After the exfoliation of the first croupous exudation, there may be several successive crops of exudation, or, ceasing to form again, a cure is effected. The false membrane is not confined to the parts on which it first appears, but extends upward into the pharynx, but especially downward into the trachea, primary bronchi, and smaller bronchi. As the membrane ex- tends toward the finer tubes, it becomes less fibrillary and more cellular, until at length it is a mere muco-purulent fluid. The lungs are affected by emphysema, and here and there atelectasis, the result of the inspir- atory obstruction and the tenacity of the exudation blocking some of the finer tubes. Symptoms. — The attack of croup usually but not invariably begins as an acute catarrh of the larynx ; there is a feeling of heat and in-ita- tion in the organ, and the voice is a little husky ; there is cough with something of stridor about it, and fever, restlessness, thirst, anorexia, and distui'bed sleep, accompany the evidences of laryngeal mischief. When the fauces are inspected, more or less redness, sometimes duskv redness, will be observed, and also small patches of a thin, pellicular exudation of a grayish-yellow color, studded over the j)alate, tonsils, and pharynx. These patches presently coalesce and then form a denser membrane several lines in thickness, of a yellowish-gray or ash color. As huskiness of voice was one of the initial symptoms, the same patches of pellicular exudation are forming in the larynx. Al- though it is affirmed of croup that the exudation spreads sometimes over the tongue, cheeks, lips, into the nose, ears, etc., these cases so behaving are examples of diphtheria, it is most probable, for true croup does not extend beyond the pharynx and soft palate. The submaxil- lary glands become somewhat tumid and swollen, but not the chain of cervical glands extending under the stemo-cleido-mastoid muscles, which are enlarged in diphtheria. Usually from one to two days are occupied with the development of the catarrhal foi'm, but other and rare cases commence with abruptness in the night, as an ordinary spasm of the glottis. In what mode soever developed, there now 28 434 DISEASES OF THE RESPIRATORY ORGANS. appear the symptoms of laryngeal obstruction. The hoarseness has become fixed, and the cough assumes a clanging, metallic, or "croupy " character, rapidly changing to a stridulous, husky, and toneless sound. Now and then, on sudden, deep inspiration, there is still the peculiar whoop, but the voice becomes more and more husky. Dyspnoea now comes on. The respii'ations increase in fi-equency, and are seen to be so labored as to require the aid of all the muscles. The child can not lie down. If, exhausted by the efforts made, the child seeks repose, resting its head high upon a pillow, it soon starts up in a fright, breathing more heavily, and with a shrill, whistling inspira tion. Tossing from side to side, he seeks, in endless changes of po- sition, for the relief which no change brings. With open mouth, rapidly working alse of the nose, and every respiratory muscle called into play, he exerts himself to the utmost to obtain the necessary air, but ineffectually, the lower portion of the chest being drawn in deej^ly with each inspiration. The air passes with difficulty through the nar- rowed chink of the glottis, and hence the slowness, and the whistling, crowing, and stridulous inspirations, which can be heard at quite a distance from the patient. Ultimately the narrowing of the glottis is such that expiration becomes difficult and somewhat noisy. To the difficulty of breathing from the swelling of the mucosa and the pres- ence of the false membrane are now added paroxysmal attacks of spasm of the glottis. When these attacks come on, suffocation seems immi- nent. The child, who has been restless when these seizures are felt, tosses wildly about with an agonized expression, tears at his throat to remove some obstacle, the face cyanosed, the alse of the nose widely separated, the inspiratory efforts gasping, and the muscles working to their utmost, the body covered with a profuse sweat from the inten- sity of the exertions ; and at last, when death seems at hand, a little air enters the chest, the breathing becomes somewhat easier, and the child, exhausted and stupefied by the carbonic acid which is accumulating, drops into a fitful sleep of a few minutes' duration. These suffocative attacks appear at shorter intervals. By some these attacks are sup- posed to be due to a paresis of the laryngeal muscles instead of spasm, and Steiner supports the opinions of Niemeyer on this point. In some cases there occur decided remissions between the attacks of suffocative dyspnoea. Considerable portions of false membrane being expelled, air again enters the lungs ; the cyanosis disappears, the fever ceases, and some refreshing sleep is obtained. As the false membrane is renewed again, the foi-mer difficulties are resumed ; the breathing be- comes difficult, and the suffocative attacks even more violent. Some- times a mass of exudation is suddenly detached and thrown against the under surface of the vocal cords ; breathing is suspended, the child turns deeply blue in the face, and violent coughing sets in, detaching the mass, and either carrying it down by inspiration, or outward by an CROUP. 435 explosive cough. In the cases which tend to a favorable termination, the appearances of improvement, noted between the suffocative at- tacks, are maintained. The paroxysms of suffocation become less frequent, and the constant dyspnoea visibly lessens ; the cough has less and less of the barking character, and the expectoration is more abun- dant and looser ; the fever disappears ; the voice gradually passes from toneless to husky and loud ; sneezing occurs, and the nose discharges. If, instead of improvement, the case goes on as usual to a fatal ter- mination, the final stage of asphyxia, or carbonic-acid poisoning, is now entered on. The cyanosis deepens, the agonized expression of countenance is replaced by indifference, drowsiness, and stupor, the eye grows dull and is nearly closed, the difficulty of breathing con- tinues, and the respirations are frequent and shallow, but without the whistling and stridor. Now and then a paroxysm of dyspnoea comes on, in which the child is roused from its somnolent condition, gasps for breath, struggles, and then lies down, passing at once into an apathetic state. The symptoms of vital failure now come on : the pulse becomes rapid and weak ; a cold, clammy sweat covers the body ; the extremities are cold, the somnolence deepens into stupor and insensibility, carpopedal contractions occur, and sometimes gen- eral convulsions. Course, Duration, and Termination. — The first stage, characterized by the symptoms of laryngeal catarrh, runs its course in twenty -four to thirty-six hours. The fulminant cases, beginning abruptly at the second stage, with its symptoms of laryngeal stenosis, will terminate fatally within two days, and sometimes within one day. The usual duration of ordinary cases is about one week, and rarely do cases ex- tend to ten days. The second stage may continue from one to four- teen days, but the latter duration must be regarded as exceptional. The third — the stage of asphyxia — lasts from thirty-six to forty-eight hours. In most of the cases the cause of death is general paralysis, due to carbonic-acid poisoning. Very rarely is death caused by ap- noea, the access of air prevented by closure of the glottis with shreds of false membrane, or by spasm. (Edema of the glottis, croupous pneumonia, oedema of the lungs, or capillary bronchitis, may be a cause of death. Diagnosis. — Until the characteristic membranous formation appears in the throat, croupous laryngitis may be confounded with pseudo- croup or laryngismus stridulus. The latter occurs frequently in some children, comes on suddenly in the night, and after a few hours ceases to give trouble. True croup develops more slowly and does not pre- sent the apparent laryngeal obstruction of false croup until the case is well advanced. The fulminant form, it is true, begins abruptly and with violence, but there is no amelioration in the condition as in pseudo- croup. The most certain means of diagnosis consists in the discovery 436 DISEASES OF THE RESPIRATORY ORGANS. of the exudation, wliich soon appears after the initial symptoms are well declared. Treatment. — The means employed in the treatment of membran- ous laryngitis are naturally divisible into two classes — local, systemic. An almost infinite variety of remedies have been applied to the throat : we mention those that are really useful. Caustic applications, as ni- trate of silver, the mineral acids, etc., are injurious ; for, although they may remove the existing membrane, they can not prevent its reforma- tion, and the extension of the exudation is invited to the healthy tissue corroded by the caustic. Solvents that are not irritating are most use- ful. The first and most important one is lime-water, which may be applied by a large soft probang, or atomized by a spray douche. The application of the spray should be nearly continuous ; of the probang, frequent. An excellent method consists in slaking bits of freshly burned lime in water placed in a wide-mouthed bottle — the patient inhaling the vapor as it arises. Next to lime-water is lactic acid, as a solvent, and it is as safe as it is efficient. Sufficient of the acid should be added to water until a distinctly sour solution is obtained, and this may be freely applied by the spray douche or probang. Recent re- ports are very favorable to washed sulphur or sublimed sulphur freely dusted over the affected j)arts in diphtheria. Chlorate of potassa is preferred by many, either atomized or on probang or brush ; it is also used with chloride-of-iron tincture, or the latter, undiluted, is applied on a camel's-hair brush to the false membrane and fauces. The bro- mides of potassium and ammonium, in solution, are also sprayed over the throat and fauces. Good results have been claimed for a mixture of fluid extract of belladonna and the bromides in solution, used in the same way, a continuous application of the spray for hours at a time, or until the pupils are affected. It is claimed for this mixture that the belladonna allays the spasms of the glottis. A solution of chloral has been employed as a local application, both for its antiseptic effects and as a moderator of the reflex spasms of the laryngeal muscles. The inter- nal remedies are equally numerous. There are three main objects to be kept in view in the treatment of true croup : to detach, remove, and prevent the formation of the false membrane ; to prevent the attacks of laryngeal spasms ; to maintain the strength. Quinia, calomel, chlorate of potassa, tincture of iron, and the bromides, are recommended, and some of them much lauded by their respective proposers. There are two of unquestionable utility — quinia and bromide of ammonium. Quinia should be administered in full doses ; for a child (three to five grains' every three or four hours) cinchonism should be kept up as fully as possible, with the object to stop the fibrinous exudation. In alternation with quinia, or by itself, should be administered full doses of bromide of ammonium. The particular fact which gives value to this and the other bromides is its elimination by the bronchial and CORYZA. 437 faucial mucous membrane, thus acting locally. Furthermore, quinia and the bromides check the spasm of the laryngeal muscles, a most important action. The mechanical effect of an active emetic is often necessary to dislodge the obstructing membrane. Apomorphia is es- pecially effective for this purpose. Ipecac is too depressing, tartar emetic is highly objectionable, alum and subsulphate of mercury are the best. According to Barker, of New York, the subsulphate has special po"\ver as a remedy for croup, an opinion in which the author is disposed to share. It should be given early, and not wait for severe obstruction. Besides the agents above advised — quinia and the bro- mides — for the laryngeal spasms chloral is to be commended. The author has preferred to give chloral and bromide of ammonium to- gether, and the quinia separately. Besides its power to allay the spasms, chloral is one of the few remedies which possess the property to check the formation of an exudation. Many practitioners hold that chlorate of potassa has this property (Steiner), and this remedy is probably more largely prescribed than any other in croup and diph- theria. There are practitioners who still hold to the aplastic virtues of calomel, and use this remedy in large doses, with asserted success, but the most approved authorities are opposed to both opinion and practice (Oppolzer, Steiner). The measures to maintain the strength are very important. Alcoholic stimulants possess, according to the Brooklyn physicians, some peculiar, possibly specific curative power. It is alleged that the best results are obtained in diphtheria by large and sustained administration of whisky, brandy, etc. How far these facts are applicable to true croup remains to be seen. CORYZA— NASAL CATARRH. Definition. — By the term coryza is meant a catarrhal inflammation of the nasal mucous membrane. It may be either acute or chronic. Causes. — Atmospherical causes are the most frequent and influen- tial. The exposure of the neck to a current of cold air, of the feet and ankles to cold and dampness, passing from a warm to a cold at- mosphere, and from a cold to a warm atmosphere suddenly, are among the most usual causes. Irritating gases and vapors, the spores of some plants, certain powders, as ipecac, tobacco, etc., excite an irritation of the nasal mucous membrane. Heredity is an occasional factor. Epi- demic influence now and then prevails on an extensive scale. Pathological Anatomy. — An intense hyperemia is the first change, with an arrest of secretion. This is soon followed by swelling or tumefaction of the membrane ; the epithelium is detached, and a great number of new cells are produced. The mucous glands furnish an abundant secretion very rich in saline constituents. If the congestion is intense, vessels are ruptured, and more or less epistaxis results 438 DISEASES OF THE RESPIRATORY ORGANS. With the progress of the case, a change occurs in the character of the discharge ; at first watery and transparent, it becomes thicker and opaque with the increase of the pus-cells (leucocytes). When recovery takes place, the secretion diminishes, the congestion subsides, and the swelling of the membrane disappears. Such is the usual course of an acute inflammation. In the chronic form, the mucous membrane is reddish-brown, in veiy old cases grayish, the veins are dilated and varicose, often forming polypoid protrusions. There may be more or less extensive ulceration, and losses of substance, in old cases. The discharge is thick, greenish , and often offensive from decomposition. Large collections of inspissated mucus form on the turbinated bones. Symptoms. — Taking cold in the head is announced by chilliness, weariness, headache, and general muscular soreness. The nares are dry, feel stuffed and uncomfortable, and an inclination to sneeze is often felt. Presently the nose pours out an abundant watery and saline discharge, the anterior nares are red and inflamed, and sneez- ing is frequent. The discharge soon assumes a purulent character, and contains numerous micrococci. The voice has a peculiar tone, rather nasal and mufiled from the swelling of the nasal mucous mem- brane. In a few days the swelling subsides, the secretion lessens, and health is restored in about two weeks from the beginning of the attack. The chronic form may grow immediately out of the acute affection, or it may be the result of repeated acute attacks, or develop from the con- tinued operation of the causes. In the chronic form of the disease, the mucous membrane is either livid, the vessels varicose, and the connec- tive-tissue basis of the mucous membrane hypertrophied, or the mem- brane is pale, thin, bloodless, and atrophied. The discharge consists of greenish, offensive pus, or of scales taking the form of casts of the bones, which are also offensive fi'om decomposition. If the mucous membrane is destroyed by ulcerations, and caries of the bones has occurred, the case is then called ozmna. The morbid process extends through the nasal passages and into neighboring cavities. Course, Duration, and Termination. — The acute form reaches its maximum in a few days, and terminates in from fourteen to sixteen days if uninterfered with. The chronic form is excessively obstinate, and continues with varying fortunes for several years. During the summer and autumn it is milder, but in the winter and spring it is worse. Although there is no danger to life, the disease in its chronic form is difficult to cure. The popular notion that extension to the lungs takes place is entirely unfounded. In the phthisical, the coex- istence of -nasal catarrh and the pulmonary lesions, which is very com- mon, is often supposed to mean the dependence of the latter on the former. Treatment. — An existing constitutional dyscrasia, especially syphi- lis, needs attention. If the least suspicion may be entertained, an EPISTAXUS. 439 iodide-of-potassium course should be carried out. When there is a strumous diathesis, cod-liver oil, the phosphates, iodide of iron, etc., should be employed. If we have to deal with an attack of acute ca- tarrh, an attempt may be made, and will often prove successful, to abort it by the administration of a full dose of quinia and morphia (for an adult, gr. xv of quinia and gr. ss. of morphia). When established, the best remedy is Lugol's solution, one drop every hour or two. If there is fever, one drop of tincture of aconite-root every hour will prove efficient. If the secretion is watery and profuse, tincture of belladon- na may be given with the aconite, two drops every two hours. In the local treatment of chronic catarrh, the first step necessary is to clear the mucous surface of adherent discharges. The nasal douche, so much employed, has so often given rise to inflammation of the middle ear, by forcing the application into the Eustachian tube, that it must be used with caution. The post-nasal syringe and tepid water containing a little common salt are the best materials for cleansing the passage. Numerous are the kinds and forms of applications — gaseous, liquid, and solid. The volatile applications consist chiefly of iodine and car- bolic acid, separately or in combination. The tincture of iodine and carbolic acid may readily be volatilized and inhaled from a small bot- tle. The liquid applications consist of solutions of chlorate of potassa, chloride of ammonium, sulphates of zinc, cadmium, and copper, acetate of lead, etc. The solutions must be very dilute, not stronger than one grain of sulphate of zinc to four ounces of water, for example, because of the very sensitive condition of these parts. When there are great thickening and ulceration, i-equiring strong applications, they must be made with the guidance of the mirror, and be confined to the part diseased. The most effective application, according to the author's experience, is a powder composed of tannin and iodoform ( 3 j — gv. x) applied by means of an insufflator. The membrane must be first cleansed, then the powder is dusted over the diseased part, using a very small quantity. Pressure by means of a graduated series of bougies is a valuable mode of treating those cases in which the mem- brane is much thickened. EPISTAXIS— NASAL HJEMORRHAGE. Causes. — The Schneiderian mucous membrane is abundantly sup- plied with blood-vessels and bleeds easily. JEpistaxis may be caused by ulceration of the membrane, by vascular tumors, by traumatism, by a constitutional state — the hremorrhagic diathesis — by irritation of the mucous membrane, and by mechanical causes, as valvular disease of the heart, and the pressure of an intra-cranial growth, etc. Sjnnptoms. — There may be a sense of fullness of the head, head- ache, noises in the ears, vertigo, precede the epistaxis, and be relieved 44-0 DISEASES OF THE RESPIRATORY ORGANS. by it, or the bleeding may occur without any previous symptom to indicate its approach. The blood may at first be observed on the handkerchief ; a sense of moisture about the nares suggests the neces- sity of blowing the nose, and then blood is seen coming drop by drop, and from a single nostril. The blood may be discharged by the pos- terior nares and be expectorated. On inspection of the fauces, it will be seen trickling down the soft palate and uvula, which will prevent the mistake of supposing it comes from the lungs. The quantity of blood discharged varies greatly. In most cases an ounce or two is lost, when the flow spontaneously ceases ; again, many ounces — a pint, a quart even — may be lost, completely blanching the patient, and only ceasing because of the faintness. If the bleeding occur in a subject of the hsemorrhagic diathesis, it may continue to faintness and be re- sumed again as soon as the circulation regains its force. Under these circumstances epistaxis may endanger life. Again, epistaxis may occur periodically, as a manifestation of malaria, or take the place, vicariously, of the menstrual or hajmorrhoidal flux. Those cases due to the pres- sure of a tumor on the cavernous sinus, or pterygoid plexus, are ac- companied by swelling of the eyelids, injections of the eyes, retinal changes, and the symptoms proper to tumor of the brain. Diagnosis. — There can be no difiiculty, if the inspection is made when the blood is flowing, in determining the source of the haemor- rhage. When, however, the bleeding occurs in sleep, from the poste- rior nares, and is swallowed, there may be, if vomiting of the blood occurs, much difficulty in ascertaining the true source. But the absence of any evidence of stomach ulcer and the occasional occurrence of nose- bleed will suggest the means of differentiation. The same method of analysis will be equally applicable to the apparent expectoration of blood, for the absence of pulmonary disease and the occasional occur- rence of epistaxis will decide the probability in favor of bleeding at the nose. Treatment. — The application of cold, in the form of ice, small pellets of which may be introduced into the nares, while a block of ice hollowed out to fit the nose may be put on outside, will often be suf- ficient to arrest the bleeding. Pressure on the artery supplying the anterior nares may be easily effected by passing the little finger under the lip, near the middle line where the artery may be felt. Simply pressing the nares together, to enable the blood to coagulate, may often suffice. If pressure and cold fail, a solution of tannic acid, or of alum, or of acetate of lead, may be thrown into the nares, and, if these fail, a solution of Monsel's salts. The measures above advised may be sup- plemented by the hypodermatic injection of ergotin, if necessary, and by the stomachal administration of arterial sedatives, as veratruni viride and digitalis. All other expedients failing, the posterior nares must be plugged. COXGESTIOX or THE KIDNEY. 4^^^ DISEASES OF THE KIDNEY. CONGESTION OF THE KIDNEYS— ACTIVE. Definition. — Hypera8mia of the kidneys signifies an increased amount of blood in tiie organs. The hypersemia may be in the arte- rial supply — active congestion, or in the venous supply — -^:/ass^ye con- gestion. Causes. — Active congestion is usually caused by some irritating substance which is eliminated by the urine. Yarious medicinal agents, containing an essential oil, or a camphor, as copaiba, cubebs, eucalyp- tol, etc., excite ii-ritation in the kidneys, as these substances pass through in the process of elimination. Turpentine and cantharides are among the most active of these agents, and more frequently cause acute congestion than any other. A mustard-plaster may also cause the same result, due doubtless to the absorption and elimination of the oil of mustard. An extensive bum, a counter-irritant affecting a consid- erable extent of surface, and possibly other injuries or impressions on peripheral nerves, may induce a reflex paresis of the arterioles of the kidneys. Symptoms. — More or less pain, sometimes very acute pain, is felt in the region of the kidneys, and extends downward along the course of the ureters, into the hips, through the bladder, which becomes very irritable, and into the testicles and penis. There is present an inces- sant and very pressing desire to pass water, which is high-colored, and rather scanty each emission, although in the aggregate up to the nor- mal. The urine may contain blood, or but a few red globules, or simply fibrin and casts, some cells of renal epithelium and albumen. If the action of the cause continue, the state of hypersemia will pass over into some of the forms of inflammation. The author is con- vinced that the persistent use of copaiba has kept up an hypersemia, out of which has developed the chronic form of Bright's disease. If the agent producing the hypersemia is withdrawn, irritation subsides in two or three days, and health is restored. The only treatment required in the mildest cases is to withdraw the irritating agent, to dilute the urine by the free administration of lemonade, or Vichy water, or Bethesda water. If there are decided irritability of the bladder and much pain, relief is quickly afforded by the administration of two or three grains of camphor every four hours, or still more promptly and efficiently by the hypodermatic injection of one twelfth of a grain of morphia, or by the stomach administration of one sixth to one fourth of a crrain. 4,4:2 DISEASES OF THE KIDNEY. CONGESTION OF THE KIDNEYS— PASSIVE. Causes. — Passive congestion of the kidneys is caused by venous stasis. The chief lesions inducing venous stasis are obstruction and regurgitation of the mitral orifice, obstructive diseases of the lungs, obstruction and regurgitation at the tricuspid orifice, compression of the ascending vena cava above the renal veins, and thrombosis of the renal veins. Pathological Anatomy. — The vessels are abnormally full, and hence the organ is larger, and more blood flows out on section. As there is a moister state of the organ, owing to mechanical effusion from the swollen veins, the capsule is easily detached. The parenchyma of the organ is darker, having a bluish aspect ; it is moist and smooth ; the glomeruli are not swollen and congested, but the vessels of the convo- luted tubes are distended. The stellate vessels of the surface can be traced with the eye into the anastomoses of the interfascicular veins, and the vessels of the vasa recta are recognized as dark reddish stria- tions (Rindfleisch). If hyperaemia becomes chronic, the over-supply of venous blood leads to important nutritional alterations — -to hyperplasia of the connective tissue — and hence the whole organ increases in size, firmness, and weight. Symptoms. — In cases of passive congestion of the kidneys, the cen- tral disorder quite masks the changes occurring in the kidneys. When dropsy occurs, attention is directed to the state of the urinary secre- tion, but previously no symptoms had arisen indicating that the kid- ney was suffering. Besides the venous stasis and increased pressure in the venous system, the disturbance in the urinary function is in part due to the diminished pressure in the arterial system. The urine is scanty, dark in color, and acid in reaction. On standing, a very abun- dant deposit of urates takes place, and the urine becomes thick. The specific gravity is increased in the ratio of the decrease in the urinary water, and is 1025 to 1035, but it is also high because of the quantity of solids, uric acid, notably of urea, which may rise to five per cent., or higher. An important change now is apparent in the composition of the urine — it contains more or less albumen, but not often any consid- erable amount. If such urine, thick and dark, is placed in a test-tube and gently heated, it will soon clear up, except some fine particles, but gradually, the heat continued, the clear urine will become milky, from the coagulation of albumen. The urates dissolve at the temperature below the coagulating point of albumen. On microscopic examination the morphotic elements present in the urine consist of a few red-blood globules, some tubular epithelium, and a few delicate, transparent casts. The amount of albumen present in such urine does not often exceed one per cent. Course, Duration, and Termination. — The kidney complication in ACUTE PARENCHYMATOUS NEPHRITIS. 443 cardiac and pulmonary obstructive disease follows the fortunes of the central lesion. When the cardiac lesion is compensated, and the pres- sure rises in the arterial and falls in the venous system, the congestion of the veins and the ischemia of the arteries of the kidneys will cease — the urinary water will increase, and the albumen will disappear. If, however, the central lesions be permanent, the condition of the kidney will grow worse, the albumen increase, and, after a time, the specific gravity will fall. Cerebral symptoms do not arise from venous conges- tion of the kidney, because the tubular epithelium remains sound and whole, and therefore equal to its function of excreting excrementi- tious materials. Death may occur from some intercurrent malady, or the patient die exhausted from the persistent dropsical accumulation. Treatment. — The management of passive congestion of the kidneys is that of the central lesion. It includes the use of digitalis, quinia, and iron, of hydragogue cathartics, of warm baths, vapor-baths, and pilocarpus, of diuretics, etc. The condition of the kidneys is improved by those remedies which affect the heart trouble favorably. The ac- count already given of the treatment of cardiac disease with dropsy is equally applicable here. ACUTE PARENCHYMATOUS NEPHRITIS. Deflnition. — Under the head of " Bright's Disease " there are in- cluded several acute and chronic affections of the kidneys, which agree in the one important characteristic of the urine containing albumen. According to many authorities, acute parenchymatous nephritis is the first stage of Bright's disease : it is "the large, white kidney," "the large, smooth kidney " of English authors, and corresponds to John- son's " acute desquamative nephritis." Although Charcot adopts the term " parenchymatous nephritis," he holds that we are not yet pre- pared to name it accurately.* By Bartels it is designated " acute parenchymatous nephritis." f Causes. — To this form of nephritis youths are more liable than the aged. An exception to this exists in infants, and the liability con- tinues till middle life, and, indeed, though greatly diminished, does not entirely cease after this period. Heredity appears to have an in- fluence, although the facts are not numerous. Type of constitution seems very important among the causes. The pale, light-haired, full but flabby subjects of the albuminous type seem to have a special sus- ceptibility to this form of nephritis. Those substances which cause active hyperaemia of the kidneys, as cantharides, turpentine, copaiba, etc., will induce inflammation of these organs, if they continue in action for a sufficient time. Scarlatina is probably the most common * On " Bright's Disease," translated by Millard. New York : William Wood & Co. I t Ziemssen's " Cyclopsedia," vol. xv. 444 DISEASES OF THE KIDNEY. cause. It is not the character of the epidemic, nor the severity of the attack itself, which wholly determines the changes in the kidneys, for the mildest epidemics and the least pronounced cases may be remark- able for the extent of the renal complication ; yet, if the epidemic have a malignant aspect, there will be more formidable cases of nephritis. As not all cases of scarlatina are accompanied by the renal disease, there must be some inherent bodily condition, or peculiarity in the structure of the kidneys, to account for the result. The same is true of diphtheria, in which an inflammation of the kidneys occurs in a pro- portion of the cases. But in diphtheria there seems to be a relation between the severity of the systemic poisoning and the occurrence of the renal complication. Oertel maintains that the disease of the kid- neys is due to the transference to these organs of " bacterian colonies " and their subsequent multiplication. In diphtheria, more than in scar- let fever, there may be albumen in the urine, without recognizable changes in the structure of the kidneys. In analogous morbid states acute parenchymatous nephritis may be produced. These are typhoid, erysipelas, malignant pustule, etc. — diseases due to the reception and development of some specific infective material which, eliminated by the kidneys, excites inflammation in passing through these organs. The skin and kidneys stand in intimate functional relation to each other, and when one is inactive the other may act vicariously in its stead. This physiological fact has a corresponding pathological rela- tion. Acute nephritis may be excited by exposure of the body to cold when the skin is warm and perspiring. The sudden arrest of the skin affection throws a greatly increased labor on the kidneys ; their ves- sels dilate, and an acute hypersemia prepares the way for inflam- mation. Pregnancy is a cause of acute parenchymatous nephritis. Usually, but not invariably, it is the first pregnancy, and it is more common in twin pregnancies. It occurs in the thin, in the robust and plethoric, in those of low and high degree, and under the most varying conditions. Having occurred in one pregnancy it may happen again, and not unfrequently becomes a permanent malady pursuing a course independently of pregnancy. No satisfactory explanation has thus far been offered. That it occurs not more frequently than one time in one hundred and fifty pregnancies renders it probable that there must exist a renal or constitutional disposition which pregnancy excites into activity. Pathological Anatomy. — The changes in the structure of the kid- ney in acute parenchymatous nephritis are much disputed. To render clear the form of the disease under consideration, it may be repeated that it is the large, pale, and smooth kidney of the English writers. It is increased in size, so that it may reach twice its normal weight and volume ; the cortex is pale, grayish-white, or a dull white ; it is smooth, because when the capsule is stripped off there are no pits or ACUTE PARENCHYMATOUS NEPHRITIS. 445 elevations as occur in the contracted kidney, and its texture is rather soft. There is but little hypersemia of the cortex ; here and there dark-red points are seen, or punctiform extravasations ; but the pyra- mids are deeply congested, bluish red, or brighter red, and contrast strongly Avith the pale gray of the cortex. In other cases, according to Bartels, the cortex may not be so pale, may be reddish gray in con- sequence of a considerable hypersemia, and there may be between this amount of congestion and the dead-white a great deal of variation. The changes ascertained on microscopical examination are found " localized almost exclusively in the convoluted tubes " (Charcot), and consist in cloudy swelling of the epithelium, which remains in situ. The change in the apptearance of the epithelium — the cloudiness — is due to the deposit of fine granulations, and in such large numbers that the lumen of the canal is almost closed by the distention of the epithelial cells. The ends of the tubules are also sometimes blocked by the dei)osit of fibrin-plugs. The convoluted tubes also become dilated and varicose by reason of changes taking place in the proper tunics of these tubes. The appearance of the kidney thus affected may be changed by localized or extensive fatty metamorphosis — by fatty change limited to a few tubes here and there, or by a general fatty change. When thus altered the color becomes yellowish, and, if localized, gives to the organ a granular appearance, and hence the name applied to it by Johnson as the fatty granular Tcidney ; if gen- eral, it becomes the large fatty kidney. It has been much disputed whether the large, smooth kidney ever undergoes an atrophic change. It is held by Charcot that in very rare instances an atrophy may be effected by the liquefaction and disappearance of the fatty epithelium and the subsequent collapse of the tubules. Symptoms. — When parenchymatous nephritis occurs during the course of scarlet fever, diphtheria, and other febrile diseases, the symp- toms are modified in various respects. Two modes of onset are de- scribed when the disease occurs independently — one sudden, with high fever, aching pains in the lumbar region ; the other slow, obscure, and with little disturbance. The first variety usually results from taking cold ; the patient, while heated and perspiring, plunges into cold water or lies upon the damp ground, and in a short time — twelve to twenty- four hours — has some chilliness, even a rigor, followed by high fever, intense headache, pains in the lumbar region and through the limbs, nausea, vomiting, and anorexia. The symptoms which attract atten- tion to the kidneys in either mode of onset are the changes in the char- acter of the urine. In some cases the first symptom referable to the urinary organs is an extremely irritable state of the bladder, frequent desire to micturate ; a few drops only, and these it may be bloody, can be passed. This symptom does not last long, and is not common. Usually there are observed changes in the quantity of the urine, the 446 DISEASES OF THE KIDNEY. amount passed in twenty-four hours being variously reduced from forty ounces, the normal quantity for an adult, to twenty, ten, even five ounces, and at the same time important new constituents appear in the secretion. There may occm* entire suppression, when the most formi- dable symptoms will arise, and death result in a few days. The urine at the onset often contains blood, when it presents various appearances according to the quantity present : it may have a faint, smoky tinge, or -with this there may be an admixture of a reddish hue, or it may be distinctly reddish without the smoky hue, or it may be dark, reddish- brown, almost black. When permitted to stand, a quantity of urates fall, and with them various morphotic constituents, chiefly blood-cor- puscles, entire or disintegrated. The quantity of urea, as compared with the amount of urine, is much less than normal ; uric acid is not less, but the saline constituents are reduced. The gross amount of solid constituents is, therefore, below the standard of health. The reaction of the urine is acid and the specific gravity is high, often reaching 1030, but this result is due to the diminished amount of Fig. 32. — Casts of Acute Parenchymatous Nephritis. (Beale.) Fig. 3. — Epithelium from Convo- luted Tubes. (Beale.) water, since the solids in the aggregate are below normal. In the further progress of the case, as the amount of water increases, the specific gravity falls ; but there is an increase in the solids and in the urea in the aggregate, although the quantity of each is small in any single specimen of the urine. The decline in specific gravity may be from 1030 to 1005. With the diminution of specific gravity or increase of water the acid diminishes, the urine becoming very faintly acid or neutral. The most characteristic condition as regards the urine is the presence of albumen, in this affection ranging from distinct traces to three per cenx. The albumen may be absent at the initial period, but only for a brief period, the aggregate amount of the urine being very small. Besides albumen and blood-globules, perfect and disintegrated, there are present casts of the tubules, of coagulated blood, and pale, transparent, hyaline casts, with an occasional epithelial cell adherent. The pale casts are usually few in number, but in the progress of the ACUTE PARENCHYMATOUS NEPHRITIS. 447 case they are supplanted by large hyaline casts and numerous large granular casts. Usually, also, the sediment contains epithelial cells cast off from the tubes and granules in great numbers. Very often it is not until oedema of the ankles and feet appears that attention is called to the state of the urine, when it is found to be scanty. In consequence of the diminution in the amount of water separated by the kidneys, the condition of the blood and the rate of absorption, especially, the cellular tissue becomes (Edematous ; if the patient is up, the water settles in the feet and legs ; if recumbent, it accumulates in the lumbar region and hips, and may first, or coincidently with its appearance elsewhere, manifest itself in the eyelids. Puffiness of the face, with a peculiar pallor of the skin, and broadening of the bridge of the nose, while the eyelids are swollen, present a striking appearance which can hardly fail to be observed, and may be the first indication of the cedema. The effusion extends, the subcutaneous areolar tissue becomes universally filled, and the great serous cavities are ultimately distended to their utmost. The retention in the blood of the excrementitious substances in health discharged by the kidneys has a disastrous effect. The nervous system is poisoned, convulsions (eclampsia) occur and vary in severity, from twitching of the muscles of the face and of the extensors of the forearms to general convulsions involving loss of consciousness and clonic spasms of all the voluntary muscular system. The appetite is lost, and there are usually nausea and protracted vomiting, and some- times there is very troublesome diarrhoea. The loss of albumen and of blood and the poisoning of the blood by retained excrementitious mat- ters soon lower very seriously the nutrition of the body. Vision is impaired, both in consequence of simple ansemia of the retina and of the changes of albuminuric retinitis. Course, Duration, and Termination. — Those cases occurring sponta- neously are more acute in character, accompanied by fever and disor- ders of micturition, which, attract attention to the kidneys. The fever does not continue longer than a few days. If there is complete sup- pression, the case may terminate fatally within a week. If, as is usual, the development is slower and the urine is greatly diminished in quan- tity, the amount of the dropsy will depend on the reduction of urine for a lengthened period. The promptness with which oedema appears is determined by the scantiness of the urine, so that well-developed dropsy may be produced in a week. When the cellular tissue and the cavities are filled with fluid, the duration of the case depends on the degree in which the kidneys can be made to functionate, for, although temporary improvement and alleviations may result from vicarious dis- charge of the urinary functions, results obtained in this way are not permanent. This form of nephritis is not nearly so fatal as the other forms ; indeed, the percentage of recoveries is quite large. When this 448 DISEASES OF THE KIDNEY. disease occurs in scarlatina, it modifies the courae of the latter mate- rially, and prolongs its duration. Death may ensue m convulsions, or result from exhaustion in consequ.ence of the protracted ansemia, and the gastro-intestinal disturbance, which prevents the retention and assimilation of food. Recovery may ensue after several weeks of dropsy, vomiting, and diarrhoea, interspersed with eclampsia, the conva- lescence being very slow. Three months or more may be occupied in the return to health. The Acute Parenchymatous Nephritis of Pregnancy. — There are points connected with this disease requiring special consideration in respect to its course and terminations. It is usually considered due to two factors — to the relatively poor quality of blood of pregnant women, and to the pressure of the enlarging uterus on the renal veins, causing passive congestion. As Bartels shows, the renal veins occupy a position which secures them against pressure, and, as so large a pro- portion of pregnant women escape the complication of albuminuria, it can hardly be due to either or both of the factors to which it is usually ascribed. There must be some special predisposition, and as the con- dition of the kidney is precisely the same as in the acute parenchyma- tous nephritis, and as it not unfrequently assumes the chronic form, pregnancy is merely an exciting cause. The change in the kidneys may take j^lace in the early months of pregnancy, when visual disturb- ances, dropsy, and miscarriage will ensue, or later, when to the visual disturbances and dropsy must bo added eclampsia. (Edema of the face and limbs and frequent micturition are often the first symptoms, but, in the ajithor's experience, visual disorders, especially hemiopia, double vision, and amblyopia, are very frequently the fii'st departure from health.* Again, persistent huskiness of the voice may be the first indication. In other cases no symptoms are felt but disorders of digestion, and, as they are like those of the first months of pregnancy, little attention is paid to them, or there may be persistent headache with vertigo. Sometimes the first symptom to attract attention is an attack of convulsions, the health being apparently good. The urine usually contains an excessive quantity of albumen. The csdema is usually not great. The important point in these cases is the violence and acuteness of the urgemia, whether manifest in the form of convul- sions or maniacal excitement. The relative frequency of eclampsia in proportion to the whole number of cases of albuminuria is about one fourth, and of those attacked by eclampsia about one third die. The symptoms usually quickly subside on abortion or delivery, but a con- siderable proportion become chronic and prove fatal in subsequent pregnancies, f * See " Die Albuminuric in ihren ophthalmoskopischen Erscheinungen," by Dr. Hugo Magnus, in which the changes in the retina wrought by albuminuria are well depicted, f Elliot, " Obstetric Clinic," chapter iii. New York, 1868. ACUTE PARENCHYMATOUS NEPHRITIS. 449 Treatment. — As the kidneys are in an irritated state, all stimulants to them should be avoided. To give them rest, vicarious functions need to be stimulated to the highest activity — notably the skin and intestinal mucous membrane. When the symptoms are urgent, the skin may be excited by pilocarpine nitrate (^ to -^ gr. for an adult), or by the vapor-bath or wai-m pack. As Barker, of New York, has recently shown, pilocarpine must be used with caution in these cases on account of its depressing effect on the heart. Those purgatives are used that produce free watery evacuations. If the stomach is very irritable and the symptoms not urgent, small doses of calomel {^ grain), frequently repeated, act extremely well. In acute urremia, the most active cathar- tics are required — as elaterium, croton-oil, gamboge, etc. — since it is necessary to procure abundant watery evacuations. If the case does not require immediate active interference, the compound jalap powder is probably the most generally useful of the purgatives in this disease. It is best administered in the early morning, so that the disturbance produced by it may be ended before the time for the administration of the other remedies directed during the day. To relieve the kid- neys of congestion, and to remove obstructions from the tubules, diluents must be freely used. The most important diluents are milk and cream-of -tartar solution. If the stomach is irritable, milk may be given with lime-water, one fourth to one third of the latter. Infusion of digitalis may be given with cream-of -tartar solution, or alone ; but it is more effective in combination. If the stomach will not bear digitalis, it acts surprisingly well in the form of a poultice applied to the back or abdomen. If eclampsia occur, what treatment is most effective ? If the sub- ject is plethoric, the superficial veins full, the conjunctiva injected, bleeding, by venesection, may be practiced with advantage. Chloi'o- form, by inhalation, can be used to abate the violence of the symp- toms, but as soon as possible an hypodermatic injection of morphia should be given according to the method of Dr. Loomis, of New York, who has shown that large doses are remarkably effective in arresting the convulsions of uraemia. Half a grain of morphia can be given at once, and it may be repeated in two or three hours, if necessary, until two grains have been taken. He shows that, if the first large dose is without effect, other doses should be administered fearlessly until the desired effect is produced. Warm baths and active purgatives are in- dicated, and must be energetically used. Excellent results have been obtained by the use of chloral by the stomach (gr. xv to gr. xlv), or, if that organ "is rebellious, by the rectum. Bromide of potassium may be given in full doses, with or without chloral, by the stomach or rec- tum, according to the condition of affairs. The same principles hold good in the treatment of the puerperal mania arising from urgemic intoxication. 29 450 DISEASES OF THE KIDNEY. CHRONIC PARENCHYMATOUS NEPHRITIS. Causes. — It is comparatively rare for the chronic form of paren- chymatous nephritis to succeed to the acute. It is a disease of youth, and is rare after forty. It arises from those causes which depress more or less permanently the vital forces, as syphilis, chronic malarial ]3oisoning, protracted suppuration, chronic alcoholismus, chronic mer^ curialismus, and other chronic poisoning by metals, etc. Pathological Anatomy. — To this form of diseased kidney is the term large, pale, or white, smooth kidney, especially applicable. One or both may be affected. The capsule is thin because of prolonged stretching, and, when divided, flies apart and is easily detached. The cortex is a dull, rather yellowish-white color, and is anaemic, while the pyramids are full of distended vessels and are dark red. The enlargement is due chiefly to an increased thickness of the cortical part. The epithelial lining of the tubules is not simply affected with " cloudy swelling," as in the acute form, but has undergone important changes — has been either detached, or is far advanced in fatty degen- eration, the cells being filled with fat-globules. The tubules are filled with a detritus, the product of the destruction of the epithelium, and consists largely of .oil-globules, and they also are seen to be blocked in places by large casts. The intertubular matrix is also greatly thick- ened — a change due to hyperplasia of the connective-tissue elements, to the migration of the white corpuscles and their subsequent multi- plication and fatty transformation, and to a quantity of fluid exuda- tion, the product of the increased pressure in the veins. The Mal- pighian tufts and arteries are sometimes affected, according to Bartels, with the amyloid change in cases arising from chronic suppuration.* Undoubtedly, many tubules are rendered entirely and permanently useless, but restoration may take place when extensive changes have occurred in the kidneys. But, when the changes are too far advanced to permit recovery, the increase in the intertubular connective tissue and its subsequent contraction bring about an atrophic degeneration. Symptoms. — The approach of this form of kidney-disease is insid- ious. There is some decline in strength, the body is more easily fatigued, the mind is rather sluggish, and the appetite is poor. A condition of anaemia is evident, and the face has an earthy or fawn color, but it is not until oedema appears about the eyelids and ankles that advice is sought and the real nature of the case made apparent. The accumulation of fluid now proceeds rapidly, and in a short time the whole body is greatly swollen. The cellular tissue, the penis, and scrotum are immensely distended, and afterward the cavities fill up to their utmost capacity, and death may be soon caused by oedema of the * Rindfleisch, while admitting the existence of amyloid change, regards it as " infre-