iMnmtt lltbrara THE TKEORY AND PRACTICE OF MEDICINE G. L. pp A TEEATISB ON THE THEOEY AND PRACTICE OF MEDICINE BY JOHN SYEH BMSTOWE M.D.LOND., LL.D.EDIN., F.E.S. FELLOW AND FORMERLY CENSOR OF THE ROYAL COLLEGE OP PHYSICIANS; SEMOE PHYSICIAN TO AND LECTURER ON MEDICINE AT ST THOMAS'S HOSPITAL; EXAMINER IN MEDICINE TO THE ROYAL COLLEGE OP SURGEONS ; FORMERLY PHESIDKNT OP THE SOCIETY OF MEDIC-Uj OFFICERS OP HEALTH, EXAMINER IN JIEDICINE TO THE UNIVERSITY OF LONDON, AND LECTURER ON GENERAL PATHOLOGY AND ON PHYSIOLOGY AT ST THOMAS'S HOSPITAL FIFTH EDITION LONDON SMITH, ELDER, & CO., 15 WATERLOO PLACE 1884 [All rights reserved] Digitized by the Internet Archive in 2010 with funding from Open Knowledge Commons http://www.archive.org/details/treatiseontheoryOObris PEE FACE TO THE FIFTH EDITION. The present edition has been edited with some care ; but no very important changes have been made in it. Eemarks on recent views with respect to the theory of inflam- mation, to the relation between septic organisms and inflammatory processes, and to the connection of tuberculosis with a particular form of bacillus, which in the last edition were placed in an appendix, have now been incorporated in their proper places in the text. The introductory chapter to the section on Diseases of the Heart has been almost entirely rewritten; and the descriptions of two or three diseases in other sections have been shifted. Descriptions of Sarcoma and Carcinoma of the Skin, of Cuta- neous Atrophy, and of so-called ' Acute Eickets ' have been intro- duced. Lastly, three woodcuts have been added : an original one of the Tubercular Bacillus ; one illustrating Septicaemia in the Mouse, after Koch ; and an admirable cardiographic tracing specially made for me by Dr. Paul Chapman. 11 Old Burlington Street : May 1884. 1II7 jiqaojd ajjoaib :d03 J3 PREFACE TO THE FIEST EDITION. amod In placing this work before those for whom it was especially wrM49i^, namely, the junior members of the profession and students in Medicine, I may be permitted to make a few preliminary remlfim, partly by way of explanation, partly by way of acknowledgriient, partly apologetic. The first thought, as I suppose, of everyone who sits down to write a scientific book is bestowed upon the arrangement ofsirfo matter. It was my first thought. The classification of disefeffie^ moreover, is a subject to which I have devoted a good deal of attorn- tion. But I had long formed the opinion that it is impossible, kici work on Medicine, intended to be practical, to arrange diseasesr da strictly scientific principles ; and in this opinion further consideratiawa of the matter only confirmed me. Consequently the arrangemtefc which I have adopted is for the most part artificial, and to be dw- fended only on grounds of convenience. Certain affections I hge^ grouped together as ' Specific Febrile Diseases ' ; but all others, witli in many cases more or less disregard of accuracy, have been clasfei^ fied as ' Local Diseases.' I may add that, in respect of the diseasHi of individual organs, I have for the most part arranged them, though without expressly indicating the fact, in the following order, nsimelyt Inflammations, Morbid Growths (including Tubercular and Syphi? litic Formations), Parasitic Diseases, Degenerations, and Mechanical and Functional Affections. I have not hesitated, however, in many instances to depart from this arrangement. I i The selection of subjects to be discussed in a treatise intended t9 occupy a moderate compass is by no means easy. Medicine is inexr tricably interwoven with Surgery and with what it is now fashionable viii PEEFACE TO THE FIKST EDITION. to term ' gyngecological medicine.' Moreover, several other depart- ments of practice, especially perhaps insanity, are now relegated to specialists, and have attained such importance as to need special hospitals, and to have a literature of their own. And again, many diseases, and more particularly local diseases, which doubtless have a substantial existence, are either not recognisable by specific symp- toms during life, or are of very trivial importance, so that it would be a waste of time and space even to enumerate them. I trust that, under such circumstances, I shall be pardoned for having treated some important subjects superficially; for having omitted many subjects which it may seem to some persons that I should have in- cluded in my work ; and for having occasionally introduced topics which may appear to be beyond the sphere of Medicine, in the restricted sense of that term. In discussing each subject, and more especially in discussing each disease, my aim has been to give in a readable form as much mfor- mation as I could include within a limited space. With that object, my practice has been in every case to read the subject up carefully; to compare the knowledge thus acquired or renewed with the results of my own experience, in those cases in which I had any experience, and then, having taken a more or less definite view of the whole subject, and while my mmd was still full of it and of its details, to write as clear and as comprehensive an account as I was capable of. Each article may therefore be regarded as expressing in a condensed form the fulness of my knowledge of its subject at the moment at which it was written. This method of procedure will partly explain both the ex cathedrd tone in which I have, I beheve, generally expressed myself, the prevailing absence of notes, quotations, and references to authorities, and perhaps also many inaccuracies and omissions. I have throughout the work given particular prominence to the pathology and to the clinical phenomena of disease ; and in all cases in which the clinical phenomena seem to be the direct consequences of definite lesions (especially therefore in the case of local diseases) my account of the morbid anatomy has been made to precede the clinical description. It may possibly, however, seem to be an PEEFACE TO THE FIEST EDITION. ix omission that I have only occasionally devoted a special paragraph to the differential diagnosis of diseases. It is so far an omission that I have been driven to it by the exigencies of space. But on the whole I do not regret it ; for the distinguishing of one disease from another disease should depend not on the simple recognition of a few leading characters, which however carefully selected are apt not unfrequently to fail us, but on a honCificle and thorough acquaintance with the collective phenomena of diseases. The more a student is taught to rely on one or two criteria, the less likely is he to investi- gate diseases intelligently, and the more apt is he to be content with hasty and inaccurate diagnoses. In respect of the treatment of diseases, again, I may appear to have been in many cases less full and less specific than I ought to have been. The principles by which I have been guided in this matter are easy to explain. In the first place, it seemed to me that works upon the Materia Medica are the proper source from which to learn the doses in which medicines may be administered, and the best modes of combining medicines. And in the second place, in considering the details of treatment, as given in most works of medicine, it appeared to me that their authors had for the most part simply recommended those doses of drugs, those combinations of drugs, and those specific modes of administering them, to which they had accustomed themselves. I admit that the subject of my last objection will be regarded by many from quite an opposite point of view. Nevertheless, while, on the one hand, I should hesitate to force my own routine and trivialities of practice upon students, I should equally hesitate to force upon them those of other people. It seems to me best, having inculcated general principles, and pointed out the specific virtues of certain drugs, to leave the young practi- tioner generally as much unshackled as possible with regard to his choice of particular combinations and modes of administration. He is far more likely to make a thoughtful physician, and, as I think, to benefit his patient, if he adapts his drugs and his methods to the exigencies of cases as they present themselves before him, than if he follows the stereotyped procedure of some predecessor. From first to last I have carefully avoided quoting illustrative X PEEFACE TO THE FIEST EDITION. cases. This course has been forced upon me by the necessity under which I laboured of compressing my work within the narrowest possible limits of space. But it is a coiu'se which I adopted reluc- tantly, and with the full knowledge that I was thereby robbing my pages of much that might have been instructive, of much at any rate that would have rendered them pleasanter readhig. Everyone who has perused them knows how much of the charm, the freshness, the vigour-, the impressiveness, and the permanent interest, that charac- terise the classical wi'itings of Abercrombie, of Graves, of Watson, of Trousseau, and of other masters of our art, depend upon the well-told cases with which they are so richly interspersed. I have akeady referred to the omission to quote authorities of which I have been generally guilty. The excuses which I have to offer in reference to this matter are mainly the following : — I was anxious to economise space ; I felt, moreover, that my work was not an encycIopEedia, stiU less a history of medicine ; and again, many important additions which have been made to our knowledge, even •durmg the last few years, have already become classical, and form an integral part of the great body of Medical Science. My indebted- ness, however, direct or indhect, to innumerable writers and workers I must fully acknowledge ; and among these I must not fail to in- clude my senior colleagues and former teachers of St. Thomas's Hospital, the value of whose teaching to myself I cannot exaggerate. But there are certain works on which I have drawn very largely, and to the authors of which on that account I owe special gratitude : these are, in pathology and morbid anatomy, Eokitansky's ' Patho- logical Anatomy,' Cornil and Pianviers's 'Manual of Pathological Histology,' and Yh'chow's wi'itings, including above all his mar- vellous work on the ' Pathology of Tumours ; ' in general medicine, Sir T. Watson's ' Lectures on the Principles and Practice of Physic/ Eeynolds's ' System of Medicine,' Aitken's ' Science and Practice of Medicme,' Xiemeyer's 'Elements of Internal Pathology and Therapeutics,' and Trousseau's ' Clinical Medicine ' ; and m special subjects, Duchenne's admirable work on ' Localised Electrisation,' and the no less admirable Lectures by Charcot on the ' Diseases of the Nervous System.' PEEFACE TO THE FIKST EDITION. xi I must apologise for the many omissions, errors, redundancies, and other faults with which I am only too conscious that my work abounds. Fresh from its completion I feel, perhaps not unnaturally, how much better I could do it were I, from the standpoint of my present experience, now to rewrite it. But this is perhaps a delusion. At any rate I can only take credit for what I have done, and not for what I conceive myself capable of doing. The tree mu st be judged by its fruits. In conclusion, I beg leave to record my smcere thanks to my friends Drs. H. Donkin and Geeenfield for the kind and valuable assistance I have received from them in the progress of this work through the press. They have each read and criticised nearly every page ; and I owe it to them that many mistakes have been corrected, many omissions supplied, and that the reader has been spared the infliction of some grammatical inaccuracies and no little careless spellmg. II Old Buelington Street : August 1876. CONTENTS. PART I. pai:e GENEBAL PATHOLOGY. .... 1 I. The Definition of Disease 3 II. The Etiology of Disease 7 A. Predisposing Causes of Disease 8 1. Age. 2. Sex. 3. Personal peculiarities. 4. Occupation, habits, &c. 5. Previous disease. 6. Heat and cold, &e. 7. Epi- demic constitution. Change of type of disease. B. Exciting Causes of Disease 13 1. Mechanical. 2. Chemical. 3. Vital — parasites, contagia, malaria, &c. III. Physiological Processes in Health 18 A. Properties and development of protoplasm. B. Simple tissues — 1, epithelial; 2, connective; 3. tubular; 4, organs. C. Development, growth, and maintenance of the organism. Func- tions, 1, of circulatory system ; 2, of digestive system ; 3, of ex- cretory system ; 4, of nervous system. D. Decay and death essential elements in the processes of life. IV. Physiologicai. Processes in Disease 23 A. Morbid Growth 24 1. General Observations ......... 24 a. Growth and development of cells, b. Conditions associated with overgrowth, c. Migration of leucocytes, d. Tendency of morbid growth to spread locally, e. Tendency of morbid growth to become generalised. /. Tendency of certain morbid growths to limit their distribution to certain tissues or organs, g. Con- nection of dyscrasia with the origin of morbid growths, h. Second- ary dyscrasia. i. Meaning of terms malignajit and innocent, k. Eelation between infective morbid growths and specific febrile diseases. 2. Hypertro2)hy. Hyperplasia 32 xiv CONTENTS. PAGE 34 3. Inflainmation ..... .... General account, a. Extra-vascular processes — in cartilage, in mesentery, in cornea, in the vascular tissues, h. Vascular pro- cesses, c. Exudation, d. Suppuration, e. Destructive processes — gangrene, ulceration, f. Organisation, granulation, and cicatri- sation, g. Spread, h. Constitutional effects, i. Varieties, k. Eelation of inflammation to septic organisms. Note in reference to recent views as to the nature and processes of inflammation . 49 4. Tumours 51 General account. a. Connective-tissue Tumours 53 i. Fibrous tumour, or fibroma, ii. Fatty tumour, or lipoma. iii. Mucous tumour, or myxoma, iv. Glue-like tumour, or glioma. b. Cartilaginous Tumours, or Chondromata .... 55 Ecchondroses ; enchondromata. c. Osseous Tumours, or Osteomata ...... 57 Ivory ; compact ; spongy. Exostoses. Odontomata. d. Nervous Tumours, or Neuromata ... . . 57 e. Muscular Tumours, or Myomata ,58 /. Vascular Tumours, or Angiomata 59 Simple; cavernous. g. Lymphatic Tumours, or Lymphomata ..... 59 i. Lymphangioma, ii. Lymphadenoma (lymplio-sarcoma) ; a, simple inflammation ; fi, scrofulous enlargement ; y, lympha- denoma. h. Sarcomata . 65 i. Bound-cell sarcoma, ii. Spindle-cell sarcovia. iii. Large- cell sarcoma, iv. Melanoid sarcoma. Psammoma. i. Carcinomata, or Cancers . . . . . . . .68 i. Scirrhus or hard cancer, ii. Encephaloid cancer ; erectile or hcBmatoid, pultaceous, lipomatous, melanotic, iii. Colloid cancer. iv. Epithelioma or cancroid, v. Adenoid or tubular cancer. j. Granulomata, or Granulation Tumours 75 i. T ubercle : grey or miliary ; caseous or yellow. Connection between tubercle and adenoid tissue. Eelations between grey and yellow tubercle. Quasi-malignancy of tubercle. Experi- mental inoculation. Belation of bacilli to tubercle. ii. Syphilitic gummata. B. Atrophy, Degeneration, and Necrosis . . . . 84 1. Atrophy and Degeneration 84 General remarks, a. Cloudy sivelling. b. Miicous and colloid degeneration, c. Lardaceous degeyieration. d. Fatty degenera- tion, e. Pigmentary degeneration, f. Uratic degeneration, g. Calcareous degeneration. 2. Necrosis, or Gangrene 92 CONTENTS. XV PAGE C. Mechanical and Functional Derangements . . .95 1. Mechanical Derangements ........ 95 a. Displacement of parts, h. Compression, contraction, and impaction, c. Dilatation : Cysts, i. Cysts by dilatation of na- tural cavities ; ii. cysts by distension of ducts or retention ; iii. cysts by extravasation ; iv. cysts by softening of tissues, d. Eupture and extravasation. 2. Functional Derangements ........ 99 a. Congestion . . . . - 100 i. Active, ii. Passive. 6. Dropsy 101 i. General, ii. Local. c. Fever 104 i. Normal temperature. Conditions which determine and re- gulate heat of body. ii. Febrile temperature. Hyperpyrexia. Symptoms attending febrile temperature. Condition of skin ; of circulation ; of respiration ; of digestive organs ; of urine ; of nervous system. Causes of death in fever. Causes of febrile temperature, iii. Hectic fever, iv. The Thermometer. d. The Typhoid Condition 114 Symptoms. Causes. e. Collapse. Syncope ' 116 Symptoms of collapse. Symptoms of syncope. Depression of temperature. Feebleness of circulation. Condition of nervous functions. /. Death . 118 i. From failure of nutrition, ii. From failure of the circula- tion, iii. From failure of the elimination of effete and poisonous matters, iv. From failure of the nervous system to perform its proper functions. V. The Treatment of Disease . 122 A. Hygienic Treatment 123 B. Prophylactic Treatment 123 1. Prophylaxis in relation to the tendency, inherited or acquired, to disease. 2. Prophylaxis in relation to parasitic, endemic, and infectious diseases. 3. Prophylaxis in relation to the compli- cations or sequelae of disease. C. Bemedial and Therapeutical Treatment . . . . 125 1. To render the patient's condition as comfortable as circum- stances permit. 2. The maintenance of the patient's strength. 3. The maintenance or improvement of the nutritive functions. 4. The elimination of effete matters. 5. The treatment of symptoms. 6. The obviation of the tendency to death. xvi CONTENTS. PAET n. PAGB SPECIAL PATHOLOGY . . . .131 Chap. I.— SECIFIC FEBEILE DISEASES . . .133 I. Introductory Eemarks in reference mainly to the Infectious Fevers 133 A. Specific Origin and spread of Epidemic and Endemic Diseases 133 1. They originate in specific causes. 2. They prevail endemic- ally or epidemically. 3. They are in large proportion infectious or contagious. 4. Behaviour of contagia within the organism. 5. Behaviour of contagia external to the body. 6. Nature of contagia. 7. Attenuation of contagia. 8. Septicemia. B. General rules to he observed in the Managevient of Epidemic and Contagious Diseases 144 II. Influenza {Epidemic Catarrh) 147 Definition. Causation and history. Symptoms and progress. Morbid anatomy. Treatment. III. Ho OPING -Cough {Pertussis) . 150 Definition. Causation. Symptoms and progi-ess. Morbid anatomy. Treatment. IV. yLvavs {Parotitis) 1-54 Definition. Causation. Symptoms and progress. Morbid anatomy. Treatment. V. Measles {Buheola. Morhilli) 156 Definition. Causation. Symptoms and progress. Morbid anatomy. Treatment. VI. Epidemic Eoseola {Botheln. Buheola.) 160 Definition. Causation. Symptoms and progress. Treatment. VII. Scarlet Fever {Scarlatina. Febris Buhra) 162 Definition. Causation and history. Symptoms and progi-ess. Morbid anatomy. Treatment. VIII. Small-Pox {Variola) 171 Definition. Causation and history. Symptoms and progress. Varieties. Morbid anatomy. Treatment. IX. Cow-Pos {Vaccinia) Vaccination 180 Definition. Causation and relations -with small-pox. Symp- toms and progress in cattle. Symptoms and progress in man. Protective influence of vaccination against smaU-pox. Dangers of vaccination. Performance of vaccination. X. Chicken-Pox {Varicella) 185 Definition. Causation. Symptoms and progress. Treatment. CONTENTS. xvii PAGB XI. Typhus 187 Definition. Causation and history. Symptoms and progress. Morbid anatomy. Treatment. XII. Plague (Pestilentia) 194 Definition. Causation and history. Symptoms and progress. Morbid anatomy. Treatment. XIII. Eelapsing Fever {Famine Fever) 196 Definition. Causation and history. Symptoms and progress. Morbid anatomy. Treatment. XrV. Dengue {Dandy Fever) . . . . . . . . 199 Definition. Causation and history. Symptoms and progress. Treatment. XV. Yellow Fever 201 Definition. Causation and history. Symptoms and progress. Morbid anatomy. Treatment. XVI. Cerebro- Spinal Fever {Epidemic Cerehro- Spinal Meningitis) . 204 Definition. Causation and history. Symptoms and progress. Morbid anatomy. Treatment. XVII. DiPHTHERLv {Membranous Croup) 208 Definition. Causation and history. Symptoms and progress. Varieties. Paralysis. Morbid anatomy and jDathology. Treat- ment. XVIII. Enteric Fever {Typhoid Fever. Abdominal Typhus) . . 219 Definition. Causation and history. Symptoms and progress. Varieties. Complications and sequels. Diagnosis. Morbid anatomy. Treatment. XIX. Epidemic Cholera {Asiatic or Malignant Cholera) . . . 232 Definition. Causation and history. Investigations during English epidemics. Experimental production of cholera. . . Symptoms and progress. Collapse. Eeaction. Relations be- tween cholera and summer diarrhcea. Morbid anatomy and pathology. Treatment. XX. Hydrophobia {Babies) . . 245 Definition. Causation and history. Symptoms and progress. Morbid anatomy. Treatment. XXI. Glanders. Farcy {Equinia) , 249 Definition. Causation and history. Symptoms and progress. Morbid anatomy. Treatment. XXII. Syphilis 251 Definition. Causation and history. Symptoms and progress. 1. Primary syviptoms. 2. Secondary symptoms. 3. Tertiary symptoms. 4. Inherited syphilis. Morbid anatomy and patho- logy. Treatment. a xvui CONTENTS. PAGE XXni. Pyemia (Septiccemia) . . . . . . . . . 264 Definition. Causation. Morbid anatomy and pathology. Symptoms and progi'ess. Treatment. XXIV. Leprosy {Elephantiasis Gracorum) 273 Definition. Causation and iiistory. Sym]ptoms and progress. "Varieties ; tubercular and ancBstlietic. Morbid anatomy and pathology. Treatment. XXV. Ague {Intermittent and Bemittejit Fever) 279 Definition. Causation and history. Symptoms and progress. A. Intermittent Fever. Varieties. B. Remittent Fever. Other varieties. Morbid anatomy and pathology. Treatment. Chap. II.— DISEASES OF THE SKIN . .291 I. Introductory Remarks 291 A. Classification and Definition of Terms . . . ' . . 291 1. Macula. 2. Exanthema, or rash. 3. Papula, or pimple. 4. Tubercles : wheal. 5. Vesicles. 6. Bullce, or blebs. 7. Pus- tules. 8. Furfura, or scurf. 9. SgxiamcB, or scales. 10. Scab or crust. B. Tendency of Spiots and Patches of Shin-disease to assume a circular form 295 II. Erysipelas 296 Definition. Causation. Morbid anatomy. S mptoms and progress. Treatment. III. Carbuncle {Anthrax). Boil {Furujiculus) .... 301 Definition. Causation. Morbid anatomy. Symptoms. Treatment. IV. Erythema. Eoseola. Urticaria. Pityriasis .... 303 Causation and description. A. Erythema simplex; pityriasis simplex. B. Erythema multiforme ; varieties. C. Erytliema owdosum. D. Erythema fugax. E. Roseola, F. Urticaria, or Nettle-rash; varieties. Treatment. V. Psoriasis {Lepra). Pityriasis Eubra 308 Causation and description. A. Psoriasis. Varieties. B. Pityriasis Rubra. Treatment. VI. Ichthyosis 311 Description. A. Ichthyosis simplex, or Xeroderma.. B. Ichthy- osis cornea. Treatment. VII. Eczema {Lichen. Strophulus) 313 Causation and description. Varieties. Treatment. VIII. Impetigo {Ecthyma) 816 Causation and description. Varieties. Treatment. CONTENTS. xix PAGE IX. SuDAMiNA. Miliaria . . . . . . . • • 318 Description. X. Herpes. Pemphigus {Pompholyx) 318 Causation and description. A. Herpes. Varieties : 1. Zona, or Herpes zoster ; 2. H. simplex ; 3. H. iris ; 4. H. circwiatus. B. Pempliigiis. Varieties. Treatment. XI. EupiA 323 Causation and description. Varieties. Treatment. XII. Stearrhcea. Acne 324 Causation and description. A. Stearrlioea. B. Acyie. C. Acne Rosacea. Treatment. XIII. Lupus {Noli me tangere) 328 Causation and description. Varieties : A. L. erythematosus ; B. L. exedens aiid non-exedens ; C. Pzisticlar lupus. Treatment. XrV. Keloid (Kelis) .330 Causation and description. Treatment. XV. Xanthoma (Vitiligoidea. Xanthelasma) 331 Causation and description. Treatment. XVI. Lichen Euber . 332 Description. Treatment. XVII. Scleroderma {Scleriasis. Addison's Keloid. Morphcea) . 333 Causation and description. Varieties. Treatment. XVIII. Elephantiasis {ElepTias. Pachydermia. Barhadoes Leg. E. Arahum) 335 Causation and description. A. Elephantiasis. B. Elephanti- asis Lymphangiectodes. Treatment. XIX. MOLLUSCUM CONTAGIOSUM 338 Causation and description. Treatment. XX. Sarcoma and Carcinoma. A. Primary. B. By extension. C. Secondary. D. Treatment . . . . . . . 388 XXI. Phthiriasis (Lousiness) 340 Causation and description. A. Pediculus capitis ; B. P. vesti- onenti ; C. P. pubis. Treatment. XXII. Scabies [Itch) 342 Causation and description. Acarus scaiiei. Treatment. XXIII. Other Skin-Aefections caused by Animalcules . . . 345 Causation and description. Leptus auttimnalis. Pulex pene- trans. Bulama boil. Acarus follicidorwn. XXIV. Tinea Tonsurans {Porrigo scutulata. Bingworm) . . . 347 Causation and description. Trichophyton totisurans. Treat- ment. XXV. Tinea Favosa {Favus. Porrigo Favosa and Lupinosa) . . 349 Causation and description. AcJwrion Schonleinii. Treatment. a2 XX CONTENTS. PAGE XXVI. Tinea Versicolor {Pityriasis Versicolor. Chloasma) . . 351 Causation and description. Microspor on furfur. Treatment. XXVII. Alopecia Areata {A. Circumscripta. Porrigo or Tinea Decalvans) 353 Causation and description. Treatment. XXVIII. Atrophy (A. Glossy Shin. B. Linear Atrophy.) C. Treatment 355 XXIX. Prurigo .356 Description. Treatment. XXX. Concluding Eemarks 357 Chap. III.— DISEASES OF THE EESPIRATOEY OEGANS . 358 I. Introductory Eemarks . . 358 ' A. Anatomical Itelations . . . . . . . . 358 1. Organs of respiration. 2. Eegions of chest. B. Pathology of Voice, Bespiration, Cough and Expectoration . 360 1. Voice ; feebleness, absence, pitch, quality. 2. Bespiration : frequency, dyspnoea. 3. Cough: varieties. 4. Expectoration: varieties. C. Investigation by Sight and Touch .366 1. Larynx and trachea. Laryngoscope. 2. Chest : form, move- ments, fremitus. Spirometer. D. Investigation by Percussion and Auscultation .... 371 1. Percussion . . . . > 371 a. Normal percussion phenomena : i. Besoiiance ; ii. Dulness. b. Abnormal percussiofi phenomena : i. Dulness ; ii. Resonance. c. Resistance. 2. Auscultation . . 376 The stethoscope, a. Normal auscultatory phenomena : i. Aus- cultation of the breath ; ii. Auscultation of the voice, b. Abnor- ; mal auscultatory phenomena : i. Tubular or bronchial breathing ; ii. Amphoric, cavernous, ox metallic breathing; iii. Bronclwphony, pectoriloquy, and cegophony ; iv. Crepitation, rales ; v. Rhonchus ; vi. Splashing ; vii. Amphoric btibble ; viii. Friction sounds. E. Detection of Cavities, Consolidated Lung, and Pleural Effitsion 388 II. Laryngitis and Tracheitis 389 Causation. Morbid anatomy. Symptoms and progress : 1. Acute laryngitis ; 2. Chronic laryngitis ; aphonia clericorum ; tubercular and syphilitic laryngitis. 3, Tracheitis. Treatment. III. Bronchitis . . . . 395 Causation. Morbid anatomy. Symptoms and progress. 1. Acute bronchitis ; 2. Chronic bronchitis. Treatment. CONTENTS. xxi PAGE IV. Pneumonia 403 Causation. Morbid anatomy : A. lobar pnetwionia ; engorge- ment, red and grey hepatisation ; B. lobular pneumonia. Symp- toms and progress. Treatment. V. Pleueisy (Pleuritis) 413 Causation. Morbid anatomy: effusion; suppuration {em- pyema) ; consequences. Symptoms and progress. Treatment. VI. Cirrhosis {Chronic Pneumonia. Fibroid Phthisis) . . . 422 Definition. Causation. Morbid anatomy. Symptoms, Treat- ment. VII. Tubercle {Laryngeal and Pulmonary Phthisis. Tubercular Pleurisy) 427 Causation. Morbid anatomy ; 1. Laryngeal tubercle ; 2. Pul- monary tubercle ; 3. Pleural tubercle. Symptoms and progress : chronic; acute. Treatment. VIII. Syphilis .441 Morbid anatomy : 1. Larynx, trachea, and bronchial tubes ; 2, Lungs. Symptoms and progress. Treatment. IX. Tumours 443 A. Tumours of Larynx ......... 443 Morbid anatomy: 1. Non-malignant tumours; 2. Malignant tumours. Symptoms and progress. Treatment. B. Tumours of Lungs and Pleurce ...... 445 Morbid anatomy: 1. Non-malignant tumours; 2. Malignant tumours. Symptoms and progress. Treatment. X. Parasites. Hydatids 448 Morbid anatomy. Hydatids. Symptoms and progress. Treat- ment. XI. Bronchiectasis {Dilatation of Bronchial Tubes) .... 450 Causation and morbid anatomy. Varieties. Symptoms and progress. Treatment. XII. Emphysema 453 Causation and morbid anatomy. 1. Interlobular. 2. Vesicular. Varieties of vesicular. Symptoms and progress. Treatment. XIII. Congestion 458 Causation and morbid anatomy. 1. Congestion of larynx, trachea, and bronchial tubes. 2. Congestion of lungs. Symptoms. Treatment. XIV. Dropsy. Hydrothorax 459 Causation and morbid anatomy. 1. CEdema of Larynx. 2. (Edema of lungs. 3. Pleural dropsy, or Hydrothorax. Symptoms. Treatment. xxii CONTENTS. PAGE XV. Pulmonary Collapse. Atelectasis . . . . . . 461 Causation and morbid anatomy. Varieties. Symptoms and pro- gress. Treatment. XVI. Hemorrhage. Pulmonary Apoplexy. ILemoptysis . . . 463 Causation and morbid anatomy. Varieties. Symptoms and progress. Treatment. XVII. Pneumothorax 466 Causation and morbid anatomy. Symptoms and progress. Treatment. XVIII. Paralytic Affections of the Larynx 467 1. a. Bilateral paralysis of the superior laryngeals : h. Uni- lateral paralysis. 2. a. Bilateral paralysis of the recurrent laryngeals : h. Unilateral paralysis. 3. a. Bilateral paralysis of ; pneumogastric nerves : h. Unilateral paralysis. 4. a. Bilateral paralysis of posterior erico-arytenoidei : b. Unilateral paralysis. 5. Paralysis of adductors. 6. Paralysis of arytenoideus. 7. Paralysis of thyro-arytenoidei. Treatment. XIX. Spasm of the Larynx and Trachea 469 1. Larynx. 2. Trachea. Treatment. XX. Asthma [Sj^asm of the Bronchial Tubes) 470 Definition. Causation. Symptoms and progress. Pathology. Treatment. XXI. Hay-Asthma {Hay-fever) 474 Definition. Causation. Symptoms and progress. Treatment. Chap. IV.— DISEASES OF THE VASCULAE OEGANS . 476 Section I. — Diseases of the Heart . . . 476 Introductory Eemarks 476 A. Anato7ny and Anatomical Relations of the Heart . . . 476 1. Dimensions of heart. 2. Eelations of heart to pericardium. 3. Eelations of heart to chest -walls and surrounding organs. B. Physiology of the Heart 479 1. Action of heart. 2. Sounds of heart. 3. Pulse : Varieties. C. Pathology of the Heart . . . . ^ . . . . 484 1. Physical Examination 484 a. Inspection. 6. Palpation, c. Percussion, d. Auscultation. 2. Displacement of the Heart . . . . . . . 486 3. Affections of Pericardium ....... 486 a. Pericardial effusion, b. Pericardial roughness and friction, c. Pericardial adhesions and pericardial growths. CONTENTS. j^xiii PAGE ; ^ A.. Affections of the Muscular Walls and Cavities . . * . 488 a. Atrophy, h. Hypertrophy and dilatation, c. Signs and symptoms of atrophy, d. Signs and symptoms of hypertrophy and dilatation. 5. Affections of the Valves ........ 491 a. Causes of valve-disease, h. Manner of valve-disease, c. Effects of valve-disease on walls and cavities of heart, d. ■ Cardiac murmurs, e. Differential diagnosis of cardiac murmurs : i. Aortic valve disease ; ii. Ptdmonic valve disease ; iii. Mitral valve disease ; iv. Tricuspid valve disease ; v. Multiple valve . . ■ disease, f. Other physical signs, g. Effects of valve-disease on general organism : i. Venous pulsation ; ii. Hepatic pulsation ; iii. Clubbing of fingers. 6. Inorganic or Htsmic Murmurs in Heart and Murmurs in Vessels ........... 501 a. From palpitation, b. In ansmia. c. From action of heart ' • on lungs, d. Scratchy murmur over pulmonic area. e. Disap- pearance of organic murmurs. /. Arterial murmurs, g. Venous murmurs. 7. Motor and Sensory Derangements ..... 503 a. Motor derangements : asynchronism. b. Abnormal sensa- tions. ' 8.' Prognosis of Cardiac Derangements 506 9. Treatment of Cardiac Derangements . . . . . 508 II. Pericakditis, Myocarditis, and Endocarditis .... 509 A. Pericarditis .509 Causation, Morbid anatomy. Symptoms and progress. B. Myocarditis . . . . . . . . . . . 514 Causation. "Morbid anatomy. Symptoms and progress. C. Endocarditis 515 Causation. Morbid anatomy. Symptoms and progress. D,. Treatment . . . . . , . 518 III. Morbid Growths and Parasites 520 A. Fatty growth. B. Tubercle. C. Syphilis. D. Malig- nant Disease. E. Parasites. F. Treatment. IV. Degenerations . 522 A. Degenerations of the Muscular Walls 522 Causation and morbid anatomy. 1. Fatty degeneration. 2. ' ■■ „ „ Granular degeneration. 3. Fibroid degeneration. Symptoms. B. Degenerations of the Valves and Endocardium . . . , . '!524 Causation and morbid anatomy. Symptoms. C. Degenerations of the Coronary Arteries . . . . . 525 D. Treatment . . ... 526 xxiv CONTENTS. PAGE V. Aneurysm of the Heart 526 Causation. Morbid anatomy. Symptoms. VI. EuPTURE OF the Heart. Effusion of Blood into Pericardium 527 Causation. Morbid anatomy. Symptoms and progress. Other ruptures of the heart. VII. Hydro-Pericardium . 529 VIII. Syncope 529 Causation. Treatment. IX. Palpitation. Graves's Disease {ExoplitJialmic Goitre) , , 530 A. Palpitation. B. Graves^ s disease. Definition. Causation. Morbid anatomy. Symptoms and progress. Treatment. X. Cardiac Neuralgia. Angina Pectoris 534 Causation. Pathology. Symptoms and progress. Treatment. XI. Cyanosis and Malformations 536 A. Cyanosis 536 Causation. Symptoms and progress. Pathology. B. Malformations .......... 537 Causation and morbid anatomy. Symptoms and progress. C. Treatment . . . 539 Section II. — Diseases of the Arteries . . • 539 I. Arteritis 539 A. Periarteritis. Causation and morbid anatomy. Symptoms. B. Endoarteritis. Causation and morbid anatomy. Symptoms. II. Degeneration of Arteries ■ 541 Causation and morbid anatomy. Symptoms. III. Aneurysm {Dilatation of Arteries) • 543 Definition. Causation. Morbid anatomy. Effects of aneurysms on neighbouring parts ; results. Symptoms and progress. Treat* ment. A. Thoracic Aneurysms 548 Morbid anatomy and symptoms, 1. Impediment to arterial circulation. 2. Impediment to venous circulation. 3. Pressure on nerves. 4. Pressure on trachea and bronchial tubes. 5. Pres- sure on oesophagus. Treatment. B. Abdominal Aneurysms . • • 554 Morbid anatomy and symptoms. Treatment. Section III. — Diseases of the Veins. . . • 555 I. Phlebitis 555 Causation and morbid anatomy. Symptoms. II. Varix {Dilatation of the Veins) . 556 Causation. Morbid anatomy. CONTENTS. XXV FAQS Section IV. — Arterial and Venous Obstructions . 557 Thrombosis and Embolism • . . 557 Definition. A. Thromhosis . . 557 Causation. Morbid anatomy. 1. In heart. 2. In veins. 3. In arteries. B. EmhoUstn 559 Causation and morbid anatomy. C. Consequences and Symptoms of Thrombosis and Em,holism . 561 1. Phlegmasia alba dolens. Treatment. 2. Cardiac Thrombosis. 3. Embolisin and thrombosis of the imlmonary artery. 4. Embo- lism and thrombosis of the larger systemic arteries. Treatment. 5. Multijple embolism of the smaller systemic arteries — ulcerative endocarditis. Treatment. Section V. — Diseases of the Ductless Glands, Blood, &c. . 566 I. Diseases of the Thyroid Body 566 A. Goitre (Bronchocele) ......... 566 Causation. Morbid anatomy. Symptoms and progress. Treat- menti B. Cretinism 570 Treatment. II. Myxcedema 573 Definition and history. Causation. Symptoms and progress. Morbid anatomy. Treatment. III. Diseases of the Supra-Eenal Capsules 575 A. Addison's Disease {Melasma Addisonii) . * . . . 575 Definition. Causation. Morbid anatomy and pathology. Symptoms and progress. Treatment. B. Tumours of the Sujpra-renal Capsules . • . • • 578 IV. Diseases of the Spleen 579 A. Congestion 579 Causation. Morbid anatomy. Symptoms and progress. Treat- ment. B. Hypertrophy 580 Causation. Morbid anatomy. Symptoms and progress. Treat- ment. C. Inflammation , 581 Causation. Morbid anatomy. Symptoms and progress. Treat- ment. D. Tubercle . . . . " 582 E. Tumours 582 xxyi CONTENTS. PAGE F. Cysts and Hydatids . . ... . . . , 583 Gr. Atrophy 583 H. Lardaceous Degeneration . . . . , . . . 584 Morbid anatomy. Symptoms. Treatment. V. -Diseases of the Lymphatics 584 A. Inflammation ° . . . 585 Causation. Morbid anatomy. Symptoms and progress. Treat- ment. B. Tubercle. Scrofula 586 Morbid anatomy. Symptoms and progress. Treatment. C. Morbid Growths . 586 Morbid anatomy. Symptoms and progress. Treatment. D. Mediastinal Tumours . . . . . . . . 587 Morbid anatomy. Symptoms and progress. Treatment. E. Obstruction and Dilatation of Lymphatics .... 589 Morbid anatomy. Symptoms and progress. Treatment. VI. Leucocyth^mia (LeuJccsonia) 590 Definition. Causation Morbid anatomy. Symptoms and pro- gress. Treatment. , VII. Idiopathic Anemia {Chlorosis, Pernicious ancBm,ia) . . ■ . 593 Definition. Causation. Symptoms and progress. Pathology. Treatment. VIII. H^mophylia {Hemorrhagic diathesis) ...... 597 Definition. Causation. Symptoms and progress. Treatment. IX. Purpura . . . . 598 Definition. Causation. Symptoms and progress. Varieties. Morbid anatomy. Treatment. X. Scurvy {Scorbutus) . . 601 » ■ Definition. -Causation. Symptoms and progress. Morbid ana- tomy. Treatment. XL Chronic Alcoholic Poisoning {Alcoholism). Delirium Tremens 603 Nervous Disorders. Delirium Tremens . ' . . . . 604 Causation. Symptoms. Pathology and morbid anatomy. Treatment. XII. Chronic Lead-Poisoning (Plumbism). Colic. Dropped Hand . 608 Causation. Symptoms and progress.- A. Lead Colic. B. Ner- vous disorders. Dropped Hand. Pathology and morbid anatomy. Treatment. XIII. Chronic Mercurial Poisoning {Mercurialism) . ° . . . 614 Causation. Symptoms and progress. Morbid anatomy. Treat- ment. CONTENTS. xxvii PAGE Chap. V.— DISEASES OF THE DIGESTIVE OEGANS . 617 Section I. — Diseases of the Mouth, Fauces, and Adjacent Parts . 617 I. Catarrh 617 Causation. Morbid anatomy. Symptoms and progress. Treat- ment. II. Thrush {ApJdhce) . . . . ... . . . 620 Causation and morbid anatomy. Oidium albicans. Symptoms and progress. Treatment. III. "Ulcerative Stomatitis . 623 Causation and morbid anatomy. Symptoms and progress. Treatment. IV. Noma. {Gangrenous Stomatitis). Gangrene of Fauces . . 623 A. Noina. Causation. Morbid anatomy. Symptoms and progress. B. Gangrene of fauces. Causation. Symptoms and progress. C. Treatment. V. Inflammation of the Gums in Dentition . . . . . 625 VI. Glossitis 626 Causation. Symptoms and progress. Treatment. VII. Quinsy {Tonsillitis) . . ..... . ; . .627 , A. Acute Tonsillitis 627 , Causation. Morbid anatomy. Symptoms and progress. Treat- ment. B. Chronic Tonsillitis . . . . . . . . . 630 Symptoms and progress. Treatment. VIII. Eetro-Pharyngeal Abscess . •. , . ■ . . . . 630 Causation. Symptoms and progress. Treatment. IX.,Oz^NA .631 Causation. Symptoms. Treatment. X. Morbid Growths 682 • A. Tubercle. B. Syphilis. C. Malignant tumours. Treatment. Section II. — Diseases of the (Esophagus . . 633 I.'iNTKoDUCftORY Eemarks . . . " . ° . " . . . . 633 Anatomical Belations ......... 633 II. Inflammation of the (Esophagus 633 Causation and morbid anatomy, Symptoms. III. Chronic and Obstructive Diseases of the (Esophagus : . . 634 A. Ulceration . . 634 Causation and morbid anatomy. xxviii CONTENTS. FAQS B. Morbid Grotvths 634 Morbid anatomy. C. Affections implicating the CEsojphagus from without . . 635 Causation and morbid anatomy. D. Dilatation 636 Causation and morbid anatomy. E. S;pasms and Paralysis 636 F. Symptoms. Dysphagia 636 G. Treatment 639 Section III. — Diseases of Stomach, Intestines, and Peritoneum • 640 I. Introductory Eemarks . 640 A. Anatomical Belations ......», 640 Bi Examination of the Ahdomen. ...... 641 1. Inspection. 2. Palpation. 3. Percussion. 4. Auscultation. II. Gastritis 645 Causation. Morbid anatomy. Symptoms and progress. Va- rieties. Treatment. III. Enteritis 649 Causation. Morbid anatomy. Symptoms and progress. Varieties. Treatment. IV. Ulceration of the Stomach 654 Causation, Morbid anatomy. Symptoms and progress. Treat- ment. V. Ulceration of the Bowels 658 Causation and morbid anatomy. Varieties of ulcer. Symptoms and progress. Treatment, VI. Perforating Ulcers of the C^cum and Eectum . . . 663 A. Typhlitis, Perityphlitis 664 Causation and morbid anatomy. Symptoms and progress. Treatment. B. Periproctitis . • 666 Causation and morbid anatomy. Symptoms and progress. Treatment. VII. Dysentery . ■ • • 667 ■ Definition. Causation. Morbid anatomy. Symptoms and pro- gress. Treatment. VIII. Peritonitis 674 Causation. Morbid anatomy. Symptoms and progress. Treat- ment. IX. Cirrhosis of the Stomach and Bowels 681 Morbid anatomy. Symptoms. CONTENTS. xxix PAGE X. Tubercle {Ahdominal Phthisis) 682 Morbid anatomy. 1. Bowels. 2. Peritoneum and abdominal lymphatic glands. Symptoms and progress. 1. Bowels. 2. Peri- toneum. Treatment. XI. Tumours 686 A. Non-Malignant Tumours 686 Polypi, villous growths B. Malignant Tumoiirs ......... 687 Morbid anatomy. 1. Scirrlwus cancer. 2. Colloid. 3. Ence- phaloid, 4. Epithelioma. 5. Adenoid cancer. 6. Sarcoma and lympliadenonm. Symptoms and progress. 1. Stomach. 2. Bowels. 3. Peritoneum and glands. Treatment. XII. Parasitic Affections 695 A. Tape-Worms and Cyst-Worms (Cestoda or Tceniada) . . 695 1. General account 695 2. Tcenia Solium, Tcenia Mediocanellata, and Bothriocephalus Latus 696 Symptoms. Treatment. 3. Tcenia EcMnococcus. Hydatid ....... 700 B. Bound-Worms {Ntzmatoda) . ....... 702 1. General accoiint .......... 702 2. Common Bound Worm {Ascaris Lumbricoides) .... 703 Symptoms. Treatment. 3. Common Thread-Worm or Seat-Worm (Oxyuris Vermicularis) . 704 Symptoms. Treatment. 4. Whip-Worm {Trichocephalus Dispar) ...... 705 5. Dochmius Duodenalis {Sclerostoma Ditodenale) .... 705 6. Trichina Spiralis. Trichinosis 707 Symptoms and progress. Treatment. 7. Filaria Sanguinis Sominis ........ 710 XIII. DEGENERATrV'E AFFECTIONS OF THE StOMACH AND BoWELS . . 713 XIV. Obstruction of the Stomach 713 Causation and morbid anatomy. Symptoms and progress. Treatment. XV. Obstruction of the Bowels 716 A. Constipation ........... 716 Causation, morbid anatomy, and symptoms. B. Stricture . . 717 Causation and morbid anatomy. Symptoms and progress. C. Compression and Traction ........ 7ig Causation and morbid anatomy. Symptoms and progress. ;xx-x: CONTENTS. PAGE D. Torsion or Twisting 720 Causation and morbid anatomy. Symptoms and progress. E. Internal Strangulation 721 Causation and morbid anatomy. Symptoms. F. Impaction of Foreign Bodies . 722 Causation and morbid anatomy. Symptoms and progress. G. Intussusception .......... 724 Causation and morbid anatomy. Symptoms and progress. H. Concluding Bemarhs in reference to Symptoms of Obstruction . 728 1. Pain. 2. Vomiting. 3. Constipation, 4. Tumour and shape of belly. 5. Condition of urine. 6. Duration of life. 7. Statis- tics. I. Treatment . . . 730 XVI. Ascites {Abdominal Dropsy) 733 Causation and morbid anatomy. Symptoms and progress. Treatment. XVII. Hemorrhage. H^matemesis. Mel^ena 736 Definition. Causation. Symptoms and progress. Treatment. XVIII. Dyspepsia (Indigestion) 739 Definition. Causation. 1. Symptoms referrible to the stomach : appetite ; abnormal sensations ; flatulence and eructation ; nausea and sickness ; pyrosis. 2. Symptoms referrible to other organs. Treatment. XIX. DlARRH(EA . . . 747 Causation. Symptoms and progress. Treatment. Baw meat in treatment. Section IV. — Diseases of the Liver and Pancreas . . . 753 I. Introductory Remarks . 753 A. Anatomical Belations ... 753 B. Bhysiological Considerations 754 C. Pathological Considerations 756 Jaundice II. Inflammation of the Hepatic Ducts 760 Causation. Morbid anatomy. Symptoms and progress. Treat- ment. III. Acute Hepatitis. Abscess of the Liver 761 Causation. Morbid anatomy. Symptoms and progress. Treat- ment. IV. Cirrhosis of the Liver. 766 A. Atrophic Cirrhosis (Hobnailed or DrunTcard's Liver) . . . 766 Causation. Morbid anatomy. Symptoms and progress. CONTENTS. xxxi PAGE B. Hypertrophic Cirrhosis . . . . . . . • 768 Causation and morbid anatomy. Symptoms and progress. C. Other conditions allied to Cirrhosis ..... 769 Causation and morbid anatomy. 1. Syphilitic cirrliosis. 2. Srjpliilitic contraction. 3. Perihepatitis. Symptoms and pro- gress. D. Treatment of Cirrhosis . 770 v.. Congestion of the Liver {Nutmeg Liver) 771 Causation. Morbid anatomy. Symptoms and progress. Treat- ment. VI. MoEBiD Growths 772 A. Tubercle 772 B. Syphilis 773 Morbid anatomy. Symptoms. Treatment. C. Non-Malignant Growths 774 D. Malignant Growths , . 774 Morbid anatomy. Symptoms and progress. Treatment. VII. Hydatids of the Liver 778 Morbid anatomy. Symptoms and progress. Treatment. VIII. Fatty Liver 783 Causation. Morbid anatomy. Symptoms. Treatment. IX. Lardaceous Liver 784 Causation. Morbid anatomy. Symptoms. Treatment. X. Gall-stones . 785 Causation. Morbid anatomy. Symptoms and progress. Treat- ment. XI. Obstruction of the Hepatic Ducts 790 Causation. Morbid anatomy. Symptoms and progress. Treat- ment. XII. Jaundice without obvious Obstruction of Ducts . . . 794 Causation. Morbid anatomy. Symptoms. Treatment. XIII. Malignant Jaundice {Yellow Atrophy of the Liver) . . . 795 Definition. Causation. Symptoms and progress. Morbid ana- tomy. Treatment. XIV. Diseases of the Pancreas 798 A. Introductory Bemarhs 798 B. Hypercemia and Inflamm,ation ...... 799 C. Morbid G)-owths 799 D. Calculi . '. 799 E. Obstruction of the Pamcreatic Ducts 799 F. Symptonts and Treatment . . . . . . , 800 CONTENTS. PAGE Chap. VI.— DISEASES OF THE GENITO-UEINAEY OEGANS 800 Section I. — Diseases of the Kidneys . . . 800 I. Inteoductory Eemaeks 800 General Physiological and PatJwlogical Considerations . . 800 A. Characters and Composition of the TJrine .... 801 1. Physical characters of morbid urine. 2. JJrea. 3. TJric acid and urates. 4. Xanthine. 5. Cystine. 6. Leiicine, and tyrosine. 7. Colouring matters. 8. Odorous matters. 9. Grape sugar. 10. Amorplwus plwspliate of lime. 11. Crystallised' plwsphate. 12. Ammoniaco-magnesian pliospliate. 13. Oxalate of lime. 14. Carboiiate of lime. 15. Albumen. 16. Blood. 17. Bile. 18. Casts. 19. Mucus and pus. 20. Fat. 21. Morbid Growths. 22. Spermatozoa. 23. Animal and vegetable organisms. B. Concretions 819 1. Uric acid. 2. Uratic. 3. Cystine. 4. Xanthine. 5. Oxa- late of lime. 6. Amorphous plwspliate and ammoniaco-magnesian phospliate. 7. Carboimte of lime. Blood, indigo, dx. C. The specific consequences of the Retention of Urea and other matters in the blood ....... 820 1. Thickening and contraction of the smaller blood-vessels. 2. Hypertrophy of the heart. 8. Anasarca and other dropsical effusions. 4. Congestions and hemorrhages. 5. Inflammatory affections. 6. Functional consequences. D. The Non-specific Morbid Phenomena lahich attend on and characterise Lesions of the Kidneys ..... 823 II. Pyelitis 823 Causation. Morbid anatomy. Symptoms and progress. Treat- ment. III. Circumscribed and Suppurative Nephritis .... 826 Causation. Morbid anatomy. Symj)toms. Treatment. rV. Acute Bright's Disease {Acute Albuminous, Desquamative, or Tubal Nephritis) ......... 827 Causation. Morbid anatomy. Varieties. Symptoms and pro- gress. Treatment. V. Chronic Bright's Disease 832 A. Chro7iic Parenchymatous or Tubal Nephritis {Large Wliite Kidney and Fatty Kidney) 832 Causation. Morbid anatomy. Symptoms and progress. B. Chronic Literstitial Nephritis {Contracted Granular Kidney. Gouty Kidney) 834 Causation. Morbid anatomy. The cystic kidney. Symptoms and progress. C. Treatment of Chronic Bright's Disease .... 838 CONTENTS. xxxiii PAGE VI. Congestion of the Kidney 840 Causation. Morbid anatomy. Symptoms. Treatment. VII. Tubercular Disease of the Kidney 840 Morbid anatomy. Symptoms and progress. Treatment VIII. Syphilitic Disease of the Kidney 842 IX. Morbid Growths of the Kidney 842 Morbid anatomy. 1. Lympliaclowma. 2. Sarcoma. 3. Carci- nonm. Symptoms and progress. Treatment. X. Parastic Affections of the Kidney . . . . . 844 A. Hydatid cysts. Treatment. B. Bilharzia hcBinatobia. Treat- ment. XI. Lardaceous Degeneration of the Kidney .... 845 Causation. Morbid anatomy. Symptoms and progress. Treat- ment. XII. Gravel and Renal Calculi B46 Causation and morbid anatomy. Symptoms and progress. Treatment. XIII. Hydro-Nephrosis and Atrophy of the Kidney . . . 850 Causation and morbid anatomy. Symptoms and progress. Treatment. XIV. Misplaced and Movable or Floating Kidney . . , 851 Causation and morbid anatomy. Symptoms. Treatment. XV. Chyluria 852 Causation and symptoms. Pathology. Treatment. XVI. hematuria . . .854 Causation and symptoms. Treatment. XVII. Paroxysmal Hematuria {Paroxysmal Hceviatinuria) . . 855 Definition. Causation. Symptoms and progress. Pathology. Treatment. XVIII. Diabetes {Diabetes Mellitics. Glycosuria) .... 857 Definition. Causation. Symptoms and progress. Morbid anatomy and pathology. Treatment. XIX. Diabetes Insipidus {Diuresis) 863 Causation. Symptoms and progress. Morbid anatomy. Treat- ment. XX. Suppression of Urine {Ischuria Benalis) 8C4 A. Functional suppression of urine. B. Suppression of urine from obstruction. Symptoms and progress. Treatment. b XXXIV CONTENTS. Section II. — Diseases of the Pelvic Organs I. Diseases of the Urinary Bladder 1. Inflammation .... Symptoms. Treatment. 2. Tubercle ..... 3. Morbid Growths .... 4. Dilatation ..... Symptoms. Treatment. 5. Dilatation of Miillerian duct II. Diseases of the Uterus, Fallopian Tubes, and Ovaries A. Metritis and Ooijhoritis ..... Causation and morbid anatomy. Symptoms. B. Morbid GroivtJis ....... 1. Tubercle. Symptoms. 2. Myomata. Symptoms. Ma- lignant disease. Symptoms. C. Cystic Tumours ......... Causation and morbid anatomy. 1. Dilatation of the uterus. 2. Dilatation of the Fallopian tube. 3. Parovarian cysts. 4. Ovarian cysts. Symptoms and progress. Treatment. III. Diseases of the Pelvic Peritoneum and Connective Tissue . PAGE 866 866 866 867 867 867 868 868 868 869 870 874 Chap. VIL— DISEASES OF THE ORGANS OF LOCOMOTION 876 I. Rheumatism {Bheumatic Fever) . 876 Definition. Causation. Morbid anatomy. Symptoms and progress. Pathology. Treatment. II. Rheumatoid Arthritis {Chronic Bheumatic Arthritis) . . 885 Definition. Causation. Morbid anatomy. Symptoms and progress. Pathology. Treatment. III. Gout {Podagra) . . , 887 Definition. Causation. Morbid anatomy. Symptoms and progress. Pathology. Treatment. IV. Rickets {Rachitis) 897 Definition. Causation. Morbid anatomy and pathology. Symptoms and progress. Treatment. V. Acute Rickets 903 Definition. Causation. Morbid anatomy. Symptoms and progress. Treatment. VI. Mollities Ossium {Osteo-malacia) 905 Definition and causation. Morbid anatomy and pathology. Symptoms and progress. Treatment. CONTENTS. XXXV PA(iE Chap. VIII.--DISEASES OF THE NERVOUS SYSTEM . 907 I. Introductory Remarks 907 A. Anatomy and Fhysiology ....... 907 1. Membranes of brain and cord. 2. Ventricles of brain and cord. 3. Cerebral hemispheres : a. fissures ; 5. convolutions. 4. Ganglia at base of brain. 5. Cerebellum and its peduncles. 6. Spinal cord. 7. Medulla oblongata. 8. Cerebro-spinal nerves. 9. Resume. 10. Localisation of function : a. cerebral hemi- sphere ; h. corpus striatum ; c. optic thalamus : d. cerebellum ; c. corpora quadrigemina : /. medulla oblongata ; g. cord ; h. olfactory and optic nerves. 11. Sympathetic system. 12. Arteries of brain. 13. Veins of brain. B. PatJwlogy 932 1. Motor Paralysis. Paresis. ....... 932 a. Cerebral paralysis, i. General paralysis, ii. Hemiplegia. b. Bulbar paralysis, c. Spinal paralysis — paraplegia, d. Nerve paralysis, e. Disease of the cerebellum, f. Condition of muscles in motor paralysis, i. Tone. ii. Electric contractility and irri- tability, iii. Nutrition, iv. Eeflex action, v. Irritability. 2. AncestJiesia. Analgesia ........ 941 a. Cerebral ancestliesia. i. General antesthesia. ii. Hemian- festhesia. b. Bulbar ancesthesia. c. Spinal ancestliesia. d. Nerve anesthesia. 3. Convulsions. S^^asms ........ 944 4. Hyper cesthesia. Dyscesthesia ....... 947 5. Influence of Nervous Diseases over the Nutritive Processes . 948 a. Sympathetic system, b. Cerebro-spinal system, i. Muscles, ii. Joints and bones, iii. Skin; bed-sores, iv. Viscei-a. Re- capitulation. 6. Ascending, Descending, and Collateral Lesions . . . 954 7. Central and 'Reflex Consequences of Lesions of the Nerves . 955 8. Headache 955 9. Vertigo 956 10. Paralytic Affections of Speech (Aj^hasia. Aphemia. Amnesia) 957 Varieties. 11. Stammering 963 12. Mental and Emotional Disturbances 965 C. Electricity in Nervous Diseases . . . ... . 966 For diagnostic purposes. Therapeutic uses. II. Inflammation of the Cerebral and Spinal Dura Mater. Pachymeningitis . • • 973 Causation. Morbid anatomy : 1. Cerebral dura mater ; 2. Theca vertebralis ; 3. Pachymeningitis. Symptoms and pro- b2 :x%i CONTENTS, PAGE gress : 1. Acute inflammation of the cerebral dura mater ; 2. Pachymeningitis of the cerebral dura mater ; 3. Acute general inflammation of the theca vertebralis ; 4. Caries of the vertebrae; 5. Cervical pachymeningitis. Treatment. III. Cerebral and Spinal Meningitis. Tubercular Meningitis. {Acute Hydrocephalus) ........ 982 Causation. Morbid anatomy : 1. Cerebral meningitis. 2. Tubercular meningitis ; 3. Spinal meningitis. Symptoms and progress : 1. Cerebral meningitis ; 2. Spinal meningitis. Treat- ment. IV. Encephalitis and Myelitis . 992 (Inflammation and Stq^JJiiration of the Brain and Cord.) Causation. Morbid anatomy : 1. Encephalitis ; 2. Myelitis. Symptoms and progress : 1. Encephalitis; 2. Myelitis. Treat- ment. V. Sclerosis {Chronic Liflammation) 999 A. Infantile Spinal Paralysis {Infantile Pa/ralysis. Essential Paralysis. Acute Anterior Poliomyelitis) .... 1000 Definition. Causation. Morbid anatomy. Symptoms and progress. Treatment. B. Adult Sjnnal Paralysis {Acute Anterior Poliomyelitis) . 1004 C. Acute Ascending Spinal Paralysis 1005 Definition. Causation. Morbid anatomy. Symptoms and progress. Treatment. D. General Sjnnal Paralysis {Subacute Anterior Poliomyelitis) 1007 Definition. Causation. Morbid anatomy. Symptoms and • progress. Treatment. E. Progressive Muscular Atrophy {Wasting Palsy, Chronic An- terior Poliomyelitis) ........ 1009 Definition. Causation. Morbid anatomy. Symptoms and progress. Treatment. F. Lateral Sclerosis {Spasmodic Spinal Paralysis) . . . 1012 Definition. Causation. Morbid anatomy. Symptoms and progress. 1. Secondary lateral sclerosis. {Amyotrophie spiiiale dciitiropathiriuc). 2. Idiopathic lateral sclerosis, a. Spasmodic tabes dorsalis. b. Sclerose latirale amyotrophique. Treatment. G. Tabes Dorsalis {Locomotor Ataxy) ..... 1018 Definition. Causation. Morbid anatomy. Symptoms and progress. Treatment. H. Glosso -labia -laryngeal Palsy. ...... 1026 Definition. Causation. Morbid anatomy. Symptoms and progress. Treatment. CONTENTS. xxxvii PAGE I, 02-)htlialvwplegia Interna and Externa .... 1029 Definition. Causation and morbid anatomy. Symptoms and progress. Treatment. J, Disseminated Sclerosis {Multiple Sclerosis) .... 1082 Definition, Causation. Morbid anatomy. Symptoms and progress: 1. Rliythmical tremors; 2. Affections of the eyes; 3. Defect of speech : 4. Vertigo ; 5. Paresis of limbs ; 6. Contrac- tion of limbs ; 7. Expression and mental condition. Stages, Treatment. VI. Paralysis Agitans {Sliahing Palsy) 1038 Definition. Causation. Morbid anatomy. Symptoms and progress. Treatment. VII. Pseudo-Hypertrophic Paralysis ...... 1042 Definition. Causation. Morbid anatomy. Symptoms and progress. Pathology. Treatment. VIII, Morbid Growths. Aneurysms. Entozoa .... 1045 Morbid anatomy : 1. Tubercle ; 2. Syphilis ; 3. Neoplasms ; a. myxoma ; b. glioma ; c. sarcoma ; d. carcinoma ; 4. Entozoa ; a. cysticerci ; b. hydatids ; 5. Aneurysms. Symptoms and pro- gress : 1. Brain : vertigo ; headache ; vomiting ; slowness of pulse ; hemiplegia and hemianassthesia ; local paralyses ; impli- cation of sensory nerves ; convulsions and spasms ; intellectual and emotional disorders ; obstruction of venous sinuses. 2. Spinal cord : a. in substance of cord ; b. in meninges : c. in tissues external to meninges. Treatment. IX. Cerebral and Spinal Hemorrhage {Apoplexy) .... 1056 Causation. Morbid anatomy : 1. hemorrhage on surface ; 2. hemorrhage into the brain ; 3. into the cord. Symptoms and progress : 1. in cerebral hemorrhage ; 2. in spinal hemorrhage. Treatment. X. Obstruction of Cerebral Arteries {Thrombosis. Embolism. Softening) 1066 Causation and morbid anatomy. Symptoms and progress. Treatment. XI. Hydrocephalus and Hydrorrhachis {Cerebral and Spiinal Dropsy) 1071 Causation and morbid anatomy : 1. a. Hydromeningocele, hy- drencephalocele ; b. Spina bifida ; 2. a. Chronic Imjdrocephalns ; b. Internal hydrorrhachis. Symptoms and progress. Treat- ment. XII. Chorea {St. Vitris's Dmice) 1077 Definition. Causation. Symptoms and progress. Morbid anatomy and pathology. Treatment. xxxviii CONTENTS. PAGE XIII. Epilepsy. Eclampsia. Infantile Convulsions . . . 1084 A. Epilejjsj/ {Morbus comitialis vel sacer) 1084 Definition. Causation. Symptoms and progress. Description of epilepsia gravior or the haiit mal. Description of abortive fit Siiad oi the jietit mal ov epileptic vertigo. The status epilepticiis. Recurrence of fits. Causes determining the occurrence of fits in epileptics. Condition of epileptics in intervals between attacks. Epileptic mania. Diagnosis. Feigned epilepsy. Morbid anatomy and pathology. Treatment. B. Eclamj^sia 1097 Definition and causation. Symptoms and progress. Treat- ment. C. Infantile Convulsions . . 1098 Definition and causation. Symptoms and progi'ess. Treat- ment. XIV. Hysteria 1099 Definition. Causation. Symptoms and progress : 1. convul- sions and spasms ; 2. hyperffisthesia ; 3. anffisthesia ; 4. para- lytic conditions ; 5. affections of the larynx and air-passages ; 6. affections of the alimentary canal ; 7. affections of the urinary organs; 8. affections of the reproductive system ; 9. affections of the spine, joints, and mammae ; 10. spinal irritation. Diagnosis. Pathology. Treatment. XV. Catalepsy, Ecstasy, and other Conditions allied to Hysteria 1112 1. Rhythmical and other Methodical Movements . . . 1112 2. Catalepsy 1112 3. Ecstasy 1113 4. Double-consciousness ........ 1113 Treatment. XVI. Tetanus {Trismus. LocTc-jaw) 1114 Definition. Causation. Symptoms and progress. Trismus or lock-jaw. Opisthotonos. Emprosthotonos. Pleurosthotonos. Diag- nosis. Morbid anatomy. Treatment. XVII. Tetany 1118 Definition. Causation. Symptoms and progress. Morbid anatomy and pathology. Treatment. XVIII. Congestion. Anemia. Sunstroke . . . . . .1121 A. Congestion and Ancemia ....... 1121 Symptoms : 1. Delirium tremens. 2. Insanity. 3. Eclampsia. 4. Apoplexy and paralysis. Treatment. B. Sunstroke {Coup de Soleil. Calenture. Insolatio) . . 1123 Definition. Causation. Symptoms and progress. Morbid anatomy and pathology. Treatment. CONTENTS. xxxix PAGE XIX. Megrim {Migraine. Hemicrania. Sick-headache) . . . 1125 ■ Definition. Causation. Symptoms and progress. Pathology. Treatment. XX. Meniere's Disease {Aural Vertigo) 1129 Definition. Causation and pathology. Symptoms and pro- gress. Treatment. XXI. Local Paralyses 1131 A. Paralysis of the Third, Fourth, and Sixth, or Oculo-Motor Nerves . 1131 Causation. Symptoms and diagnosis. Treatment. B. Paralysis of the Fifth Nerve ...... 1134 Causation. Symptoms and diagnosis. Treatment. C. Paralysis of the Portia Dura {Bell's Paralysis) . . . 1136 Causation. Symptoms and diagnosis. Treatment. D. Paralysis of the Sjnnal Nerves 1139 Causation. Symptoms and diagnosis : 1. Deltoid rheumatism ; 2. Paralysis of musculo-spiral nerve. Treatment. XXII. Local Functional Spasm and Paralysis. Writer's Cramp, Wry-Neck, Histrionic Spasm, &c 1141 Definition. Causation. Symptoms and diagnosis : 1. Writer's cramp : 2. Spasmodic lury-neck, &g. Pathology. Treatment. XXIII. Neuralgia. Tic Douloureux. Sciatica . . . . . 1144 Definition. Causation. Symptoms and progress : 1. Tic dou- loureux ; 2. Sciatica and other forms. Treatment. XXIV. Madness {Insanity) 1149 Definition 1149 Causation 1149 1. Predisposing causes. 2. Exciting causes. Symptoms and progress 1152 A. General Description 1152 1. Disorders of sensation. 2. Intellectual disorders ; destruc- tive tendencies. 3. Disorders of movement. 4. Eesemblances between insanity and dreaming. B. Si^ecial Description ........ 1162 1. Melancholia 1162 a. Hypochondriasis ; h. melancholia with stupor ; c. melan- cholia with excitement. 2. Mania 1167 Delirium tremens. Acute delirium. Recurrent mania. Folie circulaire. Mania sine delirio 3. Monomania. ......... 1171 xl CONTENTS. PiGE 4. Dementia . . . . . . . . , . 1172 Varieties of dementia. 5. General Paralysis 1175 a. Congestive : b. paralytic ; c. expansive ; d. nielancliolic. 6. Idiocy 1180 C. Madness arising tinder special physical conditions of system .......... 1182 1. Alcoholic insanity. 2. Puerperal insanity. 3. Insanity of self-abuse. 4. Insanity of febrile disorders. D. Prognosis 1184 Pathology and morbid anatomy ....... 1185 Treatment 1188 1. Moral treatment. 2. Therajjeutical treatment. Legal Management of Lunatics ....... 1191 Addendum. The Cholera-bacillus • 1195 INDEX 1197 LIST OF WOODCUTS, PAGE Fig. 1. — Inflammation of Cartilage {Coiniil and Banvier) . . .35 2. — Inflammation of Mesentery {Cornil and Banvier) ... 36 3. — Migration of White Corpuscles (Bindjleiseh) . . .39 4. — Fibrinous Exudation from Diphtheritic Membrane and In- flamed Pleura . .40 5. — Pus-cells 41 6. — Fibroma from Surface of Spleen 53 7. — Myxoma {H. Arnott. Cornil and Banvier) . . . .54 8. — Enchondroma 56 9. — Myoma from Uterus at full term 58 10. — Angioma • . . 59 11. — Lymphadenoma. Fibrous Meshwork {Cornil and Banvier) ; Section of Growth ; Invasion of Muscle .... 62 12. — Eound-cell Sarcoma 66 13. — Spindle-cell Sarcoma .66 14. — Large-cell Sarcoma, Myeloid Tumour . . . . . 67 15. — Cancer-cells 69 16. — scirrhus . 70 17. — Encephaloid Cancer 71 18. — Encephaloid Cancer forming Villous Outgrowths . . 71 19. — Colloid Cancer 72 20. — ^Epithelioma 73 21. — Adenoid Cancer from Liver 75 22. — Tubercle (VircJwiv) 76 23. — Tubercle from Lung 77 xlii LIST OF WOODCUTS. PAGE Fig. 24.— Bacilli of Tubercle from Sputum 82 25. — Syphilitic Gumma from Heart 83 26. — Colloid Degeneration of Muscle 85 27. — Lardaceous Degeneration of Kidney 86 28. — Cholesterine 88 29. — Fatty Degeneration 89 30. — Pigmental Degeneration and H^matoid Crystals . . 90 31. — Cartilage of Joint infiltrated with Urate of Soda . . 91 32. — Calcareous Degeneration of Cerebral Vessels ... 92 33. — Spirilla of Relapsing Fever 138 34. — Bacilli Anthracis 139 35. — Vein of Diaphragm of SsPTiciEMic Mouse (Koch) . . . 143 36. — Malformation of Permanent Teeth in Inherited Syphilis {HutcJiinson) .......... 261 37. — Female Acarus Scabiei with Eggs 342 38. — CuNicuLi OR BURROWS OF Itch Insect 343 39. — Trichophyton Tonsurans . . . . . . . . 347 40. — Achorion Schonleinii . . . . . . . . 350 41. — MicRospoRON Furfur 352 42. — Diagram of Hairs in Alopecia Areata 353 43. — Diagram (front view) showing Relations of Lungs, Trachea, and Bronchi to Osseous Framework and Surface of Chest 358 44. — Diagram (back view) showing Relations of Lungs, Trachea, and Bronchi to Osseous Framework and Surface of Chest 359 45. — Casts of Air-Passages in Plastic Bronchitis . . . 365 46. — Diagram showing Relations of Heart and Large Vessels to Front of Chest 477 47. — Diagram showing Relations of Heart and Large Vessels to Back of Chest 478 „ 48. — Cardiographic tracing of Cardiac Impulse {Paul Chapman) 480 „ 49.— Pulse -Trace 482 „ 50.- -Pulse-Trace {modified from Galahin) 482 „ 51. — Graphic Representation of Cardiac Murmurs . . . 496 „ 52. — Pulse-Tracings in Disease 504 „ 53. — Pulse -Tracings in Disease - 505 54.— OiDiuM Albicans . 621 {Cohb old) LIST OF WOODCUTS Fig. 55. — T^nia Solium, Cysticercus and Egg 56. — T^NIA MEDIOCANELLATA AND EgG 57. — BOTHRIOCEPHALUS LATUS AND EgG 58. — T^NIA ECHINOCOCCUS AND EgG . 59. — Hydatid Cyst .... 60. — Group of Echinococci 61. — ascaris lumbricoides 62. — Egg of Ascaris Lumbricoides . 63. — Thre.4d-Worm and Egg 64. — Trichoceph-axus Dispar and Egg 65. — dochmius duodenalis 66. — Trichina Spiralis 67. — FiLARiA Sanguinis Hominis {Lewis 68. — Female Filaria Sanguinis Hominis and Egg 69. — Sarcina Ventriculi 70. — -Yeast Fungus 71. — Uric Acid and Urates 72. — Cystine 73. — Phosphates 74. — Oxalate of Lime 75. — Epithellil Casts 76. — Hyaline Casts 77. — Granular Casts . 78. — Fatty Casts 79. — Blood-casts 80. — BiLHARziA H^MATOBiA {Kuchenmeister) 81. — Egg and Embryo of Bilharzia . 82. — Lateral View of Brain, showing Principal Cona^ulutions AND Fissures {after Ecker). The dotted lines sliotv tlie direc- tions of the sections represented in figures 84, 85, 86, and 87 . „ 83. — Inner Surface of Cerebral Hemisphere, showing Principal CoN\'OLUTiONS AND FissuRES {after Echer) ; it likewise shows Ferrier's Centres of Touch, and of Smell and Taste . „ 84, 85, 86, AND 87. — Vertic-^l Transverse Sections of Brain, showing relations of Corpus Striatum, Optic Thalamus, Internal Capsule, etc. {Pitres) xliii PAGE 697 698 698 700 701 702 703 703 704 705 706 707 710 711 714 715 807 808 811 812 815 816 816 816 817 845 845 910 910 913 xliv LIST OF WOODCUTS. PAGE Fig. 88 — Diagrammatic Sections of Spinal Cord, showing different Strands of Fibres 915 „ 89. — Diagram to show Decussation of Motor Tract and relations OF Motor Nerves to Corpora Striata 920 „ 90. — Diagram to show Decussation of Sensory Nerves and their RELATIONS TO OpTIC ThALAMI 920 „ 91. — Lateral View of Brain, showing Fereier's Centres of Movements {after Ferrier) ....... 922 „ 92. — Upper Aspect of Brain, showing Principal Convolutions AND Fissures ; also on the left side Ferrier's centres of movements, and on the right the arterial are^ {after Echer, Ferrier, and Charcot) 923 93. — Scheme of Decussation of Optic Tracts {Charcot) . . 927 94. — Lateral View of Brain, showing arterial are^ {after Charcot) 928 95. — Inner Surface of Cerebral Hemisphere, showing arterial AREiE {after Charcot) ........ 928 96. — Under Surface of Brain, showing Principal Convolutions AND Fissures and arterial aee.e {after Charcot) . . . 929 97. — Diagrams to show Parts affected in Secondary Ascending AND Descending Degenerations ...... 954 98. — Ziemssen's Motor Points on front of Arm and Leg {after Ziemssen, and Beard and BocTcwelT) ..... 967 99. — Ziemssen's Motor Points on back of Arm and Leg {after Ziejnssen, and Beard and Bochwell) ..... 969 100. — Ziemssen's Motor Points on Head and Neck {Ziemssen) . 971 101. „ ,, „ ON Trunk {Ziemssen) . . . 972 102. — Diagram to show Seat of Lesions in Infantile Paralysis . 1001 108. — Diagram to show Seat of Lesions in Tabes Dorsalis . . 1019 104. — Portrait of Boy suffering from Pseudo-Hypertrophic Paralysis 1043 105. — Horizontal Section of Eye, showing Axes of Eotation , 1131 106. — Anterior View of Eyeball, showing the Direction of the Movements effected by its several Muscles . . . 1132 107, 108, 109, 110, 111, 112.— Diagrams showing Eelations of True TO False Image in Different Varieties of Squint . . 1133 PART I. GENEEAL PATHOLOGY. GENEBAL PATHOLOGY. I. THE DEFINITION OF DISEASE. Pathology, or the physiology of disease, is the science of life under morbid or abnormal conditions. This science, and the arts of applying it in the detection and in the alleviation or cure of disease, and in its pre- vention, form the subject-matter of works on medicine and surgery. The question, then, ' What is disease ? ' naturally arises on the very threshold of a treatise on the practice of medicine. But although, doubt- less, every physician has a notion, sufficiently clear for the practical purposes of his art, of what is implied in the word, the question is one which by no means admits of a ready and explicit answer. Disease, m some at least of its forms, has been regarded by many persons, and is probably stiU regarded by some, as a real thing or entity. This view impHes that it can be either cut out by the anatomist, or extracted by the chemist, or excreted by the patient himself, or in some other way separated from his body, so as to become capable of independent existence and re- cognition ; and might be supported by reference to the discharge of an intestinal worm or the removal of a vesical calculus, or xo a patch of psoriasis, an epitheliomatous tumour, a malformed heart, or probably any other so-called ' local ' disease. A little thought, however, will satisfy the mind that the intestinal worm, or the calculus, is of itself the mere cause of disease, and not disease ; and that the patch of psoriasis, the epithelio- matous tumour, or the malformed heart, is simply a morbid fragment of the body, and no more the disease itself than the patient who is sufferino- from scarlet fever or syphilis is the actual embodiment of either of these latter two affections. But, indeed, the opinion that disease is an entity has now been abandoned by all thoughtful physicians. Another view of disease is, that it consists ua any deviation from the healthy state, or (at greater length) in any condition of the entire system, or of any part of it, attended with impairment or derangement of structure or function, or both, and tending to render life uneasy, burdensome, or useless, or to shorten it. It would be difficult perhaps to dispute the accuracy of this definition so far as it goes ; at the same time it is obvious that we gam nothing by B 2 4 THE DEFINITION OF DISEASE. it unless we have previously agreed vipon a definition of health ; and in fact, by accepting it, we simply shirk the difficulty which we pretend to solve. If we consider attentively the various morbid processes and symptoms which separately or in combination indicate the presence of disease, and trace them in each case backwards to their origin, we cannot avoid the conclusion that that origin is some definite or peculiar cause, either innate in the system or acting on it from without, and determining according to its nature and its mode of operation the character and the grouping of the morbid phenomena which ensue : in other words, that the biography of every disease comprises some special cause, and certain resultant phenomena (vital, chemical, or mechanical), which are, or which produce, the symptoms and signs by which we recognise its presence. Let us test the accuracy of this view of disease by a few examples. A patient is suffering from scabies or tinea tonsurans. In the one case his epidermis is traversed by a lowly form of vegetable growth, and the seats of this growth are indicated by rings of superficial inflammation, by desquamation and the destruction of hair ; in the other case, his epidermis is undermined by the burrows of swarming acari, which pro- duce local irritation with intolerable itching, and involve the formation of vesicles and pustules. Now in each of these examples we have an obvious cause, and certain resultant phenomena : the former being the parasite, the latter certain localised inflammatory processes. We have the two factors : namely, the cause and its consequences. We have also the disease. But where is it, and what is it ? Is it the parasite, the presence of which is essential in order that the disease shall present its specific characters ? Is it the inflammation which the presence of the parasite evokes ? The answer to both of these questions must surely be in the negative. The parasite away from the body in which it resides, or apart from the irritation which it causes, is simply a living member of the animal or vegetable kingdom ; the local inflammation, dissociated from its specific cause, is inflammation, if you will, but neither scabies nor ringworm. Obviously then, as applied to such cases as these, the word disease (if it have any real meaning) includes both the special cause of the disease, and the pathological consequences of the operation of that cause. Again, a person who has never had scarlet fever inhales the particles, or the ' contagium,' which is the specific cause of scarlet fever, and forth- with becomes the subject of that disease. The contagium multiplies within his system, and presently a characteristic rash overspreads his surface ; his tonsils and probably his kidneys become inflamed ; and, in association with these conditions, there is profound disturbance of his nutritive processes, indicated by heightened temperature, increased forma- tion of urea, and many so-called ' functional derangements.' Now here again we have the cause of the disease, and the various morbid processes which result from its operation. But where is the disease ? what is meant by the term ' scarlet fever ' ? The specific contagious particle of THE DEFINITION OF DISEASE. 5 scarlet fever gives scarlet fever, exactly as the acarus scabiei gives itcli, or the trichophyton tonsurans gives ringworm ; a group of mutually- related phenomena spring up in obedience to their cause as invariably in the former case as in the latter cases. But the contagium of scarlet fever may, as we know, gain entrance mto the living body, and yet be inoperative there ; and, on the other hand, several of the more promment phenomena which form a part of scarlet fever, or symptoms which seem to us identical with the corresponding symptoms of scarlet fever, are occasionally combined in persons who are certainly not suffering from this exanthem. Yet, obviously, in neither of these cases is scarlet fever present. Li the former case, the host remains healthy ; in the latter case, the dis- ease, though presenting some points of superficial resemblance to scarlet fever, is potentially and essentially distinct from it. Here also, then, it is obvious that, when we speak of the disease, we include in our mean- ing, not only the symptoms by which we recognise its presence, but the cause upon which those symptoms depend. Let us take another case. A man is exposed to cold and wet, and shortly afterwards one of his joints becomes swollen and painful ; febrile symptoms, attended with abundant sour-smelling perspirations, manifest themselves ; presently inflammation attacks other joints ; perhaps too the heart becomes implicated. We have here a lot of symptoms which teaches us that the patient is suffering from the disease known as ' acute rheumatism.' But what is acute rheumatism? Mere inflamma- tion of a joint, such as that which results from a sprain, does not consti- tute it ; nor even do successive or simultaneous attacks of inflammation of several joints ; for if they did, both gout and pyaemia should be embraced within its meaning. Still less are high temperature and profuse perspira- tions rheumatism ; still less acute heart-disease, or any of its various other mflammatory comphcations. Further, the merely fortuitous concurrence of most, or even all, of the symptoms which have just been enumerated would still not render the case in which they occurred a case of rheuma- tism. Something more is required for that purpose : a something which shall link all the symptoms together in a common brotherhood, a some- thing which shall constitute their common jparentage, a cause from which all shall have directly or indirectly sprung, and which shall have impressed upon them their separate and collective peculiarities. Whether that cause consist in some chemical or other change effected directly in the blood flowing through the part exposed to cold, or in some similar change (induced through the agency of the sympathetic nerves) in connection with the joints themselves, whether the precise nature of the cause be known or unknown, is immaterial for our argument. In this case, as in the other cases which have been quoted, a cause undoubtedly is or has been in operation ; and independently of it the disease ' rheumatism ' has no existence. The relation between cause and effect in disease, and the necessity for not overlooking the cause as an essential part of the disease, are nowhere more obvious than where we have to do with affections in which the cause 6 THE DEFINITION OF DISEASE. is tangible, or admits of being weighed, measured, or otherwise tested or examined ; as, for example, where mechanical impediments occur in the course of the bowel, urethra, ducts of glands, or other tubular organs ; or where poisons received into the stomach act directly upon that viscus, or on distant organs in which they are deposited, or through which they circulate ; or where, finally, pathological results follow from excess, deficiency, or unwholesomeness of diet. Now, in every one of the above examples, it is beyond dispute, that neither the collective morbid phenomena or symptoms which indicate the presence of disease, taken by themselves, nor the morbid cause on which these phenomena depend, taken by itself, constitutes a disease ; that, alone, they are simply factors of disease ; and that in each case our con- ception of a disease is fulfilled only when the cause and its results are, so to speak, welded mentally into one common whole. And hence, if these views be generally true, disease may be defined as a complex of some deleteriotis agency acting on the body, and of the phenomena (actual or potential) due to the operation of that agency. . Eegarding it, not as a matter of idle curiosity, but as one of fmida- mental importance for a clear appreciation of the aims and limits of diagnosis and treatment, that we should have a distinct comprehension of what we mean by disease, we shall pursue the question yet further, mainly with the object of determining how far the word disease is properly applicable (as it often is applied in practice) to mere symptoms or second- ary phenomena or incidents of disease. All diseases involve, some m a greater some in a lesser degree, certain groups of pathological consequences immediately traceable to their re- spective morbid causes ; but these primary pathological consequences themselves tend to evoke others, these again a tertiary series, and so on continuously. Thus, a person with carcinoma of the bowel may, as a consequence, have stricture, perforation, involvement of the glands occupying the retro -peritoneal tissue and gastro -hepatic omentum, or that form of cachexia which cancerous disease so frequently induces ; and, as a result of these several secondary morbid conditions, various other afi:ec- tions, such as enteritis, peritonitis, jaundice, ascites, melfena, thrombosis, and anasarca. Now all these phenomena, and many others which might be enu- merated, are obviously component parts of the carcmomatous affection from which the patient is suffering, and may be regarded as symptoms or incidents of that affection ; but many of them are not mifrequently also looked upon as quasi-independent diseases, and treated as such. There is no doubt that they are not diseases. They are clearly, however, elements of disease ; and inasmuch as each one of them arises out of some immediately antecedent abnormal condition which is its direct cause, they do obviously enough, in association with their respective causes, fall severally within our definition of disease. Hence the affection which has been selected for illustration (and manifestly also all other primary diseases) may be considered to comprise or involve a number of what, THE ETIOLOGY OF DISEASE. 7 regarded from one point of view, are symptoms or phenomena which are essential parts of it, regarded from another point of view are component parts or factors of secondary or subordinate diseases, issuing in collateral lines of descent from a common ancestral cause. II. THE ETIOLOGY OF DISEASE. The causes of disease have been divided by authors into three classes, namely, the predisposing, the exciting, and the -proximate : the first class comprising those conditions which so modify the health of the patient as to render him apt, or predispose him, to contract the disease, to the specific influence of which he happens to be exposed ; the second, those causes which immediately impart or excite disease, and give it its specific character ; the third, those morbid processes which the action of the exciting cause calls into play, and to which the symptoms of disease are supposed to be directly due. The proximate cause indeed is often, though erroneously, said to be the disease itself. We will illustrate the above distinctions by an example. A woman, who has frequently been exposed to the contagion of scarlet fever without taking the disease, is again exposed at the period of childbirth, and now suffers from a virulent attack. Here, parturition, which renders women peculiarly susceptible of the contagious fevers, is the predisposing cause, the scarlatinal conta- gium is the exciting cause, and the inflammatory processes going on in the skin, tonsils, and elsewhere, are the proximate causes of most of the symptoms which the patient manifests. But the exciting cause of the scarlet fever is obviously the proximate cause of that disease, and the proximate causes of its several secondary phenomena are just as obviously their exciting causes. The distinction between the exciting cause and the proximate cause is thus purely artificial. That between the predisposing cause and the excit- ing cause, on the other hand, is in general well marked ; and doubtless if we had an accurate knowledge of the causation of disease, the universality of the truth which underlies these terms would be beyond dispute. As it is, however, doubts or difficulties as to their meaning and application are apt to present themselves. An example will explain our meaning. A man, who has been suffer- ing from privation, is exposed to malarial influence, and contracts ague. In this case, clearly enough, privation is the predisposing cause, malaria the exciting cause. But after a time the ague leaves him, and he is apparently restored to health ; and he continues well, until perchance from exposure to the weather in some non-malarious district he catches cold, and straightway experiences another attack of ague. Now which in the latter case should be regarded as the exciting cause ? The answer will probably be, ' Exposure to cold and wet,' an answer which necessarily implies that on this occasion malaria is the predisposing cause. Yet, 8 THE ETIOLOGY OF DISEASE. notwithstanding, malaria is equally in both cases the specific cause of the disease, and acts (as we have no reason to doubt) in both cases in a pre- cisely similar manner. On the whole, however, we mean by exciting cause the specific cause, or element, in disease : that cause (the contagium of an exanthem, the virus of rabies, the parasite of a tinea) which stamps its individuality on the group of morbid processes which ensue, and constitutes with them a definite or specific disease ; and by predisposing causes we mean those general, non-specific conditions which by their influence so modify the health of the system, or of parts of it, as to render them (so to speak) a specially suitable soil for the growth of certain diseases, supposing the germs of these diseases happen to become implanted in them. A. Predisposing Causes of Disease. We shall not discuss the subject of predisposing causes at any length, although it is one of surpassing interest, especially perhaps in relation to preventive medicine ; but shall content ourselves with enumerating and considering briefly some of the more important and more generally recog- nised amongst them. 1. The influence of age is very remarkable. The period of growth and development, commencing with birth and terminating with the attainment of maturity, and comprising the important physiological epochs of the first dentition, the second dentition and the unfolding of the sexual system, not only is attended with a general aptitude for diseases having a special connection with the physiological processes (general or special) which are gomg on then, but is liable for less obvious reasons to the attacks of various maladies of other kinds. In early infancy a remarkable tendency exists to disturbances of the alimentary canal ; and to these a very large proportion of infantile mortality is due. Again, at this time, and especially during the period of the first dentition, epileptiform con- vulsions are of peculiar frequency. Eickets is a disease which can manifest itself only during the period of growth of the osseous system, and does in fact occur during the first few years of childhood. It is about this time also that pseudo-hypertrophic paralysis is most commonly met with. True asthma generally comes on in childhood, and is apt to disappear before maturity is reached. Chorea affects in large proportion young persons between the ages of 8 or 9 and 15 or 16 ; and epilepsy, when not immediately traceable to infantile convulsions, commences very frequently about the same time. Acute rheumatism, again, and scrofu- lous diseases are disproportionately common in young persons. Further, some parasites, such as thread-worms and the trichophyton tonsurans, are peculiarly prone to affect children. Few special liabilities to disease mark the period of maturity, excepting such as are connected with differ- ence of sex, or arise out of habits of life and other circumstances which have only an accidental connection with age. But as the decline of life approaches, and during its continuance, many disorders, and mainly such PKEDISPOSING CAUSES OF DISEASE. 9 as are connected with the decay and degeneration of tissues and organs, manifest themselves. Thus, the central nervous system becomes affected, and feebleness of mind or fatuity and paralyses supervene ; or the heart undergoes morbid changes, and dropsies and hemorrhages result ; or the vessels get weakened, and aneurysms and ruptures with extravasations of blood occur ; or the stomach, liver, or kidneys suffer, and cease to act efficiently. Gout, too, should probably be included among the proclivities of advancing years. 2. The differences in the organisation of the sexes necessitate of course differences as regards some of the diseases to which they are respectively liable. In one sex we meet with disorders connected with the uterus and ovaries, disorders of menstruation, pregnancy, and lactation ; in the other sex affections which are peculiar to the male organs of generation. But besides these necessary differences, there are others which are much more difficult to explain, and yet are nearly as constant. Thus, chlorosis and hysteria, and nervous disorders related to hysteria, are the almost exclusive heritage of females. And certain other affections which occur ill both sexes are yet, for no sufficient reason (so far as we can see), far more prone to attack the one than the other. For example, erythema nodosum, and exophthalmic goitre, and goitre itself, are all more common in females than in males. It is possible of course that some of these latter differences may not be due to the influence of sex alone. 3. Personal ^peculiarities, born with the individual, and often heredi- tary, have an important influence over the relative liability of persons to disease. Children notoriously resemble their parents, not only in the general configuration of the body, but in features, expression, complexion, and mental attributes. Trivial peculiarities in the form of some feature, in the quality of the laugh, small oddities of manner or of gesture, are perpetuated in famihes. It is not surprising therefore that malformations and other morbid conditions and tendencies to disease should be trans- mitted also. It is important, however, to note : first, that such inherited peculiarities and tendencies not unfrequently skip a generation, or appear as it were sporadically in families, so that, while out of a family of brothers and sisters some are affected and others escape, the affected and unaffected procreate indifferently healthy and unhealthy offspring ; second, that the inherited tendency to disease does not in all cases manifest itself in an exact reproduction of the morbid peculiarity of the parent ; and third, that undoubtedly in many cases peculiarities of constitution and special proclivities to disease appear altogether de novo. In some instances the morbid condition is developed, or appears, in foetal life ; in others the child is born healthy, but with a tendency to disease, which becomes realised at some later period. As examples of* the former case maybe enumerated congenital malformations, idiocy, and nsevi. Examples of the latter case are more common and far more important for the physician, and therefore need more detailed considera- tion. Certain functional nervous disorders, such as insanity, epilepsy, hysteria, asthma, neuralgia, undoubtedly run in families, and are apt in 10 THE ETIOLOGY OF DISEASE. some degree to alternate, so that a parent suffering from one of them may beget children in whom one or other of the remaining members of the group replaces as it were the particular parental malady. Again, gout, tuberculosis, carcinoma and other forms of growths, all manifest a ten- dency to hereditariness. So do many varieties of skin-disease, such as ichthyosis, psoriasis, and acne. Degenerative affections, especially those characterised by fatty or calcareous changes, also have a tendency to repeat themselves ; and hence, in some families the members are apt to be cut off prematurely by extravasations of blood into the brain, due to such degeneration of the cerebral arteries, in others the heart appears to be the selective seat of such changes. Lastly, among inherited or per- sonal peculiarities, we must not forget certain idiosyncrasies characterised by special liability to suffer from agencies which are to most persons innocuous, or to remain unaffected by conditions Avhich are generally inimical. The influence of the emanations from fresh hay in producing hay-asthma and of the smell of many flowers in creating nausea, the specially poisonous effects which even the smallest doses of mercury, opium, or other drugs, and which also certain forms of food (even such wholesome meat as mutton) have upon certain individuals, the unhappy tendency which some persons seem to have to contract all the catchmg diseases to which they are exposed, and may be to take the same one over and over again, and the remarkable way in which other persons seem always to escape, are common examples of the peculiarities re- ferred to. 4. Occupation, habits of life, quality of food or drink, over-indulgence, jprivation, and even abstinence, are all of them potent agents in modifying the constitution and rendering the frame susceptible of disease. We may quote in exemplification of this statement, the acquired proclivity of com- positors to tubercular phthisis ; that of persons who lead sedentary lives to suffer from indigestion and constipation, and the effects of accumulated fat ; and that of habitual eaters or drinkers to excess to become gouty, and to suffer from renal and hepatic disorders. It would be easy to multiply examples of these and like causes in the production of disease, and especially to adduce illustrations which might appear far more striking than any of the few given above — such, for example, as the occurrence in miners and others of special forms of lung-disease, in painters of dropped hand, in drinkers of cirrhosis of the liver, delirium tremens, and so on. But it is obvious that we have here examples, not of any mere predisposition which has been gradually acquired, but of the direct and specific influence of certain exciting causes to which the sufferers have been exposed. 5. The effects of 'previous disease in modifying the tendency to sub- sequent attacks of disease are in many cases very remarkable. In the exanthemata and allied afiections an attack of any one is in a very high degree protective against subsequent attacks of the same malady. On the other hand, many inflammations tend to repeat themselves. Thus, persons who have once had erysipelas of the face generally manifest a PREDISPOSING CAUSES OF DISEASE. 11 liability to recurrences of the same malady througliout the remainder of their lives. So it is Avitli rheumatism, pneumonia, bronchitis, tonsillitis, catarrh, renal inflammation, and intermittent hematuria. And, indeed, one of the most difficult practical problems with which physicians have to deal is that of the counteraction of such acquired tendencies. But there are many disorders which engender a liability, not to their own recurrence, but to the attacks of other diseases. Thus, scarlet fever and gonorrhoea are both curiously apt to be succeeded by attacks of acute rheumatism ; tuberculosis is generally believed to follow frequently on enteric fever and small-pox, and scrofulous enlargement of the cervical glands on mumps ; and chorea may certainly be regarded as a sequela both of acute rheumatism and of scarlet fever. To these latter examples may be added the fact, which seems beyond dispute, that organs and parts which have been the seats of repeated or continuous attacks of inflamma- tion, and have in consequence undergone structural changes, and so also pigmentary nfe^-i, often prove the selective sites for the primary develop- ment of sarcomatous and other kinds of malignant growths. It may be convenient to refer here to the special morbid predispositions of different organs and tissues. A very little acquaintance Tsdth pathology is sufficient to prove that the different parts of the system are not all equally liable, or liable in proportion to their respective bulks, vascular supply, or importance, to the same forms of disease. Thus, each one of the specific mfectious fevers mvolves in its jDrogress certain organs, alto- gether disproportionately to other organs, if not to the entire exclusion of some ; parasites, whether vegetable or animal, limit their attacks more or less exclusively to certain parts, such as the skin, muscular system, liver, or mtestinal canal ; the inflammations of rheumatism and of gout are specially wont to seize on the ligaments and other soft parts about joints ; and tumours, according to their characters, are prone to origmate in different tissues — tubercle, which is so wide in its distribution, rarely, if ever, appearing in the skin, connective tissue, or muscles ; and carcinoma, which is even less exclusive than tubercle in its choice of locality, yet preferring for its primary manifestation certain organs, as the uterus, the mamma, and the alimentary canal. 6. The influence of heat and cold, of dryness and moisture, and of atmospheric impurity in predisposing to disease is universally admitted. But here, as in some of the cases previously referred to, we are apt to confound, and it is difficult to avoid confounding, their indirect effects as predisposing agents with their direct effects as exciting causes. And further, when we come to test the relative influences of climates and seasons by their prevalent diseases, our endeavours to arrive at a just conclusion on the subject are seriously hampered by the co-existence with them (but partly no doubt arising out of them) of peculiarities of habit and modes of life, and of malaria and other special conditions of unhealthi- ness. Thus, we shall all aclaiowledge the influence of temperature in the production of bronchitis, pneumonia, rheumatism, and smistroke ; but in these cases temperature no doubt acts as the excitmg cause. Again, we 12 THE ETIOLOGY OF DISEASE. shall all be ready to allow that remittent fever, hepatitis, and dysentery are characteristic diseases of tropical climates ; but for the first malaria, not temperatm-e, is wholly responsible, and the latter two are possibly in some cases also of malarious origin. Further, we all know, by personal experience, the ill effects of overcrowded close rooms ; and we cannot doubt that deterioration of health must result from that constant breathing of vitiated air to which the children of the urban poor are generally con- demned, and we shall possibly rightly attribute much of their early sick- liness and prematurity of death directly or indirectly to this cause ; but it is certainly difficult accurately to identify either the morbid state which it produces directly, or the special predispositions to disease which it en- genders. It is well known that certain diseases prevail exclusively or with special severity in certain climates, and that their prevalence varies with season and also with local telluric and hygienic conditions. Yellow fever occurs in the West Indies and on the West Coast of Africa and in some few other localities ; dysentery and hepatic abscess are peculiarly diseases of tropical India ; Asiatic cholera, dengue, plague, all originate, and prevail chiefly or exclusively in hot climates ; tubercular phthisis is one of the scourges of the temperate zone. Again, at least in our own country, thoracic in- flammations are most frequent during the cold seasons of the year — acute pneumonia being probably most common in the early spring ; diarrhoeal affections prevail in summer ; and many other diseases have a tendency, difficult to explain, either to undergo exacerbation or to break out, or it may be to subside, at characteristic times — thus ague appears chiefly in spring and autumn, and psoriasis and some other forms of skin-disease have a similar tendency. It should be added that (fortunately for us) the human frame is adapted to live healthily under great varieties of climate, and under great extremes of heat and cold ; and that the effects of climate m the production of disease are probably due less to simple cold or heat, dryness or moisture, than to the neglect, on change of climate, to adapt our habits of life to the altered circumstances in which we find ourselves, and to the effects of sudden and unprepared-for variations of temperature. 7. In close connection with the subject under consideration is the question of variation in the so-called ' epidemic constitution ' of different years, and that of change in the ' type of disease.' By the term eincUmic constitution, Sydenham, who first employed it, meant a peculiar state of the atmosphere, determined by special telluric conditions ; to which, as specific causes, he attributed the development of epidemic diseases, such as small-pox, scarlet fever, measles, and plague ; and by variations in which he explained the epidemic prevalence of one or other of these diseases, and a tendency (which he believed to exist) for all indifferent diseases occurring during such an epidemic to be modified imder its influence and to assume some of its characteristics. The advance of pathological knowledge smce his day has proved that most, if not all, epidemic disorders spread by contagion, and that there is no EXCITING CAUSES OF DISEASE. 13 atmospheric or telluric influence to which they are due, nor anything beyond actual contagion which can give, during the presence of Asiatic cholera, or of small-pox and the like, any of the special attributes of these diseases to other prevalent diseases. Nevertheless, it must be admitted that there is something remarkable, if not inexplicable, in the way in which diseases (not contagious and miasmatic only, but simply inflam- matory also) become at irregularly recurring intervals prevalent in a high degree over wide areas. In this qualified sense the expression ' epidemic constitution ' is still not unfrequently, and may on the whole be con- veniently, employed. By the term change of type in disease is understood, not the trans- formation of one epidemic disease by gradual steps into another such disease— a process in which few now believe ; but a change in the quality of diseases, in virtue of which they present cycles of greater and lesser intensity of attack and of other deviations from the normal standard. Such changes are believed to depend partly on variations referrible to the disease itself, partly on ' epidemic constitution,' partly on cyclical changes in the constitution of mankind. There can be no doubt that differences of severity and fatality do not unfrequently characterise different epidemics of the same disease ; and further, it is beyond dispute that, even during the same epidemic, some persons are attacked with much greater or much less severity than others, or have the disease in a more or less modified form ; and in these senses the fact of variation in the type of disease must be fully admitted. There are many, however, who still believe that all diseases have undergone a change of tj-pe, say, during the last fifty years ; that they were formerly sthenic, and were to be cured by blood- letting, whereas they have now become asthenic and demand an exactly opposite line of treatment. It would be strange if, while the old descrip- tions of diseases remain accurately applicable, as in fact they do, to those of the present day, and while the health of the population has been undergomg gradual improvement, as it has done (if, at least, we may judge by the diminishing death-rates and the improved circumstances of the people), the effects of these unchanged diseases on the improved con- stitutions should be to render these latter more helpless during their attacks, and more likely to succumb from sheer debility. Many will be disposed to admit that the change of type has been rather in the medical practitioner than in disease or in the bodily constitution, and that the gradual change of treatment has been due, either to the slow advance of knowledge with respect to the effects of remedies in disease, or to fashion. B. Exciting Causes of Disease. Amongst the predisposing causes of disease just passed in review are some which act at least as efficiently in the direct production of disease. We refer especially to those discussed in paragraphs 4 and 6. It is cer- tain that to variations of temperature, combined with changes of hygro- metric condition of the atmosphere, a very large proportion of local 14 THE ETIOLOGY OF DISEASE. inflammations is immediately due. As examples may be cited common catarrh, bronchitis, pneumonia, pleurisy, nephritis, rheumatism, inflam- mation of the portio dura causing facial palsy and various affections of the skin. Again, over-indulgence in food, even though the food partaken of be fairly Avholesome, not only causes sickness and diarrhoea^ or other forms of gastro-intestinal disturbance, but leads ultimately to accumulation of fat, plethora, indigestion, gout, and various disorders arising out of these. So, on the other hand, deficiency of sustenance, or deficiency of essential ingredients of that sustenance, induces emaciation, anaemia, debility, degeneration, and various special disorders, the direct production of some of which has been demonstrated by experiment on the lower animals, and of which scurvy affords a notable example. Not far removed from such causes as these is the over-exercise or under- exercise, or abuse of the system, or of component parts of it. We need only refer, in proof of their efficacy, to the serious consequences which are apt to ensue on sudden and very violent muscular efforts, or on long- continued over-exertion of the muscular system, to the injurious effects of sexual excesses, which are not entirely due to seminal losses, and to the many nervous disorders which originate in overwork of the brain, in prolonged wakefulness, in the unrestrained indulgence of the passions, and the like. Without meaning thereby to exclude the various causes which have just been enumerated from classification among them, w^e may, with tolerable accuracy, group the remaining specific causes of disease under the heads of mechanical, chemical, and vital ; and we may further divide them into the endoiKtthic, or those which origmate within the system on which they act, and the exopathic, or those which attack the system from without. 1. Mechanical Causes. ExoiKithic mechanical causes embrace all forms of external violence, the results of which fall more particularly within the province of the surgeon. Endopathic mechanical causes, on the other hand, are of special importance and interest to the physician. They include mechanical obstructions of orifices or tubes, whether these obstructions be caused by thickening and contraction of their walls, by pressure on them from without, or by impacted concretions : such are in- testinal stricture, hernia, intussusception, and the lodgment of gall- stones, and all similar obstructions in the ducts of the liver and pancreas, in the various urinary passages, in the larynx, trachea and bronchial tubes, at the cardiac orifices, and in the blood-vessels. They also include impediments, however originating, to the transmission of nerve-currents along the nerves, dilatations of arteries and of other tubes and cavities, perforations or ruptures of their parietes, and extravasations or effusions of blood, serum, and other matters. It is obvious, therefore, that agen- cies of this kind are the direct causes of a very large proportion of the local diseases to which we are liable. But it may be observed that they would probably all have been considered by the older writers as proxi- mate rather than exciting causes of disease, and that they are m fact in EXCITING CAUSES OF DISEASE. 15 no case the primary causes of the morbid processes from which patients suffer. Thus, the person who suffers from stricture of the oesophagus or bowel, and whose grave symptoms are all referrible to the stricture, owes his stricture to previous local inflammatory thickening, ulceration, or carcinoma ; and he, who dies from the consequences of mechanical im- pediment to the passage of blood through the mitral orifice, traces the affection of the mitral valve to a long antecedent attack of rheumatic fever. 2. Chemical causes of disease include all poisonous substances, whether they be derived from the inorganic or from the organic kingdom, and however variously they exert their influence over the system. The great majority of these are necessarily exopatliic. Some, like the caustic alkalies and mineral acids, destroy the surfaces to which they are ap- plied ; others, like opium, strychnia, aconite, and snake-poisons, undergo absorption, and quickly exert their chief influence on particular organs, or on the general system ; while others, again, introduced into the or- ganism habitually and in minute quantities, slowly induce characteristic organic and other changes, and what are commonly regarded as definite diseases. Thus, dropped hand and colic, or plumbism, are the results of chronic lead-poisoning ; muscular tremors indicate mercurialism, or the ultimate effect of the inhalation of mercurial vapours ; the fumes of phosphorus after a time cause necrosis of the jaws ; the habitual use of ergotised cereals for food is believed to bring about a peculiar form of gangrene of the lower extremities ; and not improbably en- demic goitre and cretmism are due to the constant slow action of some material agent. We must obviously also include here the poisonous eifects of certain articles of food (mussels, fungi, sausages, and the like) and those which flow from the habitual use of alcohol, tobacco, and opium. Endopathic chemical causes are principally such as depend on defective action of the excretory organs, and the consequent retention in the system of efiete matters which then act as poisons. The chief emunctories for the pm-ification of the blood are the kidneys, liver, lungs, and skin. If the kidneys act inefficiently, urea and other excretory constituents of the urine accumulate in the blood, and by their presence there at length induce epileptiform convulsions, dropsy, anaemia, and other symptoms which collectively indicate the presence of Bright's disease. If the liver fail to discharge its normal functions, jaundice follows, and with that, and in some degree in consequence of it, many other grave symptoms. When, fi'om mechanical or other impediment to respiration, the blood becomes overcharged with carbonic acid, lividity of surface, delirium, and coma presently supervene. The cutaneous exhalation is for the most part merely complementary to that of the lungs and kidneys ; and hence the injurious effects of its arrest are not very apparent ; at the same time, doubtless, serious consequences are often correctly attributed to its sup- pression. Here we may refer, also, to the ill effects of that accumulation in the blood of the various ill-defined products of decomposition which 16 THE ETIOLOGY OF DISEASE. attends the specific febrile disorders, and in a greater or less degree most diseases or pathological processes. 3. Vital Causes. We now come to speak of that important class of causes to which all contagious or infectious diseases owe their origin : causes which are specific for each specific disease ; which are material ; which pass in some way or other from those already affected to those who are sound, and implant themselves in their bodies ; which grow and multiply therein at their expense, causing characteristic symptoms ; which in a greater or less degree are capable of escaping therefrom, and of then similarly infecting a second series of healthy persons, and so on con- tinually ; and of which none (so far as we certainly know) has varied in- trinsically in its effects from the earliest record of its operation down to the present time, or upon any part of the earth's surface. It is at once obvious that these causes are essentially and utterly different from those mechanical and chemical causes which have just been discussed. It is impossible to conceive of the contagiousness of a strictured bowel, an apoplectic clot, or an attack of jaundice ; it is contrary to all we know of chemistry that lead or mercury, morphia or the poison of the cobra, or a dose of medicine, should multiply within the system. But here we have poisons or irritants which do multiply in the system, it may be a billion- fold, and every unit of whose product is as efficient in imparting disease as was the unit ficom which it sprang. These facts seem quite incompatible with any other view of the nature of these causes than that they are actual living thmgs. That some of them are living is absolutely certain ; we mean para- sitic animals and vegetables. Of animal parasites, some live and swarm on the skin, or in it, and readily transfer themselves from one body to another ; some live in the alimentary canal or in the solid organs, and these, though still capable of infecting other healthy persons, infect them indirectly only, and after undergoing remarkable transformations external to the body of their host, and often in the organism of some lower animal. Superficial diseases due to the presence of vegetable parasites also are highly contagious. With regard to the contacjia, properly so called, namely, the infectious matters to which the several exanthematous and other similar infectious fevers are due, there is far less direct evidence in favour of their being li^dng things. Nevertheless some such evidence, to the effect that they consist in marvellously minute particles of living matter or protoplasm, has been adduced, and will at a subsequent page be more fully considered. The poison or malaria on which ague and remittent fever depend, although, so far as our present knowledge goes, not communicable from man to man, has a certain resemblance to the contagia, both in its mode of infecting the system and in the effects which mark its operation there, and hence not improbably is of a like nature with them. It seems convenient to advert here to the fact that many inflamma- tions, originating apparently in indifferent causes, either are uiherently infectious or acquire mider particular circumstances an infective character. EXCITING CAUSES OF DISEASE. 17 and that they spread, Hke the diseases which have just been considered, in some cases by direct contact or inoculation, in others, by atmospheric carriage. Thus, most practical medical men will readily admit the com- municability of common catarrh and of tonsillitis, the contagiousness under special conditions of even idiopathic erysipelas, and the readiness with which catarrhal ophthalmia and impetigo occasionally spread. Gonorrhoea furnishes a yet more striking example of the same fact. These cases are important, because they seem to show the possibiUty of the spontaneous development of contagious elements within the system. It must be added, however, that a very large number of diseases, funda- mentally distinct from one another, are yet linked together by the common bond of the occurrence in them of inflammation as a more or less promi- nent feature ; that one tendency of advancing pathological knowledge is to recognise that, in a larger and larger number of so-called ' inflamma- tions,' the inflammation is not the essential element in the disease, but merely one out of a group of several morbid phenomena, all starting from the direct influence of some specific cause ; and that hence, perhaps, it may eventually be discovered, that all these catching inflammations are, in the same sense as scarlet fever or mumps, specific diseases dependent on specific causes. The constant pTesence of bacteria, m the blood and tissues, in erysipelas, pyaemia, and some other inflammations of an infec- tive character lends probability to this surmise. The causes of carcinoma and other varieties of malignant disease, and indeed of proliferating tumours generally, are very obscure. It is not diflicult to understand that when once a tumour, destined to be malignant, has made its appearance in any part, the subsequent development of secondary tumours in the neighbouring lymphatic glands, and in remote organs, may be due to the conveyance thither from the primary growth of prolific particles of its specific protoplasm ; and that, hence, the diffusion of such tumours throughout the organism may, like the diffusion of small-pox throughout a population, be due to a contagium — but to a con- tagium, in this case (as possibly also in certain inflammations), originat- ing in the living tissues. But this explanation throws no light on the primary causation of such growths, and of their specific distinctions from one another. The fol- lowing remarks comprise most of what is known or suggested on the subject. It is certain that many tumours of different kinds appear secondarily to local injuries, and especially to local irritations which have been long continued. Among these may be enumerated warts, epithelioma, and scirrhus. It is certain, too, that many neoplasms, such as those which characterise syphilis, leprosy, and tuberculosis, are the immediate conse- quence of some virus or poison, not improbably some vegetable organism, with which the body has been inoculated. Many tumours resemble in their structural details the tissues in which they arise, and may be assumed to be mere local outgrowths or local hypertrophies of these tissues. But not unfrequently tumours have no structural relation what- ever to the tissues among which they appear. Thus, masses of striped c 18 PHYSIOLOGICAL PEOCESSES IN HEALTH. muscle have been fomid in the kidneys ; and tumours containing liair, teeth, bones, and various other foetal structures, not only in the ovary but in various other parts of the organism. To explain the occurrence of such heterologous or complex growths it has been suggested by Cohnheim that they owe their origin to bits of embryonic tissue which have re- mained unutilised and imbedded in the developed tissues of the organism, and have resumed at a comparatively late period their latent powers of growth and development. III. PHYSIOLOGICAL PEOCESSES IN HEALTH. The processes of disease, however widely they may seem to diverge from. those of health, are merely modifications of them, and their types must be sought in the normal physiological processes by which the body is developed, grows, maintains itself, and finally dies. It will be well, there- fore, before considering them in detail, to pass briefly in review the phy- siological processes out of which they arise. A. It is now admitted by physiologists, with almost perfect unanimity, that the first origin of every living thing, as also every living particle of the developed organism, is a viscid, homogeneous, colourless, albuminous substance, known as protoplasm or germinal matter ; and that this is endowed with remarkable powers, in virtue of which, under appropriate conditions of warmth, moisture, and the like, it is capable : first, of throwing out processes or otherwise altering its form, and so, on the one hand, of investing and absorbing solid particles, and, on the other hand, of actual locomotion ; second, of growing, and maintaining itself, by im- bibing and appropriating the nutritious matters which surround it, while discharging whatever is superfluous, excrementitious, or effete ; third, of multiplying by fission or by gemmation ; and last (in dependence on its immediate parentage and other conditions), of undergoing further develop- ment or differentiation, so as to take part in the formation of organs, or itself to become an organ performing special functions. Quiescent protoplasm generally occurs in the form of small romid or oval masses, often presenting an imbedded nucleus, or several such bodies, and under many circumstances a thin membranous investment, and hence that combination of characters which we recognise in the typical nucleated cell. The earliest stages in the development of the embryo, and the earliest stages in the development of organs, are characterised by the abundant formation of cells of this kind (without, however, the in- vesting membrane), which are hence termed embryonic cells. These bodies stand, therefore, at the bottom of all growth and all development ; and it is by their multiplication and by the changes which they effect, or undergo, that the complex organism of the body is gradually evolved and finally perfected. Thus, in the area germinativa the embryonic cells arrange themselves in three layers : the uppermost or serous, the under- PHYSIOLOGICAL PEOCESSES IN HEALTH. 19 most or mucous, and an intermediate layer. And, by a process of development or differentiation, are gradually produced : from tlie cells of the uppermost layer, the central nervous system and the epidermis with its appendages ; from those of the lowest layer, the epithelial lining of the alimentary canal and of the various glandular organs which com- municate with it ; and from those of the intermediate layer, the vascular system, with the ductless glands, and the muscular, osseous, and connec- tive tissues. B. The result of the processes here adverted to is the formation of a series of simple tissues, which group themselves here and there into com- plex specialised masses, named organs. These tissues may be arranged, according to Virchow, in three categories — the epithelial, the connective, and tliose of a higher grade. 1. The tissues belonging to the first category [the epithelial) are evolved mainly from the serous and mucous embryonic layers, and com- prise : the epidermis, with the hair, nails, and sebaceous and sudoriparous glands ; the epithelial lining of the gastro -intestinal mucous membrane, with that of the hepatic ducts and other glandular organs connected with that membrane ; the genito-urinary and pulmonary epithelia ; and the endothelia of the serous and synovial cavities of the body, blood-vessels, and lymphatics. In all these cases, or in nearly all of them, the tissue is composed of typical nucleated cells (that is, of masses of protoplasm containing nuclei and invested in membrane) so arranged as to be in exact contact with one another. Minor differences, yet of great practical importance, are observed between the cells of different epithelia ; thus they vary largely in size and form, and in the thickness and other special characters of their membranous investment. In the case of the outer layers of the epidermis and hairs, nuclei and protoplasm wholly disappear, and each cell becomes a mere lifeless horny flake. The functions of epithelia are very various : some, as those of the skin and blood-vessels, are merely protective ; others, such as that of the mucous surface of the alimentary canal, absorb ; while those of glandular organs either manu- facture and secrete products serviceable to the economy, or separate from the blood, and excrete, matters which are effete or injurious. 2. The tissues of the second category (the connective) are developed almost exclusively from the intermediate embryonic layer, and pervade all parts of the body, with the exception of the epithelia, forming a kind of network, in the interstices of which the higher tissues and the elements of organs are contained. They consist of nucleated masses of protoplasm, which are often exceedingly minute, always surrounded by a wall of greater or less thiclmess, and either rounded and isolated from one another, or stellate and furnished with processes communicating with those of neighbouring cells. The essential morphological distinction, between epithelium and connective tissue is, that in the former the cells are in absolute contact, in the latter they are separated from one another to a greater or less degree by some intervening substance : either an un- organised or lifeless deposit, or portions of the higher living tissues* c2 20: PHYSIOLOGICAL PEOCESSES IN HEALTH. According to the nature and. amount of tliis intervening substance, or to peculiarities presented by the cells, connective tissues may be di-sided into several varieties. In ordinary connective tissue, as also in fascias and tendons, the protoplasm is scanty and stellate ; and the intervals, which are large, are occupied by wavy bands of white fibrous tissue and more or less yellow elastic fibre, both of which are either simple secretions from the living protoplasmic masses, or the mummies of defunct cells. This variety of connective tissue yields gelatine. In common cartilage^ the cells are round or oval, and separated from one another by a dense homogeneous elastic substance, which appears to be formed by the pro- gressive thickening of the cell-walls and by their coalescence, and yields chondrine. In bone, the lacunae and canaliculi mark the position of the cells and their radiating processes, the proper constituents of the bone occupying the spaces which these include. The central nervous organs and the lymphatic glands possess a peculiar form of comiective tis- sue termed ' retiform,' in which the essential elements of these organs represent the separating material, and in which the proper cellular elements of the connective tissue are minute and stellate, and the rays passing between them are delicate and homogeneous, and enclose exceedingly small spaces. Mucous connective tissue, which is abimdant in the developing foetus, is represented at birth by the tissue of the umbilical cord, and throughout the remainder of life only by the vitreous humour of the eye. In this the intermediate substance is fluid (mucus in fact) and contains mucine. Lastly, passing by some unimportant modifications of connec- tive tissue, it may be pointed out that, in the choroid, spinal pia mater, and elsewhere, the proper cells of this tissue contain pigment, and that in many regirns they are distended with oil. In the former case, we have pigmental tissue ; m the latter, fat. It is upon the essential elements of the connective tissue (namely, the protoplasmic particles, or cells, and the processes springing fi-om them, which, with certain modifications of character, are distributed nearly universally throughout the organism) that, accordmg to Virchow, the action, growth, and maintenance of the organism immediately depend. And just as (to take bone for an illustration) we find certain districts or territories (the Haversian systems) under the nutritive governance of particular blood-vessels, so we find still smaller territories within them (the lacunar systems) over the welfare of each of which a single cell appears to preside. The latter are termed by Virchow ' cell-districts.' 3. The third category of tissues comprises mostly those which are tubular, and formed either by the juxtaposition and coalescence of cells, or of cells or protoplasm, which have in some other manner midergone a high degree of specialisation. Among them we may name nerve-cells, and nerves, striped and unstriped muscular fibres, capillary vessels, and lymphatics. 4. Lastly, com'plex organs, such as muscles, bones, glands, brain, and the like, are formed by the association, in various degrees of complexity, of several of the above-enumerated tissues. PHYSIOLOGICAL PKOCESSES IN HEALTH. 21 Thus, the organism may be regarded as a combination of vital and uon-\-ital elements. Of Avbicli the latter comprise various more or less complex chemical compounds, which have been prepared and deposited through the agency of the living matter, and whose subsequent changes and duration are regulated by the action of the living elements which are in their immediate vicinity. And of which the vital elements are the protoplasmic masses or nucleated cells, which, thickly disseminated, carry on between them all the living functions, and form : the universal net- work of connective-tissue corpuscles ; those lammated aggregations which constitute the various epithelia, and endothelia, and the walls of capillary vessels and lymphatics ; the massive accumulations which are observed in the central nervous organs, liver, lymphatics, and other glands ; pro- bably striped muscular fibre, and the axis-cylinders and peripheral ends of nerves ; and lastly, the corpuscles which are free in the circulating fluids. It is important to note that the vital properties of protoplasm differ in degree, and in quality, according to its age and the functions to which, by process of development, it has become subservient. Thus, embryonic protoplasm, and its nearest representatives in the mature organism (namely leucocytes and connective-tissue corpuscles), especially possess the power of multiplication and of differential development ; whereas muscular fibres and nerve-cells, which stand at the opposite extremity of the scale, probably never, at any rate in health, undergo proliferation ov development except in their own special grooves. C. The development, growth, and maintenance, therefore, of the entire organism depend essentially on the healthy circumstances, as to nutrition and the like, of the protoplasmic elements which constitute its living parts. All actively living matter is unstable and short-lived, and needs for the due performance of its vital acts (Avhich are always attended with a certain amount of waste of tissue) suitable food, which it can imbibe and transmute mto its own substance, so as at least to supply the place of that which was lost. But it needs, also, the removal of the spent nutritious fluids in which it is bathed, and of those effete and excre- mentitious matters which it continually emits. 1. For the purpose of pro\dding a constant supply of nutriment, we have the blood, impelled by the heart, slowly coursing through the capil- lary blood-vessels, and ever sweating all save its morphological elements through their delicate parietes into the extravascular tissues around, and occasionally perhaps exuding these morphological elements also ; and for the purpose of maintaining a constant removal of the spent pabulum, and of effete matters, we have the extravascular fluids ever undergoing absorp- tion, partly by the agency of the venous radicles, but mainly by the lymphatic vessels, which have their origin in the meshes of the capillary network, and in the very spaces in which the protoplasmic elements themselves are situated. 2. The nutritious matters of the blood are supplied to it primarily from the alimentary canal. Food, after having been triturated and swallowed and acted on by the secretions of the various glandular organs which dis- 22 PHYSIOLOGICAL PEOCESSES IN HEALTH. charge their contents into the stomach and howels, is absorbed at the surface of the mucous membrane : the fluid and more readily diffusible parts by the capillary blood-vessels, the fatty and albuminous matters by the lymphatics. Those substances which enter by the former route, after passing through the liver and perhaps midergoing some change there, mingle with the general mass of the blood ; those which enter by the lymphatics first traverse the lymphatic glands, carrying thence with them the white corpuscles which these glands manufacture, and then like the former blend with the circulating fluid. But the surplus nutriment, which escapes from the capillary vessels into the tissues external to them, is also taken up mainly by lymphatic vessels ; and this again, after passing through lymphatic glands, and deriving thence morphological elements, mingles, like that derived from the alimentary canal, with the blood-stream. Lastly, the important secretions furnished by the mucous membrane of the alimentary canal, and by the viscera which discharge into it, are reabsorbed m large proportion with the food, and thus re- enter the circulation. 3. Effete matters derived from the waste of the organism are dissolved in the fluids which are also the carriers of nutritious matter ; and hence are removed from the parts in which they are produced by the same channels, namely the veins and the lymphatics ; and then mingling with the blood are there farther reduced by the reducing agency of the oxygen, which it is the function of the lungs to furnish to the blood. Thus they get converted into diffusible compounds of comparatively simple constitu- tion, which are then separated from the blood by appropriate emunctories : carbonic acid by the lungs, nitrogenous compounds and salts by the kidneys and skin, and the colouring matter of the blood by the kidneys and liver. 4. Presiding over the processes of nutrition, and to a great extent regulating them, yet itself entirely dependent upon them for the means of its material and functional activity, is the nervous system, comprising the central organs, the nerves, and the end-organs of the nerves. By means of the nerves every part of the organism, probably almost every proto- plasmic mass, is brought directly or indirectly, through the intervention of ganglia or of the central organs, into relation with the other elementary parts of the organism. Sensations or impressions received at the peri- pheral terminations of afferent nerves are conveyed instantaneously to some nerve -ganglion, or to the spinal cord, or to the brain, or to all of them ; and then, reflected thence along the efferent nerves, certain responsive influences are transmitted which, accorduig to their destina- tions, result in muscular movement or in glandular action. Thus the central organs are kept mformed of what is going on throughout the organism. And thus (to omit all reference to their influence over the voluntary muscles), by acting on the walls of the heart and blood-vessels, they regulate the supply of blood to parts, and so control their nutrition and the activity of their special functions ; by acting on the walls of gland-ducts, they modify the rate of escape of the products of the glands ; PHYSIOLOGICAL PKOCESSES IN DISEASE. 23 and by means of the trophic nerves (which many physiologists now believe to exist) they probably exert a direct influence over the action of the essential elements of secreting organs. D. Ere we bring these preliminary physiological remarks to a conclu- sion, a more direct reference must be made than has hitherto been done to the fact that decay and death are essential elements in the normal processes of life. It has already been pointed out that every act of life is attended with waste of tissue, and that living protoplasm is essentially unstable and short-lived. It must be added, that every part of the organism has a limited duration, which is far shorter than that of the normal duration of the body which it contributes to form, and that the parts are either removed by slow disintegration and degeneration or cast oft" in mass. We need only advert, in exemplification, to the shedding of the epidermis and of the elements of excretory glands, to the removal and re-formation of bone -tissue, to the genera.tion and destruction of blood- corpuscles, to the atrophy of the uterus and the fatty degeneration of its muscular elements after parturition, and to the even more complete destruction, by similar processes, of the Wolffian bodies during foetal life, and of the thymus gland during the first few years of extra-uterine exist- ence. Lastly, it must never be forgotten that atrophy and degenera- tion of organs and tissues are normal physiological processes of old age, and that somatic death, in which they culminate, is their normal termination. IV. PHYSIOLOGICAL PEOCESSES IN DISEASE. If we carefully consider the intimate processes of disease, we cannot fail to recognise the fact that they consist essentially in nutritive modifica- tions of the protoplasmic or vital elements of the tissues : that under the influence of abnormal or unwonted stimuli (including the stimulus of excessive nourishment), these enlarge, or multiply, or differentiate; that when insufficiently stimulated or fed or acted on by destructive agents, they undergo atrophy or degeneration, or perish ; and that, as a necessary consequence of such changes, their functional attributes become height- ened, or impaired, or more or less profoundly modified. Thus, on the one hand, we get simple hypertrophy, inflammation, or heterologous growth, and, on the other hand, fatty or calcareous conversion, or other forms of degeneration ; and, again, functional derangements too numerous to men- tion, which constitute so large a proportion of the symptoms of disease. But when we look to the marvellous complexity of the organism, to the intimate anatomical relations which subsist between the vascular and the nervous and other subordinate systems and organs, and to the corre- lation and mutual dependence of the various functions which all these different component parts of the organism are called upon to perform ; and consider that the healthy structure and function of each are involved in a greater or less degree m the similar integrity of every other ; we 24 MOEBID GEOWTH. must admit ( what tlie slightest practical experience will confirm i that we cannot limit om- view of morbid processes to these intimate changes alone, but must embrace within it the structural and other modifications of organs to which such changes give rise, as well as those further nutritive and functional disturbances which, in a variety of ways (mecha- nical, chemical, and other), disease of one part necessarily evokes in a greater or less degree in all other parts of the system. "We proceed to discuss at length the several matters here adverted to. A. MoEBiD Growth. 1. General Ohservations. a. Growth and development of cells. — Whenever the protoplasmic par- ticles or cell-elements of a part are stimulated to unwonted growth, they first mcrease in bulk, and become turbid, or minutely and mdistinctly granular, and if stellate, fusiform, or caudate, at the same time retract their processes, and assume a more uniformly rounded shape ; and then, by gemmation or fission, each cell gives origin to two or more smaller cells, which in their turn repeat more or less accurately the processes of growth and proHferation. The results of such stimulation, so far as regards the cells themselves, are, that sometimes the newly generated cells acquh-e in all respects the same characters as had formerly belonged to their immediate ancestors, that sometimes they retain permanently the immature or embryonic condition which represents the early or indif- ferent stage of nearly all cell-growth, and that sometimes again they undergo development into cellular bodies which difler materially in size, form, and attributes, from those which gave them origin. Simple hypertrophy or hyperplasia furnishes an example of the first of these alternatives, inflammatory cell-production of the second, and heterologous tumours of the last. h. Conditions associated loith over-groicth. — But where there is exag- geration of cell-growth, there necessarily is also at least proportionate exaggeration of the various conditions which are subsidiary to such growth — ^namely, exaggerated afflux of blood, exaggerated accumulation of nu- trient fluid, exaggerated molecular destruction, and exaggerated efflux of superabmidant and efl'ete materials. Increased afflux of blood is determined mainly by reflex dilatation of the arteries, capillaries, and vems, which minister to the needs of the affected part, and in a subordinate degree by increased force and fre- quency of the heart's contractions, and produces one form of what is known as ' congestion.' Increased accumulation of nutrient fluid in the extravascular tissues is due to the preternaturally abundant escape of it fi-om the dilated capil- laries : an escape dependent m some degree on the vital mfluence exerted by the protoplasm of the capillary walls, and by the over-growing proto- plasm external to them. The tissues consequently get swollen, soft, and juicy, and in a greater or less degree ' di'opsical.' MOEBID GEOWTH. 25 All vital activity, wlietlier this manifests itself by material clianges or by fmictional excitement, is attended with molecular dismtegration, which has some exact quantitative relation with it ; and hence increased vehe- mence of growth, and of reproduction, is necessarily accompanied with a proportionately increased production of effete and excrementitious matters. But, in addition, undue rapidity of cell-growth and development always involves a corresponding tendency to fall into premature decay and disso- lution ; and hence arise fatty and other forms of degeneration, the pro- ducts of which accumulate, and mingle with those of molecular disin- tegration. It is thus that the fluids of the afl'ected region tend to become surcharged with imiutritious, waste, and often noxious materials. The increased absorption Avhich takes place is probably dependent, in some measure, on the more active passage of fluid by endosmosis through the walls of the venous radicles, but is certainly due mainly to the more direct action of the lymphatic vessels. Indeed, it is almost impossible to suppose that those slightly difl'usible substances, albumen and fibrinogen, should, in the face of the opposing pressure from within the blood-vessels, be capable of re-entering them, or that solid particles, whether indifl'erent or specialised, should be removable by any other route than that furnished by the open mouths of the lymphatics. And that these really are the mam agents in the removal of probably everything, save a variable proportion of water and dissolved salts, is shown by the tendency which, when largely over-worked, they and the glands in their course have to become enlarged and presently inflamed, or involved in the identical processes going on at the seat of absorption. c. Migration of leucocytes. — One of the most interestmg phenomena comiected with the subject of local proliferation is the fact, stated many years ago by Dr. Addison, and since then clearly established by the ex- periments of Cohnheim and the later observations of many other physio- logists, that in artificially produced irritation or inflammation of the tissues of the frog or mouse, after retardation of the current of blood m the vessels of the part has taken place, the white corpuscles gradually pene- trate the vascular walls, and presently pass completely through into the tissues external to them. It has further been shown that these emigrant corpuscles take an active personal part in the proliferation which ensues ; that is to say, that they then, as well as (if not more than) the proper protoplasmic masses of the part, give origin by gemmation or fission to new generations of cells. How far this process may be regarded as an essential element in the development of non-inflammatory growths, is at present in great measure a matter of inference. Still there are many good grounds for regarding it as an important item in all cases of abnormal cell-proliferation. And it is far from unlikely that it may be equally importantly concerned in the normal processes of growth and development. d. Tendency of morbid groivth to sixread locally. — Morbid cell-develop- ment, occurring primarily at any one spot, generally has a tendency to spread in the neighbourhood of that spot. The direction of local spread 26 MOEBID GEOWTH. is in most cases largely determined by the structure and connections of the tissue or organ in which the growth has originated. Thus, growths "beginning in the cutis or mucous membrane are prone to limit their ex- tension to these structures ; and the same rule applies to the kidney, ovary, and other organs. Nevertheless, in many cases the morbid pro- cess tends gradually to involve all adjoining parts. This local spread is sometimes effected by the progressive involvement of the healthy tissues immediately surromiding the focus of disease ; and very often partly by this process, but partly also by the appearance of new foci of disease in the vicmity of the primary focus, and by their gradual coalescence with it and with one another. It is sometimes determuaed by the lines of capillary lymphatics and blood-vessels. e. Tendency of morbid groicth to become generalised. — The tendency to the simultaneous or consecutive occurrence of the same kind of morbid proliferation in different, and even remote, parts of the organism is trace- able to a variety of causes, presents obvious and characteristic differences, and has therefore a widely different significance in different cases. The matter is one which deserves, and indeed demands, consideration ; and we proceed, therefore, to discuss it m some detail. A person, in appa- rently the best of health, finds that he has a fibrous or fatty tumour in the subcutaneous connective tissue, or an osseous or cartilaginous tumour growing from the shaft of some bone ; and probably in a short time it is ascertained that many other tumours, identical in character with the one first detected, are maldng their appearance in the comiective tissue or the bones (as the case may be) of difl'erent parts of the body. Now it is indu- bitable that we have here a curious tendency in certain tissues of the body to midergo special morbid changes. To what is this tendency due "? The first formed tumour may be distinctly traceable to some local injury; has the growth which resulted from that mjury so infected the system as to have led to the multiple development of similar growths throughout the same tissue as that which was primarily involved ? Or have all the tumours (including the first) resulted from the common operation of some independent morbid irritant or poison diffused generally throughout the system ? Or is there some inherent weakness or vice in the particular tissue, which has become thus largely affected, rendering it liable to take on specific morbid proliferation mider the influence of mechanical violence or any other indifferent cause ? In the examples which have been adduced (and many similar ones might be added), the last of the three suggested explanations will doubtless be regarded as the only tenable one ; and probably it is the correct one. At all events, we have no grounds for assuming, from the presence of cachexia or other asso- ciated abnormal conditions, that any poisonous matter either is or has been present in the system ; or from the presence of lymphatic implica- tion, that the primary seat of disease was the source of infection. The case, however, is not quite so simple as it appears to be at first sight. The skm, like the bones or connective tissue, constitutes a special constituent of the organism, and like them (though in a still higher GENEBALISATION. 27 degree i is liable to many morbid conditions which are peculiar to itself, and which may be distributed at intervals over its surface. Now a patient may have psoriasis, begmnmg perhaps in a patch on the elbow or knee, and diffusing itself in spots over the greater part of the body. His father may have suffered fi'om the same disease, and his brothers and sisters also may be subject to it. The case is one of hereditary predispo- sition. NoAv, probably no one would dream of suggesting that the spread of the disease was due here to the infecting influence of the patch which first appeared on the laiee or elbow ; and certainly no direct evidence could be adduced in favour of its dependence on any morbid irritant carried by the blood. The case would doubtless be regarded as equivalent, in point of origin, to that of multiple fibrous tumours or exostoses. But another patient has psoriasis differing a little in details of distribution and colour, but (miless we go into the previous history and subsequent jDrogTess of the case) probably in no other respect, from that observed in the former patient ; and further, at the time of observation he may in every other sense be perfectly healthy. He had a chancre, however, some tune previously, and his skin-disease is due to the syphilitic poison. Or, to take another example : an apparently healthy person becomes liable, without obvious cause, to urticaria, and suffers from it off and on for years, perhaps for the remainder of his life. It is little, if at all, in- fluenced by diet or habits and altogether uncontrollable by medicinal treat- ment, and moreover may be readily induced by a pinch or scratch. There seems no reason to regard this, any more than simple psoriasis, as the result of a specific irritant working from within. But another person takes a meal of mussels and presently presents, together with more or less violent constitutional disturbance, an abundant urticarial eruption. Now here the relation between cause and effect is as obvious as in the case of sjTphilitic psoriasis. We have, thus, clear evidence that both psoriasis and urticaria are producible by the local operation of special poisons, which have been introduced from without, and have m- fected the system, and that the former may appear without necessary contemporaneous manifestation of other symptoms of disease. But do not these facts throw doubt on the non-specific origin of so-called ' idio- pathic ' psoriasis and urticaria, and hence also on the assumed non- specific causes of fibroma, exostosis, and the like ? Nevertheless, while many specific affections of particular tissues are certainly traceable to the influence of specific irritants, it seems not im- probable that other such affections are due simply to the influence of indif- ferent causes acting on parts which have acquired special aptitude to take on such morbid action. At the same time it must be admitted that the absence of collateral evidence of the presence of systemic poisoning by no means proves the absence of such poisoning ; and, further, that the apparent commencement of the above or any like lesions from injury does not make it certain that this injury was its essential cause. The difliiculties which have just been briefly considered are equally apparent in the case of carcinoma and other infectmg tumours. These, 28 MORBID GEOWTH. like exostoses and fibromata, become multiplied througliout the organism, and like them repeat in each newly-formed growth the characteristics of the growth which was first developed. But they differ from them essen- tially in being heterologous in structure from the tissues wherein they first make their appearance, and because they are not, or not so obviously, limited in their further distribution to one special form of tissue. They differ from them also in the fact that, however we may explain their origin, the first-formed mass inoculates the system with the disease, as truly as the inserted variolous contagium inoculates a person with small- pox, and exactly in the same way as a chancre infects its subject with constitutional syphilis. Thus, if a carcniomatous tumour makes its appearance in the testicle, the patient for a time seems, and probably is, free from disease elsewhere ; but presently other organs get implicated, and in a certain sequence. First, the lymphatic glands, into which the testicular lymphatics run, become involved — these are the lumbar glands ; and then, after an interval, the disease appears simultaneously in many tissues and organs. If a patient has carcinoma of the glans penis, the next manifestation of the disease occurs exactly where the effects of syphilis first reveal themselves, subsequently to a chancre of the same part — namely in the inguinal glands. And in this case, again, at a later period the disease becomes generalised. The same rule applies equally to cancer of the breast, uterus, or pylorus, and indeed to any primary cancer, no matter what its seat : first, the lymphatic glands in the neighbourhood, and especially those which lie in the direct route between the tumour and the thoracic duct, suffer ; and, later on, patches of carci- noma appear, distributed throughout the organism. In diseases of this kind, every secondary tumour is equally infective with that which was first developed; and consequently, just as the primary tumour causes disease in the lymphatic glands related by position to its seat, so each secondary tumour tends sooner or later to infect those lymphatic glands which are in immediate connection with it. /. Tendency of certain morbid groioths to limit their distrihution to certain tissues or organs. — But although carcinomatous tumours, and such growths as are related to them by their mode of dissemination from a primary focus of disease, undoubtedly tend, when they become general- ised, to involve a much wider range of tissues and organs than do fatty tumours, exostoses, and the like, it is nevertheless certain that they have preferences or elective affinities, and that these are in some degree cha- racteristic for each species of tumour ; and further, as Virchow distmctly points out, the parts in which such affections usually originate are especially the parts which their secondary manifestations seem to avoid, and conversely. Thus tubercle and carcinoma, although severally dis- posed to involve secondarily a large number of organs, and many of them in common, present obvious pecviliarities of distribution ; for while both of them are specially apt to attack the lungs, brain, and serous membranes, carcinoma is yet more disposed to attack the liver, which tubercle generally avoids, and tubercle has a marked affinity for the mucous membrane of DYSCRASIA. 29 the bowels and for the spleen, in both of which situations secondary cancer is certainly rare. And thus, again, while primary carcinoma is common in the breast, womb, and alimentary canal, these parts rarely get involved when carcinoma originates in some other part of the system. The cause of the apparent capriciousness of distribution of secondary growths is very obscure. It is of course easy to understand why the lungs, which form a kind of filter to the universal blood, should be peculiarly liable to them ; and why organs, such as the liver and kidneys, which receive a specially copious supply of blood or have such arrangements of vessels as retard or lengthen its passage through them, should be affected more frequently than others. But neither such conditions, nor others connected with the relative functional activity of organs, influential though they be, are alone sufficient to explain the phenomenon. It has recently been ascertained that lymphatic tissue is very abundantly distributed throughout the organism ; and there is some reason to believe that the generalisation of both tubercle and lympho- sarcoma is connected with this fact, and depends either on some special proclivity to morbid processes which this tissue acquires under certain constitutional conditions, or else on the circumstance that it is the appropriate soil for the germination of the seeds of lympho-sarcoma and of tubercle. The latter is probably the correct explanation ; and indeed, probably also in other cases, apparent capriciousness is mainly dependent on the special suitability of different tissues and organs for the reception and growth of different specific morbid elements — an explanation which is in entire accordance with all we know of the behaviour of the contagia of the exanthemata, of animal and vege- table parasites, and of other organic and inorganic poisons admitted into the organism. g. Connection of dyscrasia with the origin of morbid groicths. — Nothing which has yet been said relates in any degree to the question of the primary origin of infecting growths ; it has simply been shown that when once developed they become sources of specific infection to their unfortu- nate possessors. This primary origin is referred by many persons to a ' dyscrasia ' or morbid condition of system, itself supposed to be produced by the presence of some morbific matter or influence residing in the blood ; and indeed Mr. Simon, who formerly adopted this view, regarded a carcinomatovis tumour as a newly-developed organ, whose express purpose was to effect the separation of such poison from the organism. There are several considerations which lend countenance to this hypo- thesis : — when a person exposed to atmospheric changes contracts pneu- monia or any other variety of internal inflammation, an interval elapses between his exposure and the commencement of the inflammation, during which some abnormal condition of the system (a dyscrasia) is present ; so again the incubative stage of small-pox or measles is a period of specific dyscrasia ; and further, at any rate as regards tuberculosis, we know that it is apt to come on in individuals who have fallen into general ill-health. But, on the other hand, these examples are none of them strictly analogous to that of carcinoma ; and one indeed (that of the exanthem) 30 MOKBID GROWTH. fairly considered tells the opposite way, for its incubative period corre- sponds, not to the supposed incubative stage of carcinoma, but to the period which elapses between the first appearance of a tumour and its generalisation. Besides in the great majority of cases in which we have the opportunity of observing the first manifestations of carcinoma, these are certainly not preceded by any evidence of ill-health ; and, moreover, no such evidence becomes apparent until the patient is obviously begin- ning to suffer, directly or indirectly, from the efiects of his disease. The existence, then, of initial carcinomatous and other such specific dyscrasiae may fairly be denied ; at all events, the only proof of their existence is the appearance of those very lesions which are attributed to their influence. And hence the only sense in which such a dyscrasia can be conceded, is the sense in which we should admit a preliminary dyscrasia as the source of enchondromata, exostoses, fibrous tumours, leprous patches, and the like : a dyscrasia, that is to say, of limited distribution, and consisting simply in a tendency (congenital or acquired) in certain parts of the body to undergo a special kind of proliferation under the operation of various forms of irritation. It need not of course be denied in this case, any more than in that of non-infective growths, that such a tendency may exist simultaneously in various parts of the body ; and that hence, although it is certainly not the rule, there may be a concurrent primary outbreak of infective growths in two or more localities. h. Secondary dyscrasia. — But although a state of cachexia, or a dyscrasia, is not an essential antecedent of primary infective growths, there is no doubt that a condition of cachexia speedily follows upon their appearance. The fact has already been adverted to that, from any focus of morbid proliferation, there is an abnormally large reflux of nutrient fluid into the general circulation, partly by the veins directly, but chiefly by the lymphatics, and that this nutrient excess is largely charged with effete and morbid products, generated in the diseased area. These products comprise : the ordinary waste-materials, such as carbonic acid and urea; materials which are traceable to the special chemical consti- tuents of the part involved — earthy matter if it be bone, phosphates if it be brain ; and probably also fibrine or fibrine-producing substance, which, as Virchow suggests, is manufactured at the seat of disease, and being removed thence by the lymphatics, overcharges the blood and gives it its inflammatory character. But, in addition, specific aflections yield specific elements, which also traverse the lymphatics, and presently mingle with the blood. What these are is not accurately known ; but probably (judg- ing from the analogies afforded by the infectious fevers) they are living protoplasmic particles evolved by the primary groAving mass, which get arrested in the lymphatic glands and then infect them, by either growing parasitically among their elements, or (sperm-like) imparting to them specific properties ; and which presently are shed thence in new genera- tions, through the thoracic duct into the blood- stream, to sow themselves in distant organs. Now, in all these processes, it is obvious that we have ample sources of deterioration of the general health, and of functional MALIGNANCY AND INNOCENCY. 31 disturbance of various parts of the organism — in other words, of a second- ary dyscrasia. But it is obvious, also, that the degree and character of the dyscrasia will vary according to the peculiarities of the morbid process to which it is due, and especially that that accompanying the development of infective growths will be attended with specific characteristics. Further, more or less in most cases, but in the last more particularly, dyscrasia will probably be largely increased, by the constant drain of nutriment which the growth and ulceration of tumours necessarily involve, and by the obstacles which, by pressure or otherwise, these so often interpose to the due performance of important or necessary functions. "When secondary dyscrasiae are present we often find that some me- chanical injury, or the result of some such injury, attracts, as it were, specific morbid processes. When, for example, a patient is suftering from constitutional syphilis, a local outbreak is often thus determined. It is probable that this phenomenon is due to the fact that parts, in which certain non-specific morbid processes are in progress, furnish a specially suitable soil for the growth and development of specific elements of disease, which happen to be circulating in the blood. The interesting experi- ments of Chauveau seem strongly to confirm this view. He found that, on injecting putrid fluids containing bacteria into the blood of healthy animals, no special consequences beyond some constitutional disturbance necessarily followed ; but that if, after injecting them, the operation of twisting, and thus strangulating, one testicle was performed (an operation common in France and leading to the general wasting of the organ), violent inflammation with sloughing, probably attributable to an abundant development of bacteria, took place in the injured part, the opposite uninjured testicle remaining altogether unafl'ected. i. Meaning of terms malignant and innocent. — It may be well here briefly to explain the meaning of the terms ' innocent ' and ' malignant,' as applied to morbid growths. Malignant is almost synonymous with infecting ; but not quite — for a chancre and an inoculated variolous pustule are both infecting growths, yet not malignant. The word implies, therefore, something more than is presented by either of these aflections. It implies, in fact, additionally, that the morbid process going on in any one locality has a tendency to invade all the tissues which are round about it, and none whatever towards cure, or even to remain quiescent. A malignant tumour may, therefore, be defined as one which tends to involve all surrounding structures, and to disseminate itself through the agency of the lymphatics and veins, and has no disposition to spontaneous cure. The term ' innocent ' is mostly understood to signify simply that a tumour is non -infective. Malignant tumours often present other cha- racters which, though not necessarily associated with malignancy, are yet highly suggestive : these are, aptitude to recur after removal, abundance and rapidity of cell-growth, softness and juiciness of tissue (the juice being milky), great vascularity, and marked differences of texture as compared with that of the parts in which they originate. A very characteristic feature of most morbid proliferaitions, whether 32 HYPEETROPHY. they be malignant or innocent, is their quasi-parasitic nature : their dis- position to grow and to maintain themselves, independently of the general health of the body in which they are developed, and from which they derive their sustenance. Thus, a large abscess, so far from becoming- starved by the gradual emaciation of its possessor, will often go on in- creasing even more rapidly as his body dwindles away. And so also, enchondromatous, fatty, and carcinomatous tumours, and tubercle, show no signs of impaired vigour of growth, even while the patient is progres- sively wasting under their influence. Over-nutrition and under-nutrition of the body of their host are alike without obvious influence over their progress. h. Belation behoeen infective morbid grotvths and specific febrile dis- eases. — It is impossible to overlook here the close relation there seems to be between malignant tumours on the one hand and at any rate certain of the specific communicable diseases on the other. We have shown that if a malignant tumour appear at any one spot, as a general rule the lymphatic glands in immediate relation with it before long become involved, and subsequently tumours resembling the first arise simultaneously or in rapid succession in various other parts of the system. Syphilis and small-pox (which may be taken as types of the specific communicable diseases) are characterised by the same sequence of events. If either of these be im- parted by inoculation, a specific infective growth takes place at the point of operation ; then, after a definite period, specific implication of the neighbouring lymphatic glands ensues, and concurrently or a little later the poison disseminated throughout the system gives origin to a more or less widely distributed outbreak of lesions specifically identical with that from which they took their origin. Further, in these and such like afi^ections, there is (as is also observed in malignant diseases ) a tendency for each kind in its secondary manifestations to implicate certain tissues and organs in greater degree than others. Tuberculosis has, both in structure and in behaviour, a close affinity with syphilis. Now, as we have already hinted and shall hereafter explain at some length, there are over- whelming reasons for regarding the specific causes of small-pox, syphilis, and all other specific communicable diseases as lowly vegetable organisms ; and it has recently been (apparently) proved that tubercle itself, which had hitherto been regarded as a quasi-malignant tumour, is also the product of a specific vegetable parasite. Should this view of the causa- tion of tubercle stand the test of experience, it will be difficult not to anticipate that sooner or later a like origin will be discovered for all in- fective growths, and even for many growths which are usually regarded as innocent. 2. Hypertrophy. Hyperplasia. The term ' hypertrophy ' is commonly used somewhat loosely of all organs or tissues which, from no matter what cause, have undergone abnormal increase of bulk. Thus, a liver enlarged by fatty deposit or lardaceous infiltration is often said to be hypertrophied, as also is an HYPEETKOPHY. 33 ordinary swelled testicle or a lymphatic gland affected with tubercle or carcinoma. But in such cases as these the enlargement is due essentially to the deposit of some extraneous matter, or the development of some inflammatory or other morbid growth ; and the normal structure of the organ, so far from being increased in quantity or size, has probably under- gone atrophy or degeneration. True hypertrophy of an organ consists, either in an enlargement of its essential elements, or in an increase in their number. By Virchow the latter variety of over-growth has been distinguished as 'hyperplasia.' The former process is exemplified by the enormous enlargement of the unstriped muscular fibres of the womb which takes place during the pro- gress of pregnancy ; the latter by the over-growth of bone, which is effected simply by the multiplication of its elementary parts. It is very difficult, however, in many cases to determine positively by which of these two processes an over-grown organ has become enlarged, and doubt- less they frequently co-operate. Of all morbid processes, simple hypertrophy is that which seems to approach nearest to the processes of health ; indeed it is mostly due to the operation of the very causes which produce normal increase of bulk, and in a very large number of cases is, for a time at least, protective or otherwise beneficial. Hence it is difficult to draw the line between that normal growth of the heart, which comes with advancing years and activity of body, and that excess of enlargement which sustained and over-violent exertion brings about, and which presently reacts injuriously. Again, how much more speedily would obstructive disease at the cardiac orifices prove fatal, if hypertrophy of the heart's walls did not naturally follow upon their efforts to overcome that obstruction ! Similar morbid hypertrophies of the muscular parietes of the hollow viscera are always apt to arise under circumstances which compel them to long- continued unwonted action. We may refer to the hypertrophy of the stomach which occurs when the pylorus is diseased, to that of the intestine in cases of intestinal obstruction, and to that of the bladder, or -ureter, or other ducts when mechanical impediments prevent the due escape of their accumulated contents. Such consecutive, and often beneficial, hypertrophies are not confined to muscular organs, but may occur in glands, in bones, and else- where : — in the kidney, for example, when in consequence of the destruc- tion of one its fellow attains unwonted dimensions, or when both undergo enlargement under the influence of diabetes ; in the bones, as when a protective buttress is formed in the concavity of a curved rickety tibia. Not all forms of hypertrophy, however, are a consequence of the attempts of organs to adapt themselves to conditions of increased woi"k. Hypertrophies which are essentially abnormal, and have no beneficial tendency whatever, arise in some cases from the direct influence of the nervous system; in others (and these are the most frequent), from the stimulus of excessive supply of nourishment. Amongst the former may be included the hypertrophy of the heart which long- continued nervous palpitation mduces, and that form of goitre which occurs in ' Graves's*. D B4 INFLAMMATION. disease ; amongst the latter, that general enlargement of the lower ex- tremity (in which the bones get longer and thicker than those of its fellow, and the other structures of the limb proportionately increased) met with in cases where, owing to obstruction and dilatation of its lymphatics, the whole member is succulent with nutritious fluid. A particular form of hypertrophy of the tongue in children, and the over- P'rowth of the skin and subcutaneous connective tissue in elephantiasis, also are largely due to this last condition. Occasionally, owing doubtless to some congenital proclivity, some one part of the body, as, for example, an arm or leg, grows during childhood in all its dimensions disproportionately to the rest of the frame, and while retaining its healthy structure attains relatively gigantic proportions. 3. Inflammation. General account. — The collective morbid phenomena which are in- cluded under this term occur as an essential, or as an accessory, part of the great majority of diseases. They represent the reaction of the system, or of parts of it, against the injurious effects of irritants which are morbid either from their amount or from their quality ; the efforts by which nature endeavours to destroy, counteract, or throw out what is noxious ; and those by which she strives to repair what has been injured, and to restore what has been destroyed. It need scarcely be added that inflammation often goes far beyond, or falls far short of, its aim, and often acts as it were capriciously and blindly. The classical local signs of inflammation are redness, swelling, heat, and 2}ain. These no doubt are all present in the majority of cases ; the redness being due to accumulaton of blood in the dilated blood-vessels ; the swelling, partly to this dilatation, partly to simple effusion and growth of tissue ; the heat in some degree to the increased afflux of blood, in some degree to the rapid disintegration that is in progress ; and the pain, to pressure on the sensory nerves, or to their implication in the morbid processes. But neither redness, swelling, heat, nor pain is absolutely essentia to inflammation : they are simply to be regarded as common results or accompaniments of that process. Inflammation consists primarily and essentially in an unnatural irritability, and tendency to undue proliferation, of the protoplasmic elements of a part : these giving rise, not as in simple hyperplasia to a mere increase in the number of the normal elements, but to cells which tend to resemble leucocytes, or embryonic cells, and which, never go beyond the formation of simple granulation-tissue, or some variety or modification of the various forms of connective tissue. The connective- tissue corpuscles are those in which inflammatory proliferation chiefly takes place ; but all protoplasmic masses, including those of the epithelia, those connected with the nerves and striped muscles, and also those wliich by their coalescence form the walls of capillary vessels, readily participate in the process. As doubtful exceptions may be named the EXTEA-VASCULAK PEOCESSES. 35 special cells of tlie central nervous organs, the proper liver-cells, and other cells which have attained a high phase of development.* But in con- nection with these extra-vascular* changes, vascular phenomena speedily ensue, and at once take an active share in the processes which are going on. Among the incidents which occur in the course of inflammation or follow upon it are, exudation, suppuration, ulceration, gangrene, and granulation or repair. a. Extra-vascular iirocesses. — The extra-vascular processes of inflam- mation may be best observed (observed freest from complication) in parts devoid of vessels, such as the cornea, cartilage, and certain portions of the mesentery. If a costal or articular cartilage be excited to inflammation by the mechanical removal of a bit of it, the injured surface becomes covered at the end of about a week by a soft, greyish pulp, which consists entirely of embryonic tissue, or a mass of embryonic cells together with some newly-formed blood- vessels. If now a cross- section of the cartilage be made so as to include its whole thickness, together with the wounded surface and the pulp covering it, the following appearances will he detected on microscopic examuiation in successive order from the region furthest removed from the seat of injury to the surface : — first, the cartilage- cells and the hyaline intervening substance in a perfectly normal con- dition ; second, simple enlargement of the cells and of their nuclei, and of the cavities in which the cells are contained ; third, fissiparous multipli- cation of the enlarged cells and nuclei, and the appearance therefore of several closely-packed nucleated cells in each originally miicellular cavity (each young cell, moreover, being invested in a thin cartilaginous capsule, and so still presentmg the essential characters of a cartilage- cell) ; fourth, continued proliferation (the cells becoming smaller and much more numerous, losing their cartilaginous capsules, and assuming all the characters of simple embryonic cells, and the cavities containing each group of embryonic cells still enlarging at the expense of the hyaline cartilaginous substance, and hence approaching one another and here and there coalescing) ; fifth, an irregularly scalloped border, to the whole surface of which is attached, and from the whole surface of which grows, Fig. 1. — IxFLAMJiATioN OF Cartilage. (Coruil aud Ranvier.) x250. . " It is not intended to suggest that these highly endowed cells are incapable of undergoing any form of inflammatory change, for recent observations by M. Charcot seem to prove that the proper cells of the nervous centres may be the primary and chief seats of such changes ; still less that they take no active part in non-inflamma- tory morbid growth, for the investigations of Dr. Creighton tend to show that hetero- logous growths in the liver commence with vacuolation and internal gemmation of "the proper liver-cells. d2 36 IXFLAMMATION. the grey film of embryonic tissue covering the injm-ed surface of the cartilage (each scallop representing a portion of a primitiye cartilaginous capsule, the cavity of which has come to blend with those around it, and the continuous embryonic mass representmg the united proliferating contents of these and other lost cartilage-capsules). We thus see the effects of injury to be : first, growth and prohferation of the proto- plasmic or living parts of the cartilage (the newly-formed cells gradually losing the anatomical and other attributes of cartilage -cells, and degTading into simple embryonic cells) ; and, second, progressive dehquescence and removal of the hyalhie or non-vital constituent of the cartilage under the influence of this cell-gro'«iih and multipHcation, culminating in its entire disappearance from those parts in which proliferation has attained its most advanced stage. The mesentery of the adult animal forms, not a uniform lamina, but a delicate network, of which the trabeculte are in many cases exceedingly fine, without blood-vessels, and consisting solely of a core of connective tissue, and an mvestmg layer of polygonal tessellated epithehum. If a little solution of nitrate of silver be injected into the peritoneal canity of such an animal, inflammatory changes take place in that epithelium, as they have just been shown to take place under ana- logous ch'cumstances in the cells of cartilage. At the end of about twenty- four hours, turbid fluid is found in the serous cavity — the turbidity being due to the presence of cellular elements, pre- senting all varieties between ordinary pus-corpuscles on the one hand, and larger cells containing two or more oval well-defined nuclei on the other ; and the epithehal cells at the surface of the trabecule have become plumper and larger, have lost their cell-walls, and in many case^ have undergone proliferation, giving rise to pus-cells and such other forms of cells as are found floating hi the peritoneal fluid. The cells adhere irregularly to then pomts of origin, and are invested, and to some degree retamed in situ, by bands of coagulated fibrine which has exuded from the hiflamed sm'face. If no further irritation be excited, at the end of a few days the cells floatuig in the peritoneal fluid get opaque and fatty and perish, while those which are still adherent to the trabeculfe flatten and resume the ordhiary characters of serous epithelium. In the above two cases we have proliferation simply of the cells which are proper to the irritated tissues ; in the case of the cornea, however, the results of irritation are more complex and more remarkable. The cornea of the frog consists mainly of a network formed by the imion of the rays of stellate ceUs — the meshes being occupied by mdifferent non-vital material, which corresponds to the hyaline matrix of cartilage, and to the Fig. 2.— IXFLAilJIATIOX OF ilESEXTERY. X 250. (Comil and Eanvier.) EXTEA-VASCULAE PEOCESSES. 37 ■white fibrous trabeculte of ordixiarv connective tissue. If the living cornea be irritated by the application of a point of nitrate of silver [to its centre, changes presently take place in it, which soon spread, and before long involve the whole extent of its tissue, rendering it more 'or less obviously milky and opaque. The first changes discoverable by the microscope are in the immediate vicmity of the injured spot. Here the stellate cells first become unnaturally well-defined, and a little more granular or turbid than ua health ; then they swell, their branching pro- ■cesses at the same time growing thuaner ; presently these are retracted, and the still -grossing cells, assummg a somewhat nodulated or botryoidal form, become as isolated from one another in the substance of the corneal matrix as are normally the cells of cartilage in the cartilaginous matrix. Whilst these changes arem progress the cells grow more and more opaque, and their contents more and more difficult to discriminate ; but soon, obvious proliferation occurs withm them, the nuclei divide and subdi^-ide (each division carrying with it its own particular envelope of pro- toplasm) until every corneal cell becomes the mother-cell of an irregular group of embryonic corpuscles. This increase of the vital elements of the cornea is attended, as is the equivalent process in cartilage, by the liquefaction and removal of the intervening matrix, and ultimately by the coalescence of neighbouring groups of cells and their discharge from the surface of the organ. So far the process is essentially the same as in cartilage, and indeed as in serous membrane also. But something more occurs. Whilst the changes above described are going on in the centre of the cornea, and gradually spreading from that point outwards, other changes are taking place at the periphery of the cornea and creeping thence in the centripetal direction. These consist in the gradual escape of leucocytes from the now dilated marguial vessels, and their immigra- tion (in -virtue of their amoeboid properties) into the mterstitial spaces of the adjoining parts of the cornea. These spaces they soon crowd, rendermg the corneal tissue opaque ; and soon breed, mingling their off- spring with those of the proliferatmg corneal cells, from which they become undistinguishable. Cohnheim, who first recognised this immi- gi'ation of leucocytes into the inflamed cornea, attributes all the morbid •cell-development occurring in it to their presence and action, and con- siders that the proper corneal cells remain perfectly passive. The active share, however, which these latter take in the inflammatory process, has been so often witnessed and described by competent observers, that there can be no reasonable gromad for doubt upon the matter. The concurrence of these two processes, not only in inflammation of the cornea, but in the inflammations of other parts, seems now to be thoroughly well established. Processes, essentially identical with the above, mark the occurrence of inflammation in the mtervascular spaces of the so-called ' vascular ' tissues : — they are, growth and multiplication of the protoplasmic •elements ; immigration and multiplication of leucocytes ; and, concur- rently, the liquefaction or degeneration, and disappearance, of the non- 38 INFLAMMATION. vital parts, and indeed of living parts wliich have attained tlieir liigliest phase of development. Thus we find the earthy and organic matrix of bone eroded into cavities, the trabeculae of white fibrous tissue attenuated into a comparatively delicate network, and muscular and nervous tissues midergoing fatty metamorphosis. h. Vascular iwocesses. — The condition of the blood-vessels in and about an inflamed part has long engaged the attention of pathologists. The important share which they take in inflammation is indicated by the redness which attends the process, and by the dilatation and throbbing of the arteries which lead to the spot in which it is going on. The latter fact indeed sustained, if it did not originate, the belief that the increased flow of blood to an inflamed part was determined by the active movements of the vessels of the part, in the same way that the general distribution of the blood is governed by the alternate contractions and dilatations of the heart. That the active processes going on outside the vessels in an inflamed area create a demand for an increased supply of nourishment, has already been pointed out. This demand can only be satisfied through the medium of its blood-vessels, which consequently soon dilate, and thus attract thither an excessive amount of blood. This phenomenon, indeed, so speedily follows the event which calls it into operation, that in inflam- mation produced experimentally it is often the very flrst indication of the presence of inflammation. If the web of a frog's foot, or its mesentery, or any other convenient tissue of one of the lower animals, be irritated, and the processes which follow carefully observed, it will be seen : that the small arteries of the irritated area gradually dilate and probably after some hours attain their maximum diameter, which may be double that originally presented by them ; that, subsequently to the commencement of the arterial dilatation, perhaps some hours afterwards, the capillaries and veins of the part follow suit, and that thus at length all its vessels get proportionately enlarged. It will further be seen that, while these changes of dimension are going on in the vessels, equally remarkable changes are occurring in the blood-stream within them : at first, while only the arteries are affected, the rate of flow is mcreased ; then, aS general dilatation of the vessels supervenes, the stream flows more and more slowly through them (oscillating, perhaps, in some of the capil- laries), and the white corpuscles congregate and cling to the vascular walls ; at length the blood stagnates, and loses its serum, and the red and white corpuscles get wedged together into an apparently homogeneous or amorphous mass. AVhile, however, this condition of stasis has been coming on in the area of inflammation, the vessels immediately aromid it have become dilated, and through them the blood is still circulating with unwonted rapidity. It is at the period of stasis, or rather perhaps just pre-sdous to it (at the time when the white corpuscles or leucocytes are adhering in large numbers to the inner surface of the vessels) that that emigration of corpuscles, which has already been adverted to, and plays so important a VASCULAK PEOCESSES. 39 Fig. 3.— Migration of White Corpuscles, x 250. (Riudfleiscli.) part in the inflammatory process, chiefly occurs, and may be best observed. If at this time the small veins be narrowly watched (for it is in them that the process commences and chiefly to them that it is confined), small, trans- parent, button-like bodies will be seen to sprmg here and there from their outer sur- face ; these gradually increase in bulk and number, and assume a pyriform shape, and presently, ha-vdng acquired the form and size of white corpuscles, detach themselves from the surface from which they seemed to grow — their comiection thereAvith having pre- viously been reduced to a mere thread. Prior to their complete detachment they often throw out delicate processes which aid them in their ulterior move- ments. In this way vast numbers of white corpuscles pass in a short time from the interior of the vessels into the tissues external to them, without leaving behind them a trace of the route by which their escape through the parietes was effected. It is ob\dous, then, that variations in the dimensions of vessels, and in the rate of flow of blood through them, are very important incidents in the collective phenomena of inflammation. But it is not at all easy to deter- muae upon what cause, or on what combination of causes, the several variations depend ; and especially it is difiicult to trace the exact relation between the varying diameters of vessels and the varying rates of the passage of their contents along them. We know that the smaller veins, and stiU more the smaller arteries, are capable of contractmg and dilating within comparatively wide limits, and thus of regulating to a considerable extent the amomit of blood to be admitted into, or discharged h'om, the area to which they minister ; and that this function is affected by means of their muscular walls, which, when they contract, diminish the calibre of the vessels, when they relax, permit of their dilatation. We now know also, chiefly through the labours of Strieker, that the capillary vessels are not merely passive organs, contractmg and dilating in obedience to the various degrees of blood-pressure to which they are subjected; but that^ in vhtue of the endowments of the living protoplasm of their waUs, they possess, hke the arteries and veins, a power of active contraction. And, further, we now have good reason to believe that arteries, veins, and capillaries possess, in addition to the power of active contraction and the capability of passive dilatation, a distinct power of active dilatation, or at any rate of dilatation with retention of tonicity. Again, we know that the muscular tissue of the vascular system, like that of all other parts, is under the dominance of nerves — in this case the nerves of the vaso- motor system. Contraction of vessels may be caused, either by the direct application of irritants to them, or by exciting the cut surface of the distal portion of a divided motor nerv^e, comprising vaso-motor fibres, distributed to them. Active or tonic dilatation seems specially to be in- duced by reflex action, excited by stimulating the sensory nerves of the 40 INFLAMMATION. part in or near which tlie vessels undergoing dilatation are situated. Pas- sive dilatation takes place whenever the influence of the vaso-motor nerves is abohshed or weakened, or the vascular walls lose their proper contrac- tile power. We may gather from this statement that the primary di- latation of the vessels of inflamed parts is due to reflex stimulation, traceable to the inordinately active vital processes which are taking place in the extra-vascular tissues ; and that the later dilatation is probably merely passive. As regards the question of the variations which take place in the rate of the blood-flow in the vessels of inflamed parts, it wiU be sufiicient for our purpose to point out : that the increase which occurs in the early stage of inflammation in the centre of the inflamed area, and which is mamtained continuously in the immediate neighbourhood of the lesion, is in obvious accordance with the physiological fact that dilatation of the smaller vessels not only admits of a larger presence of blood in them, but allows of a more ready transit of blood through them ; and that the stasis, which takes place after a time in the still dilated blood- vessels of the inflamed area, is obviously connected with the tendency which the corpuscular elements of the blood have then acquired to adhere to, and pass through, their walls — which conditions in their turn doubt- less depend on the altered nutritive relations then subsisting between the walls of the vessels and tissues external to them on the one hand, and the blood within them on the other. c. Exudation. — The abmidant fluid which sweats from the vessels during inflammation, though consisting essentially of the serum of the blood, presents modifica- ^ tions of constitution deter- mined by the tissues in connection with which its escape occurs, and further involves diflerent results accordhig to the circum- stances attendmg its es- cape. The swelling, which always accompanies inflam- matory processes gomg on in the substance of organs and tissues, is mauily de- pendent on this exudation ; and indeed if the parts involved be lax, serous infiltration, or oedema, is apt to spread far beyond the limits of actual inflammation. Li inflammation of mucous membranes, the mem- brane itself, and the tissues which are subjacent to it, all get infiltrated ; but, in addition, there is generally a copious discharge of fluid from the free surface. The most abmidant discharge, however, takes place into serous cavities when the membrane which invests them is the seat of inflammation. It is thus that hydrothorax and ascites are often produced. The most common distinction between inflammatory fluid-exudation and blood-serum is the presence in the former of a comparatively large quan- PiG. 4.— Fibrinous Exudation. a. From dipTitheritic membrane. ; &. From inflamed pleura. x500. SUPPUKATION. 41 tity of fibrine, or fibrinogen. This is observed to a greater or less extent in all cases, but is especially remarkable in the inflammations of serous membranes, in which the great bulk of the exuded fibrine coagulates at the moment of its escape, entangling morphological elements, and forming the false membrane which adheres so characteristically to the surface. Another, but less frequent, peculiarity is the appearance in it of mucine ; this is observed chiefly when the mucous and syno-\dal membranes are affected, and is due to the direct mfluence of the cells of the diseased surface. We have pomted out that the exudation of white corpuscles is probably an essential element in the inflammatory process ; small but variable numbers of red corpuscles also are apt to exude m company with them ; but at times the escape of blood-cells is much more abundant than can be explained by this process, and is manifestly due to actual rupture of blood-vessels — generally vessels of new formation. d. Suppuration. — A frequent event of inflammation, and one that marks one of its recognised stages, is the formation of pus. ' Laudable pus,' as it is termed, is a thick, creamy, mawkish-smelling, alkaline fluid, contain- ing a great abmadance of corpuscles, to the presence of which its opacity c Fig. 5. — Pds-cf.ll^'. x500. a. Ordinary appearance. 6. Showing amoBboid movements, c. After addition of acetic acid. d. Undergoing fatty degeneration. rand whiteness are due. The fluid part, which is called the ' liquor puris,' contains, like the serum of the blood (fi'om which it is derived), albumen, salts, &c., and differs little from it in composition. It sometimes also presents a peculiar albuminoid substance, named ' pyine.' The corpus- cular part consists almost entirely of bodies termed ' pus-cells,' which, as generally seen, are globular in form, varying between 05^00 ^'^^ Wto i^ch m diameter, and differing little, if at all, from leucocytes, or so-called * mucous corpuscles,' or embryonic cells. They are transparent, colourless, more or less granular masses of protoplasm, without investmg membrane ; which, though globular when dead or as usually examined, present active amoeboid movements of locomotion and change of form, while still lining and under appropriate circumstances. Under the influence of water, or still better dilute acetic acid, the general substance of each corpuscle swells up and increases in transparency, and one nucleus, or more frequently two, three, or more nuclei become revealed within it. It is obvious, then, that there is little or no microscopical difference between tj^pical pus-corpuscles and the corpuscles developed, previous to the suppurative stage, by the breeding of connective-tissue cells and 42 INFLAMMATION. other stationary protoplasmic bodies, or of immigrant leucocytes, and that they have both a common origin. Indeed at every suppm^ating surface the gradual transition of the one into the other may be readily observed. There is, however, some reason to doubt whether pus- corpuscles ever multiply, and some reason to beHeve that the groups of small nuclei they contain are to be regarded as the last abortive attempt at reproduction. It is not difficult to trace some of the steps which lead to the develop- ment of pus. It has already been shown that when inflammatory pro- liferation is going on the indifferent or non-vital tissues between the groups of swarming cells gradually get eroded and removed ; and that presently, as these disappear, the neighbouring groups of cells come into direct rela- tion with one another, and thus constitute an almost uniform mass of embryonic tissue. They still cohere, however, either as epithehal cells do, or through the intervention of some scanty adliesive material. It needs only the loss of this cohesive property, and the addition of the liquor puris, to convert this inflammatory hypertrophy of tissue into orthodox pus. It is thus, indeed, that suppuration takes place at the surface of an ulcer ; it is thus, also, that abscesses arise. In the latter case : softening occurs in the centre of some proliferating region, and the cells, which would other- wise have formed an ingredient of solid living tissue, change into piis- corpuscles ; by extension of the softening, the abscess enlarges, and more corpuscles are added to its contents ; and further, the existence of a cavity induces towards it a rapid migration, both of the extravasated leucocytes and of the other embryonic cells which crowd the periphery. By continu- ance of the above processes, abscesses approach neighbouring surfaces, point, and presently rupture. The pus-corpuscles contamed within abscess-cavities speedily undergo degenerative changes, and perish : they get studied with fatty particles, swell, and subsequently break up into a. detritus ; or they contract and become opaque and angular ; or they undergo calcareous impregnation. And thus the contents of abscesses are gradually absorbed, or converted mto caseous, mortary, or other such stuff, and a more or less perfect cure ensues. Pus of recent formation does not always present the exact characters above assigned to it, but sometimes is thin and watery [ichor), sometimes contains a greater or less admixture of blood (sanies), and sometimes is distinctly fetid. These obvious peculiarities are dependent on something special, either in the condition of the patient or in that of the part which is suppurating, and are connected with peculiarities of microscopical and chemical constitution. Thus, we occasionally find that all the pus-corpus- cles have already undergone degenerative change, and that in place of the orthodox cells we have only granule -cells, or it may be a mere molecular debris ; or that abundant blood-corpuscles are mingled with the other ele- ments of pus ; or that fragments of tissue (bone, and the like), are con- tained in it; or that bacteria and other minute living organisms are present. The admixture of visible particles of tissue implies the associa- tion, with the suppuration, of somewhat rapid destruction of parts, and DESTEUCTIVE PEOCESSES. 43 often indicates necrosis or gangrene ; the presence of bacteria and the Kke is a proof, cither that the pus is undergoing putrefaction, or that the blood generally is infected with them. Under these latter conditions fetor is pretty certain to be present. e. Destructive 2>rocesses. — The destructive effects of inflammation have already been adverted to. They are shown in the softening and disinte- gration which take place in the hyaline substance of cartilage, in the white fibrous element of connective tissue, and in the earthy matrix of bone, during the gradual multiplication of cellular elements, and especi- ally during the formation of abscesses. They are shown also in the fatty and other degenerative processes which, mider similar circumstances, go on in muscle, nerve-cells, and other higher tissues, taking no part in the inflammatory proliferation. Destruction occurs, however, in a yet more marked form in the various processes termed ' ulceration ' and ' necrosis ' or ' gangrene.' In gangrene a larger or smaller portion of tissue perishes, and is pro- bably separated in mass from the neighbouring living textures. The death of the part is due essentially to its deprivation of nourishment ; which deprivation depends moscly on obstruction of the arteries lead- ing to it, either by clot in their interior, or by thickening of their walls, or by external pressure arising from accumulation of inflamma- tory products or other causes. In inflammatory gangrene the parts involved are usually swollen or succulent, for the reason mainly that, like all inflamed tissues, they were previously infiltrated with abundant exudation. In ulceration the destruction of parts is molecular, or by small frag- ments, and progressive. It has long been a question whether, in the common forms of ulcer which gradually extend in area and depth, the apparent melting away of tissue, on which their extension depends, is due to absorption by the vessels or to discharge from the surface. It is obvious, in any case, that this gradual disappearance of tissue must be preceded by its liquefaction, degeneration, or death ; for these are normal and necessary processes by which, even in health, the worn-out portions of the body are prepared for removal by absorption, and equally the processes by which, during inflammation unattended with ulceration, the more lowly- organised structures (the matrix of cartilage, cornea, bone, and the like) melt away and disappear ; and indeed it is impossible to conceive of any other. Looking then to the fact that the molecular destruction, which is going on at the surface of ulcers, presents no real difference from that which is going on in the non-ulcerating stage of inflammation (the products of which are certainly removed in chief measure by absorption), it seems not improbable that a portion of the effete products of ulceration also may be removed in this way. But on the other hand, since the destruction takes place at a free surface, which is exuding a considerable quantity of fluid and even of corpuscular elements (conditions which are highly favourable for the discharge from that surface of any effete matters which are produced there) it seems hardly likely 44 INFLAMMATION. that these should be removed by absoi'iDtion only. Indeed it seems most probable on physical grounds alone, that the chief removal of ulcerative detritus should be effected in the manner last described. That it is mainly thus removed is now generally acknowledged. It may be added, in confirmation of this view, that the discharge from ulcers invohdng bone contains earthy matter, and even small fragments of bone ; and that generally, when ulceration is extending rapidly, fragments of disintegrated tissue are suspended in the fluids which exude from the ulcerated surface. In sloughing ulcers, such as those attacked with hospital gangrene, extension is attended with an abundant separation of shreds and flakes of dead tissue from the diseased surface. It will of course be understood that the above remarks apply only to those cases in which ulceration is in progress. Excavations, whether termed ulcers or not, in which the surfaces are granulating, are examples, no longer of ulceration, but of repair and restoration. /. Grganisation and granulation.— It has already been shoT\Ti that, at an earlier stage than that at which suppuration occurs, the results of inflammatory proliferation are the production of a greater or less quantity of embryonic tissue, or tissue at a low phase of organisation. If solid structures be implicated, the intervening matters melt away, and the newly-formed cells come into near, if not absolute, relation with one another ; if the process occur at the surface of a serous membrane, the new-formed cells are retained in connection with that surface by entangle- ment in the fibrine which coagulates there. In the progress of organisa- tion important changes ensue. In the latter case the embryonic corpus- cles, entangled in the fibrine, throw out delicate processes, by which they presently unite with one another to form a network, in the meshes of which the fibrine is then contained. At the same time, new vessels, starting from the normal vessels of the subjacent serous membrane, shoot into the adventitious tissue. Later, the fibrine undergoes liquefac- tion and removal, and the interspaces between the cells get occupied by a form of white fibrous tissue, which they are instrumental in manufactur- ing. In the case of the organisation of inflammatory products occupying the substance of organs, essentially the same series of events happens : — the embryonic cells undergo conversion into connective-tissue corpuscles ; new vessels are formed; the fibrine which has coagulated, and in a greater or less degree the proper or special highly endowed elements of the parts, get removed, and the non-vital elements of connective tissue are deposited in their place. In both cases the new-formed tissue belongs to the connective-tissue series, and in both tends to contract and get dense and hard iia texture. The processes, here briefly described, take place also in the heaHng of wounds, and in the filling up of ulcerous or other excavations by granula- tion. Granulations are hemispherical masses of cells, produced and increasing in size by constant cell-breeding and immigration of leucocytes. The cells in the first instance are purely embryonic in character, and many of those growing at the free surface, and others which migrate OEGANISATION AND GKANULATION. 45 thither, are shed as pus. But presently those which remain undergo differentiation ; the majority elongate or send out processes and gradually evolve connective tissue ; whilst others also elongate, but become aggre- gated into solid cylindrical loops, soon to be hollowed into channels of communication with previously existing vessels, and thus themselves to become blood-vessels, and important agents in the further growth and vitality of the granulation-tissue. Eindfleisch describes and figures the formation of lymphatic tissue in the overgrown vegetations of ' proud flesh.' Neighbouring granulations, as they grow, run together and blend, and thus at length cavities get filled up with a tolerably homogeneous mass of new-formed tissue. But when the granulating mass attains the general level of a free surface, such as that of the skin, its further growth under ordinary circumstances becomes arrested, epidermis begins to shoot from the normal epidermis at the margins over the edges of the granula- ting area, which at the same time contracts, and soon, if it be of small size, gets completely covered. It is even now a disputed point whether a granulating surface has any power of itself to generate epidermic cells. It is certain, however, that the chief development of new epidermis begms fi'om old epidermis, that very large breaches of surface never become thus covered unless aided by artificial means, and that the grafting here and there, upon such a surface, of small fragments of epidermis results in the formation of a number of epidermic islets, from which new epidermis sj)reads radially. In the healing of a clean cut, of which the edges are placed in close apposition, the process is nearly the same as that of the organisation of false membranes. The divided vessels pour out blood and serum, containing fibrinogen ; this coagulating entangles corpuscular elements, and cements the divided surfaces ; and presently the white corpuscles thus entangled, and others which migrate among them, emit processes and form a network, mapping out the fibrinous cement into comparatively small islets. The further steps of the process present no peculiarity. The ultimate product of inflammatory organisation is generally what is commonly termed ' cicatricial tissue : ' a form of connective tissue presenting m.ucli hardness and compactness, comparatively little vascu- larity, small and widely scattered plasmatic cells, and relatively abundant and dense interstitial substance ; which becomes bony when developed in connection with bone, and contains fat when it replaces normal fatty tissue ; but which, while it is capable of reproducing, with more or less imperfection, the various tissues comprised in the connective-tissue group, rarely results in the production or development of higher tissues, such as muscle, and probably never in the formation of organs. Hair and glands, for example, never appear in entirely new-formed skin. In some cases the results of inflammatory proliferation are somewhat different. The process gets chronic, cell-generation goes on compara- tively slowly, and the newly-formed tissue, instead of contracting and hardening, becomes swollen and perhaps softer than natural, and forms, in fact, an increasing projection or lump, in which the cell-elements 46 INFLAMMATION. remain predominant, but tend to fatty and other forms of degeneration. Sucli results are seen in keloid and in some forms of arterial atheroma. g. Spread. — The tendency which inflammations have to spread is at least as remarkable as that presented by other proliferating affections. If a patient has local eczema, produced by the application of some irritant, presently other patches of eczema appear in the neighbourhood ; if he has a boil, it commences in a point, and increases by involvmg more and more of the smTounding tissues, and soon other boils arise m its vicinity ; ia erysipelas and pneumonia, and in mflammations of serous and mucous membranes, the same rule of local spread, or spread by simple continuity, is even more obvious. But inflammations also tend, in many cases, to spread through the agency of the lymphatics and veins, and thus to in- volve remote parts, and other tissues besides those first affected. Thus, suppuration, occurring in a toe or finger, is apt soon to be followed by inflammation in the course of the lymphatic vessels, and of the lymphatic glands in the groin or axilla ; and indeed generally there is a tendency, if the local inflammation be sufficiently intense, for the nearest lymphatic glands to get impHcated, And thus again, in certain cases, inflammatory processes become generalised by means of the circulating blood, so that tracts of inflammation, secondary to some primary tract, appear, either simultaneously or in quick succession, in various parts of the body. Ordmary pyaemia furnishes a typical example of this connection ; and it is not impossible that the frequent association of inflammation in different organs, and even the invasion of successive joints m acute rheumatism, may admit of similar explanation. h. Constitutional effects. — We must not forget to consider, however briefly, the mfluences which inflammatory processes going on in one part of the system exert on the system generally. Patients who are suffermg from acute inflammations are soon affected with febrile symptoms. To what are they traceable ? In some degree, no doubt, to the direct influ- ence which abmidant local proliferation of tissue exerts generally upon nutrition. It "svill be recollected, however, on the other hand, that the copious and active proliferation attending the formation of an extensive surface of granulations, or the development of the foetus, produces no such constitutional disturbance. But, indeed, the inordinate consumption of nutrient matter is certainly not the main cause of the constitutional symptoms of inflammation. It has been proved by direct observation that a part generates much more heat when inflamed than when in its normal state ; and that the blood m the veins coming from an inflamed area is distinctly hotter than the blood brought thither by the arteries. It is certam, therefore, that a part of the febrile temperature of the system must be due to the dispersion of this excessive locally-produced heat. Again, as we have already pomted out, wherever mflammatory proliferation is active, there also the processes of effusion from the blood- vessels, of molecular dismtegration, and.of lymphatic absorption, are specially active ; and thus large quantities of modified nutrient fluid, and of products of decay, alike, are being constantly removed from the seat of VAEIETIES. 47 disease and poured through the thoracic duct into the systemic veins. It seems highly probable that here is the source of the comparatively large presence of fibrinogen which is so characteristic a feature of the blood of inflammation, and that here also is the main source of the excess of urea and other products of retrograde metamorphosis, which are presently discharged by the various emunctories. There can be no doubt that the general symptoms of inflammatory fever are largely due to the heightened temperature, and to the alteration and deterioration of the blood, Avhich have been thus produced — conditions which, according to their amomit, must necessarily influence in a greater or less degree the nutrition and the functions of all parts of the system. It is certain too : that the nervous system, mainly by its vaso-motor branches, plays an important part in the production of febrile disturbance, though what that part is is not easy to identify ; and that the symptoms of inflammatory fever are largely modified, chiefly in the way of complication, by the mterpolation of other symptoms, due to the modification, impairment, or destruction of the normal functions of the organ which happens to be affected. i. Varieties. — In the foregoing pages we have discussed the pheno- mena of inflammation in the abstract ; our account of inflammation would scarcely be complete, however, if we failed to point out some of its varieties : varieties depending partly on the intensity of the process, partly on the organ implicated, and partly on the nature and mode of operation of the cause ; and revealing themselves as such, either by their extent and arrangement, or by their special tendencies, or by their dura- tion. It need scarcely, perhaps, be pointed out, that we trench here upon the domain of specific diseases, or diseases in which the inflammation is a mere secondary phenomenon, excited and kept up by the operation of some specific irritant, which has been received mto the system and then distributed through it. But indeed, as knowledge advances, we see more and more clearly that in every case of inflammation which comes before ns, the mflammation has been excited by some cause which imparts to it certain distinctive features— that it is specific — and we recognise the fact, half unconsciously perhaps, by distinguishing most varieties of inflamma- tion by specific names. i. Varieties as to extent and arrangement. — In many cases inflamma- tion pervades, with tolerable uniformity, the whole of an organ or tissue — such is the case in pneumonia, peritonitis, erysipelas, and pityriasis rubra ; in many cases, it is irregularly distributed in patches or spots, as in the rashes of typhus and enteric fevers, in urticaria, shingles, and lobular pneumonia ; in other cases, it assumes certain definite patterns discs in lepra, rings in erythema circinatum and ringworm, crescents in measles, and sinuous bands in some cases of secondary sj^^hilis. ii. Varieties as to result and intensity. — It is certainly a striking fact that some forms of inflammation, no matter how severe they may seem, or threaten, to be, never pass beyond the earlier stages of the process • while others, which commence probably with the mildest indications, in- 48 INFLAMMATION. variably go on to suppuration or gangrene. In such diseases as measles,, pityriasis, and lepra, the local phenomena of inflammation are always exceedingly slight, and consist in little more than hypera3mia in patches, followed by modification, and then detachment, of the overlying epidermis. In urticaria, the process, if more intense for the time, is far shorter in its duration : for here we get pretty intense congestion, with rapid effusion of serum into the congested tissues, which subsides in a few hours or even in a few minutes, and is rarely followed even by desquamation. In eczema, herpes, and pemphigus, the local congestion is always attended with abundant effusion of serum beneath the epidermis. Now, in all the above cases, notwithstanding the marked differences of detail which they exhibit, the changes are rung only on mere congestion and effusion, to- gether with (as is of course always the case) a certain amount of nutritive change, if not of actual proliferation. In other cases suppuration seems to occur almost invariably ; it is so with small-pox and cow-pox, impetigo and ecthyma ; and in inflammation affecting the periosteum, and the womb immediately after parturition, this suppurative disposition is ex- tremely well marked. In other cases, again, the tendency of the inflam- mation to end in the death of tissues, that is in ulceration or gangrene, is a characteristic feature ; as examples we may adduce erysipelas, car- buncle, and hospital gangrene. iii. Varieties as to duration. — Inflammations are acute or chronic in their progress. Acute inflammations are sometimes, as in factitious urticaria, remarkably evanescent. Chronic inflammations are chronic in different fashions : in some instances the inflammatory process, as in the case of a patch of psoriasis on one of the knees, or of a sinus con- stantly discharging pus, is continuous and of long duration ; in a larger number of cases chronicity is due to a succession of acute attacks, each one of which may have but little intensity. It is thus that urticaria assumes the chronic form of urticaria evanida, and that erysipelas and eczema become perpetuated ; we may add to the list rheumatism and gout. It seems probable also that cirrhosis of the liver, referrible to alcohol, is rendered chronic by the repeated irritation induced by the repeated application of the alcoholic poison. It is in these latter forms of chronic inflammation, more especially, that the proliferation of tissue^ which attends all inflammations, becomes constant, and leads to a sub- stantial addition to the normal bulk of a part ; that bones acquire m- creased thickness and density ; and that the interstitial tissue of the liver, kidneys, lungs, and nervous centres gets augmented in quantity, and by its augmentation leads to the gradual destruction of the essential glandular elements. k. Belation of inflammation to septic organisms.''- — Of the important relations subsisting between micro-organisms and some kinds of infective inflammations there can be no doubt. There are some persons, indeed, who regard all inflammations as the product of septic organisms ; and Hueter, a distinguished advocate of this hypothesis, says expressly, ' Septic 1 See Dr. Burdon Sanderson's Lumleian Lectures on Inflamvuition. NEW VIEWS OF INFLAMMATION. 49 organisms exist everywhere, ready, wherever access is offered to them, to enter the body and fulfil their morbific fmiction ; consequently, inflam- mation may be defined, with reference to the universality of its cause, as an epidemic and contagious disease Avhich prevails universally over the whole world, with the exception of mountainous regions, near and above the line of perpetual snow.' There is more reason to believe, with Sander- son and others, that while inflammation may be excited by any local irritant, its spread or diffusion, and its communication from one person to another, are determined only by the agency of such organisms ; or, in other words, that inflammation caused by simple irritation remains strictly limited to the parts irritated, and incommunicable, that inflamma- tion caused by septic organisms is alone infective and infectious, and that whenever simple inflammation acquires such properties its spread is due to the superadded agency of the bodies referred to. Note in Reference to recent Views as to the Nature and Processes of Inflammation. It was taught by Virchow, and accepted implicitly for many years, that the essence of inflammation is irritative growth and proliferation of the stationary protoplasmic elements of the tissues involved in inflammation, resulting in the formation of abundant embryonic corpuscles or pus-cells ; and that the associated phenomena of the accumulation of blood plasma in the tissues, the dilatation of the blood-vessels with retardation or stag- nation of their contents, and others which need not be enumerated, are secondary to the processes occurring externally to the vessels, and to a large extent determined by nervous influence. The discovery of Cohn- lieim, that in inflammation (even the inflammation of extra-vascular tissues) leucocytes escape in large numbers through the walls of the dilated and distended capillary veins and other small vessels, find their way abundantly into the interstices of the connective tissue, and accu- mulate in the very parts in which previous observers believed they had witnessed the development of similar cells from the germination of connec- tive-tissue and other corpuscles, naturally tended to throw some doubt on the trustworthiness of these observations. It then came to be generally held (in accordance with the account already given, and provisionally adopted) that the source of inflammatory corpuscles (pus-cells, leucocytes, and the like) in inflamed arese is twofold, namely, the multiplication of stationary protoplasm, and the immigration of the white corpuscles of the blood ; and the phenomena observed when the centre of the cornea is irritated were (as we have shown) appealed to in proof of this double origin. Later investigations, however, render it more and more probable that all inflammatory corpuscles, all pus-cells which appear or accumu- late in inflammation, are simply immigrant white blood corpuscles ; and that no such local proliferation as was formerly described ever takes place, or at any rate ever takes place as the direct consequence of the irritation causing inflammation. The phenomena, indeed, observed in E 50 INFLAMMATION. corneal inflammation are now appealed to as confirming this view. It appears, in fact, that the localised area of opacity takmg place around a central point of irritation, and which is due to the accumulation of inflam- matory corpuscles, does not take place unless the epithelial covering of the cornea be damaged or removed, and that it is due immediately, and alone, to the entrance through the breach of leucocytes, or bodies resembling them, which abound in the sac of the conjunctiva. If this exclusive origin of inflammatory corpuscles and pus in an inflamed area be admitted, the hitherto accepted views with regard to the theory and processes of inflammation need important modifications in other respects also. It is clear that if the local eflects of pathological irritation be not overgrowth, proliferation and exaltation of function of the irritated living elements, either these elements maintain their normal state of health imder the adverse conditions in which they are placed and remain unchanged, or their vitality becomes impaired in a greater or less degree or destroyed. Of the inadmissibiHty of the former alternative there is abundant proof. We know, on the other hand, that at any rate in large proportion the living tissues are actually damaged or destroyed in regions that are inflamed ; and there is little or nothing therefore (apart from the supposed fact of local proliferation) to render it inlprobable that the impairment or necrosis of hving tissue is the necessary and universal immediate consequence of nritation inducing inflammation, and the fundamental fact of inflammation. Accorduig to the above hypothesis : all inflammation is a local phenome- non ; its origin is damage done to the part which subsequently inflames — damage which, if slight, may allow of recovery, if severe, may necessitate death ; the immediate effect of the damage is that the protoplasmic masses distributed throughout the part become weakened physically and function- ally, and that the embedded vessels therefore become weakened, and dilate imder the normal pressure of the blood within them ; the vessels thus passively enlarged permit of the accumulation of blood in their ulterior, and consequently of retardation of the blood-stream, with separation of the red and white corpuscles and tendency of the latter to take a peripheral position ; this stagnation of blood in the vessels involves the transudation (through their walls mto the tissues around) of the blood-serum, with its albumen, and the formation of fibrme, and further (if the vessels become completely occluded) increased impairment or destruction of tissue ; the so-called ' vital processes of inflammation ' which determme the removal or repair of the tissues devitalised by inflammation, and which comprise the mic^ration of leucocytes and their accumulation in the diseased area, and the growth or development taking place in the healthy protoplasmic masses immediately surrounding that area, form no part of the inflamma- tory process, and are simply reparative in their tendency. It follows, from what precedes, that redness, heat, swelling and (if nerves be involved) pain are the natural consequences of simple impaired vitality of tissues, and that even on the new hypothesis the clinical signs of inflammation remain the practical tests of inflammation. TUMOUES. 51 4. Tumours. General account. — It would be foreign to the purpose of this work, and to a great extent out of place, to enter into anything like a minute account of the various forms of timiours which are described by patholo- gists. We purpose, however, to pass them generally in brief re\dew — describing at greater length those of them which have a special relation to the practice of medicine, and a special interest therefore for the physi- cian. Tumours, in the proper sense of the term — that is, morbid prolife- rating growths, or neoplasms — have a very close affinity with simple hypertrophy or hyperplasia on the one hand, and with mere inflammatory overgTowth on the other. Structurally considered, they are in truth, in many cases, a simple hyperplasia or overgrowth of normal tissue, differ- ing, however, from true hyperplasia in the facts : first, that they are over- growths occurring in a limited district ; and second, that their growth has no relation to the general growth of the tissue out of which they spring, or to the general nutrition of the body. In many cases, again, tmnours and simple inflammatory overgrowths are structurally identical ; but generally the latter are more rapid in their development than tumours are, and at the same time much more ephemeral in their duration. Tumours have been variously classified. They have been divided into the two large groups of cystic and solid tumours. But cysts, although a very characteristic feature of some new formations, are for the most part merely incidental to them, and their presence or absence can in no sense furnish the basis of a scientific classification. Again they have been dis- tmguished into those which are innocent and those which are malignant. The question of the malignancy or non-malignancy of a tumour is always, in a practical point of -view, of supreme interest ; and it may be allowed that, in a large number of cases, malignancy is linked to special structural characters, and may be predicted from them. But, on the other hand, it is now generally admitted that malignancy varies in degree, and that few if any proliferatmg growths are wholly free from liability to assume malignant properties. Virchow, accepting the law which J. Miiller enunciated (namely, that ' the tissue which constitutes a tumour has its type in one of the tissues of the organism, either in its embryonic con- dition or at the period of its complete development '), classifies tumours according to their structural relations with the normal tissues of the body. Such a classification is at once scientific and intelligible ; and although many difficulties, and much room for difi'erence of opinion, present themselves when it is attempted to carry it out in detail, there can be little doubt that it is sound in principle, and will ultimately be universally adopted. But admitting that all tumours have their types in the normal tissues, it does not always happen that a tumour has its type in the precise tissue in which it originates. When a tumour arises in a tissue from which it takes its pattern, it is regarded by Virchow as ' homologous ; ' when, on the other hand, it is developed in a tissue wliich it does not thus resemble, he calls it ' heterologous.' The latter term E 2 52 TUMOURS. has often been used of malignant tumours, in the behef that they are something altogether different and distinct from the normal elements of the body — something in fact of the nature of parasites ; and it is well to know that, even in the more accurate and limited sense in which Virchow employs it, it still carries with it the sense of malignancy. Most malignant tumours are heterologous. Virchow divides tumours into four groups, as follows : — 1, tumours formed at the expense of the elements of the blood, or tumours by extra- vasation and exudation ; 2, tumours referrible to the retention of products of secretion, and the consequent dilatation of ducts or cavities; 3, tumours originating in proliferation, which he subdivides into histioid, or such as are formed out of a single tissue, organoid, or such as are characterised by greater complexity and an approach to the structure of organs, and teratoid, or those comprising a combination of organs ; and 4, or lastly, complex tumours, in which features characteristic of two or more of the foregoing groups are combined. The first two of Virchow's groups embrace a series of pathological results which can only be regarded con- ventionally as tumours ; all true tumours are included in his third and fourth groups. We shall not discuss the details of the above classification, nor shall we reproduce here the convenient modification of it which MM. Cornil and Ranvier have published ; yet, in the brief account of tumours which we are about to give, we shall be guided in a very great degree by the views of these authors. Indeed the modifications, mainly of arrangement and proportion, which we shall introduce, will have reference almost entirely to convenience of description and to clinical considerations. We shall arrange tumours (omitting, as will be observed, all further reference to the teratoid and complex forms) in the following groups :— a, tumours which have their types in the various forms of connective tissue : this includes the fibrous tumour or fibroma, the fatty tumour or lipoma, the mucous-tissue tumour or myxoma, and one or two less impor- tant varieties ; h, tumours composed of cartilaginous tissue, or cJiondromata ; c, osseous tumours, or osteomata ; d, tumours formed of nervous tissue, or neuromata ; e, tumours consisting of muscular tissue, or myomata ; /, vascular tumours, or angiomata '; g, tumours consisting of lymphatic tissue, or lymi^homata ; h, sarcomata, or tumours which resemble embryonic tissue ; i, tumours presenting an alveolated structure — the alveoli bemg formed of connective tissue, and occupied or lined by closely packed epi- thelium-like cells. All these are embraced in the general term carcinoma or cancer. j, granulomata, or tumours resembling granulation-tissue. These are for the most part, if not alw^ays, infective, and (there is reason to believe) due to organised contagia. CONNECTIVE -TISSUE TUMOUES. 53 a. — Connective-tissue Tumours. i. Fibrous tumour, or fibroma. — Tumours of this kiud consist essen- tially of connective tissue — that is of a network of plasmatic cells, sepa- rated from one another by bmidles of white fibrous tissue and different proportions of elastic fibres ; the last, indeed, are often absent. They are rosy, greyish, yellowish or white in tint ; are sometimes dense and close- grained Hke fibro-cartilage, sometimes soft, loose in texture, and succu- lent ; are provided for the most part with scanty and small blood-vessels, and are occasionally non-vascular ; and often, when involving a mucous or a serous surface, mvolve also the glandular and papillary structm-es, which then undergo hypertrophy. Fibrous tumoiu's often originate m the sub- cutaneous comiective tissue, and also in the substance of the skin — pro- ducing warts or papiUomata, ' molluscous ' tumours, and it may be pedun- culated masses of enormous bulk. Again, they are frequently developed in comiection with mucous surfaces, forming mucous polypi. The opaque cartilage- like patches seen on the sur- face of the s^sleen, heart, and other \'iscera, are fibromata ; but their plasmatic cells are scanty, mdistmct, and miich flattened, the fibrillated inter- mediate substance is densely stratified, and they are with- out vessels. The thickening and induration of the skin and subcutaneous connective tissue, in elephantiasis Arabum, are chiefly due to the growth of connective tissue, and constitute a diffused form of fibroma. It is very difficult to separate, by a defined hne, the results of chronic inflammation from fibromatous tumours, especially from the diffused forms of fibroma. Indeed, papillary growths and polypi are frequently a simple sequela of ordinary inflammatory processes ; and further, there is little if any real difference between the forms of fibroma involving the pyloric extremity of the stomach, or the substance of the mamma, which we generally regard as of the natm'e of tumours, and the fibrous growth invading the liver in cirrhosis, which is commonly considered to be simply inflamma- tory. Fibrous tumours are apt to undergo various forms of degeneration, especially the fatty, mucous, and calcareous. They are almost invariably free from malignant tendency. ii. Fatty tttmour, or lipoma. — Fat is a mere modification of comiec- tive tissue, in which the plasmatic cells have become distended with oil, so that their protoplasm and nuclei can only be recognised with difticulty, and they themselves are transformed into globular, or (from mutual pres- sure) polyhedral, bodies. Fatty tumom's consist, for the most part, simply of newly-developed fat-tissue, and present little if any structural differences from normal fat. They vary in size, and generally are lobu- Fi'J. 6.— Fibroma from Surface of Spleex. x25u. 54 TUMOURS. lated, and capable of pretty easy enucleation from the tissues in which they are imbedded ; but sometimes their limits are ill defined, and they pass gradually into the normal textures. Lipomata often originate m the subcutaneous connective tissue, and occasionally in the submucous and subserous tissues ; also in the neighbourhood of glandular organs ; and indeed generally wherever fat exists naturally. Not mifrequently they form polypi or pedunculated tumours. There are several well-defined varieties of fatty tumours : one, which may be called fibrous lipoma, is characterised by the presence of abundant fibrous tissue ; another (the myxomatous lipoma) presents the combined characters of myxoma and lipoma ; a third is the cystic lipoma ; and the last which we may enumerate is the erectile or cavernous lipoma. Further, fatty, like fibrous tumours (to which they are closely related), are liable to undergo calcareous and other forms of degeneration, and are probably always imiocent. iii. Mucous tumour, or myxoma. — Mucous tissue, which is common in the foetus, exists permanently only in the vitreous humour. The tissue ■ Fig. r. — Myxoiia. a. (H. Amott). i. (Cornil and Ranvier). of the umbilical cord furnishes a typical example of it. It consists of plasmatic cells, which are generally stellate like those of connective tissue or bone, and of an intercellular substance, which, instead of bemg solid, as in these latter cases, is transparent and fluid and contains mucine, or the characteristic constituent of mucus. Myxomata are lobulated tumours, gelatinous in consistence, translucent, and yielding a transparent, glairy, never milky, fluid. Under the microscope they are seen to consist of CAKTILAGINOUS TUMOUKS. 55 scattered cells, roimd, oval, or stellate, and an abundant network of capillary vessels, separated from one another by the structureless fluid, or semi-fluid, mucus, which gives them their specific character. They vary in colour and consistence according to the relative proportions of cells and mucus which they contain, being more opaque and denser as the cellular element predominates. They originate in most places in which normal fat occurs, and indeed there seems to be some definite relation between them and fat. But they occur elsewhere. Their most common seats are the subcutaneous and submucous tissues, and the connective web between muscles ; but they are not unfrequently met with in the brain and in the course of nerves, in glandular organs such as the breast and kidney, and beneath the periosteum. In connection with the skin and mucous membranes, they often form papillary or polypoid outgrowths. Placental hydatids are a good example of this latter variety. Sometimes myxomatous tumours contain cavities {cystic myxoma), or their cells get distended with fat [lipomatous myxoma), or their intercellular mucus tends- to condense and become cartilaginous (enchondromatous myxoma), or their vessels are extraordinarily abundant and large (vascular or erectile myxoma). Myxomata, when not occurring in situations where fat is normally present, must be regarded as heterologous ; and they then occasionally present malignant characters. Generally, however, they are innocent, and do not even return after removal. iv. Glue-like tumour, or glioma. — This is a tumour which, according to Virchow, consists of comiective tissue resembling that of the nervous centres ; and in fact it originates almost exclusively in these centres, in the course of nerves, and m the retinae . The neuroglia consists of very small and dehcate cells, imbedded in a finely granular or amorphous substance. These have a tendency to be stellate, and, in carefully pre- pared sections, appear to imite with one another by their rays, so as to map out the intervening substance into small polygonal area. Gliomatous tumours present the same structure, and are generally white and medulla - like in aspect, and exceedingly soft. They vary no doubt considerably, in respect of the relative proportions of their cellular and inter-cellular elements, and in their tmt, consistence, and vascularity ; and they run, on the one hand, into myxoma, on the other into the small round-celled variety of sarcoma, with one or other of which it is difficult to avoid con- foundmg them. They are apt to undergo mucous, caseous, or fatty degeneration, and to become cystic. The situations which they affect, and the tendency they have to attain a large size, render them dangerous ; but they are rarely malignant. h. — Cartilaginous Tumours, or Chondromata. Chondromata consist of cartilaginous tissue : that is, of cells surrounded by lamellated thickenings, and separated from one another by intercellular substance, yielding chondrine ; Avhich is generally liyalme, as in ordinary articular cartilage, but may be reticulated as hi yellow cartilage, or fibrous 56 TUMOUES. as in fibro-cartilage. Cartilaginous tumours have for the most part a sHghtly translucent or pearly aspect, and a whitish or yellowish hue. They vary greatly in consistence, being sometimes dense, hard, and crisp, sometimes forming a diffluent pulp. They are generally distinctly lobulated, the lobules being separated one from another by connective tissue, which conveys their nutrient vessels, for the cartilaginous tissue itself is entirely extra-vascular. The tumours are for the most part perfectly well-defined ; but they are sometimes irregularly diffused through the tissues or organs in which they originate. Under the microscope they present many varieties of character. Their cells vary in size and number, but are always encapsuled ; they are generally round or oval, but may be branched or stellate like those of the cornea ; further, they not unfrequently madergo fatty or calcareous degeneration. The inter- cellular substance, which, as previously stated, may be hyalme in cha- racter, or consist in part of either white fibrous tissue or elastic fibres, sometimes softens into a mucous fluid in which the cartilage-cells are Fig. 8.— Chondroma. a. Section of growth, x 250. b. Calcifying cells, x 250. simply suspended. Chondromata in this latter condition have a resem- blance to the intervertebral cartilages ; and it is by such softening in patches that they occasionally become cystic. Virchow divides chondro- mata into ecchondroses and enchojidromata. The former are merely out- growths from normal cartilages, and are therefore homologous ; they never attain important dimensions, are invariably innocent, and very apt to be converted into true bone. The most interesting examples of ecchon- drosis are the cartilaginous outgrowths which take place in joints affected with chronic rheumatoid arthritis. Enchondromata are heterologous ; they occur most frequently in bones, especially in the long bones ; but they are also met with m the subcutaneous connective tissue and apo- neuroses, in the lungs, parotids, testicles, ovaries, and mammary glands. Enchondromata generally no doubt are innocent ; but they certainly are sometimes distinctly malignant, extending along lymphatic vessels, in- volving lymphatic glands, and ultimately invading remote organs. OSSEOUS AND NEEVOUS TUMOUES. 57 c. — Osseous Tumours, or Osteomata. Osteomata are generally divided into three species — namely, ivory osteomata, compact osteomata, and spongy osteomata. The first species is met with on the inner surface of the skull, and at the joint ends of bones and elsewhere ; it is characterised by remarkable compactness of tissue, and under the microscope presents bone corpuscles and canaliculi (which latter run radially to the surface), and a total absence, or great deficiency, of Haversian canals, and hence of vessels. Compact osteomata present the ordinary characters of compact bone. Spongy osteomata, as their name implies, resemble more or less closely the spongy or cancellous tissue. Osteomata springing from the surfaces of bones are known as exostoses ; those originating in the substance of bones may be named enostoses. Both varieties are clearly homologous. But osseous tumours are sometimes heterologous. Thus, they appear in the connective tissue, in the membranes of the brain and cord, in the brain itself, in the choroid and vitreous humour of the eye, in the lungs and in the skin. True osteomata, even when heterologous, are probably never malignant. Nevertheless tumours, which have undergone more or less perfect con- version into true bone, are sometimes malignant m a very high degree. Such tumours, however, are made up in great measure of cartilaginous or embryonic tissue, and should probably be regarded as chondromata or sarcomata which have undergone calcareous or osseous transformation. The teeth occasionally present outgrowths of their own tissue, which have been named odontomata. d. — Nervous Tumours, or Neuromata. The term ' neuroma ' is often applied loosely to all growths occurring in the course of nerves ; and thus myxomatous, fibrous, and various other equally distinct tumours have, to a large extent, been regarded as varieties of neuroma. Neuroma, in the strict sense of the word, means a tumour formed of nervous tissue : either vesicular like that of the ganglia or central nervous organs, or fasciculated like that of the nerves or medul- lary substance of the brain. The former variety is exceeduagly rare, but has been described as occurring in the brain and spinal cord. The latter variety is more common, but nevertheless of unfrequent occurrence, and is met with only in the course of nerves. True fasciculated neuromata generally are small white hard tumours, occurring singly or in numbers along a nerve-trunk, or more commonly at the extremities of nerves, which have been divided in the amputation of a limb. They are invested with, and permeated by, very dense fibrous tissue, the presence of which makes them difficult of examination ; but their essential character is that they contain a large number of newly- developed nerve-fibres, which form an abundant and intricate network. These generally have the double contour ; but neuromata containing only pale fibres have been described. 58 TUMOUES. e. — Muscular Tumours, or Myomata. Striped muscular fibres have been discovered only in congenital tu- mours. Unstriped muscular fibres, on tlie other hand, are of common occurrence in morbid growths. Myomata are most frequently met with in the uterus, and it is in connection with the uterus that their characters may best be studied. The so-called ' fibrous tumours ' of this organ are, almost without exce^Jtion, muscular tumours. These vary greatly in size, have a reddish or greyish fleshy aspect, are generally exceedingly dense, and present a lobulated character with curvilinear bands of fibres inter- lacing with great complexity. They always originate within the walls of the uterus, and hence, in the early stage, are surrounded by the uterine muscular tissue ; but if seated near either the mucous or the serous surface, they are apt ere long to protrude through the fibres which embrace them on that side, and presently to become pedunculated. Microscopically, they are found to be identical in structure with the uterme muscular walls. Further, like them, they are capable of hardening in contraction, and again of under- going relaxation. Moreover, they in- crease during preg- nancy as the uterus itself increases — their muscular fibres undergomg similar and equal hyper- trophy ; and when, after parturition, the uterine walls under- go involution, they also suffer in the same sense. Uterine muscular tumours frequently degenerate : — the muscular fibre-cells get fatty, or their tissue undergoes mucous transformation — considerable patches becoming softened and infiltrated with mucous fluid, and not unfrequently converted into cysts ; but the most frequent and important change is due to the deposition of calcareous matter, partly in the comiec- tive tissue of the tumour, partly in its muscular fibres, by which means nearly its whole substance may at length be converted into a hard cal- careous mass. This latter form of degeneration generally commences in the interior ; occasionally, however, it starts from the periphery, and it may remain limited to the periphery. Myomata rarely, if ever, originate except in tissues which themselves contain muscular fibres. After the uterus, they are most frequently met with in the prostate, and alimen- tary canal. They have also been found in the scrotum, labia majora, and ovaries. They are always innocent. Fig. 9.— Myoma froji Utkrus at Full Tekji. x 250. VASCULAE AND LYMPHATIC TUMOUES. 59 /. — Vascular Tumours, or Angiomata. Several of the tumours which have abeady been described, and several of those which we shall presently discuss, are liable to be exceedingly vascular (partly fi'om excessive formation, partly from general and irre- gular dilatation, of blood-vessels), and thus to assume an erectile or cavernous character. And, indeed, although we have adopted the name ' angioma ' for a group of tmnours, there are few, if any, in which vascular hypertrophy or hyperplasia constitutes the sole, or even the essential, characteristic. Angiomata may be conveniently divided into two species, m the one of which the newly-developed vessels are properly formed arteries, veins, and capillaries, and in the other of which the blood tra- verses a series of lacunar spaces, like those of erectile organs. The former may be called ' simple angiomata,' the latter ' cavernous angiomata.' Simple angiomata form violet or red, more or less elevated, patches, the general seat of which is the sldn or subcutaneous connective tissue. Their vessels are abundant, tortuous, and dilated, and often present irregu- larities of calibre, and even pouch-like protrusions. Amongst these must be reckoned the small racemose knots, which often make their appear- ance on the face and elsewhere (sometimes in considerable numbers) and m which the chief morbid phenomenon is dilatation of small arteries and vems. Cavernous angiomata are also known by the name of erectile tumours. They occiir in the skin and subcutaneous connective tissue, in the neighbourhood of the external mu- cous orifices, and in some of the inter- nal organs, more especially the liver and spleen. They have a spongy character, which is due to the com- paratively large size of their vascular lacunas, and the comparatively small amount of their solid tissue. The lacunae are irregular in size and shape, commmiicate freely with one another, and are lined with a layer of flat epi- thelial scales. The solid or trabecular element consists mainly of connective tissue, in which the ramifications of small vessels and unstriped muscle are sometimes contained, are often congenital, and are entirely free from malignancy. Fig. 10.— Ax&ioma. x2S0. Ano-iomata g. — Lym^jhatic Tumours, or Lymjjhomata. The important relation which subsists between the lymphatic vessels and glands, on the one hand, and morbid proliferation of tissue, on the other, has already been explained. We have sho^ra, that when inflam- 60 TUMOUES. matory processes are taking place in any part, tlie nearest lymphatic glands tend soon to get inflamed ; that, if the local inflammation has specific characters, the resulting affection of the lymphatic glands shares in these characters ; and that, in all cases of malignant tmnour, it is the neighbom'ing lymphatic glands which, next in order of sequence, become the seat of malignant growth. So that, in fact, in the morbid prohfera- tions of these bodies, we have an epitome of the morbid proliferations of the whole organism ; and to describe their tumours would be equivalent to writing a complete treatise on tumours. What is meant, however, by the term lymphatic tmnour, or lymphoma, is an hypertrophy or hyper- plasia of lymphatic structure, and the new formation of similar structure in parts where normally lymphatic organs have no existence. Under the name ' Ipnphoma ' may be mcluded two perfectly different morbid con- ditions : — the one, an abnormal development of lymphatic vessels, or lymphangioma ; the other, an abnormal development of lymphatic gland- structure, or lympliadenoma. i. It is doubtful if lymphangioma, as an independent morbid growth, has any existence. There are many cases, however, in which enlarge- ment, and possibly over -development, of lymphatic vessels forms an im- portant ingredient in the morbid conditions which are present. Virchow has shown that, in elephantiasis Arabum, hyperplasia of the connective tissue is largely associated with a dilated and hypertrophic state of the lymphatic vessels, and especially of the lymphatic spaces in which they originate. This change seems, however, to be secondary to obstruction of the lymph-paths through the inflamed lymphatic glands, to which the dilated tubes converge. Li congenital hypertrophy of the tongue and lips, the same authority has pointed out the presence of a similar con- dition of the lingual lymphatic vessels. Further, cases are occasionally observed, in which the penis and scrotum, or corresponding parts in the female, or the lower part of the abdomen, or the thigh or leg, are thick- ened and brawny ; and in which groups of depressed vesicles appear here and there, and, rupturing from time to time, yield large quantities of pure lymph. Here, the hypertrophy of the skin and subjacent parts, and the formation of vesicles, are doubtless all due to dilatation of the lymphatics, and their distension with lymph — phenomena which probably are them- selves secondary to some proximal obstructive disease. ii, Lymphadenoma. — There are at least three morbid conditions of the lymphatic glands which, if we have regard only to anatomical characters, are extremely difficult and often impossible to distinguish from one another. These are, simple inflammatory hyperplasia, the so-called ' scrofulous ' form of enlargement, and that morbid condition now gene- rally known as lymphadenoma, or lympho-sarcoma, and to which also the names ' Hodgkin's disease ' and ' adenia ' have been given. a. Simple inflammation of lymphatic glands may be induced by causes acting directly upon them, but is much more commonly the result of irri- tation propagated to them along the lymphatic vessels. They enlarge and get painful, assume a homogeneous aspect and a yellowish or faint LYMPHATIC TUMOUKS. 61 rosy tinge, and under the microscope are found to ditier but little from healthy glands — ^their enlargement being due to simple hyperplasia of their cell-elements, or leucocytes, and to hypertrophy of their reticular connective tissue. Lymphatic glands thus affected may suppurate, or undergo other of the changes which are apt to follow on inflammation ; but their general tendency is to resolution. /3. The term scrofulous is commonly applied to the slow and painless enlargement of groups of lymphatic glands, which occurs for the most part in children, and almost invariably ends in the destruction of the glands by an imperfect kind of suppuration. Scrofulous glands are generally met with in either the neck, the thorax, or the abdomen, and are com- monly limited to one of these regions. Lideed, in the neck, where their progress can best be followed, we often see that the enlargement com- mences in one gland ; that the glands in the vicinity are successively affected, and often at long intervals ; and that, after a while, the morbid process ceases with the destruction of all the implicated glands — those on the opposite side of the neck possibly remaining all the time perfectly healthy. Li the earlier stages of this affection, the glands differ little, either to the naked eye or under the microscope, from such as are simply hyperplastic from mflammation ; but they tend soon to become opaque, yellow, and friable — to undergo caseous degeneration. This change commences in the central parts, and gradually involves the whole mass, which presently breaks down into a semi-fluid detritus and thus forms the imperfect pus previously adverted to. Occasionally the caseous lump dries up, earthy salts are deposited in it, and it becomes an inert earthy concretion. There is a good deal of vagueness in the sense in which the term ' scrofulous ' is generally employed. It is taken for the most part to imply that the morbid process, to which Ave attach it, is dependent on some peculiar condition of the constitution, and further that there is some close affinity, if not actual identity, between it and tubercle. But the so-called ' scrofulous glands ' are not certainly tubercular ; and, although their appearance is sometimes followed by that of tubercle, in a very large number of cases no such sequence is observed. And as regards cachexia, it is certain that ' scrofulous glands ' often develop in persons who appear m all other respects in the best of health ; and further (if we may judge by the limitation of the morbid process), that if we admit their dependence on a pre-existing state of cachexia, that cachexia must in many cases be limited to a definite part or district of the organism. It is well knoAAii, however, that when a single gland has midergone scrofulous proliferation, there is a remarkable tendency for the morbid process to spread thence to other glands in its immediate neighbourhood, and thence again to others ; it seems in fact to spread from gland to gland, through the agency of some infective material, which the diseased organs evolve. It is well known also that scrofulous enlargement of the glands of the neck not unfrequently follows upon certain diseases affecting the throat, such as mumps, diphtheria, and scarlet fever. Now, basing his arguments upon such facts as these, Virchow maintains (and we think with reason) 62 TUMOUES. that scrofulous proliferation of lymphatic glands, like ordinary inflamma- tory hyperplasia of the same organs, is always secondary to some peculiar process going on at the mucous surface, or other part, which is in direct relation with them by means of lymphatic vessels : that scrofulous disease of the glands of the neck is traceable to some inflammatory condition of the throat, fauces, or contiguous parts ; of the bronchial and mediastinal glands, to pulmonary or bronchial inflammations ; and of the mesenteric and retro-peritoneal glands, to similar conditions of the alimentary canal. He considers that there may be some specific quality or element in the primary inflammation, and a tendency in its products to undergo rapid decay similar to that which characterises the morbid products of the diseased lymphatic glands ; but that generally they are not recognisable, from the fact that in this case the cells are mostly developed at a free surface, and are speedily shed from it. But he considers, further, that there may be some special aptitude or weakness, congenital or acquired, in the lymphatic glands of certain persons, or of certain parts of them, which makes their inflammations, induced by indifferent causes, assume the scrofulous character, y. The affection now generally known as Ijjmphadenoma differs but little anatomically from the morbid conditions which have just been .^j-^s- Fig. 11,— Lymphadexoma. x250. «. Fibrous mesh-work (Cornil and Banvier). 6. Section of growth. c. Invasion of muscular tissue by growtli. described. It is characterised, like them, by a simple overgrowth of lymphatic tissue^that is, by a development of cells, which essentially LYMPHADENOMA. 63 resemble ordinary leucocytes but are sometimes large and multinucleated, in tlie meshes of a trabecular tissue like that of normal lymphatic glands. The cells here, as in healthy glands, are so abundant that, in an unpre- pared section, they conceal all other elements ; but if they be removed by pencilling or washing, the fibrous matrix and vessels come into dis- tinct view. The lymphatic glands in this affection, and other parts which become implicated, rapidly increase in bulk, acquire for the most part an opaque milky aspect, soften, and yield, like carcinoma, a milky juice. They are liable also to fibroid and to fatty and caseous degeneration, and to be the seat of hemorrhage. Lymphadenoma is generally distinguished, from both simple inflam- mation and scrofulous proliferation, by the following important facts : — first, that the morbid process tends pretty rapidly to involve the lym- phatic glands distributed throughout the organism ; and second, that there is a disposition to heterologous development of identical morbid gland-tissue in situations in which normal gland-tissue has no existence. In other words, lymphadenoma must be looked upon as a variety of maUgnant disease, in which the secondary as well as the primary growths assume the microscopical characters of lymphatic tissue. It should be remarked, however : in the first place, that by lymphatic or adenoid tissue is not meant the whole complicated organism of lymphatic glands, but merely that comparatively simple arrangement of reticulated fibres and leucocytes which is found in the solitary intestinal glands, and in the Mal- pighian bodies of the spleen ; and, secondly, that the recent investigations of several German physiologists, and of Dr. Burdon Sanderson in this country, have shown that lymphatic tissue is very abundantly distributed throughout the body (amongst other places in the subserous tissue, in the submucous layer of the intestine, and along the bronchial tubes and hepatic ducts), and that hence arises a possibility that, notwithstanding the diffusibility of lymphadenoma, its heterologousness and malignancy may, m the strict sense of these terms, only be apparent. Lymphadenoma not mifrequently afi'ects the bronchial and mediastinal glands ; and it may extend thence, along the connective tissue Avhich invests the bron- chial tubes, into the substance of the lungs, or may invade the parietes of the heart, insinuating itself between its muscular fibres, without necessarily forming any distinct tumour. The mesenteric glands also are often chief seats of the disease, which is then apt to transgress their limits, to involve the substance of the mesentery, and to creep thence into the intestinal walls, which consequently become thickened in all their layers, and probably at length present flat tubercular elevations on both the mucous and the serous surfaces. The liver, spleen, and kidneys also are peculiarly hable to sufier. Here, as in the heart, the growth tends rather to infiltrate the tissues than to form defined and independent tumours. In the fresh condition, the affected tracts of these organs pre- sent an opaque milky aspect, which may be in striking contrast with that of the surrounding healthy parts ; and if they abut on the surface they probably form a slight convexity there. When, however, the contrast of 64 TUMOUES. colour lias been impaired or lost by maceration, it is sometimes impossible by the naked eye alone to distinguish the healthy from the diseased parts. In the spleen, the microscopical characters of the morbid growth are almost identical with those of the healthy gland-tissue ; in the liver and kidneys, however, the growth infiltrates the texture of the organs, and separates their proper elements from one another. In the kidneys especially this may be well observed ; for the lymphoid growth spreads through the intertubular tissue of the organ, separating the still healthy tubes and Malpighian bodies from one another, until at length they appear to be sparsely distributed in a nearly homogeneous mass of ad^ ventitious cell-growth. Until recently it was generally held that lymphadenoma was identical with the morbid process affecting the spleen, and occasionally also the lymphatic glands and other organs, in connection with the condition known as leucocythfemia or leukaemia, and was specially characterised by large excess of white corpuscles in the blood. There is reason, however, to believe that this is not the fact ; that the morbid processes in the two diseases, though presenting many points of resemblance, are essentially distinct from one another ; and that, although in lymphadenoma, as in many other conditions associated with anemia, the white corpuscles may become relatively increased in number, this excess never approaches that observed in leucocyth^emia. Lymphadenoma is, as has already been observed, a form of malignant disease, which, beginning at one part, generally spreads first to the glands in the neighbourhood, and subsequently to other glands and tissues dis- tributed throughout the organism. The progress of the disease is generally attended with increasing anaemia, and symptoms not unlike those of leu- cocythaemia ; but the development of tumours forms an essential element in the case ; and death is likely to ensue ultimately, as in other forms of malignant disease, not merely from gradually increasing debility or inter- current disorders, but from the involvement in the specific growth of vital or important organs, such as the larynx and trachea, heart, lungs, and abdominal viscera. Although lymphadenoma is essentially a progressive and incurable disease, and always ultimately fatal, its course is by no means uniformly from bad to worse. In many cases periods of quiescence of longer or shorter duration take place ; and in most cases the ordinary course of the disease, which is not necessarily attended with fever, is interrupted (often with some periodicity of recurrence) by febrile attacks of several days' duration, during which the temperature rises to 101°, 102°, 103°, or more, and some of the affected glands (probably a group of glands) become enlarged and tender. With the subsidence of the febrile attacks the tenderness in the glands ceases, and they diminish in size. In most cases, however, a persistent febrile condition of hectic type becomes established sooner or later. The duration of the disease varies between a few months and three or four years. SAECOMA. 65 h.— Sarcomata. Tlie term ' sarcoma ' was formerly applied to all tumours which were supposed to have a fleshy character, and hence came to be used indiscri- minately, and to have no precise meaning. It is now, however, limited in its application to those growths which consist, not in their beginnings merely, but throughout the whole term of their existence, of embryonic tissue. Virchow regards them as belonging to the series of connective- tissue tumours which have already been described, and shows that the latter, especially when they madergo generalisation, tend to get more or less obviously sarcomatous — that is, tend to become more and more exclusively cellular, and to lose more and more their several distinctive characters. Sarcoma differs structurally little, if at all, from simple in- flammatory granulation-tissue ; both of them consist essentially of em- bryonic cells, which in the first instance are small, romid, and separated from one another by the least possible quantity of intercellular substance ; in both cases there is a tendency, as organisation proceeds, for the cells to grow fusiform or spindle-shaped while still retaining their embryonic characters ; in both cases the anatomical and other features of the new- formed cells are modified, to some extent, according to the nature of the tissues in connection with which they arise ; and in both cases the growths become abundantly vascular from the development of new vessels, the parietes of which are formed of cells, little if at all modified from those which constitute the general mass. They differ materially, however, in the fact that inflammatory formations tend to subside or to form mere cicatricial tissue, while sarcomatous tumours maintain a con- tinuous vitality of growth, present a wider range of variations from the primitive type of structure, and are in large proportion mahgiiaut. Many varieties of sarcoma may be described. If it affects a bone, or an osseous tumour, or is attended in its progress with osseous transforma- tion, we have what may be termed an osteosarcoma ; and if, mider analogous circumstances, we find sarcomatous growth associated with simple fatty or mucous or gliomatous tissue, we have tumours which may be named respectively lipomatous sarcoma, myxosarcoma, or gliosar- coma. Again, sarcomata may undergo fatty or calcareous degeneration or mucous softening, and hence acquire special characters. The occur- rence of degeneration, and especially of mucous softening, often leads to the formation of cysts ; and thus arises that variety of sarcoma commonly known as cystosarcoma. Sarcomatous tumours are often, and perhaps best, classified according to the characters presented by the cells which predominate in them — the presence of any of the modifications, which have just been indicated, then marking subordinate divisions or varieties. There are at least four such species of sarcoma which we may briefly consider : namely, (i.) round-cell sarcoma; (ii.) spindle-cell sarcoma; (iii.) large-cell sarcoma; and (iv.) melanoid sarcoma. i. Bound-cell sarcoma. — In this species the structure of the growth F 66 TUMOUKS. -(£) O m © MO©"*? af2 Pig. 12.— Round-cell Sarcoma. x250. «. Large-celled, 6. Small-celled. approaches nearest to tliat of ordinary granulation-tissue — tlie cells being small, round, distinctly nucleated, and separated by little inter- cellular substance. Such tumours are nearly homogeneous, but soft and pulpy in texture, greyish or white in hue, opaque or slightly translucent, and (if they have been removed some hours from the body) yield a milky juice. They are very vascular, often attain enormous dimensions, and are malig- nant in a very high degree. They originate almost indif- ferently in all parts of the organism, but especially per- haps in the skin and subcu- taneous connective tissue, in glandular organs, such as the breast and testicle, in bones and muscles. They comprise most of the tumours which were formerly called ' medul- lary sarcoma ' and ' encepha- loid,' and many of those which were termed ' fungus hfematodes.' ii. Spindle- cell sarcoma. — In this case the growth consists of cells which have become elongated and fusiform, or spindle-shaped, and hence present a higher grade of development than those of the round-cell sarcoma. The cells vary a good deal in size, and con- tain each from one to two- or three nuclei. They are arranged side by side in bands or bmidles, which take a curvilmear course and cross one another in various directions ; so that. on examinnig a micro- scopic section, we see round or oval groups of appa- rently round or oval cells, surrounded by bands of fusiform cells — the former being simply cell-bundles which have been cut across more or less obliquely. Spindle-cell sarcomata are- harder and denser than round-cell sarcomata, grey- ish or white, slightly translucent, and of a more or less distinctly fibrous or lobulated character. They yield but little juice. They have a ten- FiG. 13.— Spixdle-cell Sarcoma. xSSO. SAECOMA. 67 deucy to recur, and even to present malignant characters ; but their malignancy is far less pronomiced than that of romid-cell sarcomata, and they rarely reach the size which these latter attain. Spindle-cell sarcoma is synonymous mth ' fasciculated sarcoma,' and includes Paget's ' re- current fibroid tumours.' iii. Large-cell sarcoma. — In some cases the cells of sarcomatous tu- mours attain miusually large dimensions. The most characteristic example is that fm-nished by Paget's ' myeloid tumours ' of bone. These originate only in bones, destroy them extensively, and grow to a large size. They are made up to a considerable extent of embryonic cells, both of the round and of the spindle-shaped varieties ; but that which distinguishes them from all other forms of sarcoma is the presence of a greater or less abundance of large cells containing many nuclei. These cells, which are obviously derived from the many-nucleated cells of the healthy medulla, present much variety. They may measure as much as the hundredth part of an inch in diameter, and thus be objects distinguishable by the Fig. 14. — luARGE-cELL Sarcoma (M'i'ELorD). «r. Tissue of growth. x500. 6. Giant cells. x500. naked eye ; they may be round or oval, but generally are irregular, and present a more or less complex arrangement of buds or tails ; and they may contain any number of nuclei between two or three and two or three hundred. They consist of masses of protoplasm, unbounded by distinct cell-wall, and with the nuclei embedded in their substance. Although myeloid tumours have unlimited powers of local development, and even mvade and grow along the veins, they are rarely malignant in the true sense of that word. iv. Melanoid sarcoma. — In this form of tumour the embryonic cells, which constitute it, are more or less loaded with minute pigment-granules. The cells are round, oval, or fusiform (generally the last), and separated from one another by a small amount of intercellular substance. Each contains one or two distinct oval nuclei. The pigment -granules are roundish or angular, and separately might pass for oily or cretaceous particles ; they are deposited chiefly in the extra-nuclear protoplasm, and F 2 68 TUMOUES. sometimes iii such abmidance that the cell under the microscope appears black, and the nucleus is altogether concealed ; but they are found also in the substance of the nucleus. Melanoid sarcomatous tumours are gene- rally soft, and present, if large, a mottled sepia-browii or black appear- ance ; if small, are more or less uniformly tinted. They take their origin almost invariably in structures which normally are pigmented, such as the choroid coat of the eye and congenital pigmented naevi ; and when they become generalised, the secondary growths repeat the pigmented character of the primary growth, thus furnishing a good example of the tendency, which secondary growths always have, to reproduce the specific characters of the x^arent tumour. Melanoid sarcomata are generally highly malig- nant. Closely related to the sarcomata, and by Cornil and Kanvier placed among them, is the growth termed by Virchow Psammoma, which occurs solely in connection with the membranes of the brain and cord. It is vascular, soft, and friable, and chiefly characterised by an abundant, development of concentric earthy concretions surrounded with capsules of flattened cells or scales. The type of these tumours is furnished by the choroid plexus. They rarely attain a large size, and probably never cause mischief unless they be large. i.- — Carcinomata, or Cancers. Cancerous tumours are considered by Virchow to be of a higher type than any which have hitherto been considered. He regards them, not as the mere hyperplastic condition of a single structural element, but as con- sistmg of a combination of tissues, so arranged as to present some of the distinctive characters of an organ ; and he includes them, therefore, in his class of ' organoid tumours.' They are composed of a fibrous framework, or stroma, so arranged as to form a series of loculi, and of groups of cells which are contained ua dense masses within them. The stroma consists for the most part of ordinary fibrous tissue and plasmatic cells, and carries and supports the arteries, veins, and capillaries, which are some- times very abundant ; it may be dense or lax, and varies in quantity relatively to the size and number of the spaces which it invests. The loculi differ in size, and on casual examination seem to be round or oval, and miconnected with one another ; but as a rule they communicate freely, and form a series of branching channels. The cells are said by Virchow, and by many others, to be of an epithelial character ; and they are so far epithelial, that they are developed from the surface of the loculi, are in absolute contact with one another, have no intervenmg cement, and are never traversed as granulation-tissue is by vessels. They vary greatly in size, and on the average are considerably larger than those of sarcomatous growths. They vary even more remarkably in form, and indeed their polymorphous character is often regarded as typical of their carcinomatous nature. They may be romid or oval, or from mutual pressure polyhedral ; but more frequently they are very irregular, pre- CAECINOMA. 69 Fig. 15.— Cancer-cell?, x 500. senting convexities or concavities upon their surface, and projecting here and thereinto flattened, pointed, bulbous, or nondescript processes. They consist of masses of proto- plasm, more or less granular and often fatty, and contam- ing within them one or more nuclei, which are for the most XDart round or oval, of comparatively large size, and exceedingly well de- fined. Moreover, they not unfi-'equently become vacuo- lated, or hollowed out here and there mto globular cavi- ties, which are termed by Virchow ' physaliphores,' and are regarded by him as reproductive cavities. Cancer- cells frequently have a close resem- blance to the cells of the vesical epithelium. Cornil and Eanvier deny their true epithelial character, mainly because as a rule they have no distinct cell-wall, and because, although m contact with one another, they generally do not cohere. The origin of cancers, like that of all tumours in fact, is very obscure. Kindfleisch, takmg epithelial cancer as the type, considers that all forms of carcinoma originate in hyperplasia of epithelial structures ; which, as they grow, eat their way, as it were, into the subjacent tissues, hollowing them out into irregular cylindrical cavities, which then constitute the characteristic loculi of cancer. This mode of development calls to mind that of tubular glandular organs and hairs in the foetus. Cornil and Ean^aer, on the other hand, who expressly exclude epithelioma from true cancers, and consider cancer-cells as being in no sense epithelial, con- clude (mainly from their observations on the development of carcinoma m the bones and in the mammary gland) that the alveoli, within which the cells grow and multiply, begin in the plasmatic spaces or serous canaliculi, which are directly continuous with the lymphatic vessels, and that even when they attain their full size they maintain this connection ; so that in a sense the alveoli of cancer may be regarded as the dilated origins of lymphatic vessels. To this connection, moreover, they attri- bute the peculiarly malignant character of all forms of carcinoma. Under any circumstances, however, the early stages of cancer are generally marked by the formation of embryonic tissue : of cells, therefore, differing little from those which are found in inflammatory processes and in sarco- matous growths. But soon differentiation takes place, and the specific character of the growth is revealed by the conversion of some of these cells into the fibrous tissue of the stroma, and of others of them into the epithelium -like cells of the loculi. There is good reason, nevertheless, for considering that the matrix in many cases, and in some perhaps almost exclusively, consists of the normal fibrous elements of the part affected, which have simply undergone some degree of thickening and overgrowth ;, 70 TUMOUES. just as in other cases, where glandular organs are involved, their follicles and ducts may be stimulated to unwonted development, and so form prominent objects in the field of the microscope without necessarily constituting any essential part of the specific growth. Like other adventitious growths, but in a greater degree than most of them, carcinoma is liable to undergo degenerative changes ; these involve principally the cellular elements, and are sometimes so uniform in their occurrence as to give a special character to the case in which they prevail. Fatty degeneration of cells is the most common ; but we meet also with caseous degeneration, calcareous deposit, and mucous softening ; and not unfrequently extravasation of blood takes place owing to rupture of the morbid capillary vessels. All kinds of carcmoma are malignant : the most malignant being the ioft or encephaloid form, with its pigmentary and other varieties ; the least malignant being epithelial cancer, which speedily involves the neigh- bouring lymphatic glands, but is very rarely reproduced in other parts of the system. The chief varieties of carcinoma are (i.) Scirrhus or hard cancer ; {ii.) Encephaloid or soft cancer ; (iii.) Colloid or mucous cancer ; (iv.) Epithelioma or epithelial cancer ; and (v.) Adenoid or tubular cancer. i. Scirrhus, in its typical form, is known especially by its hardness ' and slowness of growth. It creaks on section, and its cut surface presents a white or greyish, glisten- ing, fibrous character, and yields a little milky juice on scraping. Its density and hardness are due to the great abundance and thickness of its fibrous matrix, and to the com- ^ ^ paratively small size and 0) - - - number of its cell-contain- ing loculi. The cells, how- ever (which constitute the essential element of the milky juice), present the ordinary characters of can- cer-cells. Scirrhous tu- mours rarely if ever undergo complete cure ; yet it is certain, not only that they are of slow growth, but that their progress is specially apt to be attended with the degeneration (chiefly fatty or caseous ) and the subsequent disintegration and removal of the cells of considerable tracts, and the consequent disappearance from such parts of everything except the fibrous stroma. Scirrhus is equally charac- terised by the slowness with which it obviously involves the neighbouring Fig. 16. — Scirrhus. CAECINOMA. VI Fig. 17.— Excephaloid Caxcer. x250. lymphatic glands, and becomes generalised. It invariably, however, sooner or later manifests the infective qualities "vvhich belong to it, ii, Ence'phaloicl cancer is soft in texture and rapid in growth, yields a very abmadant milky juice, presents a tolerably uniform opaque white sectional surface, which, however, may be variously studded Avith patches of congestion or hemorrhage, of fatty or caseous degeneration, or even of pigmentary deposition. Its ex- treme softness is due to the fact that the fibrous stroma forms a very small proportion of the whole mass, while the cells are rela- tively very abundant. The alveoli differ in size, but are generally •comparatively large, and their walls exceedingly delicate ; in- deed, it is often difficult to recog- nise the latter at all, unless the cells be first removed by washing or pencilling. In encephaloid cancer, the secondary involve- ment of the nearest lymphatic glands, and of the general organ- ism, takes place very speedily. Several well-marked varieties of encephaloid cancer are met with, two or three of which may be here enumerated. These are : first, erectile or hcematoicl carcinoma, in which the vessels (always abundant in encephaloid) are ex- traordinarily developed and tend to frequent rupture ; second, the variety which Cornil and Eanvier term imUaceoiLS carcinoma, in which the alveoli are thicker- walled than in most forms of encephaloid, so large that they can easily be recognised by the naked eye, and from which the contents readily escape as a thick pulpy juice ; third, lipomatous carcinoma, wherein the cancer-cells even from their infancy are loaded with oil, and in the adult state present so general and large an amount of it that, both to the naked eye and under the microscope, the tumour has (at first sight) a consider able resemblance to ordinary fat ; fourth, melanotic carcinoma, in which, as in the corresponding form of sarcoma, the cells are pigmented. iii. Colloid cancer has a close resemblance to myxoma. In both cases the tumours are more or less transparent, and gelatinous in consistence, and in both yield from the cut surface an abundant juice, which is trans- parent, glairy, and characterised by containing mucine. The fundamental anatomical distinction between them is this, — that, whereas in myxoma Pig. 18.— Encephaloid Caxcer, FORMixG Villous Outgrowths, x 250. 72 TUMOUES. the frame^vork of the tiunour consists of plasmatic cells, the mucous fluid and vessels occupying the interstices bet'ween them, in colloid carcinoma the mucus arises in the degeneration of the essential cells of the growth, the general solidity of the tumour being due to the fibrous stroma, which forms the walls of the alveoli. In colloid cancer the alveolar structure is extremely well marked, and on this accomit colloid has often been termed ' alveolar cancer.' The alveoli are so large as to be easily visible to the naked eye ; they are roimd or oval on section ; and when the growth forms a projecting mass on a serous surface, theu' aggregation presents the appearance of an accumulation of small bubbles of air in a viscid fluid. They commmiicate freely with one another. Their walls are mostly extremely thin and delicate, displaying a fibrillated structm'e mth an indistmct development of fusiform cells, which may themselves present Fig. 19.— Colloid Caxcer. «. Fibrous stroma. x250. 6. Cells, degenerating. x250 indications of fatty or colloid degeneration. The glairy contents of the alveoli vary, fi-om the consistence of white of egg up to that of X3retty firm glue, from pure white to a more or less deep yellowish, brownish, or reddish hue, and from perfect transparency to tolerably complete opacity. Microscopically, cancer-cells can always be recognised. The smaller alveoli of the newly developed parts are probably full of well-defined cells, of which some already contain globules of mucus. As, however, the growth gets older and the alveoli larger, the cells undergo more and more complete mucous degeneration, swell up, and presently disintegrate ; and thus in many cases the alveoli get distended with mucus, presenting a certain amount of granular matter, mostly arranged in irregularly concen- tric circles, with here and there perhaps the ghost of a huge dropsical cell. In addition to the mucous conversion, which is the especial feature of CARCINOMA. 73 colloid cancer, a certain amount of fatty degeneration is common. Cal- careous deposition also is not unfrequent. Although colloid cancer is certainly malignant, and affects lymphatic glands, and occasionally becomes generalised, it is specially characterised by a tendency to spread in area, and to impHcate the tissues immediately subjacent to that area. Thus, when arismg in the peritoneum, it soon diffuses itself over the greater part of that membrane, and also soon m- volves, in many situations, the whole thickness of the stomachal or intestmal walls. It shows also (though it is not peculiar in this respect) an obvious proneness to spread along the Imes of the lymphatic canals and capillaries. iv. Ejoithelioma, or cancroid, is a very characteristic form of growth, originating, but not quite exclusively, in epithehal tissue, and characterised by a very abundant formation of epithelium in cavities or locuh of con- siderable size, which as in other forms of carcmoma, communicate more or less fi-eely with one another. The commonest form of epithelioma is that which arises in the slrin, and those mucous surfaces which are in relation with the external orifices c ^^ Fx6. 20.^Epri'HEi,iOMA. o. Section of growth. x250. 6. Tree cells. x250. c. Free cells more higbly magnified. x500. namely, those of the lips, tongue, oesophagus, anus, vagina, and uterus. It forms a tumour which varies in size, soon ulcerates, and on section presents (owing partly to the fact that the tissues which it mvades are not yet wholly destroyed by it) a more or less variegated character ; it is friable in texture, somewhat granular, and yields on pressure or scraping, not a juice, but rather an opaque, whitish, granular pulp. The stroma of the growth consists of fibrous or embryonic tissue, including vessels, and more or less abundant traces of the origmal healthy structures. The pulp which exudes, and the contents of the loculi, consist solely of cells ur different 74 TUMOUES. stages of development. These are distinctly nucleated, modified in shape by mutual pressure, and for the most part large and strikingly epithelial in character. The younger cells are in relation with the stroma, and occupy therefore while in situ the periphery of each cell-mass ; the others are arranged in a more or less stratified or confused manner within. But we find additionally, in the latter situation, knots or nests or involucra of cells the presence of which is almost conclusive as to the nature of the growth. These consist of large flat cells, arranged in concentric circles around a group of cells, or even a single cell, of smaller size, of plumper form, thick- walled, and containing a nucleus, together with perhaps some mucous or colloid material, or a few small fat-globules. At first sight, these nests look not unlike transverse sections of cutaneous papillae, but they obviously differ from them in the fact that their centres are made up simply of cells, and not of stroma containing vessels. As regards the development of epithelioma, there is little doubt that when it occurs at epithelial surfaces, it commences with hyperplasia of the deeper- seated embryonic cells of epithelium : — in the skin, therefore, with hyperplasia of the cells of the rete niucosum and of the sebaceous and sudo- riparous glands ; in the mucous membranes, with hyperplasia of the corre- sponding cells of their epithelium, and of the glandular crypts. These multiply, become modified in form and arrangement, distend the cavities or depressions in which they lie, and send thence into the immediately surrounding tissues bud-like processes. The latter increase in number and size, and thus gradually invade and destroy the neighbouring textures. Pdndfleisch quotes an observation, and reproduces a drawing of Koster's, which seem to show that the extension of epithelioma is due to the in- volvement of the lymphatic networks : that the budding or sprouting epithelial processes above adverted to, instead of forming indiscriminately, penetrate the capillary lymphatics, run along them and distend them. There is probably some truth in this view ; and, if so, it assimilates the local spread of epithelioma to that of colloid cancer, and especially to that of scirrhous and encephaloid cancer, as described by Cornil and Eanvier. Epithelial cancer is undoubtedly the least malignant of all the varieties of carcinoma ; for it is the only cancer which admits of being removed in its early stage with the tolerable Certamty that it will not recur ; and although it soon involves neighbouring lymphatic glands, it rarely mani- fests itself secondarily in other internal organs. V. Adenoid or tubular cancer, otherwise termed columnar or cylin- drical epithelioma, is a rare affection, said generally to originate on some mucous surface, and to involve secondarily lymphatic glands and other parts. It occasionally, however, arises primarily in the liver or other parenchyma- tous organs. It forms tumours of various sizes, which have a close general resemblance to those of encephaloid cancer. They are highly vascular, soft, and yield an abundant milky juice. Microscopically, they are seen to con- sist of a system of tubules irregularly arranged, and separated from one another by a very small quantity of fibrous stroma ; and bear a striking resemblance to sections of the cortical substance of the kidney deprived of GEANULOMA. TUBEECLE. 75 Malpigiiian bodies. The tubules are generally cylindrical, of tolerably uniform size, and lined with a layer (usually single) of spheroidal or V'>(^ ^^^Ov^v-r o-^^l Fig. 21.— Adjcnmid Caxlkil fko.m Liver. x2o0. -columnar epithelium. They present, for the most part, a distinct central cavity or canal. This form of carcinoma is highly malignant. j. — Granulomata or Granulation Tuvwurs. The term ' granuloma ' has been employed by Virchow to include the spe^ cific growths of syphilis, lupus, elephantiasis Grrecorum, and farcy, because anatomically they differ but little from ordinary granulation-tissue, and it is often difficult to decide from mere inspection whether such growths are tumours or mere inflammatory products. Tubercle he regards as a species of lymphoma. There is no doubt, however, that tubercle has close struc- tiTral relations to the specific growths of the other affections above named. And since, moreover, they are all infective growths, and there is reason to assume, from recent observations, that the specific causes of most, if not all, of them are parasitic organisms, we have included them all in the same group. As we shall presently show, a specific bacillus has apparently been proved to be the cause of tubercle. It is alleged also that specific bacilli have been discovered both in syphilis and in leprosy. i. Tubercle. — From the time of Laennec down to within a very recent period, tubercle was regarded as a mere exudation or deposit from the blood, consisting in large measure no doubt of cells, but of cells which were degenerate from the beginning and never had any vitality. And it was recognised as occurring in two forms : one, the grey granulations or miliary tubercles (hard, greyish, translucent bodies, varying from the size of a small pea downwards, and tending to become opaque, yellow, and soft or friable internally) ; the other, the so-called ' crude ' tubercles, which are generally of larger size, of a nearly uniform opaque buff colour, and friable or cheese-like in consistence, but which were commonly 76 TUMOUES. believed to take their origin in the .general caseous conversion of grey tubercles, and therefore to represent a comparatively late stage of the tubercular process. It is now, however, generally admitted : that tubercle is no mere deposit, but on the contrary, equally with sarcoma and carcinoma, a living growth, consisting essentially of cells, but having, above all other growths, a tendency to undergo rapid degeneration and death, and especially that form of degeneration which is termed ' casea- tion ; ' that the grey semitransparent material which often forms the whole bulk of miliary granulations, and may often be recognised at the periphery of larger masses, is alone living and growing tubercle ; and that the yellow caseous substance which has frequently been taken for its essential part is merely effete and dead matter, often no doubt tubercular in its origin, but often also the detritus of quite other kinds of cell- growth. Grey granulations take their rise in the connective web of most organs and of many tissues, and, as will presently be shown, not improbably affect specially the lymphatic tissue distributed throughout the organism. They are common in serous membranes and in the pia mater, and it is probably here that their development may best be studied. If a minute tubercle from one of these situations be placed under the microscope, it will be found to consist mainly of an aggregation of cells, mostly of small size and of the embryonic character, of which those towards the centre will probably even now be angular, withered, and opaque from granular fatty deposit. A close examination will reveal other facts : — the growth will be fomid almost certainly to have taken place in connection with some minute vessel, probably to encircle it ; and further, beyond the Fig. 22.— Tubercle. (Virchow.) margins of what may perhaps be regarded as the actual growth, a zone of connective tissue will be recognised in which hypertrophy and proliferation are commencing — the plasmatic cells being larger than those of the normal tissue, and in many instances containing in their interior broods of two, three, or more secondary cells. It would seem, therefore, that the morbid process commences with proliferation of the connective-tissue elements of the adventitia or outer wall of blood-vessels, that it gradually involves more and more of the neighbouring connective tissue, and that as it spreads at the margins the central parts fall rapidly into decay. It TUBERCLE. 77 Fig. 23. — Tubercle froji Luxg, showixg Giaxt Cells AXD Degenerating Central Area, x 250. follows that the chief microscopic elements of tubercle are : first, simply enlarged comiective-tissue corpuscles (fusiform and stellate) ; second, these same cells containmg two or more new cells within them ; and third (and probably far most abundant- ly), small shrivelled granular embryonic corpuscles. But during the last few years it has been distinctly ascer- tained that, although neither peculiar to tubercle nor essen- tial to it, certam cells pre- senting remarkable characters are commonly to be found, either in the centre of ele- mentary tubercles, or distri- buted in the peripheral parts of agglomerated tubercles. These are large irregular branching bodies, termed 'giant cells,' of which each contains fi'om twenty to forty distinct nuclei. Their source is not clearly determined. Li some cases possibly they result from the fusion of smaller cells ; but M. Brodowsky has shown it to be probable that, at any rate, some of them are to be regarded as morbid modifications of protoplasmic buds from the walls of vessels, which, under other circumstances, would have become vessels. It should be added, that new blood-vessels seem never to form in the tuber- cular process ; that no higher stage of development, in fact, than the mere over-production of new cells of a low grade of organisation is ever attained ; and further, that the vessels around which tubercles form become at a very early period obstructed by the coagulation of fibrine, and the accu- mulation of leucocytes, in their interior. The intercellular substance of tubercle is, in the first instance, that of the particular form of connective tissue in which it originates ; it soon, however, gets scanty and in- distinctly fibrous or granular. Eindfleisch has described a reticulated comiective tissue, m the meshes of which the corpuscular elements are contained : an arrangement, in fact, almost identical mth that which obtams m adenoid tissue, and which, if generally present, goes far to confirm the "sdews of those who regard tubercle as an adenoid growth. It is extremely difficult, however, to satisfy oneself of the presence of any such fibrous stroma, and MM. Cornil and Eanvier distinctly deny it. They admit that a kind of reticulum, probably of artificial production, may be recognised in sections which have been hardened with chromic acid or alcohol ; but they assert that it never contains protoplasmic particles (as lymphatic stroma does) at the points where the fibres inter- sect, and moreover that in the unprepared tubercle it has no \^sible existence. 78 TUMOUES. But even if tubercular growths be not, like lympliadenomatous tumours, mere overgrowths or reproductions of modified lymphatic-gland structure, there can be no doubt at all that they are in very large propor- tion adventitious growths originating m lymphoid tissue. At all events,, many physiologists, and particularly Dr. Sanderson, have showii satis- factorily that adenoid tissue is far more generally distributed throughout the body than was formerly suspected, and that it is especially abundant in all those parts m which tubercle is most frequently developed ; and indeed, as regards tubercles produced experimentally. Dr. Sanderson seems to have clearly demonstrated their origin in hyperplasia of these normal lymphatic accumulations. "We need hardly quote, in favour of this doctrme, the fact of the frequent development of tubercle in the lymphatic tissue of the solitary and agminated glands of the intestines, and in that of the spleen and lymphatic glands. We will discuss two cases, however, which Dr. Sanderson has specially investigated in the com-se of his experiments on the artificial production of tubercle. In the first place, he has shown that in the peritoneum, as indeed in all serous membranes, small masses of adenoid tissue are distributed abundantly, in some cases unconnected with vessels, but more commonly adherent to their walls, or encircling them, or even investing whole groups of capil- lary vessels ; he has also shown that, in animals dead of acute peritonitis, all these masses have become soft, tumid, and enlarged, and further that,, when tuberculosis is in progress, it is in them and by the multiplication of their cells, rather than by that of connective-tissue corpuscles, that miliary tubercles are gradually developed. Secondly, as regards the lung, it is now generally held that grey tubercles originate in the matrix of the organ, and not, as was formerly believed, within the air-cells ; and it is generally admitted, we believe, that the part which they chiefly affect is the connective tissue surromiding the bronchioles at the point at which these lose themselves in the air-cells, and that the growth of tubercle- cells gTadually extends thence into the tissue which separates the air-cells from one another, and limits each pulmonary lobule. Now, according to Dr. Sanderson, there always are normally, in the situation here indicated, masses of adenoid tissue, and the early stage of pulmonary tuberculosis consists in a kind of hyperplasia of such masses. The frequent connection between tubercle and adenoid tissue must be admitted. Nevertheless it is certain that, like lymphadenoma, tubercle does not take its origin exclusively in adenoid tissue. The general result, deducible from recent observations with respect to the genesis of tuber- cular products, seems to be that, like the products of inflammation, they are not derived from a single source, that they are not the results of specific hyperplasia of connective-tissue corpuscles alone, as Virchow teaches, nor yet simply overgrowth of the lymphatic cells of adenoid tissue, but that they are j)robably derived, in varying proportions, from both of these sources, from the other cellular elements which happen to form part of the affected tissue, and even from immigrant leucocytes. TUBEKCLE. 79 The view here expressed has an miportant bearing on the question ' what is and what is not to be regarded as tubercle ? ' — a question of the highest interest, in reference to the status of the morbid condition of lixng commonly known as ' pulmonary phthisis,' and to the nature of closely related, if not identical, morbid conditions of other organs. According to views generally accepted until within the last few years, the grey miliary tubercle and the yellow cheesy tubercle (of which both are common in the lungs, and the latter occasionally, by coalescence, infiltrates large tracts) were regarded as being, not so much varieties, as different stages of the same disease ; and it was held that, in the dead-house, all the intermediate conditions, by which the minutest miliary tubercles lead up to the most extensive caseous infiltration, can be readily recognised. At the present day, Virchow and many other distinguished pathologists deny this relation, and maintain that caseous disease, which comprises probably all the cases recognised clinically as pulmonary phthisis, is of pneumonic- origin, the consequence of catarrhal or lobular pneumonia. The grounds of this opinion are mainly, that in caseous infiltration of the lung the presence of tubercular proliferation of the interstitial tissue is not a very obvious anatomical feature ; and that the great bulk of the morbid mass consists of degenerate epithelial cells accumulated in the air-cells and smallest bronchial passages. Many important considerations, however, may be adduced in favour of the opposite view. It is a fully recognised fact that, even in undoubted examples of miliary tubercles, the prolifera- tion of cells in the matrix of the pulmonary lobules, which constitutes their commencement, is soon attended with dense accumulation of cells, probably due to epithelial proliferation, within the pulmonary loculi. Now, unless we start with the assumption that tuberculosis consists in nothing else than proliferation of connective-tissue corpuscles, or of the elements of adenoid tissue, what right have we to assume that the proto- plasmic bodies, which fill the air-cells, are specifically different from those which occupy the substance of the matrix ? It is admitted that pus-cells may originate in epithelial as well as in other kinds of cells ; why should tubercle-cells have a more exclusive parentage ? It is a recognised characteristic of tubercle that its specific cells very rapidly fall into degeneration ; but this is even more remarkable in the cells which fill the loculi, than in those which crowd the pulmonary matrix. Again, the caseous masses of pulmonary phthisis certainly do not occupy those parts of the lung which either lobular or lobar pneumonia specially affects ; but they do occupy those situations (mainly the upper portions of the lungs) in which miliary tubercles generally originate, and are most advanced. And, lastly, caseous tubercles in the lungs are constantly associated with tubercular formations elsewhere in the body, and indeed in those very parts in which generalised miliary tubercles are specially apt to manifest themselves. For many reasons, therefore, of which we have only indicated the more important, we are disposed to maintain the relationship between miliary tubercles and caseous infiltration, to regard them simply as varieties or different stages of the same disease, and to> 80 TUMOUES. support the claim of ' pulmonary plitliisis ' or ' caseous pneumonia ' to be called also ' tubercular phthisis.' The investigations of Dr. Klein ' and Professor Charcot ^ are strongly- confirmatory of the views here advocated. Dr. Klein shows : that in miliary tubercles of the human lung, ' the first changes take place in the alveoli and inter-alveolar septa ; ' that, as regards the alveoli, .the epithelial cells become swollen, granular, and detached, that they then proliferate, and that generally, either by their coalescence or by the dis- proportionate enlargement of one or more of them, each cavity becomes fihed with a multinuclear lump of protoplasm or giant cell, which sub- sequently undergoes fibrillation, caseation, or other form of degenerative change ; and that, as regards the inter-alveolar septa, these thicken with the growth .of a tissue containing branched and spindle-shaped cells and a few lymphoid cells. He adds that, at a somewhat later period, cords of adenoid tissue are formed upon the walls of the larger vessels in the vicinity of the tubercles. He further points out, in reference to tuber- culosis of artificial production, that, although the ultimate changes are identical with those just described, they take place m an inverse order, the development of the perivascular adenoid cords preceding the changes in the mter-alveolar septa and in the air-cells ; and he concludes that, in artificial tuberculosis, the process commences from the arteries and veins, in the idiopathic affection from the pulmonary capillaries. Professor Charcot's observations are still more to the point, for he expressly shows that there is no essential, genetical or structural, difference between miliary tubercles of the lungs and so-called 'caseous pneumonia.' He pomts out, however, that in the latter variety of pulmonary phthisis the tubercular process commences in the parietes of the bronchioles, where these lose themselves in the air-cells ; that softening takes place here before any trace of inflammation is visible either in the epithelial lining of the tubes or in the pulmonary lobules comiected with them ; and that when a caseous patch is examined, it presents a central degenerate area, and a margmal zone of embryonic cells, and scattered giant cells, infil- trating the normal tissues of the lung. The quasi-malignant character of tubercle is generally admitted ; although the fact, that it appears often to originate, almost simultaneously, in many pomts of one or more organs (in both lungs, for example), might seem to imply the existence, in some cases, of a -widely diffused tendency of organs to become tubercular, independently of specific infection. The proof of its malignant attributes hes, partly in that disposition to general diffusion which it shares with growths which are unquestionably malig- nant ; and partly in the facts, that its local spread is due chiefly to the establishment of new foci of disease in clusters around the primary gro^^iihs, and that the nearest lymphatic glands always become secondarily affected at an early period. It was considered by Laennec (and his view » ' On the Relation of the Lymphatic System to Tubercle.' Report of the Medical Officer of the Privy Council. Ncav Series, No. 3, 1874. 2 Bevue Mensuelle de Midecinc et de Chimrgie, 1877, p. 876. TUBEKCLE. 81 ill a very slightly modified form has been advocated by Dittrich and Niemeyer) that a degenerate mass of tubercle (a caseous lymphatic gland, for example) is a common, if not the invariable, source of generalised tuberculosis : that the degenerate particles taken up by the blood become distributed by it, and then act as specific irritants to the parts which they infect. The remarkable experiments, in reference to the production of tubercle by inoculation, first made by Villemin, and since repeated and extended by Wilson Fox, Sanderson, Cohnheim, and others, have a very interesting bearing on the points considered in the last paragTaph. Guinea-pigs and rabbits were inoculated with tubercular matter ; and it was found that, after the lapse of some weeks, small indurated caseous nodules had become developed at the seat of operation, the next lymphatic glands had undergone hyperplastic enlargement, and the lungs, liver, serous membranes, and some other organs presented a greater or less number of small, grey, translucent, hard bodies, which accurately resembled the miliary tubercles occurring in man ; and it was assumed that all these secondary formations were really tubercle, and that tubercular detritus taken up by the absorbents, and then distributed throughout the organism, had a specific influence in the production of tubercle. It was soon proved, however, that the inoculation of other forms of growth, or of decomposing healthy tissue, or of the products of local inflammations excited by mere mechanical irritants, was quite as efficient in generating general tuber- culosis, as was the inoculation of tubercular matter itself. And hence it seemed ob\dous, that the exciting cause of the tubercular development was, not the matter which was inserted or applied locally, but the products of the inflammatory process which this matter evoked. The experiments failed, therefore, to prove the inoculability of tubercle, but they proved that tubercle might be produced locally by direct apparently non-specific irritation, and that tubercle so engendered had the capacity for becoming generalised. To a certain extent, then, these experiments may seem to favour the views of Laennee and Niemeyer as to the infective quality of caseous matter. It is more in accordance, however, with what is known of morbid proliferation, and of contagion, to assume that the infective element of tubercle is not effete and dead material, but rather living (even though degenerating) particles of protoplasm. There has long been a suspicion amongst pathologists, that tubercle, and other allied infective diseases, are determined by the presence of spe- cific parasites, as we have already shown is probably the case with spread- ing and infective inflammations ; and many observers have laboured with the object of finding them. But their labours were fruitless, until Dr. Koch, the foremost and most successful worker in this branch of investi- gation, succeeded by special methods of preparation in discovering early in 1882 the presence of apparently specific bacteria in tubercle. These are minute motionless rod-like bodies, from a quarter to half the diameter of a blood-corpuscle in length, presenting no marked morphological characters, but differing from the known forms of bacteria (excepting perhaps those G 82 TUMOUES. found in leprosy) in the effects upon them of certain dyes. They have been found in more or less abundance, not only by Koch himself, but sub- sequently by many other observers, in all tubercles, in whatever part of the body occurring, and as well in the tuber- V i. . ', culosis of the lower animals as in that of -^-^ I ' man. They are said to abound chiefly in %^J -' >*^ ^) recent tubercles and in the periphery of .^ / '" .' • tubercular aggregates, and specially to affect "" \ ' ^ ' - the giant cells ; and to be comparatively few "- ■ '|\ in number, or absent, in parts which have ^ -./f^ ' /'' /i\:' ' undergone degeneration. Moreover they are . ^ ' \ ^^^'' ^ -^ ' I ^ / found in more or less abundance in the (^.' -^ f. " sputa of phthisical patients, especially in the ""^ "-^ „ ' ' ^ '' sputa of those cases in which rapid disor- /, I ' ' ■) ganisation of lung-tissue is taking place ; \_ ' -^" '"' and are said never to be present in the sputa ^ „ ^ ^ of non-tuberculous patients. This state- Fig. 24. Bacilli op Tubercle from . . ■■- Sputum, x 500. ment, if true (and it accords with our own limited experience), makes the examination of the sputa for the bacilli important for the determination of the nature of obscure cases of lung-disease, and makes it important, therefore, that the methods by which they may be rendered visible should be well under- stood and easy of application. But Dr. Koch's researches have not been limited to the discovery of the bacilli of tubercle in tubercular growths. For by carefully devised methods of procedure he claims to have cultivated them, external to the body and apart from tubercular matter, in suitable cultivation media ; and then to have developed tuberculosis in guinea-iDigs and rabbits by inoculating them with the organisms thus grown. The bacilli require for their cultivation the maintenance of a temperature about equal to that of the human body. It is scarcely justifiable perhaps to assert at the present time that the bacilli discovered in tubercle have been absolutely proved to be the cause of tubercle. But it must be admitted that the evidence in favour of that view is very strong. Nor, even if this relationship be established, does it necessarily follow that tubercle is an infectious disease any more than ague is infectious. Still the probability of its direct or indirect infectious- ness becomes much mcreased. The parasitic origin of carcinoma remains to be discovered. It is important to observe that the tubercle bacillus is found equally in grey miliary tubercles and in so-called ' caseous pneumonia ; ' and that its discovery tends therefore to confirm the views previously expressed in regard to the identity of the different varieties of pulmonary phthisis. The following is Ehrlich's process, now generally adopted, for the detection of the tubercular bacillus : To 100 c.c. of distilled water add 5 c.c. of commercial aniline. Shake them up well together again and again, repeating at intervals for an TUBERCLE. SYPHILITIC GUMMATA. 83 liour. Pass tlirougli a moist filter into a bottle. The filtrate must be perfectly clear. Make a saturated solution of fuchsine in absolute alcohol. To between 20 and 30 c.c. of the filtrate add from 30 to 60 minims of the alcoholic solution of fuchsine. Stop at 30 minims, and observe whether the surface of the mixture is covered with a distinct metallic film. If not, continue to add the fuchsine solution mitil the film is produced. Make a saturated solution of methyline blue in distilled water. Put a little suspected sputum between two cover glasses and rub them together. Separate them ; dry them in. the air ; pass them, thus prepared, three or four times through a spirit-lamp flame in order to fix the sputum ; and float them (with the sputum downwards) on the mixtm-e of the solutions of aniline and fuchsine, alio whig them to remam for 30 mmutes. Then wash the glasses in a mixture of one part of the pharmacopoeial nitric acid "s^-ith two j)arts of distilled water. This washing must be continued until all apparent colour has been removed from the preparations. The bacilh remam stained. Take a cover glass direct fi'om the acid ; wash it in distilled water ; while it is still wet drop on to the sputum a drop of the solution of methylme blue, and allow it to remain until it has distinctly stained the whole smiace. Then wash again hghtly in distilled water. Examine the specimen while still wet, under a power of 400 or 500 diameters, when the bacilli (if present) ^oU appear as red rods on a blue ground. The above process may be varied in its details by substituting gen- tian \-iolet for fuchsine, and Bismarck brown for methyhne blue, in which case the bacilli will present a violet colour, and the other constituents of the sputum will appear brown. The most common seats of tubercle are the kmgs and the mucous membrane of the intestines. But tubercles are generally largely distri- buted throughout the bodies of those who die tuberculous ; and we may enumerate as their seats of election, after the lungs and bowels, the serous membranes, 'Sfe^-' the spleen, the kidneys and liver, the brain ^ '^'^o.'^^T A and its membranes, the mucous surface of ^ V MM^'fiJ Mi^'^- '^)^ the genito-urmary organs, the suprarenal '■^(■■^^^^^M&^!€'il:)ki^¥A capsules and the bones, and of course the lymphatic glands. ii. Sypliiliticcjummatah&xe a close ana- tomical affinity with tubercle on the one hand, and with inflammatory products on fig. 25. -syphilitic gumma fhom the other. They resemble granulation-tissue heart. x250. in the general character and arrangement of their cellular structure, and in the facts that they are provided with permeable vessels, and at an early period of their growth are capable of conversion into cicatricial tissue. They tend, however, like tubercles, to undergo early caseation and death; and, if their progress be not modified by medical treatment, o2 84 ATEOPHY, DEGENEEATION, AND NECEOSIS. this may be regarded as their normal termination. It is in this latter condition that they are almost invariably fomid post mortem in the liver, testicles, bram, bones, and other internal organs. They then form opaque, buff-coloured, toughish masses, imbedded m dense connective or cicatricial tissue. They are especially common in the skin and subcutaneous con- nective tissue, but here they generally undergo ulceration and leave indelible cicatrices. Exceptmg by their toughness, by the size which they attam, and by the paucity of their numbers, it is exceeduigiy difficult to distinguish caseous gummata from tubercles in the same condition. In the brain and testicles especially, the resemblance between gummata and tubercles is remarkably close. B. Ateophy, Degeneeation, and Neceosis. 1. Atrophy and Degeneration. The term ' atrophy ' means strictly mere diminution in the bulk of tissue from deficient nourishment. The term ' degeneration,' on the other hand, implies degradation of tissue— in other words, a qualitative rather than a quantitative change. A part which suffers atrophy simply wastes, while one which undergoes degeneration often presents an actual increase in bulk. Yet, though atrophy and degeneration imply, so to speak, different lines ■of decay, they are so constantly associated that, in a practical sense, they scarcely admit of separation. When defeneration is in progress, we find that the microscopic structure of the parts involved gradually becomes confused and destroyed, and that accompanying this process fat, pigment, or other matters, which normally have no visible existence in them, are deposited in a globular or granular form. Whence do these matters come ? Are they due simply to the de- composition of the highly organised material which is undergoing degenera- tion, and to the precipitation of its more insoluble constituents ; or do the decaymg tissues attract them to themselves from the blood or extra-vascular nutrient fluid ? There can be no doubt that both of these processes take place ; and that, although they are distinct and not mifrequently disso- ciated, they generally concur. Inmost cases, where degenerative products are visible, they are due partly to simple precipitation, partly to infiltration. It will thus be understood that degeneration, in its widest sense, involves three processes which are essentially distinct from one another: — namely, first, simple atrophy or wasting of tissue, second, degeneration proper, or the decomposition of tissue, and, third, the deposition in the affected parts of insoluble matters derived from without ; and that these processes are generally associated, although in very various proportions. It should be added that the visible products of degeneration are only the more insoluble products of these processes ; and that other effete or de- graded matters are produced simultaneously, which are probably just as important, although more difficult to recognise, partly on account of their solubility, partly because they assume no crystalline, molecular, or other MUCOUS AND COLLOID DEGENEEATIONS. 85 ^dsible form. We sliall discuss the generally-recognised varieties of degene- ration seriatim. a. Cloudy Swelling. — When cells are exposed to the direct influence of certain poisonous substances, or when they soak in the dropsical or inflam- matory fluids which escape from the blood, they often get distended from imbibition, and at the same time their protoplasm acquires a finely granular character. The same changes, according to Cornil and Eanvier, take place in the nuclei and nucleoli. Virchow regarded them as the result of nutritive irritation. But they are now generally admitted to be of a degenerative nature, or at all events passive, and in many cases a first step towards fatty degeneration. The granules, however, are not fatty but albuminous, and readily dissolve in acetic acid. Cloudy swelling is well shown by the hepatic cells in cases of acute atrophy of the liver. b. MiLcous and Colloid Degenerations. — Li many cases cells, and in some instances intercellular substances, undergo softening and conversion into matters which are known as ' mucus ' and ' colloid.' These may form a thin glairy fluid, or present all degrees of viscidity between this and a thick jelly ; and may be transparent and colourless, or of different tints of yellow, brown, or red. They have, therefore, a very close resemblance to one another ; and, indeed, are not always easy to distinguish. They differ chemically in the fact that mucus contains mucine in solution — a substance precipitable by acetic acid ; while the specific element of colloid is an albuminous substance which is not aft'ected by this reagent. Mucous degeneration involves sometimes the intercellular parts of tissues, sometimes the cellular elements. Of the former case we have examples in the mucous softening, which takes place in the matrix of enchondromata and of the cartilages of elderly persons, and perhaps also m myxomatous tumours. The latter case is exemplified in the formation of globules of mucus within the cells of mucous membranes, the consequent distension of the cells, and their final deliquescence. Mucous degeneration is common in the cells of S}T.iovial and mucous surfaces ; it is a characteristic feature of the progress of colloid cancer ; and it is not unfrequent in other morbid growths — leading to the formation of cysts. Colloid matter is most frequently met with in the cysts of the thyroid body, and in small renal cysts ; and, like mucus, generally arises within cells, which it presently fills and destroys. In the cases just referred to, it forms rounded jelly or glue- like masses filling the cavities, and containing un- bedded in them the remams of the cells which gave them origin. It seems probable that the glassy transformation of volmitary muscles in typhoid fever described by Zenker (and which is marked by a pecu.liar waxy lustre, the disappearance of the normal markings, and a tendency to crack transversely) is really an example of colloid degeneration. Further, fig. 26.— colloid degene. 4.1 • i. 1 T J.1 J- n J i £1, • RATION OP Muscle. x250. there is reason to believe that many so-called ' fibri- nous ' casts of the urinary tubules are rather colloid matter than fibrine. 86 ATKOPHY, DEGENEEATION, AND NECEOSIS. c. Lardaceous Degeneration, known also as ' waxy,' ' bacony,' ' albu- minoid,' 'amyloid,' and 'scrofulous' degeneration, has (as the many names which have been applied to it testify) long been recognised, and presents many remarkable characteristics. It occurs almost exclusively in cases of tertiary syphilis, chronic phthisis, and long-contmued suppu- ration especially in connection with bone-disease ; and indeed, since prolonged suppuration is constantly associated with both chronic phthisis and the later stages of syphilis, there is some reason to regard the lardaceous change as the consequence essentially of suppuration. It affects mainly the liver, spleen, and kidneys ; which increase slowly to many times their original bulk, grow dense and homogeneous in texture and doughy in consistence, and present when cut a pale brownish tint, m^j be derived mainly, if not exclusively, from the degradation or decom- position of the protoplasmic matter itself, and are at first few in number and small in size, and chiefly collected immediately around the nucleus. Gradually they increase in number and size, concealing the nucleus and distending the cell, which then acquires a round or oval figure, and appears by transmitted light as an opaque black granular mass, constituting what is generally knoAvn as a ' granule -cell,' and has been sometimes termed an ' inflammatory corpuscle.' The last stage is represented by the further enlargement of the cell, its rarefaction, and final deliquescence, with the setting free of the fat-granules which had been embedded in it. In the later phases of fatty degeneration, when the cells are m great measure destroyed, and the oily matter is diffused throughout the tissues, cho- lesterine, which had doubtless been suspended in the oily molecules, separates from them, and appears amongst them in the characteristic form of incomplete rhomboidal plates ; and the whole tissue gets confused, softened, and reduced to an opaque yellowish-white pulp, or ' detritus.' The ]Di'ocess above described is common in nearly all vital tissues. Pus-globules, epithelial cells, connective-tissue corpuscles, are all apt, in the course of inflammatory processes, to become granule -cells. Cartilage- cells undergo similar changes ; and the stellate corpuscles of the cornea, and those of the inner coat of arteries, are equally liable to be the seat of fatty deposition. Fatty degeneration of muscular tissue is of much interest. It occurs as a normal process in the involution of the muscular walls of the uterus after parturition ; it may often be detected in the hypertrophied muscular fibres of the walls of the stomach and intestines, when carcinoma or other such growths affect these organs ; and it is occasionally present in the voluntary muscles. But it is chiefly met with in the muscular fibres of the heart, and has indeed been principally studied in connection with this organ. It commences here with the appearance of fatty granules in relation with the corpuscles which stud the substance of the fibres, and in the immediate vicinity of their poles ; but gradually Fig. 28.— Cholesterixe. x 250. CASEATION. PIGMENTAL DEGENEEATION. 89 tliey get more general iii their distribution, the fibres progressively losing their characteristic markings, and. after a while becoming, like granule- cells, mere accumulations of granular matter. Fatty degeneration is often remarkably well seen in the cells of carcinoma, and many other kinds of morbid growths. Fig. 29.— Fatty Degeneraiiox. Heart- Eupturo of heart Tvith diseased arteries. Purpura. Pericarditis. Ordinary form, e. Uterine muscular fibres a week or two after delivery. /. Grannie-cells. g. Cancer-cells. The term caseation is applied to that condition in which tubercles,, syphilitic growths, carcinoma, and collections of pus, acquire the appear- ance and consistence of some forms of cheese. It is essentially fatty degeneration ; but it is fatty degeneration in which there is a deficiency of moisture, in wliich the degenerate cells shrivel up instead of expanding- and midergoing solution, and in which the diseased mass becomes dry and friable instead of pulpy or fluid. It was formerly supposed to be distinctive of tubercle. e. Pigmentary Degeneration. — The deposition of pigmentary matter is not, any more than that of oil, necessarily a pathological process ; nor, even when pathological, is it to be regarded as necessarily an evidence of de- generation. All pigment, originating within the body, appears to be derived from the haematine or red colouring matter of the blood, or from the colouring matter of the bile, which is itself a derivative of hsematme. In either case it may be simply diffused in a fluid condition among the tissues, or it may be deposited m the form of granules or small solid masses, or it may assume a crystalline shape. And in either case, agam, it may present various modifications of colour ; of which red, yellow. ^0 ATROPHY, DEGENEEATION, AND NECEOSIS. brown, and black may be taken as tlie t}T)es. The various stages of pigmen- tation may be observed superficially in the progress of a subcutaneous bruise ; but to follow them thoroughly, it is necessary to investigate the changes which clots, and the tissues m which they are imbedded, present at different periods after extravasation. The blood-coi-puscles soon lose their colouring matter, which speedily diffuses itself through the sur- rounding tissues, staining them, and more especially their protoplasmic particles, of a yellow colour. From this, ere long, granular pigment, of a yellow, brown, or black tuit, is precipitated amongst the tissues, and in the clot itself; and, pro- bably, at the same time, small refractive nodulated masses of a deep orange or pale red hue make their ap- FiG. 30.— Pigmental Degeneh-A-Tiox WITH H^EiLVTOiD „ T„.,+l^ r,-^^^Tl cetst.vi,s. X 250. pearance. Lastly, small thick rhomboidal crystals, of a deep ruby colour, are produced, which are generally termed ' hsmatoi- cline ' crystals. The final colour which the granular form of pigment assumes is either brown or black ; and this, together with heematoidine crystals, which are imalterable, is the permanent mdication of the pre^ious existence of extravasated blood. A nearly similar series of changes may be observed m the liver, in cases where the escape of bile is pre- vented : — namely, first, a general staiinng of the tissues, then a granular pigmentary deposit, and occasionally a more or less abundant formation of hgematoidine crystals scarcely if at all different from those obtamed from blood. According to Stadeler, bih-rubine differs from hfematoidine only in contaming two more atoms of carbon ; and the various modifications of colour which bile undergoes by keepmg are due to the development of substances which differ fi'om bili-rubine only in possessing larger quantities of water, relatively to carbon and nitrogen. The pathological precipitation of broT\^i or black pigment in a granular form is well seen : in the cells of the rete mucosum m Addison's disease, and in the brown discoloration which often succeeds various forms of sldn disease and cutaneous inflammations resulting from chemical or other irritant apphcations ; in the cells of melanoid carcinoma and sarcoma ; and perhaps in the cells of the testis and of the grey matter of the brain, during the later periods of life. The deposition of yellow, red, and brown pigmentary granules, and of hfematoidine crystals, is, as before stated, a common result of the extravasation of blood ; accordingly these matters are found in corpora lutea, hi the neighbourhood of apoplectic effusions, and in the parietes, interior, and vicinity of small vessels obstructed by clots or otherwise diseased. In certain cases of malarial fever, in which the spleen is seriously affected, black pigment masses are formed in that organ through decomposition of blood-corpuscles, and are UEATIC AND CALCAEEOUS DEGENEEATIONS. 91 c-arried thence by the chculating blood, and deposited in the capillary vessels of other parts of the system. Black deposit is h-equently met with m the tissues of the hmgs and bronchial glands, becoming more and more abmidant as age advances. Here there is no doubt that the pigment is mainly, if not wholly, of extraneous origin ; and is in fact the carbonaceous dust floatmgin the atmosphere, which, drawn into the lungs during respira- tion, is absorbed by the epithelial cells of the bronchial tubes ; and, just in the same way as pigmentspurposely introduced by tattooing, partly remains imbedded in the tissues, and partly finds its way along the lymphatic vessels and mto the lymphatic glands. /. Uratic Degeneration. — This occurs only in gout. It is characterised by the appearance of needle-like crystals of urate of soda in the substance of articular cartilages, in the periosteum, synovial mem- branes, and tendons. They are observed mainly in con- nection with the protoplasm of the cells, are often irregu- lar in theii' arrangement, but are very apt to form opaque densely arranged star - like ■clusters. cj. Calcareous Degenera- tion. — This consists in the •deposition of a combination of carbonate and phosphate of hme m some previously existing albummoid matrix, with which it combines to form minute granules and spherules. These increase in size by concentric addi- tions to their surface, and presently coalesce into botryoidal masses, the general form and arrange- ment of which are determined by the peculiarities of the tissue in which the process is going on. The precipitation of calcareous matter takes place almost exclusively in the intercellular substance, which first appears ■dusted with minute granules, and then, as these multiply, becomes black and opaque to transmitted light. Later on, the enlarging granules run together, the blackness and opacity disappear, and the calcified tissue gets refractive and transparent. The cellular elements h-equently remain intact, or nearly so, during this process ; and if they be stellate, and nmnerous, the result is the formation of a mass having a close resemblance to true bone. Calcareous granules have a superficial likeness to globules of oil, but may be distinguished from them by their ready solubility (with the giving ofl" of bubbles of carbonic acid gas) in hydrochloric and other acids, and if they be round by displaying a cross when examined by Fig. 31.- -C-VIITILAGE OP JOIKT IXFrLTR-\TED WI'I'H URATE OF Soda. X 250. 92 ATEOPHY, DEGENEEATION, AND NECEOSIS. Fig. 32.— Calcakeotts Degeneratiox of Ceeebeal Vessels. X 250. polarised light. Eindfleiscli supposes that the pathological deposition of calcareous matter, which in the blood is rendered soluble by the presence of carbonic acid, takes place primarily at the periphery of cell districts ; and that it is due to the difficulty of reabsorption of nutrient matters which have found their way thither. This difficulty favours the sepa- ration of their more diffus- ible from their less diffus- ible constituents, and thus the removal of the dis- solved carbonic acid, and the precipitation of the calcareous matters which the carbonic acid had rendered soluble. This explanation accords very well wdth Mr. Eainey's views on the formation of shells and bone. Calcareous precipitation is A^ery common. It occurs m the internal coat of arteries, and in the whole thickness of the walls of minute vessels,. m tendon and cartilage, and even in the substance of skin. It is especi- ally apt to take place in inflammatory and other adventitious products. Thus, we find plates of calcareous matter (often first assuming the charac- ters of bone) in old false membranes of the pleurae and pericardium, in the Iming of cysts, and in the choroid coat of the eye. And, indeed, most degenerative products (such as cheesy tubercles, inspissated ]pus and old clots], when they have lost their moisture, and their more soluble or diffu- sible constituents, become its seat, and, first assmning a mortary condition, finally shrink into calcareous lumps. But, although earthy matter is deposited mainly in the tissues between cells, it is occasionally found in the interior of cells, and especially in those of unstriped muscle. It is thus that the smaller arteries are sometimes converted into rigid cylinders, and large portions of uterine muscular tumours into calcareous masses. 2. Necrosis, or Gangrene. Several of the degenerations just considered end, as we have pomted out, in the dismtegTation and death of the tissues which they affect. We do not intend to pursue this question further, or to speak of that form of death which results from the direct action of destructive agents ; but we purpose discussing very briefly the subject of necrosis, or mortification. This often arises in the course of inflammation, and often affects rapidly- developing morbid growths ; but whether occurring in these cases, or mider other morbid conditions, it is always due immediately to obstruction of afferent vessels, or to wealmess of the heart's action, and the consequent NECEOSIS OE GANGEENE. 93 more or less complete arrest of the supply of nourishment to the affected region. When the death of any part of the organism takes place, the conserva- tive influence of vitality ceases in it, its constituents fall under the un- restrained operation of chemical and other physical powers, and then undergo a series of destructive and often putrefactive changes, in virtue of which its complex organic constituents gradually get reduced to sub- stances of much more simple elementary composition, and its various morphological elements lose in a greater or less degree their character- istic features. The rapidity, however, with which these processes take place, necessarily depends "upon the degree in which conditions favour- ing them happen to be present. These are chiefly heat, moisture, and exposure to oxygen or air, and to the various microscopic organisms which .air and water contain. Hence it follows that gangrene is especially rapid, and its products especially fetid, when it occurs in superficial parts, or in the lungs, or in the course of the alimentary canal, where there is free exposure to oxygen in a more or less diluted form ; or when it occurs in parts which are juicy and loaded with blood, as they are if they have been the seat of inflammation, or if there has been previous obstruction of veins, or if the arteries have continued for a time to pump blood into them — when in fact the gangrene is what is usually called 'moist.' When there is little moisture of tissue, and that moisture admits of ready removal by evapora- tion, or in other ways, and especially if there be at the same time entire protection from the influence of atmospheric air, the changes which ensue are very slow; the parts get inspissated, dried up, mummified; and even delicate structures retain for a length of time their chemical and microscopical characters, in a very slightly modified condition. A good example is afforded by the changes which ensue in an extra-uterine foetus long retained. Bone, teeth, hair, horny matter, elastic fibres, and cartilage resist putrefactive processes in a remarkable degree. But all the softer albumi- nous or albuminoid tissues, and fat, rapidly change into a series of transi- tional compounds, the nature of which is very imperfectly known. Some, however (such as leucine, tyrosine, margarine, pigment, cholesterme, . and triple phosphate) are fixed ; some are soluble but not volatile ; and ■ others again are volatile and offensive, and give to gangrenous parts their characteristic fetor. Amongst the last must be included sulphuretted hydrogen, sulphide of ammonium, and valerianic and butyric acids. Ultimately, most albuminous and fatty matters are reduced in large pro- portion into carbonic acid, ammonia, and water. The visible changes which attend gangrene are not less remarkable than the chemical, but they closely correspond with those which charac- terise ordinary degeneration. The blood stagnates, and soon the colour- ing matter escapes from the red corpuscles, permeates the vessels, and infiltrates and stains all the tissues around. Thus, the course of the superficial veins gets indicated by broad livid lines. Soon the diflused pigment is deposited in the form of brown and black grains and even of 94 ATEOPHY, DEGENEEATION, AND NECEOSIS. hEeniatoidine crystals, and its presence tends to give a characteristic hue to the parts. The red corpuscles themselves either melt away, or are converted into small angular pigmented bodies. The white corpuscles of the blood and other protoplasmic masses get opaque and granular, then the seat of deposition of molecules of proteinous matter and of oil, and finally after becoming caseous break up into fragments. The contents of fat cells ooze through their membranous parietes, and diffuse themselves in globules of various sizes among all the tissues ; and after a while the solid fats crystallise out, and plates of cholesterine make their appearance. Muscular tissue, whether striped or unstriped, suffers much the same changes as protoplasm ; it first becomes opaque and granular, soon pre- sents oil and pigment-granules in its substance, and presently breaks up (the striped fibres often splitting into transverse discs ) and forms a viscid confused mass. Double-contoured nerves early present obvious changes : the axis cylinder undergoes the same transformations as other forms of protoplasm ; but the medullary sheath breaks up into globular, oval, and irregularly romided refractive masses of an oily character, and presenting the peculiar features of what is termed by Virchow ' myelme.' Ordinary connective tissue swells up, becomes opaque and granular, and then melts away. And bone, although it retains its characteristic form and aspect, loses its animal matrix. Many lowly organisms make their appearance in putrefying tissues, but by far the most important of these are the minute omnipresent bodies known as ' bacteria.' Indeed the evidence now seems to be conckxsive that actual putrefaction is determined by the growth and multiplication of these bodies, and that the recognised effects of air and moisture in pro- moting the decomposition of dead and dying tissues are in reality due to the bacteria suspended in them. We have adverted to the fact that the appearances and progress of gangrene vary according to the degree in which the dead parts are exposed to the conditions which promote putrefaction. But the nature of the organ involved also necessarily influences the nature of the result. Hence, we need not be surprised that gangrenous parts present great varieties of character. In internal organs, as the brain, the dead portion becomes soft and pulpy, and its colou.r opaque and yellowish, with perhaps a famt greenish tinge and a little red-mottling, and the cellular constituents get granular and fatty, and presently reduced to a mere detritus ; but no putrefaction ensues, no offensive matters are developed, and the more soluble and diffusible products are at once removed by absorption. When an inflamed or congested leg, or a strangulated bit of bowel, becomes gangrenous, the affected part contains an extraordinarily large quantity of blood which escapes into the tissues, and, assuming there the charac- ters of black pigment, blackens them ; ^Dutrefaction takes place rapidly ; a sanious fluid, charged with decomposing elements, and containing numerous globules of oil and much pigment, pervades the tissues and perhaps forms blebs at the surface ; and bubbles of offensive gas probably appear in similar situations. When gangrene occurs in the lung, the MECHANICAL AND FUNCTIONAL DEEANGEMENTS. 95 tissue often looks angemic (sometimes, however, it is black with conges- tion), and presents in the first instance a translucent greenish tinge, but soon breaks do"^ai into a turbid greenish pulp of horrible fetor. In other cases again, as for example in sloughing ulcers, or carcinomatous growths, the parts which are actually dead assume a dirty opaque white or greyish appearance, and are thro^vn off in masses. Lastly, when the affected parts have been supplied with little blood, or rapidly lose the fluid which is in them by evaporation, the condition termed ' dry gangrene ' results. They then shrivel up, and gradually, by the retention of the blood-pig- ment within them, acquire a deep maroon or black colour ; and, as was before pointed out, their decomposition proceeds very slowly, and they become dry and mummified. C. Mechanical and Functional Derangements, The various morbid processes of proliferation and degeneration which have been described bring mth them a host of mechanical and functional disturbances, which form essential elements of disease, and are often far more important, at all events far more striking, elements than are those other lesions which give rise to them. As regards fmictional disturbances, indeed, it is obvious that their presence implies the coexistence of some nutritive or other material lesion of the part or organ whose functions are disturbed ; and that their gravity must depend far less on the amount or quahty of this material lesion than on the importance of the affected organ in relation to the well-being of our higher faculties, or to the main- tenance of life. Thus, a fibroma, connected with superficial parts, may attain enormous dimensions without materially influencing the general health ; whereas a very small growth of the same kind, involving the urethra or mtestine, would probably soon cause mechanical obstruction, and induce the usual symptoms of strictured urethra or bowel. And thus, again, a tubercular mass or an hydatid may exist for some time imbedded in the substance of the brain, and yet give very little sign of its presence there ; whereas those functional disturbances of the central nervous organ, which we know as acute mania and epilepsy, depend on such slight lesions that they even now, in great measure, elude detection. 1. Mechanical Derangements. These consist mainly of [a) clisplacements of organs, (6) compression, contraction, and impaction, (c) dilatation, and [cl) rupture and extrava- sation. a. Displacement of parts is exemplified in the altered position which the heart assumes when it is subjected to the pressure of unilateral em- pyema, or of a mediastinal tumour, and which this organ, together with the Imigs, acquires when there is extreme angular or lateral curvature of the dorsal spine ; it is shown also in hernia, intussusception, and prolapse of the rectum, and in the various flexions and other displacements of the uterus. -96 MECHANICAL AND FUNCTIONAL DEEANGEMENTS. b. Compression, contraction, and imjjaction. — Tliese conditions scarcely need explanation, yet it may be well to illustrate them by their effects on tubular organs. Compression of a tube means that it is reduced in caHbre and perhaps modified in shape, by forces acting upon it from without ; contraction signifies that its bore is diminished by the inherent action of its own walls, or by morbid changes taking place in them — that there is in fact a ' stricture ; ' impaction impKes that its channel is occupied by some concretion or other foreign body. It is ob^-ious that any of these conditions may end in the complete obstruction, or closure, of the tube. The effects of compression are manifested when a large quantity of blood or serum is effused upon the surface, or into the ventricles, of the brain ; when the Imig shrinks mider the pressure of accumulated pleural secretion ; when the heart gets flattened, and incapable of dilating, mider the influence of blood which has escaped into the pericardium from a rup- tured aorta ; when the trachea is squeezed by a goitre or aneurysm ; when the intestines are strangulated by bands, or the mouth of a hernial sac ; when the rectum is flattened by the pressure of a diseased uterus. They are shown also in many cases in which organs are the seats of interstitial growths : — in ciiThosis of the liver, the new-formed fibrous tissue con- tracts upon the essential elements of the organ amongst which it is distri- buted, and leads to their more or less complete destruction ; and the same thing happens, as regards the nervous centres, in the morbid condition now commonly termed ' sclerosis.' Contraction To.d.y he due, either to spasmodic action of the part affected, or to some growth (inflammatory or other) invoMng it. As examples of the first condition we have temporary contractions of the cerebral vessels, inciting epileptiform convulsions ; of the muscular walls of the bronchial tubes, causing asthma ; and of the sphincter ani and compressor urethrte, producing spasmodic stricture respectively of the bowel and of the urethra. As examples of contraction due to inflammatory or other such changes we may enumerate, obstructive disease affecting the several cardiac orifices ; laryngeal oedema ; malignant or other organic strictm-es of the oesophagus, the pyloric or cardiac orifice of the stomach, the ileo-cascal opening, or the anus ; and similar affections of any part of the genito-urmary appa- ratus. Smaller and even microscopic tubes and ducts, such as those of the breast, kidney, and sebaceous glands, may of course become similarly obstructed. Impaction. — There are few tubular organs in which impediment from this cause does not occasionally take place. In the vascular system, especially m the systemic veins, thrombi or clots not unfrequently form, and cause obstruction. And in the same system, portions of such clots, or of inflammatory vegetations developed upon the cardiac valves, often get detached, and then carried onwards by the circulatuig fluid, until they reach some vessel too small to admit of their further progress, where con- sequently they get fixed, or impacted, and block it up. In the alimentary canal, and ducts which open upon its surface, concretions frequently form, MECHANICAL DEEANGEMENTS. CYSTS. 97 and, becoming lodged, cause more or less serious consequences : — thus, the ducts of the salivary glands may be obstructed by sahvary calculi, the common hepatic duct by gall-stones, and the intestine also by gall-stones of large size, or by indurated faeces. In the intestmal canal, moreover, indigestible substances, purposely or accidentally introduced, such as masses of hair, or vegetable fibres, and the like, occasionally form con- cretions. Calculi again are of common occurrence in the urinary cavities and passages. In considermg this subject we must not forget to advert to the impaction, or (what is equivalent to impaction) the accumulation, of abundant or tenacious secretions in ca^■ities or canals, by which they are apt to become choked ; as occurs in bronchitis, when the bronchial tubes are overloaded with muco-purulent fluid, and in inflammation of the kidneys, or in Bright's disease, when the renal tubules get blocked up by epithelial masses, blood, or fibrinous casts. c. Dilatation of ca-sdties depends, for the most part, on some dispro- portion between the pressure which their contents exercise upon their parietes, and the force which these parietes are capable of exerting in op- position to that pressure ; and hence may be caused, either by unwonted accumulation of contents, or by undue weakness of parietes, or by the concurrence of these two conditions. It should be added that even when dilatation does not originate in morbid weakness (however produced) of the walls of a cavity, it very soon cau.ses it. But dilatation may occur in cavities of new formation, as well as in such as are of normal presence, and hence its discussion involves that of the growth, if not that of the origin, of cysts. Cysts are commonly classified as a subdivision of tumours. A little consideration, however, will suffice to show that they differ essentially fi'om true tumours (that is to say, from neoplastic or proliferating growths), in the facts, that they are not themselves neoplasms ; and that when they occur, as they often do, in association with such growths, that association is a mere accident, depending either upon some structural peculiarity or upon some special tendency, of the part affected, or of the neoplasm itself. Cysts may be divided generally, in accordance with their mode of d-evelop- ment, into at least four different groups, namely : (i.) those formed by dilatation of natural cavities ; (ii. ) those resultmg from distension of ducts ; (iii.) those caused by extravasation of blood ; and (iv.) those originating m the softening and destruction of tissue, or in the dilatation of natural alveolar spaces. i. Cysts by dilatation of natural cavities. — Among these must be included the pleurae, pericardium, peritoneum, tunica vaginalis, and syno\'ial cavities, distended with dropsical or inflammatory exudation. They are exemplified also in the dilatations of the ventricles of the brain and cord, which constitute respectively the morbid conditions known as ' hydrocephalus ' and ' hydrorrhachis,' and in the malformations of the same organs, termed ' encephalocele ' and ' spina bifida.' Dilatations of the cavities of the heart, aneurysmal tumours of arteries, varicose con- ditions of veins, ovarian cysts, and cysts of the broad ligament, thyroid H 98 MECHANICAL AND FUNCTIONAL DEEANGEMENTB. body, and many other organs, fall more or less obviously into this group. ii. Cysts by distension of ducts, or ' by retention,' are even more common and more important than the last. We meet with them in the lungs, when the bronchial tubes are dilated, or when emphysema is present. They occur in all parts of the alimentary canal:— in the oesophagus, when its walls are paralysed, or there is obstruction at the cardiac orifice ; in the stomach itself under analogous conditions ; and m any part of the large or small intestines above the seat of an impediment, or when the parietes are weakened by inflammatory changes. When the hepatic, pancreatic, or salivary ducts are obstructed by concretions, the tubes behind dilate. Cysts from this cause are exceedingly common throughout the whole of the genito-urinary apparatus : as, for example, when the bladder is distended, secondarily to the presence of a urethral stricture ; when, under similar circumstances, the ureters and canities of the kidneys dilate ; and when, owing to their obstruction, the tubules of the kidneys expand into renal cysts. They occur also in the uterus and Fallopian tubes, and m the tubules of the testes, in consequence of stricture or other impediment to the escape of their contents ; and so again in the breast, and in the sebaceous, and almost all other, glands. A variety of this mode of formation of cysts has been observed, by Dr. Wilson Fox and others, in certain cases of multilocular cystic tumours of the ovary. They state that papillary growths take place from the inner surface of a comparatively large cyst ; that these, as they increase in length and bulk, get closely wedged together ; and that at length they coalesce in numerous points, leavmg irregular chinks between them — which chinks, by the retention of the secretions of their parietes, gradually dilate, and ultimately form distmct canities. iii. Cysts by extravasation. — Blood effused either into cavities, or into the substance of organs, undergoes a series of degenerative changes. In some instances these result in the softening and brealdng do-noi of the central portion of the clot, and the consequent formation of a cyst. The best examples of such cysts are furnished by the brain and the cavities of the heart — in the former case, as a result of the changes which take place in apoplectic effusions ; in the latter, as a consequence of the softening of coao-ula which have formed some time anterior to death. Clots imbedded in the substance of the brain almost always undergo absorption, and leave behind them cysts filled with clear fluid, traversed by delicate filamentous bands, and bomided by tissue still coloured with blood-pigment ; those occupying the cavities of the heart break down into an opaque milky fluid, charged with degenerate blood- elements. It not unfrequently happens that cysts are formed in the interior of sarcomatous and other soft and hio'hly vascular tumours, by exactly the same process as that which produces apoplectic cysts. It may be added that extravasated blood, especially if it be extravasated in successive strata, in many cases forms solid masses, which may become organised, and which constitute, accord- inw to their position, the various forms of ' blood-tumour ' or hcematoma. CYSTS. FUNCTIONAL DERANGEMENTS, 99 iv. Cysts hy softening of tissues. — These are generally due to the occurrence of one or other of the degenerative processes, which have been described. We meet with them in abscesses, and in cases where tissues have undergone mucous, colloid, or fatty softening. Hence, putting abscesses on one side, they occur most frequently in proliferating growths; and indeed, in some cases of disseminated malignant tumours the tendency to become thus hollowed into cavities is general. Burst© in unwonted •situations must be included in this group. It may be worth while to point out that, as cysts dilate under the influence of their accumulating contents, their parietes, which often increase at the same time in thickness, tend to tear or yield at points in "their outer surface ; that thus, pits which gradually increase in area and in depth are formed ; and that these not unfrequently end in perforation or rupture, and, in the case of cysts separated by a party-wall, in the esta- blishment of communications between them. We should also mention that the inner surface of cysts, contained within the substance of prolife- rating growths, may, however the cysts have been produced, get lined with epithelium, and the seat of neAV outgrowths ; and that hence Ave not nnfrequently see fungous, papular, villous, or cystic formations, springing from the inner surface of such cysts, just as they may spring from the diseased mucous, serous, or cutaneous surface. d. BiLpture and Extravasation. — The occurrence of rupture and extra- vasation, to Avhich the distension of cavities and canals ultimately tends, is an event of great pathological importance, and often of the gravest danger. Such accidents are common. Sometimes the heart is torn, and the pericardium consequently gets distended with extravasated blood. The rupture of aneurysms and of varicose veins is of extreme frequency. In the lungs, the progress of vesicular emphysema is largely dependent on rupture of air-cells ; and in interlobular emphysema, and pneumo- thorax, we have not only laceration of tissue but extravasation of air. Laceration of the stomach in ulcer of that organ, or of the intestine in the •course of typhoid fever, is attended with the escape of its contents into the peritoneal cavity. Again, abscesses and hydatid cysts often rupture, and discharge their contents ; and, indeed (as we have already pointed out), cysts of all kinds are liable, in various degrees, and with various results, to similar accidents. 2. Functional Derangements. To discuss these thoroughly would involve an analysis of nearly all the symptoms of all diseases. Morbid processes, indeed, are mainly recognised during life by the functional disturbances to which they give rise; and some diseases (so far, at least, as we know them) are nothino- more than groups of such disturbances. Every organ of the body, every particle of the organism, has its proper duties to discharge ; and, under the influence of morbid processes, these duties become increased or ■diminished, and in either case probably more or less profoundly modified. H 2 100 MECHANICAL AND FUNCTIONAL DEEANGEMENTS. The function of the eye is to see, that of muscle to contract, that of the' kidney to excrete urine ; but the eye may be unduly sensitive to light, or its power of distinguishing objects may be impaired, or it may see things which have no real existence ; muscle may contract with spasmodic violence, or it may be thrown into convulsive movements, or it may lose its power of action altogether ; the kidney may cease to excrete urine, or it may separate from the blood a portion only of the usual urinary solids ,. or it may discharge matters which are altogether foreign to the normal constitution of that fluid. In these and in many other ways, the organs which have been named may present signs of functional disturbance ; and it is clear that similar observations may be made in reference to every other organ. We do not purpose, however, to enter here upon the consideration of functional derangements generally, for most of them will best be discussed when we come to speak of local diseases. But some,, which are connected more especially with the vascular and nervous systems, enter so largely into the complex phenomena of disease, and. form such important elements in diseases which are fmidamentally dis- tinct fi'om one another, that it will be convenient to discuss them sepa- rately, and at once. We refer mainly to congestion, dro2)sy, fever, the. typhoid condition, collapse, and death. a. — Congestion. Accumulation of blood in the vessels of a part is necessarily associated with dilatation of these vessels ; but, as we have pointed out in speaking of inflammation, this dilatation may be active, and the accumulation of blood therefore secondary to it, or it may be passive, the vascular walls yielding under the pressure of the blood within them. i. Active congestion is due to active dilatation of vessels, or, at any rate, to that kind of dilatation which may be evoked by reflex irritation, and is effected under the influence of the nervous system. This dilatation commences for the most part in the small arteries, and presently involves the capillaries and small veins. Active congestion is constantly connected with inflammation, at least in its earlier stages, and generally wit]i morbid proliferation. And as, in health, we recognise its temporary presence in the cheek which blushes with shame, and in the general surface after violent exercise, so, in disease, we recognise its temporary presence in the hectic flush of phthisis, and in the general redness which attends many forms of febrile disturbance. ii. Passive congestion has been divided, umiecessarily as it seems to us, into two varieties, namely : — first, that which is dependent solely on loss of power in the walls of the dilated vessels ; and, second, that in which the dilatation is traceable to some mechanical impediment to the passage of blood through the veins. There is doubtless a theoretical distinction between them ; yet it is obvious that in both cases the dila- tation is really passive, and due to the fact that the vessels yield under the mternal pressure to which they are subjected. The first case is CONGESTION. DEOPSY. 101 ■exemplified by that dilatation of vessels wliicli attends the later stages of inflammation, and by that permanent enlargement of them which is often seen in the vicinity of old ulcers, and of inflammatory and other formations, and is so common in the noses and cheeks of persons who are given to drink, or have been exposed to the mfluence of weather, or suffer from acne rosacea. The second variety is observed generally in obstructive heart-disease, and under analogous circumstances m limited districts of the body. In disease of the mitral valve, in emphysema and some other affections of the lungs, and especially m disease of the valves of the right side of the heart, the blood gets delayed in the systemic veins : the trunk- veins, their tributary branches, and the capillary veins successively undergoing dilatation. We often see in such cases, groups of mmute subcutaneous veins forming varicose tufts, persistent hvid con- gestion of the nose and cheeks, hands and fingers, feet and toes, due to general over-distension of their capillary veins and capillaries, and, more important than all, congestions of internal organs — especially of the liver, which assumes the ' nutmeg ' condition, and of the kidneys, which get indurated and excrete albummous urine. Agaua, whenever a vem is obstructed by a thrombus, or external pressure, the tributary vems undergo precisely the same changes which the veins midergo generally m heart-disease. Thus, if there be an aneurysm, or other tumour, in the upper part of the chest, and the descending cava or one of its branches be compressed by it, the veins of the head and neck and upper extremities, or those of one side of this portion of the body, get distended; if the femoral vein be blocked up by a clot, the veins of the foot and leg suffer similarly ; if the lateral sinus be obstructed, enlargement and congestion ■of the retmal vems, and of the veins of the conjunctivae and eyelids, not mifrequently occur. So also when, owing to cirrhosis or other hepatic disease, the passage of blood through the portal vessels is impeded, the veins of the mucous membrane of the stomach and bowels become over- distended, and occasionally relieve themselves by actual hemorrhage. It should not be forgotten that the mere statical pressure of a column of blood, which is competent to produce a varicose condition of the veins of the lower extremities, is competent also to produce dilatation of the smaller veins and capillaries ; and further, that mere feebleness of the heart's action, in other words, incompetence to propel the blood efficiently, as occurs m the later periods of heart-disease, leads to stagnation of blood in the capillary and other small vessels, and hence to passive congestion ; and that, on almost the same principle, obstruction of an artery, as in the kuig and kidney, very often allows the territory to which it is distributed to become the seat of intense congestion and even of hemorrhage. h. — Dropsy. Dropsy is the accumulation of serous fluid within the cavities of the body, or m the areolar spaces of the comiective tissue. It depends either, like passive congestion, upon mechanical obstruction to the flow of blood 102 MECHANICAL AND FUNCTIONAL DEEANGEMENTS. along the veins, or upon the presence of inflammatory or other analogous processes, or upon some morbid condition of the blood or blood-vessels, or, lastly, upon obstructive disease of the lymphatic tubes or glands. Further, dropsy may be local or general, and dependent therefore on local circum- stances or on causes which act universally. i. The causes of general dropsy, or anasarca, are for the most part obstructive diseases of the heart, morbid conditions of the lungs impeding- the circulation through the pulmonary vessels, affections involving the secreting structure of the kidneys, and certain morbid states of the blood or tissues. The general dropsy which attends heart or lung disease is, like the congestion which also attends these affections, purely mechanical, and indeed may be regarded as the sequel of that congestion. In the healthy condition the thin walls of the capillary vessels and small veins allow a constant escape of the serum of the blood into the tissues which are external to them — the quantity, which thus escapes in a given time, being largely dependent on the varying degrees of pressure within the vessels, and on the more or less facility with which the lymphatic vessels perform their proper absorbent functions. Now when a mechanical obstacle exists to the transit of blood through the heart or lungs, the systemic veins and capillaries soon get overloaded, and the pressure upon their inner surface rapidly increases. And we can readily see that, while there arises, on the one hand, an increased tendency for the serum of the blood to transude at the peripheral distribution of the venous system, there is developed, on the other hand, a tendency at the opposite end of the system to impede the entrance of the contents of the thoracic duct ; and that hence the fluid, which is effused into the tissues in abnormal quantity, is absorbed with difficulty, and drop- sical accumulation necessarily ensues. It should be observed that the effu- sion is not simply, although it is mainly, fluid, but that it always comprises a considerable proportion of leucocytes, and generally some red corpuscles. Cardiac and pulmonary dropsies are, as their mechanism would indicate, always associated with more or less obvious congestion, and almost invari- ably first show themselves in the parts which are most dependent. The explanation of renal dropsy is not so clear. It obviously does not depend on any obstacle to the circulation existing in the heart or lungs, or on over- distension of the venous system with blood, or on any similar distension of the capillary vessels ; for the patient usually presents an anaemic appear- ance, even when the blood itself is not abnormally pale. There is, however, in renal disease very unmistakable obstruction throughout the whole capil- lary arterial system ; for, as Dr. Geo. Johnson has well shown, the small arteries generally become extremely thickened and their canals proportion- ately contracted ; and we know that the left ventricle of the heart hyper- trophies to overcome some impediment (doubtless the mechanical impedi- ment which Dr. Johnson has discovered existing at the periphery of the vascular system), and that, associated with these conditions, there is, as we should expect, greatly increased blood-pressure in the arteries. It seems hardly likely, therefore, that in this case the escape of fluid into the tissues should take place from the capillaries and capillary veins ; but, on the other DEOPSY. 103 liancl, it seems very probable that it occurs through the thickened capillary arteries, in consequence of the extreme internal pressure of fluid to which they are subjected. It can scarcely be objected to this explanation, that the thickened walls of the small arteries would materially counteract the tendency for fluids to transude through them, in face of the fact that the hyaline thickening of the walls of the Malpighian vessels of the kidney, in lardaceous disease of that organ, is not incompatible with a profuse dis- charge of urine. In pure renal anasarca the skin is usually remarkably anemic and waxy-looking, and the dropsy is often first detected, not in the lower extremities, but in the eyelids and scrotum. General dropsy occasionally takes place in persons who, from whatever cause, are in a state of anemia ; it is especially common in chlorotic girls. We know that in these cases the blood is in a state of unnatural dilution ; that the muscular tissue generally, including that of the heart and probably that of the blood-vessels, is enfeebled ; and that the circulation, therefore, even though the heart acts quickly, is languid ; and we are hence justified in assuming that the anasarca is due either to the fluidity of the blood, or to the languor of the circulation, or to a combination of these conditions. The supervention of antemia, in the course of disease of the heart or kidneys, is very often the determining cause of an attack of anasarca which otherwise would have been escaped ; and hence anaemia is, in many respects, a very serious complication of the diseases of these as well as of other organs. ii. Local dropsy depends either on mechanical obstruction of the principal vein or veins leading from the dropsical part, or on obstruction of the lymphatics, or on the presence of inflammatory or other like processes. When it depends on venous obstruction, we have, within a circumscribed space, very nearly the same conditions as those which, in cardiac disease, affect the whole body : a vein is impervious ; its tributary branches down to the capillaries get distended with blood, the serum of which presently escapes into the tissues in larger quantities than the lymphatics are able readily to remove. The most important variety of local dropsy from venous impediment is that which takes place in the" abdomen, when the passage of blood through the portal vein is impeded : as m cirrhosis, or by growths occupying the transverse fissure of the liver. But any vein maybe obstructed either by pressure from without or by a coagulum within it. Thus, by obstruction of the superior cava, enormous anasarca, limited to the head and neck and arms, may be produced ; from obstruction of the inferior cava (even from so shght an amount of it as results from the pressure of ascitic fluid) dropsy limited to the lower extremities may arise ; and, in conse- quence of obliteration of the brachial or femoral vein, anasarca of the cor- responding arm or leg may ensue. It has already been pointed out that, whenever inflammation is in progress, a considerable excess of the serum of the blood is poured out mto the tissues ; and that, especially when the parts involved are lax or present some suitable structural peculiarity, the effused serum accumulates in them, producing a more or less obvious dropsical con- dition. We see this in the oedema of the eyehds, which attends the forma- 104 MECHANICAL AND FUNCTIONAL DEEANGEMENTS. tion of a common stye ; in the dropsical condition of the tissues aromid the joints, in rheumatism and gout ; in the cedematous state of the leg, when erythema nodosum or sHght periosteal inflammation is present ; but we see it especially in inflammation of the serous and synovial membranes — inflammation of the pleura causmg hydrothorax, inflammation of the pericardium hydropericardium, inflammation of the peritoneum inflannna- tory ascites, and mflammation of the synovial membrane hydrops articuli. Effusion of serum in excess also attends the development of tubercle, and of carcinoma and other forms of malignant growths ; and consequently we often find the serous cavities full of dropsical fluid, in coiniection with the growth of such tumours from their parietes. It may, perhaps, be a question in some of these cases, as to how far the dropsy is due to the mere excessive efiusion naturally attending morbid proliferation, how far it may be attributed to obliteration of some of the veins leading from the great omentum and other parts. The last form of dropsy to which we have adverted is that due to lymphatic obstruction. We have already briefly considered this subject in connection with fibroma and lymphoma ; and need say no more about it now, than that the lymphatics of a hmb or organ occasionally get obstructed, and that then (to take the case of the limb) the whole member becomes tense, elastic, pale, and infiltrated with fluid, having the chemical and microscopical characters of lymph ; that the tissues thus soaked in nutrient fluid tend to become hypertrophied ; and that here and there subcutaneous vesicles, which may be regarded as simply dilated lymphatic passages, make their appearance, and from time to time rupture, and discharge lymph. In cases of general dropsy, Avhether of cardiac or renal origin, both the general connective tissue and the various serous cavities, as a rule, suffer in pretty nearly equal proportion ; but now and then, in association with slight anasarca, there may be extreme ascites, or extreme effusion into one of the pleurae. In such cases the local excess is necessarily due to the co-operation of some local cause — the ascites, for example, to a nutmeg condition of the liver, or to slight peritoneal inflammation ; the pleuritic accumulation either to slight general pleurisy, or to the circum- scribed serous inflammation which is usually excited in the neighbourhood of pulmonary apoplectic clots. c. — Fever. By the term ' fever ' is meant that abstract condition which is common to all so-called 'febrile disorders,' and the ]presence of which gives them their claim to that designation. Essentially it means, undue elevation of temperature ; the immediate or proximate cause of that elevation ; and the consequences which these conditions entail. i. The normal temperature of the body has been variously estimated, but, on the average, seems, in the adult, to range between 98-4° and 99-5°, in the infant to stand at a somewhat higher figure. It presents, however, withm narrow limits, numerous variations. First : the most constant FEVEE. 105 .and important of these is the diurnal variation, -wliicli rarely exceeds 1*5°, tut occasionally amounts to as much as 3'5°. The minimum temperature, according to Dr. Jiirgensen, occurs fi-om 1.30 a.m. to 7.30 a.m., the maxi- mum from ■i P.M. to 9 p.m. ; the temperature between 7.30 a.m. and 4 p.m. rising with some fluctuation, that between 9 p.m. and 1.30 a.m. gradually falling. This daily variation corresponds pretty accurately to similar variations m the activity of respiration and circulation. Second : a slight but decided elevation of temperature usually follows the mgestion of food. Third : muscular exercise has a similar influence ; although, as Dr. Davy has shoT\m. this elevation manifests itself, less by actual increase of the temperature of the internal organs, than by the general diffusion of tem- peratm-e throughout the organism. Fourth : the external temperature, again, influences that of the body in a greater or less degree. But, under ordinary circumstances, its uifiuence is much less than might be supposed ; for variations of season in our own climate have a scarcely perceptible effect, and even tropical heat and arctic cold rarely disturb the tempera- tm'e of the internal organs beyond a degree or two. The influence of external temperature depends, however, upon the conditions mider which it is exerted ; for, if these be favourable, the general heat of the body may be largely and rapidly augmented or lowered, and even to a degree which is incompatible with the maintenance of life. Thus, whenever the medium (ah- or water), in which the body is immersed, is m rapid movement, it will, if of a higher or lower temperature than the body, elevate or depress its temperature in a much greater degree than if it were at rest ; and again, whenever perspiration is impeded, as it necessarily is in a moist atmosphere, or in water, the effects of heat are exerted with special -efficacy. The conditions which determme the heat of the body, and which regulate it, have been mvestigated with considerable success. It is certain, in accordance with the laws of force, that no heat can be de- veloped in the body save such as may be traced, directly or indii-ectly, to the latent heat of the substances which are ingested as food ; that the total amomit of heat which the body is capable of evolvmg, is simply that which would be emitted in the com'se of its entire destruction by burning ; and that, neither in its parts nor as a whole, has it any more power of creating heat than of creating matter. It is obvious, therefore, that the development of heat in the body is due simply to the setting free of latent heat by the destructive oxidation which is constantly going on in it ; and that the quantity of heat developed in any given time is an exact measure of the amount of oxidation which has taken place in that time. It is equally obvious, that the excreta furnished by the skin, Imigs, kidneys, and alimentary canal (representing as they do the lowest degree of degra- dation to which, after various changes, the ahmentary matters have become reduced), must furnish the means of determming exactly both the amomit of oxidation which has been effected, and the amount of heat which has been evolved. Eanke, by comparing the daily quantity and quality of the food with the daily quantity and quality of the excreta, has arrived at the 106 MECHANICAL AND FUNCTIONAL DEEANGEMENTS. conclusion that tlie healthy adult body evolves on the average enough heat in twenty-four hours to raise 441bs. of water from the freezing to the boil- ing point ; and it has been estimated further, that of this heat 2-6 per cent, goes to the elevation of the temperature of the food ingested ; 5 '2 per cent, to the warming of the air breathed ; 14-7 to the vaporisation of the water discharged by the lungs ; and 77'5 to the radiation and evapora- tion from the skin. The above statements, however, only represent the final result which is attained, after many transmutations within the body, during which heat becomes alternately latent and sensible. We know, for example, that heat is as essential for the maintenance of the corporeal functions, as it is for that of the functions of the steam-engine ; that every act of growth and development, every nervous operation, every muscular contraction, is dependent on the heat developed by oxidation, and is attended with the temporary disappearance or absorption of a certain quantity of heat ; while, on the other hand, everything which interferes with, or impedes, or arrests the performance of these functions (the friction of the blood against the walls of the capillary and other vessels, and of the muscular fibres against one another, every opposed muscular effort, and possibly even the constant passage of nervous currents along the nerves) is attended with the reappearance of that heat in a sensible form. It remains to consider on what conditions the regulation of the amount of heat developed, and the regulation of the temperature of the body, depend. As regards the former question, there can be no doubt that that degra- dation of tissue and of material which results in the evolution of heat,- although in itself a purely chemical process, is indirectly largely under the influence of the nervous system, and especially of its sympathetic portion ; for it is to this that the varying rapidity and force of the heart's contractions, and the varying diameters of the vessels (which between them so powerfully affect the molecular changes which are going on in the body) are due ; and it is possibly by its direct operation on the essential elements of glandular organs that the secretions of these organs are to a large extent regulated. The maintenance of the body at a uniform temperature is due to the existence of a remarkable power of adjustment between the amount of heat developed in the interior of the body, on the one hand, and the amount of cooling, on the other, which takes place during respiration by the admis- sion of cold air and the exhalation of water, and at the cutaneous surface by radiation and evaporation — processes, however, which again are under the control of the nervous system. The equalisation of the temperature of the body is dependent on the circulation of the blood : the more active this is, the more does the temperature of the surface and extremities approximate to that of the internal organs, and at the same time the more rapidly is the general cooling of the body effected ; while, on the other hand, the more feeble the circulation, the cooler do the surface and ex- tremities become, the wider grows the difference between the temperature FEVEE. 107 of these parts and that of the mterior of the body, and the more slowly does the internal temperature undergo reduction. ii,^ The presence of abnormal or febrile temperature is usually attended with various symptoms and phenomena more or less characteristic of the febrile state. The skin gets hot, the pulse and respirations accelerated,, the gastro-intestinal functions impaired or modified, the urine and other secretions diminished, and headache and muscular pains are complained of. There is generally also a tendency for the febrile phenomena to assume a remittent character, for paroxysms to recur perhaps once or twice in twenty-four hours, and for each paroxysm to comprise three more or less distinctly marked periods, known respectively as the cold, the hot, and the sweating stage. In the first of these the patient feels chilly or cold, shivers or has rigors ; in the next his skin gets hot and dry ; and in the third more or less abmidant perspirations break out. The increase of temperature may vary from the slightest rise above the normal up to 110° or 112°. If it do not exceed 101°, slight febrile action oiiLyis present ; if it lie between 101° and 103°, the febrile condition may be regarded as ' moderate ; ' if between 103° and 105°, the fever is con- siderable or ' high ; ' if it exceed 105°, the febrile disturbance is excessive, and there is usually considerable danger ; from 106° upwards the tempera- ture is frequently termed hyperpyretic ; and (with one or two notable exceptions) if it surpass 107° or 108° death is almost certain to supervene. Febrile temperatures, like normal temperatures, undergo variations ; and. on the whole (exceptmg when interfered with by the influence of specific diseases] these correspond to the normal variations, but are exaggerations of them. Thus, there is usually a matutinal fall and an evening rise, and the difference between them generally amounts to 2 or 3 degrees ; but it may be much more considerable. The skin is usually dry and hot, but it is liable to considerable changes. Not mifrequently, during the early period of a febrile attack, or of a febrile paroxysm, while the internal parts of the organism are preternaturally hot, the vessels connected with the surface of the body, especially those of the limbs and head and face, are so contracted as to allow comparatively little blood to reach the surface. This then looks shrunken and dusky, and in certain parts, especially the hands, feet, nose, and ears, may even be much colder than natural. But more or less general heat of skin is present even when the surface displays this appearance of chilliness ; and before long the contracted vessels dilate, blood is admitted freely to the comparatively exsanguine parts, which then become plump, congested, dry, and often to the touch pungently hot. This latter condition is usually succeeded after a time by more or less copious perspiration. The frequency of the heart's beats is always increased, and this increase has usually some relation to the temperature present. Thus, if the latter range h-om 100° to 101°, the pulse usually ranges from 80 to 90 ; if the temperature range from 101° to 103°, the pulse ranges from ' Several corrections and additions to this article have been derived from Dr, Burden Sanderson's papers on the ' Process of Fever ' in the Practitioner for 1870. 108 MECHANICAL AND FUNCTIONAL DEEANGEMENTS, 90 to 110 ; if the temperature range from 103° to 105°, tlie pulse ranges from 120 to 130. With still higher temperatures, the pulse may rise to 140, 160, 180, or even over 200 beats in the minute. The rule, however, which is here laid down is Hable to frequent exceptions : especially in the case of irritable or nervous persons, in whom the pulse, in relation to temperature, is usually disproportionately frequent. The character of the pulse varies. In its typical condition it is more or less large, hard, and bounding, and its trace displays a sudden rise with an almost equally sudden fall, but no indication of dicrotism. This is its state during the height of fever. But dviring the cold stage it is small and hard, and in the sweating stage large and soft. Although increase in the frequency of the respirations is undoubtedly one of the normal phenomena of fever, and we often observe the respiratory acts rising to 80 or 40, and in the case of children to 50 or 60, in the minute, the respiration-rate does not bear that close relation to the temperature which the pulse-rate does. It is not uncommon to find the respirations normal in frequency even when the temperature is consider- ably elevated ; and, on the other hand, to find them greatly accelerated in febrile states of the mildest type. When the temperature is hyper- pyretic, the respirations are usually very rapid and shallow, and the inspirations often attended with opening of the mouth and of the alas nasi, and with a sniffing, sipping, or sucldng sound. The amount of air respired in fever in a given time is always considerably greater than in health, and although the expired air contains a diminished percentage of carbonic acid, the total quantity of carbonic acid discharged appears to be largely increased. Thirst is usually present, and often extreme, and for the most part there is impairment or loss of appetite ; the mouth feels dry and clammy and acquires a bitter taste ; and the tongue tends to be more or less thickly coated and dry. The bowels are generally constipated. The urine is almost invariably modified in character : it is scanty, high-coloured, of high specific gravity, and deposits on cooling a more or less abundant sediment of urates and perhaps uric acid. But although ihe bulk of urine passed daily is generally below the healthy average, the quantity of solid matter which is passed with it is usually above the average. The chief increase here is in the urea, of which more than twice as much may be excreted as in health. Dr. Parkes has discovered 885 grains in the day's urine of a patient suffering from enteric fever, Alfred Vogel as much as 1235 grains in that of one suflering from pyaemia, and Dr. Anstie over 1600 in that from a case of pleuro-pneumonia. Uric acid also is increased, and may be increased twofold. Again, the colour- ing matter may amount to three or four times the quantity discharged in health, and there is a more or less important rise in the quantities of hippuric, sulphuric, and phosphoric acids and of the salts of potash. On the other hand, chloride of sodium and other salts of soda are diminished. Pebrile urine is usually more acid than healthy urine. But although the general fact of the increase of the solid constituents of the urine in fever FEVER. 109 has been well ascertained, it has also been well ascertained that the dis- charge of solid matters occasionally falls, sometimes suddenly, sometimes gradually, far below the normal, the urine becoming pale, limpid, and of low specific gravity. Such occurrences, however, are only of temporary duration, and are always followed sooner or later by an abundant discharge of effete matters which had been accumulating in the system. Among the febrile phenomena referrible to the nervous system may be enumerated, headache, vertigo, delirium, a sense of weariness, soreness or aching in the loins and limbs, and alternations of subjective chilliness with flushes of heat. The sensation of chilliness is exceedingly common, and occurs most frequently at the beginning of a febrile paroxysm. It is often associated with rigors. These are violent tremulous movements of all parts of the body (legs, arms, trunk, head, and neck) attended with chattering of the teeth and that pallor or duskiness of surface which has already been adverted to. The patient feels intensely cold, although the interior temperature of his body is probably far above the normal. Eigors appear to be explicable by the fact that, owing to excessive contraction of its arteries, the skm receives less than its due share of blood, and less than its due proportion of the heat generated within the body. It is, therefore, either generally or in certain parts, relatively cold. The feet, hands, nose, and ears, indeed, are often livid, shrunken, and actually cold. Rigors may not unfrequently be reinduced by exposing portions of the surface to the influence of the air. In children, convulsions sometimes take their place. There are several points of interest in relation to fever which may be briefly referred to. First : it is a remarkable fact that, notwithstanding the extreme thirst of most fever patients, and the large quantities of fluid which they drink, but little water comparatively is discharged from the kidneys or bowels, and often little apparently from the skin. Dr. Parkes suggests that this may be due to the presence in the system of some inter- mediate waste product which, like gelatine, is powerfully hygrometric There is reason, however, to believe that the collective dischai'ge of water is usually much greater than it seems to be, and than it is in health, and that in fact a considerable proportion of the loss of body-weight of fever- patients is due to this cause. If, then, the discharge of fluid from the bowels and kidneys be diminished, it is obvious that there must be aug- mented discharge from the lungs and skin. And, as regards the skin, it may be observed that it is only during the cold stage and during rigors that exhalation is in abeyance, that in the sweating stage the discharge of fluid is obviously excessive, and that even during the hot stage the escape of watery vapour by insensible perspiration is abundant. Second : the condition of the blood is a matter of much interest ; yet little of import- ance is known about it. It seems, however, that after a time the red coi'puscles, albumen, and alkaline salts diminish in quantity, and the blood consequently becomes impoverished. Third : that excessive waste' of tissue goes on during fever is plainly shown by the condition of the urine, and by the gradual and often rapid emaciation of the patient, which 110 MECHANICAL AND FUNCTIONAL DEEANGEMENTS. occurs even if he be taking considerable quantities of nutriment. The tissues that especially suffer are the fat, which may almost entirely dis- appear, and the muscles, which dwindle away in a remarkable degree. But the more permanent tissues, such as the bones, also undergo some diminution. Eecent observations show that, although the amount of Tirmary solids discharged daily in fever is often not larger than that dis- charged in health, the amount is always much larger than that which would be discharged iia health under fever diet. It has also been shown that the increase in the urea precedes the elevation of temperature, and that it is maintained even durmg defervescence. That this urea is due mainly to the disintegration of the tissues of the body and of the blood- cells, and not, as in health, mainly to the albuminous matters derived •directly from the food, is proved by the fact that the salts of potash (which are normal constituents of the living tissues ) become excessive in febrile urine, whereas the salts of soda (which abound in the plasma of the blood, and in food, and which in healthy urine exceed those of potash) diminish, sometimes almost to zero, to reappear in excess during convalescence, when the potash salts decrease. The undue disintegration of the red blood-cells is demonstrated by the excessive presence of colouring matter in the urine. Fourth : the supervention of convalescence is described as taking place in two different ways — gradually by lysis, or suddenly by crisis. In the former case all the febrile phenomena gradually disappear, and the patient lapses gently into convalescence. In the latter case the progress of the attack is abruptly arrested with the appearance of a so- called ' critical ' chscharge (copious perspiration, profuse diarrhoea, or abundant secretion of urine loaded with effete matters), by means of wrhich it is supposed that the morbid blood rapidly purifies itself. But fifth : fever may also end in death. This event, however, can rarely be attributed to the influence of fever alone, inasmuch as fever is always secondary to some specific or other disease of which it is a mere epiphe- nomenon or symptom. Nevertheless it is obvious, if we consider the physiological and other recognised consequences of fever, that fever itself tends to the induction of death n some two or three different ways. The chief of these appear to be asthenia, blood-poisoning, and the direct influence of sustained high temperature. The continuous excessive waste of tissue, mth the consequent emaciation, loss of strength, and impair- ment of the functions of various organs (which is an essential element of the febrile state), must clearly, if it be not arrested, involve sooner or later a fatal issue. The progress of the hectic fever of phthisis, and other chronic wasting disorders, furnishes a sufficiently apt illustration. This waste of tissue necessarily leads also to the passage through the blood of an excessive quantity of effete products, such as urea and other matters related to urea in composition, some or all of which are poisonous to the system in a greater or less degree. So long as these are freely eliminated by the emunctories, the blood may remain fairly pure, and little mischief ensue. We have sho"v^■n, however, that this elimination is sometimes arrested temporarily. There is no doubt that it is often insufficient to FEVEE. HECTIC FEVER. Ill ■effect the purification of the blood. Under such circumstances urfemic poisoning and typhoid symptoms are only too apt to usher in a fatal issue. The persistence of a temperature above a certain elevation is incompatible with the maintenance of life. It has been shown by the experiments of MM. Delaroche and Berger that animals, placed in an atmosphere ranging from 122° to 201° until the heat had killed them, were found at the time of death to have an internal temperature of only 11° to 13° above their natural standard ; whence it may be inferred that an elevation to this degree is necessarily fatal to them. We do not, of course, know with accuracy what is the upper limit of temperature which is compatible with the maintenance of life in the human being. We may say, however, with some degree of assurance, that a persistent temperature above 110° will certainly cause death, and that there is good reason to believe that a temperature of even 107° cannot be supported for any length of time. Death from high temperature is attributed by M. Bernard to a condition of the heart analogous to rigor mortis : 'the auricles are found full of blood, the ventricles contracted and empty. The injurious influence of excessive heat, however, is not exerted on the heart alone, but equally on all living tissues, and especially probably upon simple protoplasm wher- •ever it is distributed. In cases of hyperpyrexia, the symptoms referrible to the nervous system are particularly striking. They usually commence with restlessness, confusion, and tendency to mental disturbance, and lead, through maniacal excitement, muttering delirium or convulsions, to •coma and death. Nevertheless, it is by no means clear to what extent these symptoms are referrible to abnormal heat. It is a remarkable fact that frequently, when the advent of death is attended with rising temperature, the heat of the internal parts continues to increase for some hours after death. It will be readily gathered from the foregoing discussion that the imme- diate cause of febrile temperature lies in the excessive degradation of the tissues of the organism, and the consequent evolution of their latent heat. The abnormal activity of circulation and respiration, which accompanies fever, alone implies unwonted activity in some at least of the processes which these functions subserve ; and the progressive emaciation of the frame and the continued over- discharge from the lungs of carbonic acid, and pre- sence in the urine (notwithstanding, in many cases, almost total abstinence from food) of an excessively large quantity of those matters Avliich are the result of the degradation of albuminous compounds, clearly demonstrate the character of these processes a This explanation obviously does not touch that further important question, ' What is the cause of the tendency, which is always present in fever, to that preternaturally rapid destruction and oxidation of tissue on which the febrile elevation of temperature -depends ? ' This question, however, notwithstanding its importance, scarcely calls for discussion here. iii. Hectic fever. — The term ' hectic ' is applied to those varieties of fever that attend various diseases of long duration, and more especially such affections as malignant disease, tuberculosis, and chronic syphilis, 112 MECHANICAL AND FUNCTIONAL DEEANGEMENTS. which are characterised by the gradual development of proliferating growths-- in many organs, or such as caries of bones, disease of joints, and the like, in which purulent discharges are kept up for an indefinite period. The phenomena of hectic fever are essentially those which have been described in the preceding account of fever. They are chiefly pecuHar in their comparative mildness and long duration. The symptoms of hectic come on insidiously, and the febrile condition may be already far advanced before its presence is fully recognised. The patient probably finds himself gradually losing flesh and strength, and becoming disinclined for exertion. He observes that he is disposed to be chilly in the mornmg ; that in the evening, and in a less degree after meals, his hands and feet are hot and dry, and his face flushed ; and that he wakes towards the morning with a moist perspirmg skm. But his tongue is clean, his appetite good, and, although he may be thirsty and his pulse quickened, his functions generally are properly discharged. At this time a careful thermometrical examina- tion will probably show his temperature to be elevated by two or three degrees ; but also that, as in health, it is lowest in the morning and highest in the evenmg, and that his indistinctly developed cold, hot, and sweating stages correspond pretty accurately with the usual cycle of the healthy temperature- variations . As the morbid condition on which the fever depends progresses, the symptoms (although of the same character as before) get more distinctly developed, the patient becomes pallid, his emaciation and debility more' obvious, and the febrile character of his illness more striking. The tem- perature, even now, often does not exceed 103° ; but it is liable to occasional higher degrees of elevation, and in its matutinal remissions may sink below the normal. The patient is apt to be chilly in the morning, with cold and livid feet, hands, and nose. In the evening exacerbation the skm gets hot and dry, the palms and soles burning hot, the lips dry and red, and the cheeks flushed with a circumscribed red flush ; and towards the morning he wakes to find himself drenched in profuse (colliquative) perspirations. The chief exacerbation occurs almost invariably in the evening, and it is often the only one ; but there is occasionally a second, earlier in the day ; and generally the ingestion of food, and especially of an ample meal, is followed by more or less marked febrile reaction. With the progress of the other symptoms, the pulse becomes accelerated ; and even if it feels sharp, as it may do during the febrile exacerbations, it is positively enfeebled, and midergoing progressive enfeeblement. Even now probably the tongue is- clean, ^Derhaps morbidly clean, and the appetite good. There is, however, more or less thirst, the bowels are probably constipated, and the urine (especially in the febrile paroxysms) is scanty, high-coloured, and concen- trated. At a later stage the symptoms are modified, and other phenomena (not wholly referrible to the fever) superadded. The emaciation and debility get extreme, the pulse more and more feeble and rapid, the circulation imperfect ; bed-sores form ; the fingers grow livid and bulbous, and the skin harsh and scaly ; diarrhoea not unfi-equently supervenes ; the tongue THE THEEMOMETEK. 113 gets dry and fissured or aphthous ; the appetite fails ; and death from exhaustion presently ensues. It is remarkable that the intellect is rarely affected, and that, in a large proportion of cases, the patient continues cheerful and hopeful even to the last, iv. The thermometer of late years has become to the physician almost as important as the stethoscope. It is in general use, and is certainly of extreme value, not only in the diagnosis, but in the prognosis of disease. It is desirable, therefore, to make a few observations in reference to it. A clinical thermometer should be accurate and sensitive, should have its degrees divided into fifths, and be so marked as to be easy of perusal. It should be furnished with an index, consisting of a single fragment of mercmy, between one-fourth and one-third of an inch long, detached from the upper part of the mercurial column. For ordinary use an instrument, which may be carried in the waistcoat pocket in a case, and marked from 95° to 112°, is sufficient. It is well, however, to be provided, for special purposes, with a thermometer of greater range (say from about 80° to 112°), and probably, therefore, of greater length, and comparatively cumbersome. The index should never be allowed to descend into the reservoir, and so to mingle with the rest of the mercury ; nor should supplementary indices be allowed to detach themselves from the mer- curial column. The former accident may be prevented by never violently shaking the index into the reservoir, and to some extent by the presence of an annular constriction in the channel of the thermometer a little above the reservoir ; the second, by always carrying the thermometer horizontal or with the reservoir downwards, and by never permitting the mercury when it has risen into the tube to be too suddenly cooled. Prior to taking a temperature, the index should be brought into the lower part of the tube, at least below the mark indicating the lowest temperature we are likely to meet with. The bulb of the instrument should then be placed in the part selected (m the axilla, beneath the tongue, in the anus or vagina), and retained there sufficiently long to permit of the rise of the mercurial column, and the carriage of the index, to the position corresponding to the temperature of the part. It is important, especially as regards the axilla, that the bulb of the instrument should be tightly grasped, and entirely protected both from the influence of the air and from the contact of the clothes, and that it should be allowed to remain in sitti from three to five minutes at least. A casual observation is of course often of considerable value ; in many cases, however, and especially in fevers and inflammations, periodical observations should be made. Sometimes morning and evening determinations of the temperature are sufficient for all practical purposes. But not unfrequently, especially in very severe and acute diseases, in certain specific diseases, or when the effects of particular forms of treat- ment are under investigation, periodical observations of much greater frequency are called for. 114 MECHANICAL AND FUNCTIONAL DEEANGEMENTS. cl. — The Typhoid Condition. Tlie condition here referred to, like fever, is common to many different diseases. Wlien erysipelas, carbmicle, pneumonia, or any other severe in- flammation, is tending to a fatal issue ; in the latter stages of typhus, enteric fever, scarlatina, small-pox, and other specific fevers ; towards the fatal close of acute atrophy of the liver, and of urtemia consequent on Bright's disease ; and at the corresponding period of many other affections ; typhoid symptoms, or symptoms resembling those of the later stages of typhus fever, are apt to supervene. The patient becomes prostrate ; he lies on his back in bed, with eyes closed, features shrunken and ghastly, and a dull stupid aspect, unconscious or nearly unconscious of everything that is going on about him. His skin is dusky, moist, and sometimes bathed in SAveat, which often yields a fetid odour, and is for the most part, especially in the extremities or exposed situations, cold. His lips are dry, black, and probably fissured, his teeth loaded with sordes, his tongue dry, brown or black, and often contracted in all its dimensions. He has no inclination for food, and probably no ma- terial thirst ; but he has a difficulty (partly due to the condition of his mouth) in swallowing and utterance. His bowels are sometimes consti- pated, but often relaxed, and the evacuations are apt to be offensive. His respirations are shallow, but for the most part not much accelerated — ranging probably between twenty and thirty in the minute. They may, however, be much more frequent, and are liable to variation. The pulse is rapid and feeble, and tends to get more and more rapid and feeble, and, towards the end, imperceptible at the wrist, and irregular. It may vary at first from 100 to 120, but often attains a frequency of 140 or more, and at the same time assumes an undulating dicrotous character. The first sound of the heart is liable to become inaudible. Shortly before death, the super- ficial capillaries often dilate, the blood accumulates and stagnates within them, the surface acquires a rosy aspect, and a profuse flow of perspiration takes place. Bed-sores are apt to form upon the sacrum and other parts exposed to pressure. The condition of the urine presents considerable variety : — sometimes it is scanty, high-coloured, and loaded with urates ; sometimes it is abundant, pale, and limpid, and of low specific gravity. Muscular debility is shown in the tendency which the patient has to lie upon his back, and to sink towards the bottom of the bed. His senses are blunted ; often he is deaf ; he takes little notice (even if his eyes be open) of surrounding objects ; he rarely complains of pain or uneasiness, or acknowledges its presence, and is insensible to conditions which at other times would have caused much personal discomfort ; his intelligence is impaired, especially his memory fails ; his mind is full of delusions, and he is more or less constantly muttering — he is in a condition of ' low- muttering delirium ' or typho^nania ; he can probably, however, be re- called to himself momentarily if addressed loudly, and will then half open his eyes, endeavour to do what he is told, and even give an intelligent response ; but he soon lapses into the state from which he was aroused ; THE TYPHOID CONDITION. 115 lie picks at the bed-clothes ; his limbs are tremulous when he endeavours to use them, and his muscular fibres are in constant vibratile movement, giving rise to the condition known ShS sub suit us teudiiiuvi; he passes his evacuations unconsciously, or allows the urine to accumulate in his bladder. "With the advance of the typhoid symptoms, the mind becomes more and more obtuse, and the patient gradually passes into stupor, and thence into profound coma. The temperature presents great variety, de- pendent in a considerable degree on the nature of the disease upon which the typhoid symptoms supervene : — sometimes, as in Bright's disease, it is a good deal below the normal standard ; sometimes, as in the hyper- pyrexia of acute rheumatism, it attains an elevation of 110° or more. The typhoid condition is always one of great gravity, and in a large proportion of cases terminates in death. The collective phenomena of the typhoid state have generally been at- tributed to the presence of some poisonous matter in the blood. Formerly this was believed to be the specific virus of the disease in the course of which they were developed ; or, in the case of local inflammations, some morbific elements generated at the diseased spot and thence thrown into the circulation. It is difficult, however, to understand how it can happen that numerous poisons, distinct from one another, and having different actions in other respects, should yet have the common property of inducing the complex phenomena of the state luider consideration. Another view is now commonly entertained, and has far higher claims to acceptance. It is to the effect that the poisonous matters which circulate in the blood are not the specific elements of diseases, but those products of the disintegra- tion of nitrogenous tissues (urea and the like) which are known, when accumulated in the blood, to have poisonous effects ; and which are apt to accumulate in the blood in all those diseases in the course of which typhoid symptoms supervene. The excessive production of these effete matters in various local inflammations, and in the infectious fevers, is an established fact. And as regards some of the latter diseases, it has been distinctly proved, not only that the kidneys (even when healthy) often fail to elimi- nate them in normal quantity, but that even when these organs excrete them profusely, the blood still remains overloaded with them ; and further, that, in such patients, when they die with typhoid symptoms, urea in •excess is discovered in the blood. In chronic Bright's disease there is the same accumulation of urea and such like matters in the system ; and the typhoid symptoms which come on in its course have long been regarded as of urasmic origin. Indeed in this case it is impossible to suggest any other. The facts, of the presence of uraemia in all cases in which typhoid symptoms are present, and of the dependence of the typhoid symptoms in Bright's disease upon the condition of the blood, are almost conclusive in favour of the dependence of the typhoid condition generally upon uraemic poisoning. The circumstance that in some cases the accumulation of effete matters is due to their over-production, in others to their retention, does not tend in any degree to invalidate this conclusion. i2 116 MECHANICAL AND FUNCTIONAL DEEANGEMENTS. e. — Collcqose. Syncope. The states of collapse and syncope are in many respects tlie opposite of" that of fever, and are attended with either general or partial loss of tempera- ture. It is important, however, to observe that a general depression of the temperatm-e of the body may take place, without any of the other symptoms of collapse being present, especially during the remissions of various febrile disorders, or the periods of convalescence from them ; and that, on the other hand, profound collapse may occur while the temperature of the internal organs is still many degrees above the normal. The conditions under which collapse or syncope may come on are very various. It may occur in the cases above mentioned — namely in the periods of remission of fevers, or during convalescence from them ; it may come on in rigors, or when (as in cholera) a high internal temperatiire prevails ; it may be consequent upon the presence of urea, or of extraneous poisons, in the blood. Other causes are mental emotions, more especially such as are of a depressing character ; sudden and excessive pain ; un- wonted distension of tubes (the urethra, the ureters, and the bile-passages to wit ) by foreign bodies ; rupture or perforation of internal organs ; hemorrhage and profuse discharges, especially from the bowels ; vomiting ; severe injaries of all kinds, including those due to the operation of irritant substances or poisons upon the stomach ; mechanical obstacles to the cardiac circulation ; and many others. The symptoms of collapse are mainly the following : — coldness and pallor of surface, more especially of the extremities and face, which appear shrunken, pinched, and occasionally livid ; perspiration more or less pro- fuse, somethnes limited to the extremities and face, and generally formmg large drops in the latter situation ; infrequency of the respiratory acts, which are shallow, sometimes scarcely perceptible, often irregular, and now and then sighing or gasping ; feebleness of heart's action, indicated sometimes by increased frequency, sometimes by slowness, of the pulse, which often becomes irregular and often scarcely perceptible, or impercep- tible, at the wrist ; occasionally hiccough and nausea, or even vomiting ; . extreme muscular debility ; noises in the ears, indistinctness of vision, general soreness or sense of compression, want of breath, giddiness, depression or anxiety, and confusion of thought. In some cases there is restlessness, transient delirium or maniacal excitement, occasionally attended by convulsions, or complete insensibility ; in some cases, on the other hand, the mental condition is wholly unimpaired from first to last. In severe cases the patient lies almost motionless, with eyelids half closed and perhaps slightly twitching— looking hke a corpse. In true collapse there is probably always more or less marked fall of temperature ; and that is the case even when, as in the collapse of cholera and other febrile dis- orders, the internal temperature is still abnormally high. But in all cases the extremities and the head lose heat rapidly, and usually become posi- tively cold. In cholera, the thermometer m the mouth or axilla may stand at 90° or less, while that in the rectum marks 105° ; and incoUapse,. COLLAPSE. SYNCOPE. 117 "tlie result of severe injury, the temperature even in the rectum may fall (as is shown by Mr. Wagstaffe) as low as 82*15°. Much more commonly, liowever, collapse-temperatures range between 92° and 97°. Syncope differs from collapse (of which indeed it is a mere variety) mainly in the suddenness of its access and the rapidity of its progress, but generally also in the fact that the symptoms of syncope, during their con- tinuance, are more severe than those of collapse. This latter distinction is, however, by no means essential ; for, as is well known, syncope may present all degrees of intensity, from a simple sense of faintness to a prostration so profound as to simulate death. The short duration of syncope necessarily precludes the occurrence of any marked depression of the general temperature. When recovery from collapse or syncope takes place, there is always more or less reaction ; the surface gets smooth, its colour returns, and a general glow supervenes, the circulation re^dves, the temperature rises, And other febrile phenomena manifest themselves. And if the collapse have been profound and of long continuance, the consecutive fever may ■assume serious proportions. In considering the pathology of collapse there are three factors of that condition the importance of which is especially obvious. These are depres- sion of temperature, feebleness of circulation, and the condition of the nervous functions. First : the depression of temperature, so far as regards the limbs, face, and other exposed parts, can no doubt be traced mainly to the comparative failure of the circulation in them. But that this is not the sole cause of that depression is obvious from the fact that the internal temperature, instead of rising, as under such circumstances it should normally do, itself tends to diminish, and sometimes diminishes rapidly. It is clear indeed that there is throughout the organism a more or less complete arrest of those disintegrating processes upon which the mam- lenance of the temperature of the body depends, and presumably also a more or less complete arrest of those vital processes with which these latter are intimately interwoven. Second : the feebleness of the circula- tion is shown by the obvious weakness, and frequent irregularity, of the heart's action, by the failure, more or less complete, of the pulse at the wrist and in other peripheral situations, and by the concurrent disapjjear- ance of blood from the cutaneous surface and other textures. The details of the processes by which the faihire of the circulation is induced doubtless differ in different cases. It may, however, be assumed that there is always cardiac debility, and in a large proportion of cases diminished -supply of blood to the left side of the heart, and hence to the vessels which it supplies. In collapse from hemorrhage the latter condition is of -extreme importance. And, indeed, it is found, in a large proportion of cases of death from sjnicope or collapse, that the cavities of the right side of the heart are distended, while those of the left side, and more espe- cially the ventricle, are contracted and empty. In other cases, however (especially if death has been sudden), the left ca^dties may be found over- loaded. Third, and most important, is the condition of the nervous 118 MECHANICAL AND FUNCTIONAL DEEANGEMENTS. functions. We have pointed out tlie not unfrequent dependence of collapse or syncope on affections of the mind, and on many other conditions which, can be operative only through the medium of the nervous system ; and we have enumerated the various phenomena, referrible to the nervous- system, which attend and characterise a large proportion of cases. These facts are sufficiently suggestive. But when we look a little more closely into the matter, and consider how many different causes, of different operation, equally produce the same collective phenomena of collapse ; how rapidly these phenomena come on, and how universally the organism is affected by them ; how impossible it seems that a smash of the leg, a per- foration of the bowel, or an agony of terror, should directly arrest the chemical changes going on throughout the organism, and so reduce the temperature of the body, or should directly influence the action of the heart and arteries, it is impossible to doubt (what many other considerations tend to prove) that all the phenomena of collapse are directly traceable to the operation of the nervous system — not however of the brain or cord, but of that department, namely the sympathetic, which presides over circulation, nutrition, and the functions of the various organs, including those of the brain itself. /. — Death. Death is one of the natural terminations of disease; and according to- the nature of the disease, or the office, bulk, or position of the organ which may be its seat, the phenomena which usher in that event differ in a greater or less degree. Many of the specific fevers prove fatal with the superven- tion of typhoid symptoms ; many exhausting diseases cause death by simple debility or asthenia, and other affections by the allied conditions of syncope or collapse ; diseases of the air-passages or lungs prevent the due aeration of the blood, and are fatal by asphyxia ; renal affections lead to the accumulation of urea in the blood, and death by uraemic poisoning ; and diseases of the brain induce coma, from which death presently results. In a large proportion of cases, no doubt, various morbid processes concur in the induction of the fatal issue. Nevertheless, a careful consideration of the phenomena of death enables us to bring the different modes of dyings numerous as at first sight they may appear to be, into a comparatively small number of distinct groups. Bichat, in his ' Kecherches sur la Vie et la Mort,' speaks of ' death beginning at the head,' ' death beginning at the heart,' and ' death begm- ning at the hmgs,' It is obvious, however, that these are not the only- organs from which death commences ; and even those who follow Bichat most closely find it necessary to adopt his views with some modification or addition. To us it appears that the principal sources of somatic death are to be found : first, in failure of nutrition ; second, in failure of the circulation of the blood ; third, in failure of the emunctories to effect the elimination of efiete and poisonous matters ; and, fourth, in failure of the: nervous system to perform its proper functions. i. Death froon failure of nutrition. — This maybe due to many cu'cum- DEATH. 119 stances, and may arise in tlie course of many diseases. It may depend on actual deprivation of food, as in simple starvation, or in obstructive disease of the oesophagus or cardiac orifice of the stomach ; or on persistent vomit- ing or diarrhoea, or any other affection (structural or functional) of the alimentary canal, which interferes with the due absorption of nutritious matters at the mucous surface ; or on the presence of diabetes, or of rapidly-growing malignant tumours, in which there is a misappropriation of the nutrunent received into the blood ; or on the presence of inflam- matory processes, or febrile disorders, in which excessive waste of tissue takes place -^dthout equivalent reconstruction ; or, lastly, it may be referrible to the continuance of wasting discharges or losses of blood. The symptoms which precede death in these several cases depend largely upon the special conditions under which they arise, and are therefore liable to considerable variety. But such as are peculiarly referrible to innutrition are, more or less rapidly increasmg emaciation and debility, mental languor, feebleness of circulation, and inability to resist the influence of external cold. The general emaciation is not always proportionate to the muscular debility, which, after a while, becomes extreme. The patient probably lies on his back, motionless or almost motionless, with hands, feet, nose, and ears more or less cold and dusky ; breathing feebly and at long inter- vals, with the pulse barely perceptible at the wrist ; sensible, but dull and languid, taking little notice, and not even caring to restrain the escape of his evacuations. With possibly no addition to the symptoms, the general feebleness passes almost insensibly into death — the last indication of life being furnished by the barely perceptible movements of the heart. Li simple starvation there is a general lowering of temperature, which pre- vious to death becomes considerable. Here life may sometimes be main- tained for a while by the application of warmth. In disease, however, although loss of temperature is not unfrequent, rise of temperature, under certam circumstances, is of common occurrence. ii. Death from failure of the circulation. — The failure may commence in various situations, may arise from many causes, and may come on Avith different degrees of rapidity. It most commonly takes place at the heart, which ceases to propel the blood : either from actual inability or faihire to contract upon its contents ; or from spasmodic contraction which opposes the entrance of blood into it ; or from the compression exerted upon it by accumulation of serum or blood in the pericardial cavity ; or from the obstruction of one of its orifices by clot, or some other equivalent caiise. It may also depend upon obstruction of the pulmonary arteries by throm- bosis or embolism ; or upon general contraction of their smaller branches, as occurs in asphyxia ; or upon similar contraction of the smaller systemic arteries, as probably happens in angina pectoris. Death from the causes here referred to may take place quite suddenly — the patient fainting and falling down insensible, and with a gasp or a convulsive tremor yielding up his breath. It may take place suddenly, yet still rapidly — the victim getting pale, cold, bedewed with sweat, insensible or nearly so, and possibly convulsed, with slow and shallow or gasping respiration, extreme 120 MECHANICAL AND FUNCTIONAL DEEANGEMENTS. feebleness of the heart's action and miperceptible pulse. When the process of dymg from failure of the circulation assumes a more chronic form, the phenomena of collapse are doubtless always present in some degree, and there is more or less obvious disposition to depression of temperature ; but, in addition, the blood tends to accumulate and to stagnate in the capillaries and veins ; dropsy and congestion, with extravasation of blood, are apt to take place ; and not unfrequently the parts furthest removed from the influence of the heart (nose, fingers, toes) become gangrenous. Certain differences in the details of dying depend, no doubt, on the situa- tion in which obstruction occurs. It is stated that, if it take place sud- denly on the right side of the heart or in the trunk of the pulmonary artery, extreme dyspnoea is one of the prominent symptoms. If, on the other hand, the sudden obstruction occur on the left side, insensibility and convulsions will probably be amongst the earliest of its consequences. Further, if gradual impediment arise on the right side of the heart or in the course of the pulmonary artery or its branches, more or less over-accu- mulation of blood wiU speedily ensue in the systemic veins and capillaries ; if such impediment arise on the left side of the heart, the consequent con- gestion will first involve the pulmonary vessels. iii. Death from failure of the eliminatioii of effete and poisonous matters. — The poisonous matters, to which reference is here specially made, are those which accrue in the course of the disintegratmg and excretory processes which are always going on, and are mamly, therefore : carbonic acid, which is evolved by the Imigs ; urea and other nitrogenous m.atters, which are discharged by the kidneys ; and some of the consti- tuents of the bile, which are formed in the liver and under certain circumstances absorbed into the circulation. The retention of carbonic acid in the blood produces the condition which is commonly known as asphyxia, but might perhaps be better designated anthrac^emia. It may arise in various ways : — from obstruction of the larynx or trachea ; from bronchitis or other affections causing block of the bronchial tubes ; from disease of the lungs ; from mechanical impediment to respiration, due to accumulation of fluid in the pleural cavities ; from paralysis or spasm of the respiratory muscles ; or from deficient supply of atmospheric air. The symptoms of sudden asphyxia .are manifested in their typical completeness in cases of drowning, or of choking from the intrusion of a solid mass into the upper part of the larynx. The sense of dyspnoea is extreme, and violent but futile respi- ratory eiforts take place. But soon vertigo comes on, the respiratory agony diminishes, and the eiforts at inspiration get less violent. Gradually unconsciousness comes on, convulsive movements may occur, and in the course of a few minutes all muscular action ceases. The heart con- tinues to beat, perhaps for a minute or two, after respiration has come to a standstill. During the progress of sufi^ocation, the non-arterialised blood is impeded in its transit both through the small arteries and capillaries of the lungs, and through the corresponding systemic vessels, and the pressure of blood in the systemic vessels becomes augmented. DEATH. 121 But gradually, the obstruction getting more and more complete in the vessels of the lungs, less and less blood reaches the left cavities of the heart, and consequently less and less is propelled into the arteries, which .also by gradually contracting on their contents drive them slowly onwards into the vems. Thus, while the pulmonary veins, left cavities of the heart, and systemic arteries, become comparatively empty, blood is .gradually accumulating in the pulmonary arteries, right side of the heart and systemic veins and capillaries, and the general surface gets more and more livid and swollen, and the superficial veins more and more obviously distended. But poisonuag by carbonic acid takes place much more gradually, in the course of many diseases, and may extend over a period of many months. The general phenomena, in such cases, are essentially the same as those which have just been detailed, but they are, as it were, more diluted and of less intensity. The surface gets dusky or livid and cool, the veins distended, the right side of the heart dilated, the pulse quick, feeble, intermittent ; there is more or less distressing dyspnoea and anxiety ; but gradually the struggle for breath grows less pamful and violent, the patient gets drowsy, and rambles, and then, passing mto a •condition of coma and general debility, gradually sinks. The accumulation in the blood of urea and other matters, which should iDe eliminated by the kidneys, leads to many important consequences. By their slow action they induce more or less marked anemia, contraction of the smaller systemic arteries, hypertrophy of the heart, and dropsy, with, sooner or later, impairment of the nervous functions, and especially delirium, eclampsia, and coma. It is to them also that are mainly due the collective phenomena to which the name of ' typhoid condition ' has been given, and which (as has been already pointed out) are apt to come on in the course of various febrile disorders and in structural diseases of the kidneys. iv. Death from failure of the nervoiLS system to i^crform its proper functions. — Diseases of the nervous system are fruitful sources of death. Coma is not only a frequent precursor of death in cases in which the brain is not primarily involved, but it is a common symptom of grave cerebral lesions. In coma there is profomid unconsciousness, the patient breathes slowly, irregularly, and stertorously, the saliva and other secre- tions from his mouth, throat, and air-tubes accumulate in these several passages, and are not expelled ; and gradually, partly from this cause, partly from failure of the respiratory muscles, he dies of asphyxia. Again, spasm, or motor paralysis, may equally produce death by asphyxia : in epilepsy spasm of the glottis, in tetanus spasm of the muscles of respi- ration, may stop the breath and asphyxiate the patient ; and the like result may ensue from paralysis of the muscles of the throat and larynx, or those that govern the movements of the chest. But in these cases it is obvious that, although death may be said to begin from the brain and cord, the patient dies in reality of carbonic acid poisoning. In truth, however, it is not the brain and cord, but the sympathetic system of nerves which has the direct control over the functions, the sum of which 122 THE TEEATMENT OF DISEASE. constitutes life. It is tliis which has within its grasp, so to speak, the whole of the circulatory system, the excretory, secretory, and nutritive processes, and even the functions of the brain itself ; and it is to this- system, therefore, that we should especially refer when w^e speak of death commencing from the nervous centres. It is to the influence of this system that both paralysis and spasmodic contraction of the heart and blood-vessels are due ; it is to the influence of this system alone that the phenomena of shock or collapse (which have been previously described) are directly referrible. NoAV, although, in the foregoing paragraphs, we have distinguished several modes of dying, or groups of processes by which death is induced, it is obvious, if we come to compare them among themselves, that they have much in common, and tend to shade the one into the other. Thus, death from coma, or tetanic spasm, resolves itself eventually into death from asphyxia, and death from asphyxia into death from arrest of the circulation of the blood, and this arrest of the circulation of the blood into spasmodic and insuperable contraction of the pulmonary arterioles, which in its turn is referrible to the influence of the vaso-motor nerves. And, indeed (excepting probably those cases in which death is induced by the sudden cessation of the heart's contractions under the influence of shock), the last obvious efforts of life are those of the heart : the patient becomes unconscious ; the respiratory efforts cease ; yet still we listen for the sounds of the heart, and only when these finally disappear consider life extinct. But in neither shock nor asphyxia does the heart (at all events as a rule) cease to act because its muscular parietes have wholly lost their aptitude for contracting. In the former case the heart is, as it were, stunned, and may yet, under the influence of artificial respiration, have its movements re-established ; and in the latter case, where the heart seems to cease from sheer debility, this debility is rather in the ganglionic centres and nerves, which fail to supply the accustomed stimulus, than in the muscular tissue itself, which may still be made to contract under the influence of artificial stimulation. Hence it would seem that while, as a rule, the cessation of the heart's beats may be regarded as the last observable phenomenon of life, this cessation, as well as that of many other phenomena of organic life, may in their turn be referred to the sympathetic system. V. THE TEEATMENT OF DISEASE. Details of treatment are discussed, with more or less fulness, under the heads of the various maladies which are described later on in this volume. There are, however, some general principles involved in the treatment of disease which it will be convenient to touch upon briefly here. They come mainly under the beads of ' Hygiene,' ' Prophylaxis,' and ' Eemedial Treatment.' HYGIENE AND PEOPHYLAXIS. 123 A. — Hygienic Treatment. By the term Hygiene is meant tlie science of health, or the study of those conditions on which the mamtenance of health depends. Hygiene, therefore, takes cognisance : of the sanitary mliuences of the atmospheric and telhuic circumstances among which we dwell ; of the conchtions, m relation to density of population, ventilation, di'ainage, cleanliness and the like, in which we live ; of the quahty of the water and food which we swallow ; and also of our dress and personal habits. The immense im- portance of attention to this department of medicine is beyond dispute ; yet the subject is so vast, and the details which it involves are so nu- merous, that it would be out of place to engage m their chscussion in such a work as the present. But attention to the laws of hygiene is not less important for the wel- fare of the sick and convalescent, than it is for the welfare of those who axe as yet in the enjoyment of good health ; and, indeed, it not unfre- quently happens that it is to hygienic measures, rather than to di'ugs, that we must look for the cure of our patients. Even in this restricted sense, the subject of hygiene is too extensive to admit of satisfactory dis- cussion Avithm the limits of space at our cUsposal. It must be sufficient (by way of example) to refer : to the important beneficial influence which a mild balmy air exerts upon those who are suflering fi'om iiiflammatory aft'ections of the respiratory organs, or h'om pulmonary phthisis, and upon convalescents from many different diseases ; to the injury which cold winds or variable weather inflicts on rheumatic patients ; to the essential importance of treating the sick in airy, well-ventilated apartments, and of yet securing an equable genial temperature, of maintaining perfect clean- Ihiess of the patient's person and of everything around him, of remo\ing at once from his chamber all evacuations and other offensive matters, and of taking care that the water which he druiks is free from miwholesome impurity, and the food which he takes is of good quality ; and as regards those who are suflering from illnesses which do not necessitate confine- ment to the house, or those who are recovering, to the need for seeuag that their dress is sufficiently protective against the weather, that they are not intemperate in meat or drink, and that they do not keep bad hours, or indulge in any other habits which are or may be hm'tful. But difi'erent diseases are obnoxious to different injurious influences, and call for more or less important modifications in the emplojiaent of hygienic measures. But these are points which, so far as is necessary, will be dealt vdth subsequently. "S) .—Prophylactic treatment. By Prophylaxis is signified the preventive treatment of disease. In some respects this subject may be regarded as a part of hygiene, in some as a part of ordinary remedial treatment. ^Ye prefer, however (mahily for convenience of discussion), to look upon it as distmct from both. We 124 THE TEEATMENT OF DISEASE. understand by it the adoption of special measures to prevent the outbreak of special diseases which threaten, or the supervention of anticipated dangers in the course of diseases, and shall briefly consider it under the following heads : — 1. Prophylaxis in relation to the tendency, inherited or acquired, to disease. — We know that many persons derive from their parents proclivi- ties towards certain diseases, such as phthisis, gout, epilepsy, and insanity. We know also that many of these affections may be induced, in those who are free from taint of hiheritance, by circumstances which tend to impair the general health. We know, further, that exposure to similar conditions is pecuharly apt to act injuriously on those in whom such tendencies already exist. And hence the importance, which is fully recognised, of adoptmg precautionary measures in reference to such persons : of sending the patient, in whom phthisis threatens, to an equable chmate ; of re- stricting the diet, and especially of curtailing the alcoholic driak, of him who has reason to anticipate gout ; and similarly with reference to many other affections. Again, there are many diseases of which one attack imparts a hability to subsequent attacks : such are rheumatism, erysipelas and other mflammations, ague, and intermittent haematuria. It is ob-\dous here, again, that it is of the utmost importance, for the welfare of the patient, that he should be protected from those injurious influences which he knows by experience to be the sources of his malady. 2. Prophylaxis in relation to parasitic, endemic, and infectious diseases. — Many parasitic diseases are developed under circiunstances which are well understood. Tape-worms are derived mainly from the use of the insufficiently cooked flesh of oxen and pigs, and the trichina spirahs from the ingestion of that of the latter animal ; the Guinea- worm and the bilharzia both prevail in certain regions. It is needless to dwell on the importance which the knowledge of such facts has in reference to the prevention of maladies of this kuid. Endemic diseases are due to the operation of local causes, a knowledge of the behaviour of which, or of their distribution, clearly furnishes an important clue to their prevention. Thus ague prevails in certain regions, goitre and cretinism in others ; and in both instances the occurrence of disease may be prevented by removal to some more salubrious district. In the former case, indeed, the mala- rious poison may be ehmuiated or destroyed by effectual drainage. Amongst endemic affections may be included ergotism from the use of spurred rye as food, and lead-poisoning from drinking lead-mfected water ; the suitable prophylactic measures against which are sufficiently obvious. Epidemic diseases are probably always directly or indh'ectly contagious ; but the several poisonous matters or contagia, to which their spread is due, are thrown off from different parts of the organism, gain entrance hito the system by different portals, and present in other respects essential differences of habit. The knowledge that the contagimn of t}-phus becomes especially virulent in the presence of overcrowding, and that that of relapsing fever has some pecuhar relation with starvation, is of great importance in reference to the measm-es which should be adopted in order EEMEDIAL AND THEKAPEUTICAL TEEATMENT. 125- to prevent the development, or arrest the spread, of these diseases ; the knowledge also that measles is in the highest degree contagious previous to the occurrence of the rash, and that scarlet fever is comparatively little contagious during the corresponding period, or even for a few days subsequently to the appearance of the rash, is of importance also in refer- ence to the management of these affections. Agam, the knowledge which we now possess that, while most of the exanthemata are propagated through the atmosphere by the breath or cutaneous emanations, cholera and typhoid fever are infectious only through the intestinal excreta, and their poisons received into the system mainly by means of contaminated drinking-water, supplies us with practical data of the highest value as to the methods by which their outbreaks should be dealt with. The fact that in most of the diseases coming within the epidemic class, one attack is protective in a greater or less degree against future attacks, is also of great, importance in relation to prophylactic medicine. 3. Prophylaxis in relation to the complications or sequela of disease. — Most diseases bring in their train liabilities to specific incidents of more or less gravity — a fact, the appreciation of which enables us in many cases to take early measures for their prevention or alleviation. The knowledge that rheumatism is apt to involve the pericardium or valves of the heart ; that, in scarlet fever, renal inflammation, albuminuria, and anasarca are liable to supervene ; that in enteric fever perforation of the bowel may take place at certam stages of the disease ; that in gonorrhoea the eyes- may get infected and destroyed, enables us, in deahng -^dth these affections, to take precautions which are often successful against the supervention of the mischances which have been enumerated. C. — The remedial and therapeutical treatment of disease. The great aim of medical art is the cure of disease. Unfortunately, however, a direct cure (at all events a direct cure by means of drugs) in the great majority of cases is totally impossible. In some parasitic affec- tions, and more especially in such as involve the surface of the body, we may kill or expel the parasites, and so restore the patient to health ; by surgical operation or other mechanical measures we may get rid of foreign bodies or concretions from internal cavities or canals, remove diseased parts, discharge the accumulated contents of normal or abnormal cavities,, reinstate displaced organs, dilate contracted channels, or, failing this, make new openings above the seat of obstruction, and so provide passages for the habitual escape of matters that need evacuation ; and we may, in a small number of cases, by the use of specific medicines or diet, materially alleviate, and even cure absolutely, certain diseases : by arsenic or quinine ague, by mercury syphilis, by colchicum gout, by iron chlorosis, by fresh vegetables scurvy, and by suitable food, possibly rickets and some other affections. But neither by mechanical measures, nor by specific druo-s, nor by the restoration to the dietary of matters in which it has been want- ing, can we cure the infectious fevers, internal inflammations, carcinoma,. 126 THE TEEATMENT OF DISEASE. degenerative changes, or many of the functional and other disturbances to which the organism is hable. Most of these affections, indeed, take a course pecuhar to themselves, tending in some cases to ultimate recovery, in some to chronic ill-health, in some to speedy death. We can do little, often nothing, to arrest them in their progress, or to put limits to their duration. And frequently all that remains to us is, hy mamtaining the patient's strength, by relieving symptoms, and by taking precautions against the supervention of complications or accidents, to enable him to pass with comparative safety or comfort through his malady — hastening convalescence if the disease be one that does not necessarily end fatally, postponing the final issue if the disease be in the nature of things mortal. The chief general indications under such circumstances seem to be : — 1st, -to promote the patient's general comfort ; 2nd, to support his strength by appropriate nourishment ; 3rd, to maintain or to restore the healthy tone of his nutritive functions; 4th, to promote the free action of his emunc- tories; 5th, to relieve the secondary phenomena or symptoms of his disease ; and 6th, to obviate the tendency to death. 1, The rendering the patient's condition as comfortable as circum- stances permit involves of course careful and judicious nursing, and the closest attention to all hygienic and other details of management. The latter will necessarily differ in different cases ; but, in illustration of our meaning, we may signalise the following points : — keeping the room dark in eye-diseases, or where it is important to promote sleep ; maintaining quiet where in brain diseases and other affections there is acoustic hyper- festhesia ; soothing the patient when he is irritable or excited ; raising his hopes and spirits when he is depressed or desponding ; and when he is in a condition to enjoy such pleasures, to gratify, without worrying, his mind with pleasant surroundings and diversions. It needly scarcely be added that patients should always be kept as clean, dry, and free from undue pressue or friction as possible, and should not be allowed to soak in their own discharges ; for in a large number of cases, and particularly in those of chronic wasting, diseases, of inflammatory and febrile disorders in the typhoid stage, and of paralytic affections of the central nervous organs, there is a pecuHar aptitude, especially under such circumstances, for the speedy production of bed-sores. 2. The maintenance of the patient's strength by the judicious adminis- tration of food is an essential element in the successful treatment of disease. In most diseases, the tissues of the body disintegrate with unwonted rapidity, and emaciation and debility tend to supervene in a proportionate degree ; and in most, this over-rapidity of disintegration is accompanied with loss of appetite, loathing of food, impairment of the nutritive functions, or some other condition, which renders it difficult or impossible to supply to the organism the alimentary matters necessary for its renovation and maintenance. If the obstacle lie in the patient's determination not to take food, as is the case with some lunatics, food must be administered by means of the stomach-pump ; if it depend on some mechanical impediment in the oesophagus, stomach, or elsewhere, EEMEDIAL AND THEEAPEUTICAL TEEATMENT. 127 the food must be administered in such a form (for the most part fluid), and in such quantity, as will permit of its comparatively easy transmission through the constricted, compressed, or paralysed part. Failmg such measures, operative procedure of some kmd or other may under certain circumstances become advisable. If the patient's inability to take food depend upon irritability of the stomach, this condition must be remedied by suitable treatment, and all food admhiistered meanwhile must be nutritious, unirritatmg, easy of digestion, and given in small quantities, and, if possible, frequently. Milk, barley-water, gruel, and the like, are generally best adapted for such cases. Occasionally, however, small quantities of solid but well comminuted food are preferable. If the patient be suffering from inflammation, fever, or other constitutional conditions, in which utter abeyance of all desire for food exists (associated as such abeyance often is with irritability of the stomach, and even difficulty of swallowing), it is generally advisable, in order to insure the due adminis- tration of nutriment, to draw up, for the guidance of the nurses or other attendants, some scheme indicating how much food it is desirable to admmister in the twenty-four hours, the intervals at which it should be supplied, and the quantity which should be given on each occasion. A teacupful, a wineglassful, or a tablespoonful of fluid nourishment may, according to the nature of the case and the circumstances which arise, be directed to be administered every two hours, every hour, or every half- hour. The quantity given at one time should never (if it can be avoided) be so large as to cause sickness ; and the frequency of administration must be regulated in some measure by the quantity which is given at each meal ; but we must not be disheartened if we find (as is too often the case) that the patient is miable to take the whole amount of nourishment which we have determined upon as his mmimum allowance. Li cases of this kind nothing, as a rule, can be better than milk ; and generally even those with whom it habitually disagrees can now take it with little difficulty ; but it is often necessary to alternate its use with that of other nutritious fluids, such as gruel, barley-water, rice-water, arrow-root, corn- flour or biscuit-powder properly prepared with water or milk, or beef-tea, mutton-broth, chicken-broth or soup, or to replace it by them. Alcohol, in some form or other, is frequently necessary, and must then take its place in the rota. Li all cases, whether of inflammation, fever, gastro- intestinal aflection, or mechanical obstacle to the entrance of food into the stomach, if the amomit admmistrable by the stomach be insufficient to maintain hfe, nutritious enemata must be systematically used ; and, indeed, this mode of giving food may sometimes be employed temporarily with great benefit, to the total exclusion of that by the mouth, in cases of extreme irritability of the stomach. In many chronic diseases, such as pulmonary phthisis, the appetite often remains good, thoiTgh perhaps variable and capricious, and hence it is a comparatively easy task to insure the due administration of nourishment. The appetite is generally good, also, during convalescence from wastmg disorders, and for the most part may be taken as an indication that the patient needs to be well fed. 128 THE TEEATMENT OF DISEASE. Although the rules above laid down are generally true, there are occasional exceptions to them ; and moreover special diseases in some cases need special modifications of diet. A day or two of abstinence or of starvation is often beneficial, sometimes imperative ; and, again, the importance is obvious of the avoidance of amylaceous matters by diabetic patients, and of excess of nitrogenous food by those who are suffering from Bright's disease. Persons frequently come under our care who are suffering not only from disease, but from starvation, which may have commenced prior to the commencement of their disease or supervened upon it. Here especially the good effects of careful attention to the nutritive functions; are often strikingly exemplified. 3. It has already been hinted, in the foregoing paragraph, that in many cases it is essential for the successful exhibition of nourishment that the stomach and bowels should be first rendered capable of retaining and acting upon the alimentary matters which are introduced into them. It is, in fact, always important, in the presence of disease, to maintain, or as far as possible to improve, the general welfare of the nutritive functions. To some, and indeed to no inconsiderable, extent this end may be attamed, as we have pointed out, by the judicious administration of food. But in a large proportion of cases tonic medicines of various kinds are of extreme efficacy in this respect. It is needless to indicate the numerous- cases in which iron, cinchona, cod-liver oil, and the like, act almost as specifics in the cure of disease. We wish, however, particularly to msist on their value in the treatment of many morbid conditions, in reference to which they do not possess obviously specific powers. Among these we- may name the various forms of dropsy, and many other consequences or- secondary phenomena of organic lesions of the heart, lungs, liver, kidneys,, and other organs. In such cases it is generally necessary to adapt the form of tonic to the condition of the alimentary canal, or it may be to associate with it medicines which tend to soothe or stimulate the mucous- membrane, or to act otherwise beneficially on it. 4. The notion of getting rid of the poisonous elements of disease, hj eliminating them by the various emunctories or other routes, is an old one. It happens unfortunately, however, that as a rule we have little or- no power of thus discharging the proximate causes of disease. It is entirely beyond our competence to promote the separation from the system of the material factors of the various forms of inflammation, of the livuig elements of malignant growths, or of the contagia of the infectious fevers. Neither can we, by the use of drugs taken into the stomach, cause the elimination or death of parasites imbedded in the organism, or even of such as infest the surface of the body. It is very different, however, with regard to the effete matters which are so abundantly produced in many diseases, which so frequently tend in them to accumulate within the blood,, and which so often by their presence therein cause toxasmic symptoms and thus add seriously to the dangers which the patient incurs. For this reason it is generally advisable to maintain, as far as possible, free action of the various secretory organs— the skin, kidneys, alimentary canal, and EEMEDIAL TEEATMENT. 129 lungs. In febrile disorders not only is there usually a large over-pro- duction of urea and of matters related to urea, but the urine, by which alone they can be efficiently removed, is usually scanty. It is obviously desirable, therefore, in these cases, to promote the flow of urine ; a result which may generally be best attained by allowing the patient to drmk freely. In gout, a somewhat similar accumulation of effete matters, and especially of urate of soda, takes place in the blood, and consequently here again eliminative treatment is indicated. But not unfrequently poisonous matters accumulate in the blood in consequence of structural disease of the organs by which they should be separated. In disease of the kidney, urea and other waste nitrogenous matters are retained in the blood, m disease of the liver the elements of bile, in disease of the lungs carbonic acid. Under these circumstances unconquerable obstacles frequently exist to the purification of the blood. Still, good may often be effected, if not by promoting the elimmative action of the impHcated organ, at any rate by encouraging the \dcarious action of other organs. In renal disease much benefit is generally obtained by the regulated use of drastic purga- tives, and by promoting profuse perspiration ; and in liver disease mth jamidice, by encouragmg diuresis. Again, many substances, poisonous and other, which occasionally gam entrance into the organism, tend, like urea and other effete matters, to be thrown off" : sometimes by the kidneys, sometimes by thekmgs, sometimes into the parenchyma of certain organs. Then discharge may often be hastened by appropriate measures. It is an important statement that lead and mercury, which have an aptitude to be deposited in certain of the tissues, can be removed thence by means of iodide of potassiinn, with which they are said to miite in the organism, and m company with which then to escape with the urine. But elimma- tive treatment is by no means called for m all diseases ; and, even where it is indicated, it must not be assumed that the emunctories must be powerfully stimulated into action, still less that we should act violently upon aU at the same time. Here, as m other cases, we must be guided in our efforts by the nature of the case with which we have to deal, and by the phenomena which manifest themselves during its progress. 5. No inconsiderable part of the duties which a medical practitioner is caUed upon to perform consists in the treatment of the secondary phenomena or symptoms of disease : in relievuig pain or uneasiness, m givuig sleep, in soothing irritabihty or anxiety of mmd, m promoting or checking the action of certain organs, in removing or dissipatmg matters which, from then position or quantity, interfere with the due performance of functions that are important to life or health. And it is certain that, if we do not by such measures actually cure the primary disease, we often make life tolerable, we are often successful in prolonging life, and not mi- frequently succeed in prolongmg it mitil the disease, which would other- wise have carried the patient off, itself subsides, and by its subsidence leaves him convalescent. The importance of reUe^dng pain m acute in- flammation of the peritoneum or pleura, or in enteritis, and in various forms of neuralgia, is fully admitted by every one. The necessity of giving 130 THE TKEATMENT OF DISEASE. sleep in traumatic delirium, in the wakefulness which sometimes precedes the outbreak of acute mania, and in many febrile and organic diseases, is equally recognised. The relief of spasmodic action of the voluntary muscles in tetanus, or of the involuntary muscles in spasmodic stricture of the urethra and various other tubular organs, is often a matter of urgent need ; as also, on the other hand, is the stimulation of an inactive organ — of the heart under certain conditions, or of the flaccid uterus after parturition, when profuse hemorrhage is taking place. The last examples which we shall adduce are supplied by the removal, whether by tapping or by medicinal means, of dropsical accumulations in serous cavities, and the dissipation of effusions, tumours, or foreign bodies, wlaich by their position compress or interfere with passages (such as the larynx, or bowel) the patency of which is necessary for the maintenance of life. 6. To obviate the tendency to death is to a great extent implied in the foregoing discussion. In a sense it is the principal aim of all medical treatment. The expression, however, is generally employed in reference to the duty which devolves upon us at the time when death appears to be imminent, and when the exact nature of the process by which death will be brought about becomes more or less clearly indicated. On a former page we have discussed the various modes of dying, and we must refer to what was there said for the special indications for treatment furnished in the several cases there enumerated. PART II. SPECIAL PATHOLOGY. k2 SPECIAL PATHOLOGY. Chap. I.— SPECIFIC FEBEILE DISEASES. 1. INTEODUCTOKY EEMARKS IN EEFEKENCE MAINLY Ta THE INFECTIOUS FEVEES. A. Specific Origin and Spread of Epidemic and Endemic Diseases. The diseases, to which the following remarks are intended to be intro- ductory, are for the most part linked together by the possession of certain striking characteristics. They originate severally in definite specific causes, they prevail endemically or epidemically, and are in large pro- portion infectious or contagious. 1. They originate in specific causes. — To this subject we shall presently recur ; meanwhile, the truth of the statement here made is proved by the fact that the several diseases of this group never pass the one into the ■other, or (notwithstanding that, withm certain limits, they may present variations of character) lose their specific identity : that while malarious poison never causes small-pox, typhus, or scarlet fever, so the specific poison of either of these latter affections never gives origin to ague or to any other disease than that from which it was derived. Small-pox produces small-pox, typhus typhus, scarlatina scarlatina ; and ague arises mider special conditions which are productive of ague and of ague alone. 2. They prevail endemically or epidemically. — The term ' endemic,' as applied to disease, signifies the prevalence of disease among a people. For the most part, also, it implies its limitation within certain restricted are^e, its dependence on local or localised causes, and a tendency to persist in the district which it affects. The term ' epidemic,' on the other hand, implies that the disease of which it is used falls as it were suddenly upon a people, and generally implies, further, that it spreads widely and rapidly, and that its prevalence is of limited duration. Goitre is the very type of an endemic disease, influenza perhaps the most characteristically epidemic of all epidemic diseases. It is important, however, to observe that epidemic diseases comport themselves in many different ways, and 134 SPECIFIC FEBEILE DISEASES. that tlie epidemic and endemic conditions not nnfrequently pass into one another. Influenza, and it may be added small-pox, scarlet fever, measles, and other like affections, when occurring for the first time in an unprotected community, diffuse themselves generally with marvellous rapidity. Typhus and relapsing fever, virulent though they be, limit their spread mainly to those who are under certain defective sanitary conditions. Cholera, though distinctly epidemic, diffuses itself mainly by irregularly scattered local outbreaks ; a peculiarity still more markedly belonging to enteric fever and to diphtheria, which, moreover, are apt to persist in an endemic form, in the localities into which they have been introduced. Further, many affections, which are now more or less characteristically endemic, or epidemic within restricted arese, have been, or are liable to become epidemic in the wider sense of the word, under certain ill-understood conditions ; among these may be enumerated leprosy, syphilis, plague, and yellow fever. 3. They are in large 2^foportion infectious or contagious. — It was formerly largely believed that epidemic disease was the result of the operation of some mysterious influence diffusing itself like a vapour over the surface of infected regions, involving equally the whole population, modifying the general health, tincturing the already prevalent diseases, and causing among those who were predisposed to it the specific epidemic attack. This view w^as once held with regard to syphilis itself : a disease now known, like hydrophobia and glanders, to be imparted only by direct inoculation. It is even now entertained by many in respect of influenza : a malady which is one of the most eminently contagious of maladies,, and in this respect allied with small-pox, scarlet fever, and measles. That the origins of cholera and enteric fever were long enshrouded in mystery is not surprising ; yet even in the case of these diseases there is now scarcely any difference of opinion as to their diffusion by means of specific contagia. And, indeed (though it has not yet been distinctly proved of every epidemic affection), the progress of pathological science leaves little room for doubt that all truly epidemic diseases are communicable directly or indirectly from the sick to the healthy, and that their spread is due solely to the operation of a specific virus which the former yield and the latter absorb. Endemic affections, on the other hand, are not necessarily infectious ; and some (such as ague and goitre) seem clearly to originate in certain poisonous matters developed, or existing, in the soil of the localities which they affect. 4. Behaviour of contagia within the organism. — The virvis or con- tagium of an infectious fever, having gained entrance into a susceptible body, apparently remains dormant in it for a time, which varies according to the nature of the fever, and is termed the period of latency ov incubation.. To this succeeds the period of invasion, during which the first symptoms of the disease manifest themselves. And on this soon supervenes, in its turn, the period during which the specific symptoms become declared. This, in the case of the exanthemata, is termed the eruptive period. In other varieties of infectious fevers, the period of invasion, and that CONTAGION. 135 coiTesponding to the eruptive period, are for the most part indistinctly divided. In most cases, after the symptoms have endured for some definite time, they begin to abate : the period of decline or defervescence comes on. On this convalescence ensues, and the patient is presently restored to health. In order to impart disease, the contagium must enter into the system. But the mode of its entrance, and the route by which it enters, differ in different cases. Some contagia (such as those of syphilis, glanders, hydrophobia, and vaccinia) can be introduced only by direct inoculation, effected by placing them in substance on some delicate mucous surface, or by inserting them beneath the epidermis ; some are carried by the atmosphere, are inhaled, and enter through the respiratory mucous membrane ; some are introduced mainly with the food, and act primarily on the gastro-intestinal tract. Many of the diseases which are ordinarily conveyed by the air, or by food, have been found to be also communicable by inoculation; and it seems not improbable that, under favourable conditions, all such diseases might be thus imparted. In some of the inoculable diseases (syphilis and small-pox to wit) a specific pimple gradually rises at the point of inoculation ; specific affection of the lymphatic glands next above speedily ensues ; and, at or about the time when these have attained their full devolopment, febrile symptoms supervene, to be followed in a short time by the characteristic rash. In vaccmia, the same sequence of events takes place, with the exception that the febrile symptoms are not succeeded by any specific cutaneous eruption. In these cases, the period of the development of the primary pimple or pock, and of the affection of the neighbouring lym- phatic glands, corresponds accurately to the period of incubation of natural small-pox, or of other infectious fevers not acquired by inocu- lation. It is reasonable to believe that what occurs in these particular affections, during the period of incubation, occurs during the same period, with some modification of detail, in others : in other words, that specific local processes (followed by specific affection of the next lymphatic glands) take place in all of them during the period of incubation, and preliminary to the general diffusion of the poison, at the spot or spots at which the virus enters the organism. It is not improbable that the specific lesions of diphtheria, cholera, and enteric fever, are to be regarded as the immediate consequences of the local action of the specific poisons of these diseases, and as corresponding therefore to the syphilitic chancre, or the primary pock of inoculated variola, and not to the eruption of the gene- ralised disease. The period of general diffusion follows ; the infected lymphatic glands shed specific elements into the blood, with which they are distributed throughout the organism, to sow themselves in, or to infect, those parts of it which offer a suitable soil for their further development or growth. Various constitutional phenomena, due to the effects of the poison upon the blood and tissues, attend their diffusion ; but, in addition to these, various specific lesions of particular parts ensue, which are more or less 136 SPECIFIC FEBEILE DISEASES. characteristic for each form of disease. Iii many cases (tlie exanthemata) a rash appears upon the skin ; in some the tonsils, in some the sahvary glands, in some the respiratory tract, m some the alimentary canal, m some certam other internal organs, are mamly involved. It is obvious, from the above account, that the contagious matters of the contagious diseases must at some time or other be contamed withm the blood. The blood, indeed, in some cases and under certain conditions, is undoubtedly infectious. But, for the most part, this fluid rapidly purities itself of the poisonous elements which enter it, dischargmg them mainly mto those organs or tissues, or at those smiaces, which are the seats of the specific lesions of the diseases to which they belong, and which consequently become surcharged mth infectious matter. Durmg the progress of a contagious disease, the contagium which gave it origm undergoes enormous development within the organism. An in- conceivably mmute quantity of the variolous poison, placed beneath the. skin, results m the formation of a pock, which itself contams an infinitely larger amoimt of poison than was introduced in the first instance, and subsequently in the formation of thousands of pocks scattered over the general surface, each one of which is as fully charged with contagium as was the first. There can be no doubt that, in other diseases besides small-pox, this development of contagion goes on during the whole period of mgravescence : beginning at the seat of its mtroduction, con- tinuing in the Ijnnphatics and probably m the blood, but taking place with especial energy in the cutis in exanthematic diseases, and in con- nection generally ■v\-ith specific lesions. In the majority of cases the poison, which is thus manufactured within the organism, is discharged from it in greater or less abmidance, and serves to propagate the disease of which it is the specific cause. This discharge, which occm-s mainly in connection with the seats of specific lesion, takes place at different periods m diflerent diseases, and necessarily also from different surfaces. Thus, the contagia of cholera and enteric fever are discharged with the alvure evacuations ; those of measles, hooping cough, and influenza from the respiratory surface ; that of scarlet fever probably from the throat and skin ; that of hydrophobia with the sahva or oral mucus ; that of glanders mainly with the nasal secre- tion ; and that of syphilis with the discharges from its specific sores. It is very remarkable that the majority of contagious fevers end in recovery : that the poisonous matters which they engender either die out or escape from the body by one or either of the routes which have been enumerated. This latter process has been compared to the discharge of urea, or other eftete matters, by the emunctories. But it is obviously of quite a different character ; for (to take small-pox agam as an example I there is not simply a discharge from the diseased surface of matters which had^ accumulated m the blood, but there is an actual manufactm-e of poison going on at each spot of disease. There arises, further, a remark- able condition of the organism, by which its susceptibility of the specific poison is destroyed ; for not only does the poison within it die out, but CONTAGION. 137 the system refuses to reabsorb any of the abundant poison which it manu- factures, and remains for many years, it maybe for hfe, free from Habihty to become agam affected. 5. Behaviotir of contagia external to the body. — There is a time during which contagia exist external to the body. How do they then comport themselves '? It is clear that, in this respect, they present as important differences among themselves as they do in their influence over the body. The contagium of influenza is remarkable for its amazing diffusibihty ; that of t}^hus chngs as it were aromid the patient and is readily destroyed by atmospheric dilution ; that of scarlet fever remains dormant for months in articles of clothing ; that of smaU-pox, or of vaccinia, may be pre- served for years between two pieces of glass, or concreted upon an ivory pomt. But the most remarkable pecuHarities are presented by the con- tagia of enteric fever and cholera. In both cases the specific poison is j-ielded by the bowel, and escapes with the faeces ; and in both, probably, the poison is innocuous at the moment of escape, and only acquires virulent properties after the lapse of some time — in the case of cholera, after the lapse of four or five days. There can be httle doubt, however (and the reasons for this statement will become more apparent subsequently), that under various conditions (of which only a few are understood), most contagia are apt to multiply or increase outside the body, and to present alternately phases of dormant or inert existence and phases of activity and virulence. Further, it is important to know that contagia, at any rate many of them, tend to cling to articles of clothing and furniture, to lurk m dirt and in neglected corners, and even to infect water, milk, and articles of food which have been exposed to their mfluence. The spread of enteric fever and searlatma, and we believe also of diphtheria, has been traced m many instances to milk thus contaminated. 6. Nature of contagia. — Having briefly considered the dependence of ■epidemic diseases on specific contagia, and the modes by which these poisons enter the body, act upon it, and finally get discharged from it, together with some of their pecuHarities of behaviour outside the organism, it remains to discuss the c^uestion of their nature. In reference to this subject, we must not lose sight of some of the important facts with regard to contagion which have been adduced : we must bear chstinctly m mmd, that the virus of one disease produces that disease only and never any other ; that a virus received mto the body multiplies indefinitely within it ; that it leaves the body, not by the organs provided for the separation of effete matters, but by a process of efflorescence or multiplication, taking place in certain situations and modes, which are characteristic for each disease ; and that external to the body it comports itself in various mamiers, of which some (as in cholera and enteric fever j evidently imply progressive developmental changes. It seems impossible that these con- ditions can be fulfilled by any element, or any combmation of elements, unendowed with life. No inorganic solid, stiU less any inorganic fluid or gas, no dead organic compound, could thus multiply itself either within or without the body, or thus affect the body in its progress through it. 138 SPECIFIC FEBEILE DISEASES. It is impossible to conceive of a bubble of siilpluirettecl hydrogen, a di'op of gill, a fi-agnient of marble, or a grain of morphia, multiplymg itself a thoiisandfolcl withm the system, makmg for its discharge some special route, and leaving the system henceforth incapable of its further produc- tion. Nothing analogous to this has been shown to exist in the whole range of inorganic or organic chemistry. The facts, however, are aU compatible vdth. what we know of the development and behaviour of organised beings, and especially of such as are lowest in the scale of Hfe. We know how, when the spores of fungi are deposited in a suitable soil, they grow and multiply and rapidly pervade it until they have exhausted it ; how each fungus fructifies accorduig to its specific character, and yields iimumerable spores, which become -s^idely diffused, and, though retaining their specific characters and their vitality under apparently the most adverse circumstances, remain dormant until the opportunity for their development offers itseK. The above, however, is not the only argument in favom of the dependence of infectious fevers on hving organ- isms. Others of greater value remain to be adduced, (a) We know that many diseases, among which may be mentioned tinea tonsm-ans, tinea favosa, tinea versicolor, scabies, and those in which trichinse and hydatids are present, are actually due to the presence of animal or vegetable para- sites ; and that the behaviour of the h-sing contagia in these cases mani- fests at least as great variety as does that of the wus of the infectious fevers, (b) The important experiments, first made by Chauveau, with regard to the infectious fluids of cow-pox, sheep-pox, and glanders, and since repeated in the case of cow-pox by Dr. Burdon Sanderson, show clearly that the contagious element is not uniformly diffused throughout these fluids, that it resides neither in the inflammatory corpuscles which they contain, nor in the dissolved constituents, but in certain minute protoplasmic particles or Hving bodies which, at the period of then chief infectiveness, they contam m great abimdaiice. (c) Specific parasitic growths have actually been detected ui comiection with several of the diseases in question, under circumstances which leave httle doubt that they are the actual contagia, or specific elements,. of these diseases. The most important observa- tions relate to relapsmg fever, and anthrax or the splenic fever of cattle. In relapsmg fever, a form of bacterium named ' spirillum ' was first detected in the blood by Dr. Obermeier in 1872, Spirilla are moving spiral filaments of extreme tenuity and measurmg from xgVo fo 3^ hicli in length. They are found in the blood m con- FiG. 33.-spmiLLA OF nection with the febrile paroxysms only : makmg Eelapsis-g Fevi:ii. x 500. , , . • • , i , i i p ^i • J^ their appearance m it shortly before the rise oi temperatm-e commences, and disappearmg from it just before the occur- rence of the crisis. They vary in number from day to day during the persistence of fever, and disappear absolutely during the remission. The above facts have been confirmed by many subsequent observers, among CONTAGION. 139 others by Dr. Heyclenreicli of St. Petersburg, wlio also shows experiment- ally that spirilla are very short-lived at febrile temperatures, and even at the normal temperature of the blood, and that there is good reason there- fore to believe that their variable prevalence in the same attack is con- nected "s\ith the development and disappearance of successive generations. Experiments in regard to the inoculability of relapsing fever tend to sub- stantiate the belief that spirilla constitute its contagious element ; for the disease can be readily imparted by the blood of a patient in the febrile paroxysm, but not by that of the same patient durmg the apyrexial period, nor by his secretions at any time of his illness. Li splenic fever, which is communicable only by direct contagion, and occasionally spreads in this way to man, peculiar organisms are always to be found in the blood, lymphatic glands, and spleen during the height of the disease. These are motionless, rod-like, bacteria from -ywo^ ^o 3Wo ii^di in length, and have been named ' bacilli anthracis.' Dr. Koch has cultivated them Fig. 34.— Bacilli Axthracts. x500. a, rods ; b, filaments in different stages obtained by cultivation ; c, spores. externally to the body, and finds that under suitable conditions they grow into branchmg filaments of considerable length ; that the filaments, which are at first structureless and transparent, after a time become studded with small dots ; that these gradually increase in size until they form oval spores, which presently, on the breaking down of the filaments, get detached. He also finds that the spores, like all spores, are bodies of robust vitality and comparatively indestructible ; that under favourable circumstances they elongate into rods ; and that under the continuance of such circumstances the rods themselves are capable of indefinite multi- plication by fission. He further finds that mice are highly susceptible of the disease ; and that while disease is not imparted to them by the bacillus in its filamentous form, it is readily given by either spores or rods. Further, the spores appear always to become rods in the organism, and the mycelial stage is never attained there ; so that the rod-like form is the only one under which they seem to live parasitically. These observations have since been confirmed by other observers, among whom may be named Dr. Cossar Ewart and Dr. Greenfield. The arguments in favour of the dependence of the specific contagious 140 SPECIFIC FEBKILE DISEASES. diseases on living organisms, apart even from the remarkable series of observations wliicb have just been adduced, seem almost conclusive. It migbt still, however, have remained a question whether these living organisms were animalcules, as some have supposed, vegetables as others believe, or particles of the livmg tissues of the patient, as Dr. Beale thmks, endowed with specific properties. But these recent discoveries go far to give a positive solution to this question, and at the same time to confirm the belief of those who mamtain that the specific fevers (in other words, their specific causes) never originate de tiovo. If contagia be lowly vegetable organisms, it is easy to understand how it is that they present so many characteristic differences of behaviour, how it is that they are infectious at different periods of disease and mider different circumstances, and how (if like the bacillus anthracis they pass through different phases of living, of which some are parasitic, some non- parasitic, some mfective, some mnocuous) they may fi"om time to time pass an innocent or dormant existence externally to the body mitil favourmg conditions bring them again to active infective life : how in fact (as in cholera, plague, typhus, and relapsing and enteric fevers) they may, from time to time and under special combinations of circumstances, appear to undergo spontaneous development. Certain facts concerning splenic fever and ague have much interest and importance m relation to the subject adverted to in the above para- graph. Pasteur has demonstrated that the bacillus anthracis still flourishes in pits in which animals dead of splenic fever have been buried, even for ten years, and still retains all its virulence. On a subsequent page it is shown that ague occasionally reappears, apparently in consequence of extensive recent upheavals of the soil, in places which have long been free from it ; and attention is drawn to the investigations of Klebs and Tommasi-Crudeli, which serve to prove that this disease is caused by a vegetable organism, the bacillus malarise, which flourishes in the soil of malarious districts. If these observations be true, we have in them a sufficient explanation of the occasional apparently spontaneous origm of ague and splenic fever, which is entirely compatible with the behef in their specific nature which we have endeavoured to inculcate. 7. Attenuation or mitigation of contagia. — In June 1880 Dr. Greenfield published the results of some experimental inquiries which seemed to show that by cultivation the bacillus anthracis can be so mitigated in virulence as on inoculation to produce a mild and non-fatal form of splenic fever, which is nevertheless protective against future attacks of the disease. About the same time Professor Pasteur was proving experimentally that the virus of a very fatal infectious disease of fowls, known as ' chicken- cholera,' can be attenuated with like results ; and his researches were made public two or three months later. Since then he has extended his urvestigations to splenic fever. And in August 1881 he gave a collective account of his experiments and results in a remarkable address dehvered before the International Medical Congress. The following is a brief abstract of his more important statements. CONTAGION. 141 The "sdrus of chicken-cholera is an extremely minute micro-organism, for the most part resembling the figm-e 8, which, like the yeast plant in beer, multipHes by fission or gemmation, and never produces spores. At a temperature of 77° to 95° this may be cultivated in chicken broth ; and the cultivation may be carried on indefinitely by successively impregnating fresh portions of broth with minute particles of fluid from the portions in which cultivation is already in progress. Now if this cultivation take place in vessels hermetically sealed, every cultivation, no matter how far removed from the original stock, retains the full virulence of the primary virus. But Pasteur discovered that if the process be conducted in vessels closed with stoppers of cotton wool, which, while preventing the entrance of organisms from without, give free access to the oxygen of the atmosphere, and sufficient time {a fortnight or more) be allowed between successive cultivation-experiments, the cultivation-products gi'ow less and less virulent ; until at length, ■s\dthout change of anatomical character, they become absolutely innocuous. He discovered also that at certain stages of attenuation, before complete innocuousness is reached, the cultivation- fluid on inoculation causes, like vaccme-lymph, local mischief with only slight constitutional disturbance — a trivial malady, always followed by speedy restoration to health ; and that this attenuated attack of chicken- cholera is protective ( at any rate for a year) against future attacks of the disease. The \-irus of splenic fever, as we have shown, forms, when cultivated, jointed filaments, within which spores are developed. Now spores, like the seeds of higher plants, produce offspring endowed mtli all the funda- mental properties of the parent organisms ; while by gemmation or fission (as by buds or cuttings) accidental or acquired peculiarities are also per- petuated. It might almost have been assumed therefore that so long as cultivation produced spore-bearing filaments, its products would retain all the ^'irulence of the original virus. And so Pasteur found. He discovered, however, that by performing his cultivation- experiments at a temperature of 107'5 to 109'5 (or just a little below the temperature at which cultiva- tion becomes impossible), a filamentous growth results wholly free from spores ; and that on repeated cultivation this form of the bacillus presents all the dynamic peculiarities manifested under similar conditions by the virus of chicken-cholera. By this attenuated poison he imparted to sus- ceptible cattle a mild form of splenic fever, unattended with danger to life, which has proved perfectly protective against subsequent inoculations of the disease in its most virulent form. This method of protection has already been practised in France on a large scale and with entire success. Pasteur believes that the attenuation of the poison is due mainly to the influence of oxygen. It is scarcely necessary to draw attention to the important bearing these investigations appear to have on the relation of cow-pox to small-pox, and to the hope which they raise that the contagia of other infectious diseases may also prove capable of mitigation. 8. Sevticcemia. — In connection with the subject just discussed, as well 142 SPECIFIC FEBEILE DISEASES. as on accoruit of tlieir intrinsic importance, it seems desirable to call attention, however briefly, to the obsen"ations made in recent years m regard to the uafluence of septic organisms or bacteria hi the production of disease. It seems now to be well ascertained that septic bacteria, or thek invisible spores, are largely diffused throughout nature, but mainly in connection with water and watery vapour ; that they rapidly attack all organic uifusions and all dead or djing animal or vegetable matters which are not specially protected h'om them ; and that they are in fact the essential agents in all putrefactive processes. II has also been ascertained that these organisms tend to breed in our bowels, and on those other mucous surfaces to which the air has ready access, and especially to attack external woruids or ulcers. And it has fui'ther been ascertained, beyond the possibihty of doubt, that when such parts become foul and unhealthy, and their secretions fetid, these conditions are always associated with an enormous development of septic bacteria, which are then found mainly m the diseased tissues, but also in the adjoinhig Ijniiphatics, and generally to some extent in the circulatmg blood. It was a natural inference, that under these circumstances the bacteria were not only important (if not essential) agents m the local mxhealthy processes, but largely (if not solely] mstrmnental in causing the constitutional disturbance which was associated "ttiththem, and in the pro- pagation of unhealthy mflammation from patient to patient — that they were, in fact, contagia m the sense in which we have hitherto employed that word. Further investigations have partly confirmed, partly corrected this inference. They have confirmed it, by demonstratmg that the develop- ment of bacteria is essential to the production of the local putrefactive changes and general febrile symptoms, and to the commmiicabihty of the morbid process. They have corrected it, by proving that while under some conditions bacteria diffuse themselves throughout the organism and multiply in it, and behave in all respects hke true contagia, mider other conditions their growth and mcrease are purely local, and whatever injmious influence they exert over the system is due, not to their direct action, but to an unorganised poison which they generate, and becomes absorbed. Whether this difference in behaviour of micro-organisms which seem to be identical be due to accidental conditions in themselves or in the soil in which they grow, or to the fact that they comprise various species having different properties, which thus reveal themselves, is a question difficult of solution. The latter is the explanation to which "we inclme. Dr. Sanderson's investigations relate mainly to those cases in which the local growth of bacteria tends to produce specific s}Tnptoms by throwing into the system, either continuously or from time to time, a poison which is of local manufacture, which has no power of self-multiph- cation, and which is incapable, therefore, of impartuag disease to others by simple inoculation. This septic poison is soluble, and can be obtained in solution, entirely free from bacterial or other organisms, and fi-om putrefactive taint or tendency. It is of extreme virulence lits effects CONTAGION. 143 being proportionate to its dose), and lias exactly tlie same effect on tlie system as the material containing bacteria from wbich it is obtained. When injected into the tissues of the dog, it gives rise to the following phenomena : the animal first shudders and then moves about restlessly from place to place ; its gait becomes unsteady, and in a short time it staggers, and falls on its side ; in the meanwhile, vomiting and violent tenesmus, followed by the discharge first of fiecal and subsequently of mucous dejecta, take place ; and then, if death do not ensue, the symptoms quickly subside, and the animal recovers its normal appetite and liveliness. During the attack the temperature rises gradually to about a couple of degrees above the normal, and then, whether recovery or death ensues, gradually falls. Immediately before death the fall is rapid. In fatal cases, small extravasations of blood are found beneath the endocardium (mainly of the left ventricle), pericardium, andpleuras ; and the abdominal organs are generally congested ; but the mucous membrane of the stomach and small intestines is hyper^mic to an extreme degree, and the spleen large and infiltrated with blood. The blood is darker than natural, owing mainly to the fact that the red corpuscles are partially dissolved, and their colouring matter is diffused to some extent through the plasma. Extreme anaemia is generally observed after recovery. The infective variety of septicaemia (that, namely, in which the intro- duction of small quantities of septic organisms into the blood is followed by Fig. 3S.— Veix op the Diaphragm of a SEPxiciEMic Mouse, x 700 (Kocli). a. Nuclei of the vascular waU. 6. SepticEemic bacilli. c. White corijuscles trausformed into masses of bacilli. d. Capillaries opening into the vein. the rapid increase and diffusion of such organisms throughout the system, with the development of characteristic symptoms, and by communicability of the same disease by inoculation to other individuals) has been ex- perimentally investigated by Koch and others in mice and rabbits. The symptoms observed during life and the appearances found after death are 144 SPECIFIC FEBRILE DISEASES. much the same m this affection as in the last, with the exception that in this case numberless bacteria are found in the blood and tissues, and that the disease is much more fatal. The term septic ijoisoning may be conveniently applied to the former- variety of scepticfemia, and that of septic infection to the latter. The relations of human septicaemia and pyaemia to the diseases above described are extremely interesting, but not absolutely clear. There can be no doubt that they, as well as the affections experimentally imparted to the lower animals, are due to bacterial influence. It seems probable that the constitutional symptoms attending local unhealthy inflammations, and which are by no means generally fatal, are due to septic poisoning. There is little reason to doubt that deaths, attributed to septicaemia or pyaemia after childbirth, and under other circumstances, and in which none of the characteristic lesions of true pyaemia are found after death, are cases of septic infection. And as regards pyaemia itself (in which we find vessels obstructed by emboli or clots, and local foci of disease more or less widely distributed, and in which all these lesions are centres of abundant bacterial development), it may be admitted that, if not identical in aetiology, it has, at any rate, a very close affinity with true septic infection. In the foregoing discussion we have dwelt on the distinction between the bacteria of septic poisoning and the true contagia — that in the former case the organisms undergo development m some limited area where they evolve a material, unliving poison, which is thrown into the system and thus acts injuriously upon it, while in the latter case the organisms themselves enter the system, undergo development within it, and thus produce their characteristic effects. But while admitting the reality of the distinction, is it, we may ask, a fundamental one ? It can scarcely be supposed that the true contagia act otherwise on the body than by some poison which they yield or produce ; and if this be the case it can only be a matter of subordinate scientific importance, whether the contagia which evolve poison multiply within the blood as in relapsing fever, in the skin (mainly) as in small-pox, or m ready-formed ulcerated surfaces as in septic poisoning. These remarks not merely have reference to the organisms of septicaemia on the one hand and the contagia of the exan- themata and continued fevers on the other, but they bear upon the question of the nature of the contagious elements in diphtheria, enteric fever, and some few other diseases in which lowly organisms (micrococci or bacteria) have been detected in connection with the characteristic local lesions, but in which the relations between these organisms and the disease have not yet been satisfactorily determined. B. General Bides to he observed in the Management of Epidemic or Contagious Diseases. We can, as a rule, do little or nothing medicinally for the direct cure of ^ the infectious fevers. So far as the patient is concerned, we can only GENEKAL KULES OF MANAGEMENT. 145 treat symptoms as they arise, support liis strength by suitable nourishment, promote the action of his excretory organs, and take precautions against the supervention of compHcations. It is, however, a most important duty of the medical man to prevent their spread. The measures to be adopted for this end will differ to some extent, according to the character of the disease he has to deal with, and according to the properties and pecu- liarities of the contagium on which it depends. The following general rules, partly derived from ' Suggestions by the Society of Medical Officers of Health,' partly from other sources, may be laid down as generally applicable : — 1. The patient should be at once separated, as efficiently as circum- stances permit, from the other inmates of the house, and if possible placed in a top room, and have that floor devoted to him and his attendant. 2. All bed-curtains and other hangings, and carpets, and all articles of dress and the like in wardrobes and cupboards, and all unnecessary articles of furniture, should be removed. 3. The room should be well ventilated ; windows should be kept partly open, communication with the chimney free, and, if the weather or size of the room permit, the fire burning. The floor should be sprinkled daily with disinfectant fluid and cleansed. 4. The door should be kept closed, and a sheet kept wet with a solution of carbolic acid, chloride of lime, or Condy's fluid, hung outside it so as to cover every crevice. 5. Everything that passes from the patient (spit, vomit, urine, faeces) should be received into vessels containing either of the above solutions ; and an additional quantity of solution should be added to the vessel before removing it from the room and emptying it into the closet. All super- abundant food or drink, and all scraps, should be similarly treated, and under no circumstances partaken of by other persons. 6. Pieces of rag should be used for wiping discharges from the nose or mouth, and burnt immediately after use. 7. All cups, glasses, spoons, and such-like articles used in the sick- room should be placed in some disinfectant solution before leaving it, and subsequently washed in hot water. 8. All bed and body linen after use should at once, and before leaving the room, be put into a disinfectant solution. After remaining in this, for at least an hour, they should be boiled in water. 9. The patient's person and bed should be kept scrupulously clean ; and when, during the progress of the disease, scales or crusts form upon the skin, their diffusion should be prevented by smearing the surface daily with oil. 10. Nurses in attendance should, if possible, be such as have already had their patient's disease ; their dresses should be of cotton or some other washable material ; they should keep their hands clean, using car- bolic acid soap, or adding Condy's fluid to the water in which they wash, and should as far as possible avoid inhaling the patient's breath, or other emanations from his person or discharges. They should remain with £• 146 SPECIFIC FEBEILE DISEASES. the patient ; or, if compelled to leave the room, leave it under proper precautions, and mider no circumstance mix with other members of the household. 11. Visitors should not be allowed; or, if allowed, should conform, as closely as circumstances permit, to the conditions required of the ordinary- attendant. 12. The medical attendant should remain no longer than necessary in the sick-room, and expose himself as little as possible to contamination ; should wash his hands before leavhig ; hold as little subsequent commimi- cation as possible with the inmates of the house ; and never go direct, or without proper precautions, from the infectious to other patients. 13. The patient must not be allowed to mix with the rest of his family until all peeling of the skin has ceased, or until all specific phenomena of disease have disappeared, and until he has been well purified by the use of warm baths and carboHc acid soap or Condy's fluid. Clothes used durmg the time of illness, or in any way exposed to infection, must not be worn agam mitil they have been properly disinfected. 14. When the sickness has terminated, the sick-room and its contents should be disinfected and cleansed. This should be done in the following manner : — Spread out, and hang upon lines, all articles of clothing or bedding ; well close the fireplace, windows, and all openings ; then take from a quarter to half a pound of brimstone, broken into small pieces ; put it into an iron dish, supported over a pail of water, and set fire to it by putting some Hve coals upon it ; then close the door, stopping all crevices, and allow the room to remam shut up for twenty-four hours. At the end of this time the room should be freely ventilated by opening doors, wmdows, and fireplace ; the ceiling should be whitewashed, the paper stripped from the walls and burnt, and the furniture and all wood and painted work washed with soap and water contairdng a Httle chloride of hme. Beds, mattresses, and other articles which camiot weU be washed should, if possible, be submitted to a heat of from 210 to 250 degrees, for two hours or more, in a disinfecting chamber. 15. The house in which the patient, suffering from infectious disease, resides, should, during his illness, be well ventilated and kept very clean ; aU sinks and water-closets should be in good order, and have solution of sulphate of iron, carbolic acid, or chloride of lime poured into them daily ; dustbins should be regularly emptied, all offensive accumulations removed or dismfected by the free use of chloride of lime, and all water-butts and cisterns kept clean and well covered. Indeed, the greatest possible care should be taken to prevent any contammation of drinking-water. For the purposes of direct disinfection, many different substances may be employed. The following are among the most commonly useful : — Sulphate of iron, one pound to the gaUon of water ; chloride of lime, one pound to the gallon ; carbolic acid (No, 4), a quarter of a pint to the gallon ; Condy's red fluid diluted with fifty times its bulk of water ; the green fluid with thirty times its bulk of water. Chloride of hme, carbohc acid, and Condy's fluid are, on the whole, preferable for disinfection in connection INFLUENZA. 147 ■with the infectious fevers. For the disinfection of linen and other wearing apparel, chloride of lime should be avoided, on account of its corrosive 'quality. Solution of carbolic acid, or of Condy's fluid, is preferable. II. INFLUENZA. (Eindemic Catarrh.) Definition. — A contagious catarrhal affection of the respiratory tract, of short duration, but attended with much prostration, and occurring, for the most part, in widespread epidemics. Causation and history. — Influenza is one of the most mysterious, and at the same time one of the most interesting, diseases with which we are acquainted. The obscurity of its origin ; the swiftness with which it spreads throughout a district into which it has been introduced, and passes from one •city to another city, from one country to another country, thus involving entire continents -within very brief limits of time ; the shortness of its stay in any locality, which rarely exceeds six weeks or two months ; the sudden- ness and completeness of its disappearance ; and the irregularity of its -epidemic visitations, all combine to render it the most typical of all epidemic ■diseases. Its origin and diffusion, therefore, have not unnaturally been sought for in some occult telluric, atmospheric, or electrical condition, some widespread morbific influence external to, and independent of, the frames which it affects. On the other hand, experience has shown that its pre- valence is altogether independent of climate and season, and has no relation to defective drainage or other local sources of sanitary evils. But its con- veyance has frequently been traced from locality to locality by the direct agency of those who are suffering from it, and its diftusion in fresh localities from these infected immigrants as centres. It is certain, therefore, that it is infectious in a very high degree, and that it may be imparted by a con- tagium, which, like other contagia, is specific, multiplies indefinitely in the body into which it has gained access, and is thence evolved in marvellous abundance. Under these circumstances it seems most philosophical, at all events most consonant with the present state of our knowledge, to reject the vague theories first adverted to, and to assume that the contagious influence, which certainly causes it to spread in large numbers of cases from man to man, affords the true explanation of its epidemic diffusion. The virus is doubtless given off with the breath. The disease has never been imparted by inoculation ; its attacks are in no degree determined by age or sex ; and it is quite uncertain whether, or to what degree, one attack is protective for the future. It has been held by some that epidemics of influenza have a tendency to precede, or to follow, or to be associated with, other epidemic diseases, such as cholera. This relation is doubtless accidental. Symptoms and progress. — The duration of the latent period of influenza has not been accurately ascertained. According to Dr. Squire it is very short — namely, three or four days, or at the outside a week. Its invasion l2 148 SPECIFIC FEBEILE DISEASES. is for the most part sudden, and marked by elevation of temperature ; chills, especially along the spine, sometimes amomiting to rigors, and alternating with flushes of heat ; pain, uneasiness, or a sensation of burning in the back and limbs ; and sometimes vomiting. With these phenomena are associated, occasionally from the beginning, but more commonly after the lapse of some hours, severe catarrhal symptoms, indicated by dryness, redness, and swelling of the mucous membrane of the nose, sneezing, and, in consequence of involvement of the frontal sinuses, intense frontal headache ; affection of the conjunctivae, and pam in the eyeballs ; mflammation of the fauces, larynx, trachea, and bron- chial tubes to their smallest ramifications, with soreness of throat, hoarse- ness, constant hacking, often croupy, cough, rapidity and difficulty of breathing, and a sense of tightness or constriction of the chest. Generally at this time the skin is dry, the tongue covered with a moist fur, the appetite lost, the pulse quickened and moderately full, the bowels confined, and the urine febrile ; but, above all, there is extreme prostration, with muscular weakness, depression of spirits, and praecordial oppression. In the subsequent progress of the disease, general prostration and inflam- mation of the bronchial tubes constitute its most striking features. Now, the heat of skin probably subsides somewhat, but the patient is still apt to have alternate chills and flushes ; the fever assumes a remittent character ; perspirations, which are sometimes very copious, break out ; not unfrequently sudamina appear, and occasionally a herpetic eruption about the lips ; the mucous membrane of the nose and respiratory passages secretes a thui, colourless mucus, which before long assumes a muco- purulent character ; the soreness of the throat and hoarseness probably contmue ; the difficulty of breathing and the cough increase ; and on auscultation the breath-sounds are found to be feeble, or masked by sibilant and sonorous rhonchi and sub-crepitation ; the face gets congested or livid ; the pulse increases in rapidity, and loses fulness and strength ; the tongue becomes more thickly coated, except perhaps at the tip and edges, and maybe dry and bro^vn ; the sickness possibly continues, and diarrhoea may come on ; debility grows extreme, and muscular tremors and sub- sultus may appear ; the intelligence becomes markedly dull and impaired, and delirium sometimes supervenes. Epistaxis is of common occurrence, and otitis and jaundice are neither of them unfrequent. In mild cases, the disease is at its height on the second or third day, and then declines gradually ; but in more severe cases (cases in which there is much pulmonary affection) convalescence does not commence until as late as the tenth or twelfth day. The patient is always much reduced in strength at this time, and convalescence is protracted in con- sequence, partly of persistent debility, partly of the contmuance of catarrhal affections, or of a proclivity to catch cold. The most important of the complications of influenza are those arising out of the characteristic lesions of the air-passages :— namely, laryngeal inflammation, bronchitis (especially bronchitis of the smaller tubes), and lobular and lobar pneumonia, often associated with pleurisy. These affec- INFLUENZA. 149 tions creep on insidiously during the progress of the case, and reveal themselves only by aggravation of the ordinary symptoms, or by the blenduig of their proper symptoms with those diie to the iiiflixenza itself. Gastro-intestmal complications also are described, and occur ; but there is no doubt that the accidental concurrence (which is so common) of mfluenza with other diseases explains a large proportion of the cases m which it is found associated with these gastro-intestinal and other less frequent complications. Single cases of influenza may readily be confomided with severe catarrhal affections of the nose, throat, and bronchial tubes. But the high fever, extreme prostration, and short duration of the graver symptoms are, all, important characteristics pointing to the specific nature of the disease. If to these peculiarities be added the fact of epidemic prevalence, mistake is no longer possible. The percentage of deaths from hifluenza is very small, and indeed the uncomplicated disease is rarely fatal. Still, it attacks so large a propor- tion of a population (in some cases between a quarter and a half of the total number) that that small percentage does very largely augment the mortuary rate. Indeed, the prevalence of influenza has been found to swell the death-rate much more than the prevalence of cholera. The disease is chiefly fatal among the old, and such as are already suffering from pulmonary or cardiac affections. Morbid anatomy. — There is nothmg distinctive in the morbid anatomy of mfluenza. Patients die chiefly of pulmonary mischief, and the evidences of this may be detected in the form of inflammation of the bronchial membrane, secretion into the tubes, emphysema or collapse of lung-tissue, or both, or pneumonia, combined or not with pleurisy. Treatment. — In treating influenza, it is important to adopt the hygienic measures which are generally useful m the treatment of infec- tious febrile affections. Medicinal treatment is not generally very effica- cious. Small doses of nitre, alone, or combined with a few drops of laudanum, have been highly recommended. But probably nothing is better than a few drops of ipecacuanha wme combined with a little lau- danum, or ammonia associated with solution of acetate of ammonia, administered every two or three hours. If the bowels are confined, they may be moved either by mild aperients or by enemata. The mhalation of steam may relieve the laryngeal and bronchial affection, as also may the diffusion of moisture through the atmosphere of the room. The removal of blood, even by leeches, is rarely admissible ; still, m cases in which the congestion of the lungs is extreme, and death by asphyxia impending, they may be justifiably employed. Blisters again are of doubtful efficacy. Flannel or cotton wool, bran-poultices or hot fomenta- tions to the chest, on the other hand, are often beneficial, as also are mustard plaisters. But little food Avill probably be taken, or needed, dur- ing the earher days of the disease, and such as is swallowed should consist mainly or exclusively of milk, and the various farinacea, suspended or dis- solved in milk or water. Thirst may be relieved by these means, or by the 150 SPECIFIC FEBEILE DISEASES. administration of water, tea, lemonade, soda-water, or other such drinks.- Owing to the remarkable prostration which generally is present, stimu- lants are for the most part soon required. The nature of the stimulants to be employed must depend on circumstances. When the patient begins to amend, tonics are indicated, and the diet must be gradually modified, - until it combines the ordinary proportions of solid and fluid, and of animal and vegetable matters which constitute the diet of healthy persons. The presence of complications will necessarily, in many cases,-. make some modification of treatment desirable. It need only be said, however, in reference to this point, that, as in the uncomplicated disease^ so here, depletory measures are generally attended with risk, and rarely: called for. III. HOOPING COUGH. [Pertussis.) Definition. — An infectious disorder, for the most part of long duration,., characterised by inflammation of the respiratory tract and a peculiar par- oxysmal cough. Cosusation. — Hooping cough is met with both sporadically and in an. epidemic form, mainly attacking children, but not altogether sparing adults- or persons of advanced age. It is said to be more common in sprmg and: autumn than in other seasons ; it is probably not more common at these times, but attended then with a specially high mortality. Neither climate,, nor other hygienic conditions, have any notable mfluence m promoting^^ its spread ; but epidemics of it are often associated with epidemics of scarlet fever or measles, and it is held by many that there is some kind of mysterious relation or attraction between them. It is contagious in a very high degree, especially durmg the earlier period of the disease, and before, the whoop is established. Its contagion is given off with the breath, and conveyed mainly by the atmosphere ; but it is readily carried by clothes, and preserved in fomites. One attack confers almost complete immmiity. agamst subsequent attacks. Sym23toms and progress. — As in all similar diseases, a period of latency intervenes between the inception of the virus and the occurrence of sym- ptoms. The duration of this period has not been accurately ascertained. It v/as exactly a fortnight in some cases which we had the opportunity of. investigating in reference to this point. The invasion of hooping cough closely resembles that of an ordinary - catarrh, and is often midistinguishable from it. There is more or less fever, with irritability or inflammation of the mucous membrane of the respiratory tract, and frequent cough, attended with much tickling in the throat and some expectoration of mucus. Some sonorous and sibilant rhonchus may be detected on listening to the chest, but in other respects the respiratory sounds are healthy. There may be injection of the con- junctivae, photophobia, and nasal catarrh, with sneezing. The main points in which the disease differs thus early from ordinary catarrh are : that HOOPING COUGH. 151 the fever is commonly higher ; that the cough is much more troublesome, sometimes occurring incessantly night and day, several times in the minute ; and that these symptoms are all much more persistent, often lasting for a week or fortnight without undergoing any change. About the end of this time the symptoms become modified ; the fever abates, and probably soon disappears, and gradually the irritative cough of the period of invasion subsides, to be replaced by the peculiar paroxysmal cough which characterises the disease. > Single paroxysms of this cough may be almost exactly simulated, especially in children, by the effects of the application of pepper or other irritants to the laryngeal mucous mem- brane. But in its best-developed form, and by its recurrence, it is quite pathognomonic. The paroxysm is preceded by tickling in the throat, and perhaps pain beneath the sternum, and at the same time a little rhonchus is probably audible on applying the ear to the chest. The child seems to know what is impending, becomes quiet and anxious, and for a short time seems to struggle against it. If lying down, it rises to the sitting or standing posture, and when up, clutches any firm object which is near, or rushes to its nurse or mother. The actual attack usually begins with a deep inspiration. This is at once followed by a rapid succession of short coughs, with no intervening inspirations, which, gradually becoming feebler and feebler, are continued until the cavity of the chest is contracted to the utmost, the veins of the head and neck are turgid, the face congested and livid, the eyes watery and starting from their sockets, and the whole surface bathed in sweat, and asphyxia seems imminent. Then succeeds a long, whistling, crowing, or whooping inspiration, which is prolonged until the chest is once more distended with air. But the patient is not yet relieved ; for the cough immediately recurs, and may be repeated two or three times in continuous succession, until the child is utterly ex- hausted. During the paroxysm, which often lasts for two or three minutes, and more especially at its close, a considerable quantity of viscid trans- parent mucus is discharged, and very often the contents of the stomach are vomited. In the attack the child may faint or become insensible ; the urine and even the faeces may be voided ; punctiform extravasations of blood may occur beneath the conjunctivae, and in the skin of the eye- lids and other parts of the face ; and there may be hemorrhage from the nose, and even from the air-passages and ears. The membranse tympani have been ruptured. The attack does not invariably begin in the manner above described, for occasionally the paroxysmal cough precedes the long- drawn noisy inspiration, and occasionally complete spasmodic closure of the glottis, followed perhaps by insensibility, replaces it altogether. After the paroxysm is over, the child remains more or less exhausted for a time, but for the most part soon resumes his amusements, and appears to have little or nothing the matter with him. The paroxysms recur at irregular intervals, and vary in number from twenty to two hundred (according to the severity of the case) in the course of the day and night, but are almost always more numerous, as well as more severe, at night time. In the interparoxysmal period, auscultation of the chest reveals only slight 152 SPECIFIC FEBRILE DISEASES. indications of eatarrh, but Tvben tlie patient is making the crowing inspira- tion no breath-sounds whatever are audible within the chest. Ulceration of the frsenum linguae is often observed in childi-en affected with hooping cough, and has had some importance attached to it. It seems to be due to injury by the lower incisors dm'ing the acts of coughing. After the above symptoms have lasted with little change for several weeks (usually from three or four to eight or tenl, the period of conva- lescence commences. This is of very various duration, and is especially apt to be prolonged if the weather be inclement, if the patient be neglected, or if complications have supervened. During its continuance, the attacks of cough gradually decrease in number and severity and lose their par- oxysmal character ; the expectoration becomes thicker and opaque, and then ceases ; and the patient more or less rapidly regains health and strength. Attacks of hoopmg cough vary much in severity and duration ; and, just as scarlet fever or measles may occur without the delevopment of its characteristic rash, so hooping cough may pass through all its stages and yet its cough never be attended with the characteristic whoop. This is especially the case when the disease is of exceptional mildness, or when it affects the adult. Trousseau records a case in which an attack lasted three days only. Its entire duration may certainly be as short as a week or two, but much more frequently ranges between six and twelve weeks. Occasionally the disease does not wholly disappear for six, or even twelve months. If, in the fully developed disease, the paroxysms of cough do not exceed twenty in the four-and-twenty hours, the case maybe regarded as a mild one. If they exceed forty or fifty, the case is certainly severe, and the child probably is iU and feverish, and has signs of pulmonary congestion or bronchitis ui the intervals between them. If they are still more numerous, the danger of comphcations, and to life, is serious. Hooping cough (although one of the most common causes of death in children) is rarely fatal in the absence of complications. These are apt to come on in the second period of the disease, especially in cases of great severity. They are mainly vomiting, bronchial inflammation, pulmonary collapse, lobular pnemnonia, and emphysema, together with epileptiform convulsions and other forms of head-mischief. Vomitmg chiefly attends the paroxysms of cough, and, if these be frequent, innutrition, emaciation, and debiUty will necessarily result. The pulmonary complications reveal themselves by difficulty of breathing, lividity of face, crepitation and sibilant rhonchus (without any necessary dulness on percussion of the chest), increased frequency of pulse, and rapid impairment of strength. The emphysema of the lungs, which is the result of laceration of the air-cells, is in children often interlobular, and occasionally spreads through the roots of the lungs to the connective tissue of the neck, face, and chest. Convulsions occur, chiefly in infants who are teething, and may be either ordinary attacks of eclampsia, or attacks resembling those of laryngismus stridulus, in which respiration is arrested by spasmodic closure of the glottis, and insensibility supervenes, attended with convulsive movements HOOPING COUGH. 153 of the muscles of the face and eyes. These complications are no doubt serious, and the latter especially may be suddenly fatal, yet the great majority of children who experience them recover perfectly. Dr. E. Smith has shown that hooping cough is the most fatal of all diseases of children tmder one year of age, that sixty-eight per cent, of all the deaths from it occur under two years of age, and only six per cent, above the age of five years. Morbid anatomy. — The lesions observed after death from hooping cough are always those of its complications — namely, congestion of the mucous membrane of the larynx and other air-passages with secretion into the bronchial tubes, collapse of lung tissue in patches, lobular pneumonia, emphysema, and in children interlobular emphysema. Post-mortem examination, indeed, throws no light whatever on the nature of the disease. Congestions of the medulla oblongata, and of the pneumogastric nerves, which have been described as occurrmg in hoopmg cough, are probably purely accidental conditions, if not the result of mere post- mortem changes. So, again, enlargement of the bronchial glands, which has often been observed, has no necessary connection with it. It has been much discussed whether the disease is essentially nervous, or a mere inflammatory condition of the respiratory mucous membrane. It seems probable, however, that it is not exactly either one or the other ; but that, hke other mfectious fevers, it is the result of a virus, which affects more or less the whole system, but has a special tendency to involve the respiratory mucous membrane, producmg in it a slight but specific inflammatory change, to the effects of which on the peripheral ends of the pneumogastric nerves the cough, with its peculiar characteristics, is due. This view is confirmed by the fact that it is evidently from the implicated mucous surface that the contagium of the disease is chiefly, if not exclusively, emitted. Treatment. — As is the case with all diseases of uncertain duration and of intractability, many specifics have been vaunted for the successful treatment of hoopmg cough. Among the more important of these are hydrocyanic acid and belladonna. With respect to the latter remedy, Trousseau strongly urges that it should be given in one dose daily, and that in the morning on an empty stomach ; and that, if an mcrease be necessary, it should be by augmentation of the morning's dose. For infants under four he recommends, to begin with, a pill made with -j^^^ gr. of the extract and y^ gr. of the powdered leaves, or -^ gr. of the neutral sulphate of atropia. Large doses of belladonna are borne by young children, and from five to ten or even fifteen minims of the tincture may be administered to them several times a day. If hydrocyanic acid be preferred, from one to two minims of the dilute preparation may (accord- ing to Dr. Koe) be given to young children every three or four hours. Strychnia, hyoscyamus, conium, arsenic, iron, bromide of potassium, and bromide of ammonium have also been strongly recommended, as also have alum, tannin, and the mmeral acids. But it is almost certain that no drug has any direct influence over the course of the disease, and that 154 SPECIFIC FEBKILE DISEASES. hence our efforts must be directed to the relief of distressing symptoms,, to the prevention of complications, and to the maintenance of the patient's strength. To these ends it is important that he be kept to his room, which, though well ventilated, should be maintained of uniform tempera- ture ; that, if not confined to bed, he be clothed in flannel ; and generally that he be not exposed to draughts, or conditions liable to cause pulmon- ary inflammation. For medicine there is probably nothing better than a combination of a few drops of ipecacuanha wine with a minute propor- tion of laudanum or belladonna, to be administered every two, three, or four hours. Counter-irritants are sometimes useful ; and the application of a strong solution of nitrate of silver to the larynx has been much recommended, especially by Bouchut and Eben Watson. The patient's diet must be regulated accordmg to circumstances, but generally it should be plain, wholesome, and nutritious. In the period of convalescence,, tonics and change of air, or, failing this, daily exercise in the open air,, are advisable. When complications arise they must of course be treated specially. But they need no treatment distinct from that of the same affections occurring under other circumstances. IV. MUMPS. [Parotitis.) Definition. — A contagious fever, of which the chief characteristic phenomenon is inflammation of the salivary glands. Causation. — Mumps, like scarlet fever, measles, and hooping cough, is a malady which is generally present among us in a greater or less degree, and every now and then assumes an epidemic character. Like them, moreover, it is extremely infectious, infects, as a rule, but once in a lifetime, and may be regarded as mainly a disease of childhood. It is not, however, confined to childhood, and unprotected adults, and even persons of advanced age, may suffer from it. It is probably not in- fluenced by sex ; and there is no reason to beheve that its prevalence depends, in any degree, on season, weather, or climate. The virus of mumps seems to be contained principally, if not solely, in the breath. Symptoms and progress. — The incubative period of mumps probably varies between fourteen and twenty-one days. The invasion of the disease is sometimes indicated by febrile symptoms and headache, on which, after a few hours or a day or two, parotid inflammation supervenes; but, in many cases, the affection of the parotid gland precedes the febrile phe- nomena, or accompanies them from the first. The patient usually com- plains of aching and tenderness behmd one of the ascending rami of the lower jaw ; and, in a short time, a little fulness is perceived there, com- pletely obliterating the groove normally existing in that situation. But occasionally the inflammation begins in that part of the parotid which lies upon the masseter muscle. The aching, tenderness, and swelling gradually increase for three or four days, until the whole of the parotid MUMPS. 15^ region is occupied by a dense elastic tumour, which extends forwards over the masseter muscle, and downwards below the angle of the jaw, and over which the skin may assume a rosy hue. Sometimes the inflamma- tion remains hmited to one parotid gland ; but more frequently it involves, both parotids, and both submaxillary glands as well, attacking them successively at short intervals, so that all become implicated in the course of two or three days. The inflammation spreads also to surrounding parts, and especially to the fauces and tonsils. "When the affection em- braces all the glands, and is fully developed, the swelling (which then involves the parotidean and inferior maxillary regions of both sides) marvellously alters the character of the face, giving to its sides great fulness and breadth, and adding beneath a large double chin. The glan- dular affection generally reaches its full development in from three to six days, and remains stationary for a day or two longer. During the whole of this period the swollen parts are firm and tense, very tender on pres- sure, and attended with much aching, which becomes exceedingly severe when the jaw is moved, and even when the act of deglutition is per- formed. Hence the patient cannot masticate, and has much difficulty in swallowing, and the saliva tends to accumulate in his mouth. The febrile symptoms, moreover, continue — the temperature sometimes attaining a height of 103° or 104° ; and there is more or less thirst and anorexia. The character of the saliva, and its quantity, are not usually altered, at all events not altered materially. After a time, which varies according to the severity of the case, and rarely exceeds a week, the swelling of the glands begins to subside, and therewith all the general symptoms. The whole duration of the illness may be a week, but more frequently extends to ten or twelve days or a fortnight ; but even at the end of that time the shrunken submaxillary glands may often still be felt of almost stony hardness. Occasionally the skin over the swollen regions desquamates. It sometimes happens in the course of mumps (either in the period of decline, or more rarely after it has apparently disappeared) that in the male one or both of the testicles get enlarged and painful, and m the fem.ale inflammatory swelling of the mammae or labia comes on. These complications appear generally without warning, but at times are pre- ceded by apparently unaccountable symptoms of the most alarming kind — such as severe collapse, or high fever with delirium. They subside in the course of a few days. Atrophy of the testicle occasionally follows. Swelling of the testicle is very exceptionally the first indication of the presence of mumps. Mumps is a disease of little gravity, and rarely, if ever, terminates in death. But it is apt to leave behind it a good deal of feebleness of health. It is most likely to be confounded with non-specific inflamma- tion of the parotid, and inflammatory enlargement of the cervical lym- phatic glands ; but mider any circumstances the confusion can only be temporary. Morhid anatomy. — So little opportunity is afforded of investigating the morbid anatomy of mumps, that little can be said positively on the 156 SPECIFIC FEBEILE DISEASES. subject. The salivary-gland inflammation probably differs anatomically in no respect from that arising from other causes, but it never proceeds to suppuration. There is doubtless considerable infiltration of the connec- tive tissue of the glands ; and indeed the infiltration extends beyond the limits of these organs, involving the subcutaneous connective tissue on the one hand, and that of the fauces on the other. Treatment. — Persons suffering from mumps should be kept out of draughts, and, if not confined to the bed or sofa, at least debarred from making active exertion. The swollen parts may be relieved by fomenta- tions or the application of flannel or cotton wool. The bowels may be kept slightly open. The patient should be fed, during the ingravescence of the disease, on milk, bread and milk, eggs, and other like foods, which need no mastication. When alarming symptoms show themselves, ammonia and other stimulants are indicated. V. MEASLES. {Pvubeola. Morbilli.) Definition. — A contagious exanthem, characterised by the presence of catarrh of the respiratory mucous membrane, and a peculiar eruption, coming out on the fourth day. The disease usually lasts between one and two weeks. Causation. — Measles is one of the most virulently contagious of dis- eases ; and although its virus can probably not be so long preserved in an active form by fomites, or in other ways, as the contagia of scarlet fever and small-pox, the presence of a case of measles among a number of unprotected persons will, as a rule, induce a more certain and widespread outbreak of disease than either of the other exanthems would do under similar circumstances. This peculiarity is due, in some measure, to the fact that its contagiousness is fully developed at a very early stage ; being at its height on the second, if not the first, day of invasion, and conse- quently before the specific nature of the attack is revealed. Hence the great difficulty, if not impossibility, of effectually preventing its spread in households and schools. Measles is generally present in a sporadic form, but at irregular intervals assumes an epidemic character, spreading rapidly among those who have not yet suffered from it, and subsiding when its pabulum gets exhausted. It is mainly a disease of childhood ; not, how- ever, so much because adults are naturally indisposed to take it, as be- cause, from its constant presence among us and its extreme contagious- ness, almost all persons have it early in life, and are thus protected from subsequent attacks. In exceptional cases, the same individual takes it a second and even a third time ; and occasionally the second attack follows so quickly on the first that it constitutes a relapse. This proclivity to repeated seizures occasionally runs in families. In the great majority of <;ases, however, one attack is permanently protective. Symptoms and progress. — The latent period of measles varies like MEASLES. 157 that of all other similar diseases ; its extreme limits are probably seven and twenty-one days. When the disease has been given by inoculation with the nasal mucus, the first symptoms are said to have manifested themselves on the seventh or eighth day. But when it is caught, in the usual way, by inhalation of the virus, the incubative period is generally from twelve to fourteen days. During this time the patient, with rare exceptions, is apparently in good health, but occasionally he suffers from lassitude, debility, and slight febrile disturbance. The invasion of the disease is marked by catarrhal symptoms, in association with slight fever. Chills or slight rigors occur, with elevation of temperature and acceleration of pulse ; and, at the same time, the mucous membrane of the nose gets injected and irritable, and secretes a thin mucus, and there is frequent sneezing and sometimes epistaxis. The catarrhal affection speedily extends : to the frontal sinuses, causing frontal headache ; to the eyes, causing congestion of the conjunctivae, watering, and intolerance of light ; to the fauces and mouth, mducing patchy redness ; and to the larynx, trachea, and bronchial tubes, causing soreness, hoarseness, and a hacking cough. Occasionally, in children, the disease is ushered in with an epileptiform convulsion, or several such convulsions ; while, on the other hand, not unfrequently the initiatory symptoms are so slight as to escape observation. During the period of invasion the skin is mostly dry, though sweating may come on from time to time, especially after the rigors ; the tongue remains natural or becomes somewhat furred ; there is loss of appetite, sometimes sick- ness and thirst, swimming in the head, and occasionally on the third day some remission of symptoms. On the fourth day (inclusive) after invasion (sometimes a little earlier, sometimes later) the catarrhal symptoms and fever become aggravated, the temperature rises, the pulse quickens, the patient gets dull and perhaps a little confused, diarrhoea sometimes comes on, and the characteristic eruption begins to appear. This first shows itself on the forehead and temples, near their junction with the hairy scalp, on the cheeks, chin, and back of the neck, whence it gradually difi^uses itself over the general surface from above downwards, invading first the chest and arms, then the abdomen and legs. Hands and feet are both affected. It usually becomes most developed on the back of the trunk, and prob- ably least on the generative organs and neighbouring parts of the abdomen.. The rash attains its height generally in a couple of days (on the sixth day of the disease), sometimes in three or four, and then declines in the order of its appearance. Its subsidence is followed, in ten days or a fortnight, by a very fine scurfy desquamation, which is chiefly observable about the forehead and cheeks. The severity of the symptoms continues to increase so long as the rash itself increases ; and, with the height of the eruption, the temperature attains its highest point, which rarely exceeds 103° or 104°. When, however, the eruption begins to fade (namely, on the sixth day, or it may be a little earlier or later), the tem- perature almost suddenly falls several degrees, the severe symptoms 158 SPECIFIC FEBEILE DISEASES. subside, and convalescence commences. The temperature in some cases at once sinks to the normal, but more frequently it descends to 101° or 100°, at which elevation it remains for a day or two, and then reaches the healthy level, or even sinks below it. The catarrh of measles is very characteristic and important. It usually commences in the nose, and extends as has been already de- scribed. In favourable cases it involves simply the discomforts of ordin- ary catarrh. But it may assume a more serious character : sometimes it induces inflammation of the eyes, which may terminate in chronic or in purulent ophthalmia, and even in their destruction ; sometimes it reaches the tympanum, through the eustachian tube, causing earache and deafness, upon which suppuration of the middle ear or permanent deafness may supervene ; and very often croupy symptoms manifest them- selves, or acute bronchial catarrh, or capillary bronchitis. The tongue may be clean, or covered with a whitey-brown fur, but does not usually get dry. Occasionally, however, when typhoid symptoms manifest themselves, it becomes both dry and black, and sordes appear on the teeth and lips. There may generally be seen, early in the disease and before the appearance of the cutaneous eruption, spotty redness of the palate and fauces, of the inner surface of the cheeks and lips, and of the gums. This often gets uniform and intense, especially on the gums and at the back of the mouth, and is sometimes attended later on in the disease with aphthae or excoriation, and ulceration of the gums. Gan- grene of the mouth is met with in rare cases. Sickness is by no means a constant symptom, and seldom lasts beyond the period of invasion. Diarrhoea frequently comes on with the eruption, and is often very trouble- some. Sometimes late in the disease it assumes a dysenteric character. The urine is scanty and somewhat high-coloured, and often deposits a isediment of urates. Albumen is occasionally present in it during the height of the fever. The eruption on its first appearance has a dusky pink colour ; it con- sists of small slightly elevated papules, which gradually increase in area until they attain a line or even two lines in diameter. They are darkest at the centre and fade towards the periphery, and are momentarily effaced by pressure. They are at first discrete, although arranged in groups which have a tendency to form irregular crescents or circles. When they have attained their full size, however, neighbouring spots often run to- gether ; and sometimes, where the rash is very thick, an extensive area of nearly uniform redness results. Whilst the eruption is well marked, there is always more or less subcutaneous infiltration, and the face ap- pears swollen, and the hands and feet feel tight and uncomfortable. The spots fade very quickly; but, for the most part, there remains some pigmentary discoloration, and perhaps, too, some shght tendency in the vessels of the affected spots to dilate under excitement, which collectively render indications of the rash visible long after the actual rash has dis- appeared. The skin is generally hot and dry. Gangrene of the vulva occasionally occurs in young children. MEASLES. 159 The presence of frontal headache has ah-eady been adverted to. The chief other pains to which patients are liable are those connected with the occurrence of diarrhoea or dysentery, and otitis. If young children seem to be in severe and continuous pain, the latter complication may be suspected. Patients, especially children, are somewhat dull and irritable, and occasionally, during the earlier period of the eruptive stage, slightly delirious. Marked delirium is unusual, except in severe cases, and cases assuming a typhoid character. In the latter, coma or convulsions some- times come on. Convulsions in the eruptive stage are far more serious than those occurring during the period of invasion. Measles, if unattended with any serious complication, is commonly a mild disorder, convalescence from which commences about the sixth day, and is completed by about the tenth. Sometimes it is so little developed that its presence is only indicated by slight feverishness and fretfulness, and an inconspicuous rash about the cheeks and back of the neck, asso- ciated or not with catarrhal symptoms. In such cases the patient may be well within three or four days from the first manifestation of symptoms, and it may be impossible by these alone to recognise his disease. Some- times the attack of measles is inherently very severe, and such severity of attack occasionally characterises epidemics. In this case the patient manifests obvious prostration from the beginning ; the pulse is rapid and feeble ; the eruption is scanty and of a dusky hue, sometimes almost black, or petechial ; the lungs get congested ; typhoid symptoms, characterised by black tongue, tremulousness, and delirium, soon come on ; and the patient dies collapsed, perhaps comatose, at an early period. When the crisis is delayed beyond the sixth, seventh, or eighth day, the cause of the delay is generally the supervention, or aggravation, of one of the ordinary complications of the disease, especially laryngitis, bronchitis, lobular pneumonia, or pneumonia. These in fact constitute the main causes of the unfavourable results of measles. Death, however, may ensue from any of the other complications which have been enumerated — namely, diarrhoea, dysentery, epistaxis, gangrene of the mouth or other parts, or the results of otorrhoea. Pulmonary phthisis is a not unfrequent sequela of measles, following upon the more common pulmonary or bronchial inflammation. Diarrhoea of a very persistent and troublesome character often comes on after measles in children. Morbid anatomy. — Internal organs manifest no post-mortem appear- ances peculiar to measles. If the patient die early, or of the malignant form of the disease, the blood is dark-coloured and coagulates imperfectly, and there may be hypostatic congestion of the lungs, and congestion of other organs. Later on, we necessarily detect the lesions which have been instrumental in causing death — lesions chiefly of the air-passages and lungs, or bowels. Treatment. — The patient, for the sake partly of counteracting spread, partly of preventing aggravation of the various mucous inflammations by exposure to cold, should be confined to his room, and, if possible, kept in bed until febrile symptoms have entirely subsided. His room should be 160 SPECIFIC FEBEILE DISEASES. airy and well ventilated, but of an agreeable temperature, and he should be carefully protected from draughts or chiUs. It is not generally neces- sary that medicmes should be given ; but, partly to promote the excretions, and partly to reheve the irritation of the respiratory mucous surface, a mixture containing a small quantity of ammonia with the acetate of ammonia, to which may be added ipecacuanha wine and minute doses of laudanum (very minute in the case of young children) , may be frequently admmistered ; and for the soreness of the throat a little black-currant jelly may be used, and the patient may gargle with warm milk. In con- sequence of the tendency to dysenteric diarrhoea, purgatives should be avoided, or employed with great caution. The diet should be mainly bread and milk, beef-tea, and other such fluid, bland, nutritious articles of food. When convalescence is in progress, vegetable tonics are useful, and a substantial diet must be gradually adopted. The various complica- tions of the disease, and its sequelse, will require each its appropriate treatment, which need not differ materially from that of the same affec- tion occurring independently ; only it is important to recollect that deple- tory measures are in this case specially injurious. When the eruption is dusky, or comes out imperfectly, and the patient at the same time appears to be very ill, a warm bath is often of great service. It may also prove beneficial when, late in the disease, convulsions come on. When the patient shows signs of exhaustion, and especially therefore in the malig- nant form of the disease, and when typhoid symptoms are present, stimulants are imperative. In most cases of measles they are quite mi- necessary. VI. EPIDEMIC EOSEOLA. {Botheln. Buheola.) Definition. — A contagious disorder, having a close resemblance to measles, with which it is often confounded. Causation. — This disease is said to occur chiefly in hot seasons, and to affect children much more readily than adults. It is doubtful, how- ever, whether season or age exerts any special influence over it. It certainly spreads by contagion, and doubtless, therefore, depends on a specific virus. Its contagiousness is apparently much less active than that of measles. Symptoms and i^rogress. — The incubative period of epidemic roseola is probably about a week. Some authors state it to be about a fortnight. In one case under our care, about which there could be no dispute, it was exactly five days. Its invasion, in many cases, is coincident with the appearance of the rash, or at any rate invasion and rash occur on the same day. Not unfi-equently, however, the eruptive period is preceded by a day, possibly two, of poorliness ; the patient has a headache, is feverish, and may even have rigors ; or he complains of cold or catarrh ; or he has pains across the loins and polyuria ; or, according to Trousseau, EPIDEMIC EOSEOLA. 161 he may, if a child, have diarrhoea and comiilsions. The latter occur- rences, however, must be very rare ; and, mdeed, among the chief dia- tinctions between this affection and measles are the slightness, the want of character, and the uncertain but always short duration of its stage of premonitory fever. The rash generally appears first on the sides of the nose and adjoining parts of the cheeks, the lower region of the forehead, and the lateral aspects of the inferior maxilla ; but it shows itself almost, if not quite, as early on the forearms and hands, and correspondmg parts of the lower extremities, and then rapidly diffuses itself over the whole cutaneous surface. It usually attains its height on the second day, and, in the course of the next two, three, or fom* days, rapidly disappears. The rash has much resemblance, in tmt and general appearance, to that of measles, but is said not to assume the crescentic grouping which is characteristic of that affection. This latter statement however is not absolutely true. The spots, which fade on pressure, are of a dusky red or purplish hue, of irregular shape and often clustered (sometimes running together over considerable tracts), and vary in size from mere pomts up to a line or more in diameter. They are, for the most part, scarcely elevated above the general level of the skin ; but occasionally, and more especially on the face, form considerable papular or tabular elevations. The rash is generally most abmidant on the face, where it is often confluent, and on the forearms and legs (especially about the ankles and wrists), where also there is often a similar tendency to confluence. It is less thickly developed elsewhere, but no part is free ; and, generally, abmidant discrete spots may be observed on both the palmar and the dorsal aspects of the hands and fingers, and on the corresponding parts of the feet and toes. It may appear only on the extremities. It is attended with considerable itching, and is often followed by bramiy desquamation. The patient does not generally complain much, possibly not at all, of soreness of the eyes, or lacrymation ; nevertheless there is nearly always marked congestion of the conjunctivge. There is frequently sore throat ; and somethnes red puncta, or more or less diffused redness, may be recognised on the soft palate and fauces. There is not, as a rule, defluxion from the nose or sneezmg, or, if these symptoms are present at all, they are by no means promuient. There is often a httle cough. Durmg the first day or two after the appearance of the rash, the patient may be somewhat feverish, with slightly elevated temperature, headache or s-^dmming in the head, and other shght symptoms referrible to fever ; but not unfrequently he feels and expresses himself as being perfectly well. The affection is unattended with compHcations, subsides ordinarily "vvithm a week, and has no sequels. Lymphatic glands are said to become enlarged during the progress of the disease. We have not observed it as a distinctive feature, and know that, at any rate in a large proportion of cases, no such enlargement ever takes place. Epidemic roseola has been described as a hybrid of scarlet fever and measles, and some have regarded it literally as such. There is little like- 162 SPECIFIC FEBEILE DISEASES. ness, however, between it and scarlet fever. Its resemblance to measles, on the other hand, is very close. It differs from measles, chiefly in the slightness and short duration of its initiatory fever, in the almost com- plete absence of coryza, and in the general mildness of its symptoms ; but these differences are chiefly of degree, and only such as might be observed between very slight and severe cases of true measles. The main distinc- tions are these : that roseola and measles are mutually unprotective ; that roseola is of frequ.ent occurrence in those who have had measles only a short time previously ; and that when it breaks out in a family or school of children, of whom some have had measles and some not, it attacks them indiscriminately, and with equal mildness, and never develops into true measles. No special treatment is needed. VII. SCAELET FEVEE. {Scarlatina. Febris Bubra.) Definition. — A contagious malady, characterised mainly by a general punctiform scarlet eruption, usually appearing on the second day, and by inflammation of the fauces, tonsils, and kidneys. Causation and history. — Down to the sixteenth or seventeenth century scarlet fever was confounded with measles. Yet they are two perfectly distinct diseases, and are now fully recognised as distinct. Whatever its original source, or however it may formerly have been limited in area, it is now general throughout the world, occurring in most parts sporadically, but frequently breaking out into epidemics of greater or less severity. Its prevalence seems independent of season or climate, but, as with other infec- tious epidemic disorders, is largely promoted by overcrowding and poverty. Children suffer from it in much larger proportion than adults ; not, how- ever, because there is any special proclivity to it in childhood, but because, from its frequent prevalence and highly infectious nature, the great majority of children are exposed to its influence during the first few years of life, contract it, and thus acquire protection. Scarlet fever rarely occurs a second time ; yet second and even third attacks have been noticed. It is a common observation, however, that protected attendants on scarlatinal patients frequently suffer from sore throat during the period of their attendance, and the question naturally arises, whether such attacks should not be regarded as abortive attacks of scarlet fever. They probably are so. The contagion of scarlet fever is very powerful and diffusive. It may be carried considerable distances by the atmosphere — certainly through the whole dimensions of a large ward ; it clings to clothes and other fomites with great tenacity, and may thus lie latent yet capable of action for an indefinite period ; and it is liable to infect milk and other articles of food exposed to its influence. Scarlet fever occurs only as the result of con- tagion, usually conveyed by the means which have already been indicated. It seems that it may also be transmitted by direct inoculation. For there SCARLET FEVER. 163 is reason to believe that it can be imparted by inserting the fluid of the scarlatinal vesicles beneath the cuticle of persons who have not yet had it ; and it is certain that women, at the time of parturition, are specially liable to take it, receiving it then, in some cases, apparently direct from the fingers of the accoucheur. The time at which a scarlatinal patient begins to be infectiovTS is uncertain. We knoAV, however, that his infectiousness is not very well marked during the first two or three days. It probably increases Avith the development of the rash and sore throat, and pretty certainly does not cease until desquamation has been completed. Symptovis and progress. — The incubation of scarlet fever is shorter than that of most diseases of the same class. It usually varies between six and eight days, but is occasionally longer, and very often less. Many cases, indeed, of undoubted authenticity have been recorded, in which it certamly did not exceed twenty-four hours. Especially in puerperal women, and probably also in persons sufiering from large wounds, the period of latency seems generally to be of very short duration. Scarlet fever varies, perhaps more than any other like disease, both in the degree of severity of its attacks, in the symptoms which it presents, and (in fatal cases) in the cause •and period of death. In a typical case, the invasion is sudden, and usually marked by chills, vomiting, and sore throat ; with which are associated, or on which soon supervene, great rise of temperature, general dryness of skin, much acceleration of pulse, languor, drowsiness, frontal headache, giddiness, aching in the limbs, slight coating of tongue, thirst, anorexia, and sometimes diarrhoea. The most characteristic of these symptoms are : the sore throat and vomiting ; the remarkable rise in the frequency of the pulse, which may attain 120 in the adult or 160 in the child ; and the rapid augmentation of temperature, which may reach very nearly 105° during the first day. The disease is sometimes ushered in with rigors, and not unfrequently there is some delirium or even tendency to coma. On the second day, the rash makes its appearance, first on the chest, and simultaneously or very soon afterwards on the forearms, lower part of the abdomen, and upper part of the thighs. It becomes general in the course -of four-and-twenty hours, more or less, and attains its full development on the third or fourth day. It consists, m the first instance, of very minute rosy papules, due for the most part (as those of so-called ' goose's skin ' ) to the conical elevation of the cutis around the points of emergence of the hairs ; hence they are closely and pretty uniformly arranged, but discrete and separated from one another by healthy skin. But they soon increase in size and intensity of redness, and presently, blending with one another by their congested margins, give to the surface a uniformly scarlet hue. The papular character, however, of the rash is still, for the most part, ■distinguishable on close inspection. Not unfrequently the papahie on the chest and sides of the neck become vesicular ; and generally the rash is attended with more or less infiltration and thickening of the cutis. Very rarely, either when the rash is at its height or at the beginning of its decline, serous fluid is poured out extensively beneath the epidermis, especially that of the trunk, so that the surface becomes covered with m2 164 SPECIFIC FEBEILE DISEASES. small flat blebs, which tend to run together — a condition which leads to a larger and coarser desquamation than usually occurs. The vivid redness, of the skin disappears readily on pressure, as by drawing the point of the nail firmly along the surface ; and the line thus formed remains anaemic for a second for two. The scarlatinal rash varies much in its intensity and in its diffusion. It is sometimes very pale and almost imperceptible ; and it may be strictly limited to the parts in which it usually first appears. When general, it is most vivid on the neck, chest, abdomen, and inner aspects of the thighs and arms. It is rarely distinct upon the face, which, however, often presents irregular patches of redness. The feet and hands are not unfrequently stiff with it, and its attendent oedema. While the rash is attaining its full development, the other symptoms are all undergoing aggravation : — The heat rises ; the pulse increases in frequency ; the respirations grow more rapid ; the tongue, which was at- first covered (excepting at the tip and edges) with a thickish whitey-brown fur, soon cleans, and towards the end (that is in four or five days from the invasion) becomes morbidly red, with swollen papillae, and presents the remarkable strawberry-like appearance so characteristic of this disease. At this time too it is apt to get dry. The soreness of the throat increases ; and, on inspection, more or less vivid or dusky redness of the pillars of the fauces, soft palate, uvula, and tonsils, is apparent. These parts, moreover, swell ; and the tonsils often enlarge as in common quinsy, and present here and there on their surface imbedded, or adlierent, spots of inspissated secretion. With the faucial swelling and inflammation are usually associated pain and difficulty in swallowing, fuhiess and tender- ness behind the angles of the jaw, and some enlargement of the neigh- bouring lymphatic glands. The patient's muscular weakness increases, and his limbs get tremulous ; he becomes and looks dull and stupid, or restless, is forgetful, and slow to answer; delirium probably increases; vomiting is now not common, but thirst and anorexia continue ; and the bowels, though variable, are generally constipated. From the fourth to the sixth day of the disease, the rash begins to fade ; and it disappears, according to its intensity and the date at which it attained its maximum, between the sixth and twelfth day of the disease, or between the fifth and tenth day from the commencement of the rash. It is frequently about this time that, if the case be going on badly, the patient passes into a typhoid condition, or throat complications become serious (the tonsils suppurating, ulcerating or sloughing), or the urine gets albuminous and anasarca and uraemia supervene. If, however, the case be .going on favourably, all the symptoms now gradually subside; the temperature, with slight daily remissions, ere long becomes normal or even sub- normal ; the pulse by degrees sinks to its healthy rate or below it ; the soreness and inflammation of the throat subside; the tongue gets clean and moist ; thirst abates ; appetite returns ; and delirium, with other symptoms referrible to the nervous system, vanishes. With the disappearance of the rash, desquamation commences. It may be observed, indeed, on the chest before the rash has quite left other parts SCAELET FEVEE. 165 of the surface. It usually begins on the neck and chest ; whence it spreads to the rest of the trunk, and then to the limbs, involving lastly the palms of the hands and soles of the feet. Desquamation always takes place in considerable flakes, the size of which is greater according as the epidermis is thicker. Hence, they are small and delicate on the chest and abdomen, large on the limbs ; and from the hands and feet the epidermis occasionally sejoarates in the form of a glove. Desquamation, indicated at first by the formation of a transverse fissure at the root, sometimes afl:ects the nails. The period of desquamation is of very various duration ; it is sometimes completed in one or two days, not unfrequently extends over a week or two, and occasionally is prolonged for several weeks. It is a period of some danger ; for it is chiefly then that albuminuria arises, that dropsy and uraemia threaten, and that rheumatism and other serious sequelae are liable to come on ; moreover, there is good reason to believe that the desquamating particles of skin are charged with the contagium of the disease, and are highly infectious. We will now pass briefly in review some of the more important pheno- mena of scarlet fever. Acceleration of the pulse, especially in children, is a notable feature of the disease ; it probably rises on the first day to between 100 and 120 — in children still higher ; and it generally continues to in- crease up to the time of full development of the rash, sometimes attaining a rate of from 120 to 160, or more ; after which, if the case go on favour- ably, it gradually falls. This great acceleration of pulse is hot necessarily an indication of danger. Nevertheless, imusual rapidity with marked wealmess of pulse, especially when associated with other unfavourable symptoms, is of grave import. Eespiration is always more or less hurried, but there is mot necessarily any cough or difficulty of breathing. Sometimes, however, in cases of .great intensity (as also in pyaemia and other forms of so-called ' blood- poisoning ' ) the respirations become very rapid and shallow, and the inspirations attended with dilatation of the nostrils, and a sniffing or sucking somid — conditions which, unassociated with distinct pulmonary lesion, indicate very great danger. During the latter part of the eruptive stage, or subsequent periods of the disease, inflammation may extend to the larynx and trachea, and produce the usual symptoms of laryngitis ; or coryza, bronchitis, or lobular or lobar pneumonia, with their several groups of symptoms, may come on. Thirst and loss &f appetite are always present in a greater or less degree. Vomiting is for the most part a characteristic feature of the invasion, and few children fail to suffer from it ; but it does not usually persist. Diarrhoea is not uncommon at the commencement ; after which, the bowels are generally, but by no means necessarily, constipated. The tongue varies in character : in very mild cases, it is only slightly furred, and soon cleans, without ever displaying the strawberry-like appearance ; sometimes, it very early becomes thickly coated, dry, and even black, sordes appearing at the same time on the teeth and lips ; but more frequently, as has been pointed f)\xt, it is coated at the beginning, and on the fourth or fifth day gets clean 166 SPECIFIC FEBEILE DISEASES. and unnaturally red, Avith prominent and swollen papillte ; after which, it may either gradually acquire the normal characters, or become dry and mahogany-like. The soreness of the throat causes difficulty and pain in swallowmg and a nasal quality of voice. It involves all the parts at the back of the mouth, the fauces, and the upper part of the pharynx, biit does not usually include the larynx. The tonsils chiefly suffer ; and, as has been pointed out, they generally get enlarged, and present on the surface opaque patches, which have been secreted by the glandular follicles. In mild cases, the soreness may be very slight, and may speedily subside. Very often, however (sometimes at the beginning, more frequently in the second or third week) the tonsils suppurate, ulcerate, or slough ; or abscesses and buboes form in their neighbom-hood ; or a false membrane appears upon the surface and extends to other neighbouring parts. The urine, during the febrile stage of the disease, is scanty and high- coloured, contains a diminished quantity of chlorides, and not necessarily, according to Dr. Gee, any increase of urea. Subsequently it becomes more abundant and of lower specific gravity. Albuminuria is frequently present, and its presence is a matter of importance. It appears to have no par- ticular connection with the degree of severity of the attack. Indeed, many of the severest cases escape it altogether, and many of the mildest suffer severely. The time of the first appearance of albumen varies. It has been detected on the second or third day of the disease, but commences far more commonly in the course of the second or third week, or during the period of desquamation. Its amount varies, as also does the period during which it persists. The urine is not unfrequently smoky. Under the mi- croscope are found hyaline and epithelial casts of the renal tubules, and usually also blood-corpuscles, or casts containing altered blood. The characters of the rash have already been fully described ; it must be added that, during the height of the disease, the skui is generally dry and feels pungently hot, and that in ' malignant cases ' petechise often make their appearance. The temperature of the body attains a greater height in scarlet fever than in any other disease of the same class ; it frequently reaches 104° or 105° when the eruption is fully developed, and occasionally rises to 110° or even 112°. It differs in its course from that of small-pox, in the fact that it rises, instead of falling, when the rash appears ; and from that of measles, by subsiding slowly after the rash has reached its acme, instead of undergoing a sudden fall. The patient complains of soreness of throat, and has some headache and giddiness, with general aching of his limbs ; but the pains are not so severe as in many other febrile disorders. In the beginning of the disease he is generally restless and sleepless, and often a little delirious. When the eruption comes out, and during its persistence, he may stiU be restless and excited, or dull and inclined to coma, or he may have more or less delirium. In grave cases, violent delirium is sometimes one of the earliest symptoms. On the other hand, delirium of an alarming kind may arise at various stages of the disease without necessarily implying serious SCAKLET FEVEE. 167 danger. In one such case, in a boy of about sixteen, on the fifth day of the disease, when the rash was fading, the temperature falHng, and the urine free from albumen, busy dehrium, hke that of dehrium tremens, came on. This continued with wakefuhiess for six and thirty hours ; at the end of which time, without the aid of drugs, he fell suddenly into a pro- found sleep, lasting for twenty -four hours, when he woke sensible, and ad- vanced in convalescence. Symptoms of acute mania also may arise, as in other acute febrile diseases, without necessarily endangering the patient's ultimate recovery. Occasionally, in children, convulsions come on early in the disease ; they are rarer, however, than at the commencement of measles or small-pox, and are far more serious — indeed are generally followed by a fatal result. Coma, delirium, or convulsions not unfre- quently usher in death. Tremors of the muscles, subsultus, and picking at the bed-clothes occur in serious cases. No known disease is more unequal in its attacks than scarlet fever. In individual cases it often proves one of the mildest and most trivial of ailments, often one of the most terrible and rapidly fatal of plagues. In one household all the members may have it so sUghtly that they scarcely acknowledge to themselves that they have been ill ; and in another not one that is attacked survives. And varieties of this kind characterise epidemics. Thus, in many cases, the disease spreads rapidly through a village or town, or over a large extent of country, and its attacks are so mild that scarcely a death results ; while in other cases, the epidemic is characterised by great malignancy and terrible mortality. The mildest form has been termed latent scarlet fever. In this the cases are so slightly developed that they would probably not be recognised as scarlet fever at all, were it not for the fact, either that they occur while scarlet fever is prevailing, or that they impart scarlet fever, or that de- squamation, or albuminuria with anasarca, or both, supervene. The patient may suffer from slight febrile symptoms only, lasting for a day or two, with which may, or may not, be associated evanescent traces of a rash, or some degree of roughness of the throat. It is a question, which has already been raised, whether the sore throat, which protected attend- ants on scarlatinal cases so frequently experience, is not the visible sign of latent scarlatina, or rather perhaps of the disease in a modified form. The more ordinary form of scarlet fever is that to which the previous detailed description applies. The symptoms of invasion are well marked, the rash is abundantly developed, the throat and tongue are typically affected, and the rash disappears between the sixth and the twelfth day of the disease, to be followed by desquamation. But cases of medium seve- rity may present considerable varieties among themselves. Thus, m some, while every other characteristic symptom is present, the throat may escape ; in some, while the throat suffers severely, the eruption may be imperfectly developed. The former cases are often spoken of as scarlatina simplex ; the latter as scarlatina anginosa. The epithet 7?iaZi(77za?z^ is commonly applied to those cases of scarlet fever in which the symptoms are unusually severe, and death tends to 168 SPECIFIC FEBEILE DISEASES. come on rapidly. It is somewhat loosely applied, liowever, and embraces cases of widely different characters. The most terrible of such cases are probably those m which the patient seems to be struck down by the severity of his attack, and dies collapsed dm.'ing the first three days of the disease : sometimes on the first day, often before the rash has had time to appear or to develop, or before the affection of the throat has become a special cause of complaint. The symptoms of invasion are severe ; the vomitmg probably is distressmg ; the chills or rigors are unusually well marked ; the temperatm-e attains an extraordinary elevation ; the pulse becomes extremely rapid and weak, the respirations quick, shallow, and suspirious ; prostration and muscular debility are extreme — there is tre- mulousness of the muscles and jactitation ; the face is dusky and the expression anxious. The patient is sometimes sensible, almost to the last ; sometimes there is from the beginning fierce or muttering dehrium, which lapses before death mto coma, occasionally preceded by an attack of convulsions. Another variety of malignant scarlet fever is that in which the throat is gravely implicated. The throat -affection may be serious from the first ; but more frequently, in a case which presents no very imusual features at the beginning, it undergoes aggravation either at the acme of the fever, or during the subsidence of the rash, or even on its disappearance. The nature of the affection has already been adverted to. There may be abscess of the tonsil, or ulceration or gangrene, with oedema of the sm-rounding tissues ; and supervening thereon, the glands in the neck may inflame and suppurate, and suiuses form. Under these circimistances the patient is apt to fall rapidly into a typhoid condition, and so die ; or he may be carried off' by cedema of the glottis, perforation of an artery, or pyemia. Scarlet fever occm-ring at or just subsequently to partmition is excessively fatal, and constitutes one of the gravest forms of so-called ' puerperal fever.' It does not appear, however, to be specially dangerous during pregnancy, or to lead to abortion. The sequelfe of scarlet fever are numerous and important. It is difiicult, however, to make any clear distinction between the comphcations which fonn an essential part of the disease, and have ah-eady been de- scribed, and the phenomena which are simply secondary. It is needless to repeat what has been said about bronchitis, pneumonia, and ulceration of the throat, all of which are apt to complicate the disease in its later Btages. We wiU briefly consider the more important of those sequelae which have not yet been referred to. First ; the conjunctivfe not unfre- quently iirflame in the course of scarlet fever ; and occasionally in the second or third week of the disease the ophthalmia becomes intense and purulent, and sloughing of the corneas may result. Second ; inflamma- tion sometimes extends along the eustachian tube to the tympanic cavity, producmg ear-ache or otitis, with disease, maybe, of the petrous bone, and, possibly, sooner or later, abscess of the brain, pyasmia, or some other fatal lesion. Liflammation may extend also to the nose, and produce chronic catarrh of its mucous surface. Third ; inflammation of the peri- cairdium or of the pleurae (the latter often purulent) is not uncommon. SCARLET FEVEE. 169 Fourth ; during the dechne of the fever, or even durmg the period of con- valescence, rheumatism is very apt to supervene. This differs in no respect from ordinary rheumatism, involves successive jomts and in many cases the pericardium or the cardiac valves, and adds seriously to the fever and distress of the patient. To scarlatmal rheumatism, as to other varieties of rheumatism, chorea or embohsm occasionally succeeds. Fifth ; the most important sequelfe of all are, undoubtedly, anasarca and uraemic poisoning. We have pointed out that m a large proportion of cases (and for the most part in the second or third week) the urine becomes albu- minous. Now this condition generally passes off without any ill result. But not mifrequently, and more frequently after mild than after severe cases, anasarca and uraemia come on, which may presently be attended with severe headache, and followed by epileptiform convulsions and death. Under judicious treatment the albummuria and the dropsy may subside ; but sometimes the urine remains permanently albuminous, and the Iddneys undergo slow disorganisation. It may be observed that anasarca some- times survives the disappearance of the albuminuria, and that it is some- times developed in those who have never had albumen in the urme. Urfemic comiilsions generally involve a fatal issue. Morbid aiiatomy. — On post-mortem exammation of scarlatmal patients most mternal organs appear to the naked eye fairly healthy. The liver and kidneys may be somewhat softer than natural, and the blood im.perfectly coagulated. Yet, well-formed fibruious clots are not mrcommon in the right ventricle. In so-called ' malignant ' cases, there may be collapse and hypostatic congestion of the lungs, and hemorrhage mto and at the surface of internal organs. The throat generally presents distinct traces of in- flammation and ulceration. The sohtary intestmal glands and Peyer's patches are somewhat enlarged. The only other morbid appearances (and they are sufficiently important) are such as are comiected with the sequelae and comphcations of the disease. These, however, though common in scarlet fever, are not peculiar to it, and will be considered with the special diseases of the various organs to which they belong, or under other appropriate heads. The microscopic morbid anatomy of . scarlet fever has been mvestigated with minute care by Dr. Klein, ^ who shows that even at the earliest stages of the disease there is a marked tendency to mflammatory hyperaemia and proliferation, not only in the skin, mouth, throat, and kidneys, but throughout the alimentary canal, and in the sahvary glands, pancreas, liver, lymphatic glands, and spleen. Generally in aU these parts there are observed, germination of the endothelium of the small blood-vessels, hyalme thickening of the intima, germination of the nuclei in the muscular coat, and accumulation of lymphoid cells in the tissues around ; besides which : in the epidermis, swelling and proliferation of the ceUs of the rete mucosum, with serous effusion and migration of leucocytes between them, and tendency to detachment of the horny-layer ; in the various epithelia (including those ' See Keport of the Medical Officer of the Privy Council. New Series, No. viiL p. 23 et seq. 170 SPECIFIC FEBEILE DISEASES. of tlie renal tubules) changes resembling those in the skin ; and in the- interior of lymphatic glands, especially those of the neck, disappearance of the lymphoid cells, and development in their stead of many-nucleated, giant-cells, which ultimately become fibrous. A more minute description of the changes which take place in the kidneys will be given hereafter. Treatment. — Whenever scarlet fever breaks out among a number of susceptible persons, the sick should be at once separated from the sound. The patient should be placed in a suitable room, at the top of the house if possible, and if possible should have a floor to himself. All the usual measures should be taken as regards nursing, ventilation, disinfection, cleanliness, and removal of surplus furniture. He should be kept strictly in bed, with only so much covering as is absolutely necessary. His diet should consist of milk, beef-tea, eggs, and other such articles. And for medicine, acetate of ammonia or nitrate or chlorate of potash in solution may be serviceable. Some strongly recommend ammonia in large and frequent doses ; and some dilute hydrochloric acid, or the perchloride of iron. Ice is often used to allay vomiting. To relieve the soreness of the throat, ice, or the inhalation of steam, or warm milk slowly swallowed,. or astringent or antiseptic gargles may be employed. The patient is generally benefited also by tepid sponging, or the tepid douche bath. If the bowels are much constipated, they should be relieved by laxatives ; if there is diarrhoea, they should be restrained by opium or other astrmgents. When convalescence is takmg place, it is recommended to keep the body well greased ui order to prevent the dissemination of the flakes of cuticle. The practice is a good one, and may be associated with the daily use of warm baths. Tonics must now be had recourse to, and the diet should be nutritious and include a fair pro^Dortion of solid food. It is during this period that the dangers of rheumatism and of dropsy are greatest. It is important, therefore, that the patient should be kept warm, that he should not be exposed to draughts, that he should keep his room (either confined to bed or encased in flannel), and that the excretory functions should be carefully attended to, until the period of desquamation has come to an end. In most cases stimulants are not needed, but in malignant cases, and all cases where the muscular debility is great, and there is a tendency to collapse, or to the coming on of typhoid symptoms, they are imperatively demanded. In the severest cases of the disease, however, all treatment is futile ; and in the milder cases, the care of the physician must be directed, not so much to the cure of the disease, as to the relieving of discomfort, and to the obviation by precautionary measures of complications and sequelae. If there be nasal catarrh with discharge, it is well to syruige the nos- trils with warm water, or water containing chlorate of potash, nitrate of silver, or some antiseptic. If the throat be ulcerated or gangrenous, solution of perchloride of iron or of nitrate of silver, or even the latter in a solid form, or hydrochloric or nitric acid, may, according to cir- SMALL-POX. 171 cumstances, be applied. Warm fomentations or poultices should be employed externally ; and if there be suppuration in the glands or con-^ nective tissue behind and below the jaw, a puncture or incision should be made. Otorrhoea, rheumatism, renal dropsy, and uraemic convulsions must be treated as these affections are treated when they arise under other circumstances. And so with regard to other complications. Only it must not be forgotten that these affections, occurrmg as complications, bear depletion less, and need stimulation more, than do the same affections when they are of spontaneous or idiopathic origin. VIII. SMALL-POX. iVanola.) Definition. — A specific fever, spreading by contagion, and especially characterised by the appearance on the third day of a papular eruption, which gradually becomes pustular, and attauis is full development on or about the eleventh day of the disease. The eruption shows itself also in the mucous membrane of the mouth, fauces, and larynx. Causation and history. — As with many other of the infectious fevers, the history of small-pox cannot be traced further back than the Christian era. The first recorded epidemics, indeed, seem to have occurred in the sixth century. Since when it has never disappeared from among us, has been carried from Europe and Asia over all parts of the world, and, down to within a recent period, has formed one of the most formidable and fatal of pestilences. The disease was robbed of many of its terrors by the prac- tice of inoculation, introduced first into this country, early in the eighteenth century, by Lady Mary Wortley Montagu, who had mtnessed the efficacy of the procedure in Constantinople, whither it had been imported from Persia and China. It was yet more marvellously con- trolled by the application of Jenner's discovery, made at the end of the same century, of the protective influence of vaccination ; since the general adoption of which small-pox has become a comparatively rare and unimportant affection. But it still maintains all its old virulence when it attacks those who are not protected by vaccination or by a previous attack of the disease, and all its old epidemic violence when it is introduced among susceptible communities. Small-pox has no special predilection for age or sex ; but it is said that dark-skinned races, and especially negroes, suffer more severely from it than the denizens of temperate climates. All persons, mdeed, are liable to take it, unless protected in one or other of the ways which have just been adverted to, or (as rarely happens) by some peculiar constitutional msusceptibility. Instances, however, are, on the whole, not uncommon in which persons have a second and even a third attack — such attacks being for the most part mild; and it is a curious circumstance that those who, in spite of constant exposure, have enjoyed immunity from the disease for many years, not unfrequently end by contracting it, and have it in a severe 172 SPECIFIC FEBEILE DISEASES. form. Whatever the source of small-pox may origmally have been, there is no doubt whatever that it now conies solely by contagion, and that this may be conveyed either through the atmosphere or by fomites, or by direct inoculation with the contents of the variolous pustules. Few diseases, indeed, are more virulently contagious than small-pox, and there is none whose virus remams effective for a longer period. Symptoms and inogress. — The period of latency of the inoculated disease has been distinctly ascertamed to be seven or eight days. On the second day a small papule shows itseK at the seat of puncture, which by the fourth day is converted into an umbilicated vesicle. On the seventh day the vesicle has formed a pustule, and about the same time the lym- phatic glands above have become swollen and tender. And on this day, or the eighth, rigors and other symptoms mdicative of the invasion of the disease occur. About the tenth or eleventh day the pustule is fully developed, and at the same time the general varioloiis rash appears. By the fourteenth day the pustule has dried up into a scab. The period of incubation is always longer when the disease has been acquired in the usual way. It is generally considered then to range between ten and sixteen days. According to Mr. Marson it is almost invariably twelve days. The facts connected vnih. inoculation prove that the variolous contagium is present, in a concentrated form, in the mature pustules. There can be httle doubt, therefore, that small-pox is especially infectious about the period of maturation. But it is probably infectious dm-ing the whole period of its duration, fi'om the first signs of invasion up to the separation of the last scab. The incubative stage of small-pox is, with rare exceptions, miattended with symptoms. But occasionally the patient suffers from languor, peevishness, and other vague feelmgs of illness. The mvasion is more or less sudden, and is indicated by : rise of temperature, chills or rigors, followed by or alternatmg with heat of skin, and generally (m adults) copious perspiration ; severe sickness, with anorexia, thirst, and consti- pation or (in children) diarrhoea ; headache, aching of the limbs, and intense paia in the lumbar region of the sphie ; drowshiess, and not im- fi-equently dehrium, stupor or coma, and (in children) convulsions. There is sometimes maniacal excitement. The most characteristic of the above symptoms are the vomiting, constipation, and acute lumbar pain ; it is important, too, to note the frequency of perspirations, and of con- vulsions wliich for the most part are unattended with danger to Ufe. The symptoms of this stage are severe in proportion to the severity of the attack which they usher in. Other things being equal, therefore, the higher the temperature, the more persistent the vomiting, the acuter the pain in the back, and the more pronomiced the imphcation of the brain, the more quickly will the disease assume grave proportions, and the greater will be its intensity and the prospect of a fatal issue. Absence or scanti- ness of perspiration, and in adults the presence of diarrhoea, are also indications of a severe attack. The above symptoms usually attain their maximum on the third day — SMALL-POX. 17a the day on which the characteristic rash first manifests itself. In a small proportion of cases, and these are for the most part fatal cases of great malignancy, the eruption appears on the second day ; and occasionally it is delayed to the fourth or even later. In modified small-pox, it is not unusual to find the true eruption preceded for a day or two hy a roseolous efflorescence, which has some resemblance to the scarlatinal rash. And in cases which threaten to be severe there may be on the second or third day of the disease, first, a sub-papular patchy redness on the face, triuik, and elsewhere, which is almost undistinguishable from the rash of measles ; or second, an abundant petechial rash chiefly about the sides of the chest and abdomen and on the loins. The true rash usually commences, however, on the third day, in the form of minute reddish papules, which are first visible on the face, head, neck, and wrists, and in the course of the next two days invade successively the upper part of the chest, the arms, the rest of the trunk, and the lower extremities. The spots are hard, solid, hemispherical or acmnmated, and feel Hke shot imbedded m the skin ; they gradually enlarge, and m the course of two or three days get vesicular ; then, still increasing m area, their contents become opaque and milky, and about the sixth day (eighth day of the disease) distmctly purulent. With their conversion into pustules, there is a marked extension of uiflammation ; each pock acquires a deep -red areola, and the subjacent tissues swell with inflammatory eflusion. The pustules still increase in size, and the surrounding inflammation still augments, down to about the ninth day (eleventh day of the disease). The process of maturation, as it is called, is then completed. The above remarks apply more particularly to the eruption on the face ; on the lower part of the trmik, and on the extremities, its several stages occur some- what later. The eruption of small-pox is always more abundant and close-set on the face and neck than elsewhere, and is generally, even in severe cases, scanty on the lower part of the trunk. When sparse the papules, like those of measles, often appear in crescentic groups ; but when they are more thickly clustered this arrangement is not observed. If the primary papules are much crowded, the pustules which result from them tend to coalesce, and thus to form extensive tracts of suppuration, in which the limits between the constituent pustules are scarcely or not at all distinguishable. When the pustules remain distmct from one another on the face, the attack of small-pox is termed discrete ; when they run together m the same situation, it is called confluent. The pustules of discrete small-pox are larger than those of the other variety, and the surrounding inflammatory areola is more obvious. The confluent form, however, is much the more severe, and attended ■with far greater subcutaneous oedema and ultimate destruction of tissue ; the face, and especially the eyelids, are apt to get enormously swollen ; and the hands are often so much enlarged and tense that the patient cannot close them. The variolous rash is not limited to the skin, but is generally developed also more or less abimdantly on the mucous sm-face of the nose, mouth, fauces, and pharynx, and even on that of the larpix and 174 SPECIFIC FEBRILE DISEASES. trachea, and sometimes upon the coujmictiva. The fully -developed cutaneous pustules are circular in outlme, unless altered in form by coalescence or other accidental circumstances, vary from ^ to ^- inch in diameter, are somewhat flat, and mostly depressed in the centre, or ' umbihcated.' In some cases their contents, even from an early stage, are mixed with blood ; and not unfrequently they are associated with petechite and vibices. In all cases of small-pox there is, on the first appearance of the rash, a sudden diminution of the severe symptoms which characterised the in- vasion ; the temperature falls, and becomes m some cases nearly normal, the pulse lessens in frequency, the vomiting ceases, the febrile pains and pains in the back subside, delirium and other nervous symptoms disappear, •appetite perhaps returns, and the patient seems to be convalescent. At the same time, however, the cutaneous eruption is producing some in- -convenience ; and he begins to complain of soreness in the mouth and tongue, with ptyalism, and his throat gets painful, his voice hoarse, and a ringing or metallic cough probably conies on — phenomena which are due to the mvolvement m the rash of the mucous sm-face of the upper parts of the respiratory and alimentary tracts. The degree in which the symptoms of invasion subside, and the duration of the period of their abeyance, depend on the severity of the attack. In very mild cases, the pocks, at the period at which they usually suppurate, begin to contract and dry up, and there may then be no interruption to the favourable progress of convalescence. In cases of medium severity, the period of apparent convalescence continues up to the sixth or seventh day of the rash (eighth or ninth of the disease), at which time the maturation of the pustules commences. It is then interrupted by a sudden recurrence of febrile sjonptoms, which last for some three or four days, or mitil about the completion of maturation. This is the period of secondary fever, and is marked by chills or rigors, increase of temperature (which may even surpass that of the period of invasion), acceleration of pulse, dry furred tongue, and delirium. When the disease is of the confluent kmd, the remission of symptoms at the commencement of the eruptive stage is very shght ; the temperature may, perhaps, sink a degree, and there may be some slight general amelioration for four and twenty hours, or less ; after which, the febrile symptoms and delirium increase with the pro- gress of the eruption, attainuig their maximum severity, without any particular change in quality, dm'ing the period of maturation. It is in such cases that the swelling of the face, hands, and feet is greatest, that salivation is most profuse, that other symptoms referrible to the mouth and throat are most violent, and that dehrium is most continuous. There are generally also, in these cases, tremulousness, subsultus, want of control over the evacuations, and extreme prostration ; and not un- frequently diarrhoea occurs. After the completion of pustulation, and at the end of the secondary fever, which events are generally nearly simultaneous, a period of very uncertain, duration and of very variable phenomena, during which the SMALL-POX. 175 pustules dry up and disappear, comes on. During the first three or four days, that is from the eighth or ninth up to the eleventh or twelfth day of the eruption, the pustules ooze or di-y up, dark-coloured, thick, ad- herent scabs form, and the skin begins to exhale a characteristic fetid odour — the cutaneous inflammation at the same time rapidly subsiding. The separation of the scabs usually takes place during the third ^yeek of the disease ; but the healing of all the sores may not be completed for a week or two more, being preceded by the formation and detachment of successive crops of scabs. If the case be going on favourably, the febrile S}anptoms rapidly subside, the functions of the various organs are restored, the appetite returns, and convalescence is established. But it is during this period that many of the serious complications and sequelae of small- pox manifest themselves, and delay the patient's recovery, or carry him off. These are most fr'equent after confluent small-pox, but may super- vene on the milder forms. The following Hst comprises the chief of them. During the third or fourth week, boils are apt to appear on different parts of the surface ; and then, though more generally later, subcutaneous and even deep-seated abscesses often form rapidly, attam a large size, and are long in healhig. Erysipelas, more especially of the face and head, is not uncommon ; and gangrene, or pyaemia, occasionally supervenes. Pustules sometimes form on the conjunctivae ; and from these or other causes ophthalmia is apt to ensue, which may be suppurative and end m ulcera- tion or sloughing, and perforation of the cornea. Otitis is sometimes observed. Of internal complications, the most serious are suppurative pleiu'isy, pneumonia, and bronchitis. Inflammation or oedema of the larpix may also be fatal about this time ; but this event is chiefly to be feared dm'ing the period of secondary fever. The eruption of small-pox generally leads to more or less destruction of the cutis vera, and the formation of mdehble cicatrices. In some cases (especially of the discrete variety) only a few scattered pits may result. But in the confluent disease, the destruction, especially on the face, is often most extensive, and the patient recovers, pitted, seamed, and scarred in all directions. The description of small-pox just given is so full that we shaU now, instead of discussing at length the groups of symptoms referrible to the various systems and organs, merely supplement it by adding certain details, which either have been omitted from it or only slightly touched upon, or are of special importance. The temperature, during the stage of invasion, usually rises rapidly to 104°, or even as high as 106*5° ; during the early period of eruption, it falls several degrees, but for the most part remains distinctly febrile ; at the period of maturation, the temperature again rises, in mild cases to 102° or 103°, in more severe cases to 104°, and when a fatal result threatens to 107°, or even beyond this. The pulse is quickened, especially dming the periods of primary and secondary fever, but otherwise presents no special peculiarity. The re- spirations also are accelerated in relation with the amount of febrile 176 SPECIFIC FEBEILE DISEASES. disturbance, and, under conditions of great prostration and danger, become shallow and suspirious. Vomiting is a characteristic sj-mptom of the period of invasion, and anorexia T\ith thirst of the whole duration of the malady. In adults the bowels are generally constipated, and the occur- rence of diarrhoea diu'ing the development of the rash is an unfavourable symptom. In children, however, diarrhoea is a common, and on the whole a favourable sign, both in the period of mvasion and subsequently. Sahvation is almost invariable m confluent cases ; comparatively rare and ill-marked in mild cases. The urine presents the ordinary febrile characters ; and m some cases (about one-tldrd of the total number) contains albimien, with casts and occasionally blood-corpuscles. Albuminmia appears early m the disease and may continue to the end ; but it rarely, if ever, leads to permanent mischief or to anasarca. According to Mr. Marson, suppression never occurs. Inflammation of the ovary or testicle is occasionally observed during the eruptive stage. Perspirations are usual in discrete variola fi'om the beginning of the disease up to its termination ; but they are generally absent in confluent cases, and are not common ha children. According to the older authors, and also according to Trousseau, the sweUing of the hands and feet which takes place in confluent smaU-pos dui'hig the period of matui'ation is a favoiu-able sign. The invasion-period, in children, is often marked by drowsiness, and coma and convulsions are not unfrequent ; in adults, there is more or less giddiness and duhiess, and com-ulsions occasionally arise even in them ; there is also frequently, and especially in severe cases, maniacal, busy, or muttering dehrium. In confluent cases, the dehrium may continue dm-mg the early period of efflorescence, and it generally re- appears or becomes more severe at the time of the secondary fever. At this time, too, the patient is hable to outbreaks of violent mania. Tremulousness of muscles, subsultus, and picking at, the bed-clothes, occur in the worst cases. The pain in the back, which is so character- istic of the onset of the disease, appears to be spinal, and is often associated with temporary paraplegia and loss of control over the bladder and rectum. Many varieties of small-pox have been enumerated. Exceedingly mild cases are sometimes observed in which the period of invasion is well marked, but in which no appearance of rash follows, or a few scattered pocks only are discovered on the skin or mucous membrane. Other ex- ceptionally mild cases are met with, m which the disease begins vnth all the symptoms that usher hi a well-marked attack of the disease : in which the pocks appear numerous yet cUscrete ; but in which, at the period when suppmation should take place, the vesicles dry up. In both of these cases there is no secondary fever, and the patient rapidly convalesces. The most important foiTQS of natural smaU-pox, however, are those which are kno^^oi respectively by the names of ' discrete,' ' confluent,' and ' mahgnant ' small-pox. In the discrete form the invasion-phenomena are generally well pronounced ; but the subsidence of febrile symptoms on SMALL-POX. 177 the first appearance of the rash, and their abeyance until the commence- ment of suppuration, are constant ; the secondary fever, too, is generally slight ; and the patient for the most part recovers without any complica- tion. Nevertheless, in discrete small-pox there is some danger of death on the eighth or nmth day of the disease, from the sudden accession of cerebral symptoms, especially of coma. In the confluent variety, the symptoms are at all stages far more severe than in the discrete form ; especially, there is little and very temporary remission of febrile symp- toms ; and, moreover, phenomena which are rare or absent in the latter and have already been considered assume considerable prominence here. It is in this variety, too, that complications and sequelae are specially liable to come on. Death from confluent small-pox usually occurs from the tenth to the fifteenth day of the disease, and is due for the most part to a combination of coma and asthenia. But it may also supervene during the next month or two from the effects of sequelae. Malignant small-ijox is characterised especially by the early appearance of petechias and vibices, hemorrhagic efl'usion into the pocks and conjunctivae, dis- charges of blood from the various orifices, and rapid collapse. The symptoms of invasion are usually intense, the patient looks from the first as if struck down by a mortal disease, and often dies on the fourth or fifth day, or before the eruption has had time to become distinct. Occasionally, indeed, the patient dies collapsed on the third day, before the appearance of the eruption, but possibly presenting chemosis, together with a few petechial spots about the lower part of the abdomen. There may be delirium, but the patient often remains conscious to the last. Small-pox occurrmg after vaccination is generally modified in character, and is termed modified small-pox, or sometimes, and inappropriately, varioloid. It commences with all the usual symptoms of small-pox, and may assume the characters of the discrete, confluent, or even malignant form ; but about the time when the tissues around the pustules should inflame and swell and secondary fever be established, or even before that period, the eruption begins to dry up, and the febrile symptoms subside or present only very shght and transient exacerbation. Trousseau says that delirium is more common in modified than in natural small-pox, but is less serious, and that salivation rarely occurs in the modified confluent affection. It need scarcely be added that the degree of modi- fication varies ; that the attacks, though generally benign, are sometimes serious ; and further, that those occurrmg, even after successful vacci- nation, sometimes do not deviate appreciably- from the natural disease. Modified small-pox is for the most part a mild disease, and rarely fatal. Natural small-pox, on the other hand, is fatal in a very high degree. The statistics of the Small-pox Hospital for twenty years show, that of those patients who had previously been vaccinated the mortality was at the rate of 6' 56 per cent. ; and that of those who had good vaccme cicatrices only 2*52 per cent. died. It is very different, however, as regards unmodified small-pox, which destroyed 37 per cent., or more than one-third of the total number attacked. Discrete small-pox was N 178 SPECIFIC FEBEILE DISEASES. attended with a mortality of 4 jper cent., semi -confluent with a mortality of 8 per cent., and confluent with a mortality of no less than 50 per cent. Statistics from the same hospital show that the mortality among patients under five years of age was 50 per cent., and among those upwards of thirty still higher. The lowest rate of mortality was between five and twenty. According to Trousseau, children mider one year never recover from small-pox (a statement, however, which is not absolutely true), those between one and two rarely. Mr. Marson states that persons above sixty also almost invariably succumb. Pregnant women usually abort and die. They do, however, occasionally recover, whether abortion takes place or not. Morbid anatomy. — The post-mortem examination of small-pox cases reveals but little beyond what has been already described. In most cases the blood is dark and imperfectly coagulated ; although, in the ventricles of the heart, fibrinous clots may be discovered. In the malignant form of the disease, extravasations of blood may be found beneath all the serous and mucous surfaces. Generally the heart is flabby, the liver pale and soft, and the spleen pulpy. The tongue presents a thick fur, which may be detached at the edges and elsewhere in patches. And the palate, fauces, nasal fossas, larynx, trachea, and bronchial tubes, and even the oesophagus, may be found more or less deeply congested, and covered with a granular film due to increase and softening of the epithelial layer ; and may present, in addition, numerous excoriations which from their size and distribution are suggestive of their origin in the small-pox rash. Under such circumstances, the bronchial tubes are loaded with muco -purulent fluid, and the lungs are congested and cedematous, and possibly pneumonic. As regards the skin -eruption, we may here add a few details which were out of place in a clinical account of the disease. The papules are due, partly to punctiform hyperfemia and germination of the cutis, partly to swelling, mucous degeneration and vacuolation of the cells of the rete mucosum. The central vacuolated cells of the thickened rete presently rupture, and unite to form an irregular anfractuous cavity. Into this central cavity, and into the surromiding vacuoles, serum exudes from the subjacent vessels, together with abundant leucocytes, and often a greater or smaller number of red blood-discs. By the continuance of these processes the pock enlarges in area and becomes purulent : its superficial wall being formed by the horny layer of the epidermis, its deeper wall by the surface of the corium, and its cavity, even to the last, presenting a multilocular or anfractuous character. The umbilicated form of the pock appears to be connected with its mode of development, and to be due to the fact, that while it extends peripherally its centre remains crossed by bands and filaments. The suppurative process need not implicate the true skin below ; but not unfrequently it involves and destroys it to a greater or less depth, and is prolonged inwards along the hairs or glands. Under the former circum- stances the pustule leaves no permanent trace ; under the latter a de- pressed cicatrix results, presenting numerous pits upon its surface. SMALL-POX. 17SJ Treatment. — In the mildest forms of small-pox medicinal treatment is scarcely called for ; in the severest it is useless ; and indeed, under -any circumstances, it has but little influence over the course of the disease. The patient should be placed in an airy chamber, which should be well ventilated, and kept at a uniform and medium temperature. He may take as medicine some cooling drink — lemonade, soda-water, or other saline or acidulated solution. If the bowels be confined, they may be acted upon by some mild laxative ; if there be diarrhoea (especially in adults), they must be restrained by opium, or other astringents. The soreness of the throat may be relieved by warm bland drinks, or black- currant jelly ; and if there be much discharge from the nose and about the fauces, these parts may be washed with some mild detergent or astrmgent sohition. Opium is often of value both in relieving the delirium and in assuaging the pain of the mvasion period ; but it is especially useful during the period of secondary fever. If there be great tendency to collapse, ammonia may be serviceable. Nourishment should be regularly administered, and should consist of the materials generally suitable for febrile conditions, namely, milk, rice-water, gruel, beef-tea, and such like. Alcoholic stimulants must be given according to circum- stances ; but are especially important in the malignant form of the ■disease, and in the later periods of confluent small-pox, or whenever there is tendency to collapse. As to local treatment, the patient should be kept clean, and frequently sponged with tepid water ; and, as the eruption reaches its height, and in its declme, the eyes and various mucous orifices need especial care. They should be sponged and dried, and anointed with olive oil ; and if there be any tendency to conjunctival inflammation and ulceration, weak solutions of nitrate of silver or sulphate of zinc should occasionally be dropped into the eyes. Various plans have been suggested and employed to prevent pitting ; but it is questionable if any are really efficacious. It has been recommended to puncture the pustules, to wash away their contents, and then to insert into each a fine pomt of nitrate of silver. If this be done, it should be when the pocks first distinctly contain fluid ; but the plan is scarcely applicable to the cases in which the prevention of pitting is most needed, namely, confluent cases. The local application of strong carbolic acid has also been recom- mended. It is probably best, generally, to anoint the surface with -carbolised oil. During the period of decline of the eruption, and that of ■convalescence, the strength of the patient needs to be supported in every way, by good diet, by stimulants, and by quinine or other tonics. The various complications of small-pox must be treated according to ordinary principles, bearing in mind, however, that their presence as a rule enfeebles the patient, and is therefore an indication for sustaining strength. But the most important treatment of small-pox is the preventive, by means of inoculation with the small-pox -sdrus, or that of cow-pox. The former plan has fallen into disuse, and is now penal in this country, yet no doubt under certain conditions it might be revived with advantage. 180 SPECIFIC FEBEILE DISEASES. The inoculated smaU-pox is a much milder disease than that contracted in the usual way ; and, according to Dr. Gregory's analysis of the records of the SmaU-pox and Inoculation Hospital of London, from the year 1746 to 1822, the deaths from it were at the rate of only three in a thousand. The mildness of the moculated disease appears to he promoted by usmg the ^irus from a mild case, and by repeated selection of inoculated cases for the purposes of inoculation. It may be further promoted by inocu- lating those only who are at the age at which smaU-pox is least dangerous to life. The ^irus should be taken h'om a pock which has not yet begma to suppurate ; and the operation of inoculation should be performed exactly like that of vaccination. Our remarks on vaccination will be given in the next article. IX. COW-POX. (Vaccinia.) YACCIXATIOX. Definition. — A contagious disease of cattle, characterised by the local development of pustules ( almost exactly resembling m their progress and results the pocks of variola), and commiuiicable by inoculation. Causation and relations icitli small-pox. — Cow-pox has been found to prevail epidemicaUy at times ia every comitry m Europe. Yet, although thus common, it is doubtful if it is communicable from animal to animal either by the breath or by the secretions. It is certain, however, that it is eminently contagious by inoculation from its specific pocks. Like most other affections origmating from contagion, cow-pox by one attack protects against futm'e attacks, but it similarly confers immunity against attacks of smaU-pox. It is this fact which gives so great an interest to all questions relating to its intimate pathology, and especially to the question of its exact relations with smaU-pox. Its identity ^dth the latter disease was early surmised ; and many arguments, in addition to the fact that it is protective against it, have been adduced in favoin- of this view. Thus, there is scarcely any appreciable difference between the pocks of the two affections, either in their anatomical characters or in their progress ; it has been over and over again observed that epidemics of small-pox and cow-pox occur m relation to one another ; and it is certain that since the mtroduction of vaccination the so-called ' natural ' cow-pox has in great measure disappeared. But far more important than such facts as these are the experimental proofs which have been obtained by Messrs. Ceely and Badcock, and some foreign observers. They have inoculated cows with smaU-pox lymph ; have succeeded by this means in producmg pustules at the seat of inoculation exactly like those of cow-pox ; and Tsdtli their contents have successfully imparted cow-pox to healthy cattle, and to the human being an affection exactly like that induced by ordinary vaccmation. Further, by Ijnnph thus obtained many years ago from bovine smaU-pox successful human vaccmation has been perpetuated dowoi to the present time. As confirmatory of this view of COW-POX. VACCINATION. 181 the relation between small-pox and cow-pox, it may be pointed out tliat natural cow-pox occurs only in the teats and udders of coivs — that is, in exactly the situations in which small-pox would be most likely to be given to them by inoculation from man ; and also that cow-pox when experimentally inoculated from cow to cow, instead of being perpetuated, as it is in man, tends before long to die out. It seems clear, therefore, that cow-pox is small-pox, modified and deprived of its virulence by transmission through the cow.' Symptoms and progress in cattle. — Natural cow-pox affects chiefly the udders and teats of cows, and is indicated in them by the development of a number of pustules which individually run through all the stages characterising the small-pox pustule. They begin as papules, in a few days become vesicular, and by the seventh, eighth, or ninth day attain their full development, measuring then from ^ inch to | inch in diameter. From that date the contents become purulent, and a congested areola, with much subcutaneous induration and thickening, forms. A thick dark adherent scab is developed by about the thirteenth or fourteenth day, which gets detached in the course of the following week, leaving a depressed cicatrix. The febrile symptoms which attend the progress of the disease are very slight, and for the most part of no importance ; generally, more- over, the local affection is quite free from untoward complications. When cow-pox is given by inoculation, the papules as a rule first make their appearance at the end of three days ; occasionally, however, on the second or the fourth day. Symptoms and progress in man. — Cow-pox as it affects the human sub- ject differs but little from the same disease in cows. No specific change is observable at the pouit of inoculation until the end of the second day, or the third day, when a small congested papule makes its appearance. This gradually increases in size, and on the fifth or sixth day has become a circular greyish vesicle, with a somewhat depressed centre. By the eighth day it has attained its full development — forming then a well- marked prominent greyish vesicle, with a flat or cupped surface, and con- tainmg in its interior a colourless transparent viscid fluid. On the eighth or ninth day the contents of the vesicle begin to get purulent, a red areola forms, and thickening and induration of the inflamed area take place. These phenomena increase during the next two days ; the induration and thickening become greater and more extensive, the areola attains a diameter of from one to three inches, the pock itself undergoes some little extension, and its contents get wholly converted into pus. After the tenth or eleventh day the pustule begins to dry up, and the areola and other signs of inflammation to subside. By the fourteenth or fifteenth day a hard dark-coloured scab has formed, which contracts and blackens, 1 Basing our opinions on some experiments of Chauveau, -we adopted the opposite view in the first edition of this work. We have since then reconsidered the evidence on both sides, and are now satisfied that no merely negative evidence can invalidate the positive results obtained by Messrs. Ceely and Badcock, especially when we bear in mind that, as is admitted by all, small-pox is not readily inoculable on the cow. 182 SPECIFIC FEBEILE DISEASES. and from the twentieth to the twenty-fifth day falls off, lea-sdng a depressed pitted permanent scar. The vaccinated patient does not usually present general symptoms or complications until about the eighth day, and during the two or three days immediately following. There is generally then some febrile distm-bance,. with restlessness, irritability, and slight derangement of the digestive: organs ; the glands next above the seat of operation usually get enlarged and pahiful ; and sometimes a roseolous rash spreads over the vaccinated limb, and thence maybe to other parts of the body. This rash is some- times vesicular or papular. The consequences of vaccination direct from the cow are identical with those of vaccination with humanised lymph ; occasionally, however, there is a little difficulty in imparting the disease, and the eruption in some cases is somewhat retarded. In cases of revaccination one of three results may follow : if the patient be fully protected, it produces no effect beyond a little local irritation due- to the lancet -puncture and the mtroduction of irritant matter ; if all pro- tection have ceased, the operation is followed by the development of the typical pock ; if there be simply impairment of protection, the results of the operation are modified. In the last case, the local effect comes on early, the papule (which may remain a papule or become an acuminated vesicle) attains its full development on the fifth or sixth day, and imme- diately after forms a scab which falls off in the course of a day or two ;, but there is generally a good deal of attendant local and constitutional irritation — much more, in fact, than occurs in primary vaccination. Other circumstances besides those which have been considered occa- sionally modify the results of vaccination — among them, the age of the pock from which the lymph has been taken, and the health of the patient, operated upon. It must not be forgotten that cow-pox, whether in the cow or in man,, is not comprised within its local manifestations ; but that (however mild. its attack may be) it is a disease involving the whole organism, as is proved by the marvellous influence which one attack has in protecting the body from subsequent attacks both of cow-pox and of small-pox, by whatever route and in whatever manner they may be introduced. Guided by what we know of inoculated small-pox (namely, that at the seat of inoculation a papule appears, which gradually becomes a well-developed pock ; that this is simply a local affection, which is followed about the eighth day by feverishness and other symptoms of invasion, and in two or three days more by the general eruption), it seems obvious to assume that the pustules of cow-pox which appear on the udders of cows, and those which result from vaccination on the arms of men, are simply, as they appear to be,, local affections, on which the true generalised disease (in this case abortive and altogether trivial in its symptoms ) supervenes at about the period of' maturation : in other words, that the period which elapses between mocu- lation and the full development of the pock corresponds strictly to the, latent period of other exanthems. COW-POX. VACCINATION. 183 Protective influence of vaccination against small-ijox. — A belief in the protective influence of cow-pox against variola seems to have been com- monly entertained in Gloucestershire during the latter half of the eighteenth century. And a similar behef appears to have prevailed about the same time in some parts of Germany. It is said, indeed, that a schoolmaster, named Plett, in Holstein, vaccinated two children in the year 1771 ; and it seems to be established that an English farmer, named Benjamin Jesty, performed the same operation on his wife and two sons in the year 1774. The value of vaccination was, however, first established on a solid basis by the scientific investigations of Edward Jenner, whose attention was directed to the subject while he was yet an apprentice, and whose first publication in reference to it appeared in the year 1798. We need not pursue m detail the further history of vaccination. It is suf- ficient to say that its practice has been adopted since then throughout the whole ci^alised world ; that the claim which Jenner originally made for it (namely that it is as protective against subsequent attacks of small- pox as an attack of small-pox itself is, and neither more nor less so) has been verified by universal experience ; that experience and experiment alike have shown that its protective influence is in no degree diminished by its continued transmission from man to man ; and, lastly, that small-pox has died out or diminished in severity in exact proportion as efficient vaccination has been generahsed. It is certain, indeed, that thorough vaccinal in- oculation confers in most cases absolute exemption for life ; but that in some cases the protective mfluence diminishes in the course of years, so that if the patient contracts small-pox, he has it in a modified and mild form ; and that where small-pox has been rife, or epidemics have pre- vailed, the unwonted occurrence of the disease has been distinctly traced to neglect of vaccination, or to imperfect vaccination, or to both. Mr. Mar- son's tabulated results of the experience at the Small-pox Hospital, during twenty years, show at a glance the accuracy of the above state- ments : — Patients admitted witli small-pox. 1. Ha^dng one vaccine cicatrix . 2. ,, two ,, ,, . . 3. ,, three ,, 4. ,, four or more ,, 5. Stated to have been vaccinated, "1 n„^ SS-'iT but having no cicatrix . J It will be recollected that the mortality of primary small-pox is shown, by the same authority, to be 37 per cent. Dangers of vaccination. — The only valid objection to vaccination is that it may, and occasionally does, induce or introduce maladies which the patient would otherwise have escaped. We do not here refer to the immediate accidental results of vaccination, such as erysipelas and pyaemia, which may equally follow on a mere prick or the simplest scratch, but to certain constitutional disorders, such as scrofula and syphilis. Number admitted. Mortality per cent. 2,001 7-73 1,446 4-70 618 1-95 544 0-55 184 SPECIFIC FEBEILE DISEASES. which have been attributed to it. There is no doubt that syphihs has been thus imparted ; but the recorded cases are marvellously few, and these have been the result of gross carelessness or ignorance ; for there is httle reason to believe that a vaccinated child, who presents no visible indications of syphilis, could impart that disease, and it is certain that the pure lymph of a distinctly syphilitic child is not necessarily charged with the syphihtic virus. As regards scrofula, the only ground for assuming its inoculability by vaccination is the circumstance that lichen, eczema, and impetigo (affections which are common in children, especially about the period of teething, and by some erroneously regarded as scrofulous) occasionally supervene on vaccmation, as they do on other forms of local irritation. Performance of vaccination. — The operation of vaccmation should be performed at as early a period of life as possible, especially if small-pox has been in any degree prevalent. It is now required by law that a child shall be vaccmated within three months of birth. It is desirable that it should be in good health, and free from skin-disease. Ino*rder to obviate the ten- dency which the vaccinal influence has to die out, it is now almost mii- versally held that the operation ought to be repeated about the period of puberty. And, further, it is always important, in the case of persons who are, or are liable to be, exposed to small-pox (especially if they have only imperfect vaccinal marks and have not been successfully revaccinated), that the operation should be at once repeated. But it should be borne in mind that vaccmation has no modifying effect on small-pox which has been pre- viously contracted, unless it be so timed that the maturation of the vaccine vesicle shall precede the period of the variolous invasion. Thus, since the primary vaccme vesicle attains its full development on the ninth or tenth day, and the latent period of small-pox is usually twelve days, primary vaccmation, to have any beneficial effect, should be performed certainly not later than the second or third day after exposm'e to the variolous contagion. The vesicle, however, which follows revaccmation attains its maximum on the seventh or eighth day ; so that if the patient has been previously vaccinated, the operation may possibly be beneficially performed as late as the fourth or fifth day after exposure. The lymph for vaccmation should never be taken from persons who are diseased, or in whom there is any suspicion of syphilis or other mfectious disorder ; nor from pocks which are ill-developed or purulent ; nor from those which are the product of revaccination. Good vaccme lymph is yielded by normal pocks from the fourth or fifth to the eighth day after inoculation. That of a later date should never be employed. As a rule the lymph is taken on the eighth day. The vesicles should be freely punctured with the point of a lancet, care being taken to avoid hemor- rhage ; and the fluid which exudes should then at once be employed for vaccination, or should be preserved on ivory points which may be dipped into it, or between glasses, or preferably in capillary glass tubes. No squeezing of the vesicle should be had recourse to ; but if, after all the lymph which first flows has been used, the surface be gently wiped, a CHICKEN-POX. 185 fresh exudation of good lymph usually takes place. Lymph may also be diluted with glycerine, in the proportion of from one to two parts of glycerine to one of lymph, and thus preserved — a method of great value when lymph is scarce. Vaccination is generally, and certainly most conveniently, performed on the upper and outer part of the upper arm. There, four or five distinct punctures should be made at ^ or | inch distance from one another. Various modes of performing the operation are recommended. The simplest is to make with a sharp, clean, well-charged lancet, in the stretched skin, a valvular pmicture directed from above downwards, and sufficiently deep to wound the vessels of the cutis. A second method, of which there are numerous modifications, is to make groups of parallel or ■crossed scratches, or fine punctures, so as to allow of a little oozing of blood, and then having wiped the blood away to anomt the surface with the vaccine lymph. If the groups be small they should be five in number ; if large, three will suffice. If the lymph which is employed be fresh, or have been preserved in capillary tubes, it may at once be applied on the point of the lancet ; but if it have been preserved in the dry con- dition, it is essential that it be first moistened thoroughly with a small quantity of water. If no result whatever follow the operation, whether it be in a case of primary vaccination or in one of revaccination, either the lymph employed is mefficient, or the operation has been imperfectly performed, or (which is less probable) the patient is insusceptible. Under any circumstances the operation should be repeated until a definite local result of some kind or other is obtained. X. CHICKEN-POX. {Varicella.) Definition. — A specific contagious disorder, characterised by the appear- ance of vesicles in successive crops, which in the course of two or three days form scabs. Causation. — Varicella has been largely confounded with small-pox, of which it has been regarded as a modified variety. This view is still entertained by Hebra and some other writers. Of the perfect distinction, however, between them there can be no doubt ; for the one disease is not protective against the other, although each is protective against its own future attacks ; the one disease never imparts the other ; and they occur in independent epidemics. Chicken-pox is contagious in a high degree, and spreads both by means of the air and through the medium of fomites. It is doubtful whether it has hitherto been imparted by inoculation. It occurs epidemically ; but its epidemics seem to be neither so frequent nor so widespread as those of measles, hooping-cough, and scarlet fever. It attacks children mainly, yet adults are by no means exempt. Symptoms and progress. — The period of incubation is somewhat mi- •certain. According to different authors, it varies between four or five and 186 SPECIFIC FEBEILE DISEASES. sixteen or seventeen days. In some cases this stage is of exactly a week's- duration, but more commonly perhaps it lasts a fortnight. The mvasion is marked by febrile symptoms, which are occasionally severe but present no distinctive character, and which, generally in a few hours, at all events before the completion of twenty-four, are followed by the appearance of the rash. This consists in the first instance of a number of rosy papules, not unlike the spots of typhoid fever, appearmg singly, or in groups of two or three, on various parts of the body (head, face, trunk, limbs), but most commonly, perhaps, first upon the chest. These m the course of a short time, even after a few hours, become distinct vesicles, containing a transparent fluid, and usually surromided by an inflammatory halo. The vesicles, which are at first small and romided or acuminated, increase in size for a day or two, becoming sometimes as large as a split pea, occa- sionally irregular in form, and often umbilicated ; their contents at the same time get milky. They then rupture or dry up, and small dark- coloured adlierent scabs result. The formation of the scabs is completed at the end of four or five days or a week from the first sign of illness, and they may remain adherent for two or three days or even a week longer, when they separate, leavuig red stams, which are slow to disappear, and not unfrequently permanent depressed cicatrices. The eruption is not limited, however, to the generally scanty crop which first appears. But during the first three or four days of the disease fresh crops of papules in largely increased numbers, and irregularly distributed, sprmg up day by day, and these go through the same stages as those which were first developed. During the progress of the disease vesicles with inflamed areolae usually appear, in small numbers, on the palate, sides of the tongue, and mucous surface of the lips and cheeks. The general symptoms of varicella are for the most part slight and unimportant. There is commonly some feverishness, languor, and loss of appetite ; and the fever is liable to nocturnal exacerbations during the maturation of the vesicles. The temperature often rises to 101°, and may reach 104°. The tongue probably remains clean throughout.. Occasionally, the symptoms are much more severe, though never probably so severe as to excite serious alarm. Death rarely if ever results. The malady usually attains its height in a week or ten days, and runs its course in ten days or a fortnight. The complications and sequelfe are unimportant ; nevertheless, children often remain weak and out of health, for some time after an attack. Treatment. — The patient should be separated from those who are liable to take the disease, and confined to his room, if not to bed. He should be prevented, if possible, from scratching his pimples, those at least upon the face, in order to diminish the liability to pit. No further special treatment is necessary. TYPHUS. 187 XI. TYPHUS. Definition. — A highly contagious fever, lasting from two to three weeks, and attended ^\\t]l a characteristic measly eruption coming out from the fourth to the seventh day. Causation and history. — Typhus fever seems to be a disease especially of temperate climates. No Em'opean country is free from its occasional epidemic prevalence, but from Ireland it is probably never entirely absent ; and indeed Great Britam and Ireland may be regarded as its head- quarters. Epidemics have occurred in the United States and in Canada. There is even now some doubt as to whether it has ever been observed in India ; but, exceptmg this doubtful case, it is quite unknown m tropical countries. It has been mtroduced into AustraHa and New Zealand, but has not spread there. Typhus appears, for the most part, in casual out- breaks which assume an epidemic character, spread widely, and after lasting for months or~years subside and die out. Almost aU recorded epidemics seem to have been traced to long-continued overcrowduig, m association with defective ventilation and personal filth. With these conditions starvation no doubt is often to a large extent combined. But starvation alone, such as results from famine or widespread want (from whatever cause) of the necessaries of hfe, leads to the development rather of relapsmg fever than of typhus ; while, on the other hand, typhus has not mifrequently become epidemic where there has been no starvation, but where the other conditions enumerated have prevailed in a marked degree. Epidemics of typhus have originated mainly m the overcrowded parts of great cities, during seasons of distress and want and consequent exceptional overcrowding ; in armies, under equivalent conditions ; and in prisons. There can be no doubt, indeed, that overcrowding and bad ventilation are most efi'ective agents in concentrating the tj^Dhus poison, and m promoting the spread of the disease ; and it may be added, that anything which depresses body or mind (want of food, fatigue, intoxica- tion, fear, anxiety, perhaps even the debility of convalescence) must be regarded as a predisposing cause. In the comitries in which tyx^hus chiefly occurs, season and weather appear to exert no direct influence over its origin or spread. All ages are liable to its attacks, although it is shown by statistics to be most common between fifteen and twenty- five ; and males and females sufler fi-om it in nearly equal proportion. One attack confers almost complete immmiity against subsequent attacks ; yet, occasionally, two and even three seizures have been observed in the same indi\ddual. Excepting those who have thus acquired protection, every one is hable to take typhus. It is true that some unprotected persons, even when exposed daily to the influence of the disease, fail to contract it ; but many cases are on record where such persons, after years of immunity, have been attacked with it at last and have then succumbed to the attack. That typhus is a highly contagious disease is established by over- 188 SPECIFIC FEBRILE DISEASES. whelming evidence. Its poison is carried by the atmospliere, and is absorbed and retained in a potent condition for a considerable time by fomites. But it presents certain marked peculiarities of behaviour external to the system ; thus it chngs, as it were, aromid the body of the j)atient, and seems to be rapidly destroyed by diffusion through the atmosphere ; so that while its operation is intense mider appropriate conditions of over- crowding and bad ventilation, it is almost nil under opposite circum- stances ; and hence the disease rarely spreads (excepting to the immediate attendants) in the wards of a well-arranged hospital, or among the house- holds of the middle and upper classes. The contagium of typhus is probably exhaled with the breath and from the general surface. It is doubtful, however, whether the other excretions are infective, and whether the disease can be imparted by the dead body. Both the breath and the sweat of typhus patients yield a characteristic offensive odour, and there is reason to beheve that the contagiousness of a case has some direct proportion to its smell. Dr. Murchison considers that the disease is most contagious from the end of the first week up to convalescence. Although it is now admitted by all the best observers that typhus when once it has made its appearance is eminently contagious, it is still a moot question whether typhus epidemics owe their origin to new developments of the typhus poison, or are due to the presence in a latent form of the contagium, which is rendered operative by the concurrence of suitable conditions. The former hypothesis is strongly advocated by Dr. Murchison. His arguments, however, though forcible, are not conclusive ; and we must confess that the latter view seems to us infinitely more consonant than his with the analogies afforded by the exanthemata, and with the present state of pathological knowledge. Symptoms and progress. — The latent period of typhus appears to be of very uncertain duration. Cases are recorded in which the symptoms of invasion manifested themselves almost immediately after exposure to the concentrated poison. On the other hand, the primary symptoms have m some cases failed to appear mitil after the lapse of twenty-one days, or even more. The usual period varies probably between five or six and twelve or fourteen days. The invasion is occasionally heralded by an ill- defined sense of poorliness lastmg for a day or two ; at the end of which time, or much more commonly without any such warnmg, the initial symptoms manifest themselves. These generally consist in a sense of chilliness or slight rigors, pain m the forehead and back, and soreness in the thighs and other fleshy parts of the limbs ; with which are associated before long, or from the commencement, increased heat of skin, occasional slight sweats, diffused dusky redness of face and congestion of conjunctivae, acceleration of pulse, furring of tongue, anorexia and thirst, scanty and high-coloured urine, muscular weakness, lassitude, gidduiess, and loss of sleep, or disturbed sleep with tendency to dream. Occasionally there is some nausea or even sickness, and generally the bowels are constipated. For the first two or three days, notwithstanding gradual aggravation of his symptoms, the patient may not feel sufficiently ill to take to his bed. TYPHUS. 189 From the third to the seventh day (generally on the fourth or fifth) the characteristic measly eruption makes its appearance on the sides of the chest and abdomen, and on the backs of the hands, wa-ists, and elbows, and m the course of a couple of days becomes general over the trunk, arms, and legs, and sometimes, but much more rarely, shows itself on the neck and face. It remains out, well developed hut midergoing shght changes of colour, for two or three days more, then gradually fades, and finally disappears by about the fourteenth day, unless it assumes a petechial form, when its disappearance is retarded. About the time when the eruption commences, or a httle earlier, the patient has probably taken to his bed, and has begun to be apathetic and forgetful, to present a dull and listless expression, and to ramble at night. Presently he loses his headache, becommg, however, uicreasingly dull, forgetful and stupid ; and the delirium, which had hitherto been nocturnal and probably hmited to the moments between waking and sleepmg, becomes constant. Occa- sionally the dehrium is violent and maniacal, and the patient requires restraint ; sometimes it is the busy delirium of delirium tremens ; but much more commonly it is of the low muttering kind, known by the name of ' typhomania,' into which, indeed, the other varieties tend soon to merge. In this condition the patient can at first be readily recalled to himseK, and will answer correctly, and do what he is told to do. His aspect becomes more oppressed ; the redness of his face and eyes, and his rash, assume a more dusky tint ; sordes begm to collect on his teeth, and his tongue becomes dry and brown ; his respirations and pulse increase in frequency, and the latter gets small, weak, and sometimes dicrotous or irregular ; his temperature faUs somewhat ; his skin becomes clammy, his limbs tremulous ; and general debility mcreases rapidly. By about the tenth day the tj^phoid symx^toms of the disease are fully developed ; the patient has become still feebler ; he lies in bed on his back with his mouth half open and his eyes half closed, taking no notice of what is going on aromid him ; he is m a semi-comatose condition, muttering at times unintelhgibly and incoherently, breathing sometimes more rapidly sometimes less rapidly than natural, and probably moanhig or groaning with each respiratory act ; his hps and teeth are coated with sordes, his tongue is small, hard, di-y, and black ; he tends to smk towards the bottom of the bed ; his muscles are tremulous, and he has subsultus tendinum, especially in the arms, and floccitatio or a tendency to pick at the bed- clothes ; his motions are passed unconsciously, but his urme is generally retamed, though dribbling away perhaps fi-om the over-distended bladder ; his pulse has become extremely feeble, dicrotous, irregular ; his tempera- ture probably still shows an induration to sink ; the rash fades or becomes replaced by petechiae ; and perspirations break out. There is a tendency also to the formation of bed-sores. These s}inptoms probably continue for several days, the patient mean- while becoming more and more prostrate and comatose. And then, generally on or about the thirteenth or fourteenth day, either the coma becomes profound, the temperature rises rapidly, and the patient sinks ; 190 SPECIFIC FEBEILE DISEASES. or lie falls into a gentle sleep, from wliicli, after some hours, lie awakes sensible and convalescent, with a greatly diminished temperatm^e and pulse, but in a condition of extreme debility. If the case continues to go on favourably, the tongue cleans, the appetite returns, and restoration to perfect health ensues at the end of three or four weeks. We will now discuss some of the more important phenomena of tyx^hus seriatim. The temperature rises at once, and generally attains its maxi- mum, which rarely exceeds 106° in adults and 107° in children, between the middle and end of the first week. Exceptionally it does not rise above 103°. It remains at its maximum for two or three days, and then ( usually between the seventh and tenth day) falls slightly; continumg to fall until the period of crisis, when, according as death or recovery takes place, there is either a rapid rise, which may exceed by several degrees that pre^^ously attained, or a sudden faU. The diurnal variations are slight and irregular, though on the whole tending to present an evening rise and a morning fall. If a high temperature be mauitained or an unusual rise take place during the second or third week, some mflamma- tory complication is probably present. The eruption of typhus embraces two factors, namely, a mere mottling of the surface, and distinct dusky-red spots. They are usually present together. The motthng, which soon becomes general, precedes the de- velopment of the rash, and first appears m those situations in which the rash subsequently commences. It is due to the appearance of abmidant ill-defined dusky patches which are not elevated, vanish on pressure, and individually are scarcely perceptible. The rash presents the colour and very much the aspect of that of measles. The spots, however, are smaller and less elevated, and do not assume a crescentic arrangement. They are shghtly raised, romidish, faduig at the margins, and at first disappear on pressure. For the first day or two their colour is comparatively bright, and due simply to stagnation of blood in the capillary vessels ; during the subsequent two or three days they assume a dusky hue, the result probably in some degree of the transudation of the colouring matter of the blood ; and then either they fade away, or hemorrhage takes place into them and they become converted into petechiae. The tj^ihus erup- tion is almost mvariably present. In the year 1864 it was obseiwed in the London Fever Hospital in 97*77 per cent, of the cases admitted. In children it is often very slight and of short duration, and may therefore be readily overlooked. In adults it is usually well developed, and generally the severity of the disease is in proportion to the abundance of the rash. The copious formation of petechiae which often occurs towards the latter part of the second week is an unfavourable sign. The respirations are generally slightly increased in iimnber during the earlier period of the disease. In the typhoid stage they may rise to thirty or forty in the minute. From the beginning of the disease there is very often a slight cough, and this may continue throughout the ill- ness ; or it may increase and be attended with mucous expectoration which is sometimes tinged with blood. It is connected "vsdth the con- TYPHUS. 191 -gestion of the bronchial tubes and kings which so commonly attends typhus. The action of the heart is weak, and towards the latter period of the ■disease the first sound often becomes inaudible. The pulse is always feeble and generally small, and its feebleness and smallness increase as the disease advances, until at length it becomes undulating, thready, irre- gular, and almost imperceptible. Its rate presents great variety. In adults it usually ranges between 100 and 120. During the first few days it rarely exceeds 100. Subsequently it rises in frequency, and it may reach 130 or 140 or more in the minute. But when it exceeds 120 the ■danger is generally very great. Occasionally it falls in the second week to 40 or 50. In children the pulse is usually much quicker than in adults. Sickness is not a common feature of typhus, although it occasionally marks its onset. The bowels are generally constipated and the motions normal. But occasionally diarrhoea occurs early in the disease ; and it is by no means uncommon about the period of the crisis, when also it maybe dysenteric. The tongue at the begmning may be only abnormally red, or even natural ; but it is soon covered with a thick whitish fur, which gradually gets yellowish, and towards the end of the first week brown. Later the tongue shrinks and becomes black ; and equivalent changes take place' in connection with the lips, palate, and fauces. The urine is scanty, high coloured, of high specific gravity, and acid during the early period of typhus, and contains an excess of urea and sometunes of uric acid and of urates ; which latter may be deposited. Later on the urine becomes paler and more abundant, and the urea falls considerably below the normal standard. Chlorides are deficient and occasionally disappear during the pyrexial condition. Albumen in small quantities, sometimes accompanied by blood corpuscles and granular casts, is fi'equently present in the urine. It is not certain at what date albumi- nuria generally appears, or when it generally ceases ; nor is it a symptom of importance. It is most common, however, in severe cases, and pro- bably usually commences on the third or fourth day. Pregnant women rarely miscarry ; nor does pregnancy or miscarriage add materially to the danger of the patient. The prematurely-born foetus, if old enough, generally survives. The symptoms referrible to the nervous system always form a charac- teristic part of typhus fever. Most of these have already been considered. The patient at first has headache, with some dulness and confusion of mind (which impress themselves on his manner and on the expression of his features) and sleeplessness. In a few days he begins to wander at night between waking and sleeping, gradually becoming more stupid and forgetful in the intervals. At the end of the first week, or earlier, the delirium becomes constant, though still worse at night time ; and the patient is perhaps drowsy in the day. The delirium, as has been pointed ■out, may vary in character, but generally soon lapses into typhomania. ■Gradually the patient becomes more and more unconscious ; and if the case 192 SPECIFIC FEBEILE DISEASES. be about to end fatally, be probably falls into profound coma, occasionally preceded by convulsions. Tbe coma sometimes assumes tbe character of what is termed ' coma-vigil,' in wbich the patient lies quite unconscious, with his eyes open and fixed. In the early part of the disease there is generally some intolerance of light and singing in the ears. At the latter part deafness often comes on ; and if the patient be comatose the pupils usually contract to mere points. The muscular pains of the first period, the muscular tremors which soon supervene, and the subsultus, flocci- tatio, and loss of control over the rectum and bladder of the later periods, are all more or less directly dependent on nervous implication. Typhus fever varies in its severity. It is sometimes so mild, of such short duration, and so free from distinctive character, that excepting under the guidance of attendant circumstances correct diagnosis is impossible. In many cases, again, even where the fever is present in a well-marked form, the typhoid stage is never developed ; biit somewhere between the seventh and tenth day, when usually the patient begins to manifest the gravest symptoms, amendment takes place— the tongue never be- coming dry and black, the delirium never occurring at other times than between sleex3ing and waking. Next, we have the typical case from which our description has been drawn, in which all stages are well developed and the commencement of convalescence is delayed to between the thirteenth and twenty-first day. Further, we meet with cases in which recovery is delayed by the supervention of complications or sequelae. And, lastly, cases occur in which the patient dies prostrate and delirious, or comatose, within the first week of the attack or even within the first day or two. Death is due for the most part to a combuaation of asthenia and coma. It is most common about the end of the second week. Occasionally, and more in some epidemics than others, the patient dies from the sixth to the eighth day. And many cases are recorded where death has occurred even as early as the first or second day. Death at the end of the first week is often due in some measure to pulmonary congestion ; and after the fourteenth day either to this or to some other complication or sequela. The fatality of typhus is considerable. Of patients treated in hospital the mortuary rate is about 15 per cent. But these comprise an exceptionally large proportion of the gravest cases ; and there is reason to believe that the death-rate among all persons attacked with typhus is no more than 10 per cent. Among the causes which determine its fatality by far the most important is age. Under twenty the mortality is very low. Dr. Murchison's statistics, taken from the records of the London Fever Hospital, show a mortality in cases under five of 6"69 per cent. ; between five and ten, of 3-59 per cent. ; between ten and fifteen, of 2*28 per cent. ; and between fifteen and twenty, of 4-46 per cent. Between twenty and twenty-five the mortality rises to 10' 33 ; from which date upwards it in- creases pretty uniformly, lustrum by lustrum, until between fifty and j;fty-five it amounts to 49*62 per cent., and between seventy-five and ighty to 84-37. TYPHUS. 193 The sequelae of typhus are not very numerous or characteristic. Among the more important may be enumerated bronchitis and pneu- monia, which may occur during the progress of the fever or during con- valescence ; gangrene, in the form of bed-sores, or affecting the toes, fingers, nose, penis, or pudenda, or in children mainly in the form of noma ; erysipelas ; abscesses in the parotid or submaxillary region, or in the axillse or groins ; suppurative inflammation (said to be pyaemic) of joints ; anasarca of legs ; and mental imbecility or mania. These sequel© are all serious ; and two of them (noma and suppuration of the joints) are almost invariably fatal. Morbid anatomy. — The post-mortem examination of typhus patients reveals little that is special. There is a tendency in the body to rapid decomposition ; the internal organs are for the most part softened and congested ; and the blood is dark, stains the vessels which contain it, and coagulates imperfectly. The lungs are usually deeply congested and very lacerable in their dependent parts, and sometimes solid from in- flammatory changes. The spleen generally is softened, and not un- frequently somewhat enlarged. The large intestines occasionally show traces of dysenteric inflammation. Treatment. — It is important that typhus patients should be treated in large, airy, well-ventilated chambers, and therefore that they should be removed from the overcrowded tenements which as a rule they occupy. The attendants upon them should be seasoned and young. In the later periods of the disease, the bladder should, if necessary, be periodically emptied by means of the catheter, and the patient be kept scrupulously clean, so as to prevent the formation of bed-sores. The general medicinal treatment of typhus is of little importance. There is no specific remedy, and no means which enable us to cut it short. It is desirable, however, to relieve the thirst from which the patient suffers, and to promote the evacuation by the kidneys of the effete matters which speedily overload the blood. For this reason, so-called ' febrifuge ' medicines, which are at the same time mildly diuretic, are doubtless useful. Among them we may enumerate soda-water, and chlorate, nitrate, citrate, or other salts of potash well diluted, acetate of ammonia, and the like. It is desirable also to keep the bowels fairly open either by occa- sional laxatives or by enemata. On the other hand, if there be diarrhoea, it should be checked by opium or other ordinary forms of astringents. When pulmonary congestion complicates the progress of the fever, a httle ipecacuanha or antimonial wine with a few drops of laudanum may be added to the mixture, or, better still, ammonia. If there be much in- somnia or acute or busy delirium, opiates in larger doses may be ad- ministered by the mouth or subcutaneously, or recourse may be had to chloral or bromide of potassium. Best, too, may be promoted by cutting the hair short or shaving it, and applying cold lotions or ice to the head. Opiates should not be given when there is any tendency to coma, or to suppression of urine. In the typhoid stage ammonia is probably the most valuable medicine. 194 SPECIFIC FEBEILE DISEASES. Whether to exhibit stimulants always becomes an important question. There is no doubt that in a large proportion of cases patients do not require them ; but there is also no doubt that many need them, and that few if any are injured by them in moderation. In persons of enfeebled consti- tution, in habitual drinkers, and in such as are of advanced age, it is for the most part desirable to commence their administration early ; and in all cases where the heart shows signs of unusual feebleness, where there is extreme prostration, or where typhoid symptoms come on early or are severe, stimulants should be at once had recourse to. The amount to be given under such circumstances must depend on the condition of the patient, and on the effect which they produce. It matters little what form of stimulant is selected. From the beginning the patient loathes food ; but the maintenance of his strength is imperative. Hence, those foods which he can be made to take should be given to him. systematically, in small quantities and at fre- quent intervals. Nothmg is better than good milk, of which, by judicious management, from two to three or four pints may often be given daily. But all patients will not take milk. Alternative articles of diet are rice- water, barley-water, gruel, and eggs beaten up with milk, wine, or tea. Beef tea, broth, arrowroot, and jelly are useful adjuncts. Ice may often be added beneficially to the patient's drinks. During convalescence quinine or other tonics are important ; and the food should be gradually modified to that of health, and should be abmi- dant, frequently administered, and wholesome. XII. PLAGUE. {Pestilentia.) Definition. — A contagious fever, closely resembling typhus m its symptoms, but distinguishable from it by the absence of any true rash,, and by the development of buboes and carbuncles. Causation and history. — The early history of the disease to which the term ' plague ' is now applied is micertain. It is known, however, to have prevailed from an early period of the Christian era m the countries which it now mainly affects (namely, Turkey, Asia Minor, Egypt, and Morocco), and to have spread thence at various times over the continent of Europe. In the seventeenth century numerous epidemic outbreaks occurred m Hol- land and in this comitry, the last being the Great Plague of 1665., Since then it has occasionally been imported into the countries bomiding the Mediterranean basin, and into Eussia. In Asia Mhior and Egypt it may almost be regarded as endemic ; but occasionally, at irregular intervals » breaks out into terrible epidemics. Whatever the specific cause of plague may be, it is certam that its epidemic occurrence is materially influenced, if not determined, by conditions almost identical with those which deter- mine outbreaks of typhus — namely, privation, filth, and overcrowding. PLAGUE. 195 Like typhus it affects mainly the poor, is apt to break out in armies engaged in warfare, and among the inhabitants of beleaguered cities. Plague is emmently contagious, and is communicable by the breath, by fomites, and by inoculation. The cause of its spread, therefore, is doubtless a specific contagium. Although an attack of the disease is to some degree protective, subsequent attacks have been abundantly met with. Symptoms and progress. — The duration of the incubative period is un- certain. The symptoms generally commence with chills or rigors, rise of temperature, pains in the forehead, back, and limbs, giddiness, anxiety, and sickness ; on which speedily supervene, great loss of muscular power, extreme feebleness of the heart's action (indicated by rapidity, irregularity, and smallness of pulse, and prostration), and marked dulness or stupidity of expression, with corresponding hebetude of mind, passing quickly into delirium and coma, and sometimes convulsions. The tongue, thickly coated from the beginning, soon becomes dry and black. The bowels are generally somewhat loose, the urine scanty and occasionally suppressed. And hemorrhages from the various mucous surfaces are not unfrequent. Within two or three days after the first appearance of symptoms pete- chiae not unfrequently appear over the surface of the body ; and besides these, the more characteristic glandular swellings or buboes, which are chiefly to be detected in the neck, axillae, and groins. Subsequently car- bmicles become developed at various parts of the surface, generally, how- ever, in the extremities. The appearance of petechias is by no means invariable, and is regarded as being of bad augury. The buboes enlarge, sometimes to a considerable size, reach their height (if the patient survive so long) at about the end of the eighth or ninth day, and then either subside or (more rarely) suppurate. Carbuncles are comparatively unfrequent and for the most part show themselves towards the decline of the disease ; they vary in size and intensity of inflammation, and in numbers from one to about a dozen. Death from plague sometimes takes place within twenty-four hours after seizure. Severe cases not unfrequently prove fatal on the second or third day of the disease. Many patients die on the fifth or sixth day. Occasionally death is delayed until the second or third week ; but is then probably due mainly to the effects of complications. It is generally acknowledged that it is impossible to distinguish plague positively from typhus, either by its early symptoms, or by the first few cases that come under treatment — the mode of invasion and the general symptoms and progress of the two diseases presenting many points in common. Petechiae are frequent in both diseases, and buboes are of occasional occurrence in typhus. But plague does not present the true typhus rash ; and the buboes, which are quite exceptional in typhus, are almost constant in plague ; and, further, the mortality of plague is much greater than that of typhus, and its fatal issue occurs much earher. Morbid anatomy. — Patients dead of plague show, as in typhus, a ten- dency to rapid decomposition, fluidity or imperfect coagulation of blood, o2 196 SPECIFIC FEBEILE DISEASES. congestion, softening and enlargement of organs, and petechial extravasa- tions beneath the serous and mucous surfaces. But besides these pheno- mena, there is a general enlargement of the lymphatic glands, which vary individually from the size of a goose's egg downwards. This enlargement is not limited to the superficial glands, but involves those of the interior of the thorax and abdomen, and is often attended with congestion and softening, and in some cases with suppuration. Treatment. — The rules and details of treatment which have already been given in regard to typhus are applicable to plague. No specific reme- dies are known. Buboes and carbuncles only call for the usual treatment of such affections. XIII. EELAPSING FEVEE. {Famine-Fever. ) Definition. — A contagious disorder, characterised by a sudden attack of high fever, lastmg for about a week ; and then apparent convalescence, followed after about fourteen days from the primary accession by a second attack of fever. A further relapse now and then occurs about the twenty- first day. Causation and history. — The geographical limits of relapsing fever have not been fully ascertained. Our knowledge of it has been chiefly derived from epidemics originating in Ireland, whence it has spread to England and Scotland. It appears also to have broken out independently in Scot- land. Epidemics of it have, within the last few years, been observed in Eussia and Silesia ; and also in America, India, and parts of Africa. There seems to be a close relation between starvation and relapsing fever, which has hence been denominated famine-fever. All the more recent and most fully investigated epidemics appear to have arisen during the prevalence of extreme destitution, and among the classes that have mainly suffered from destitution. Further, although the disease is highly con- tagious and liable to affect all who come withm its influence, it is mainly carried by tramps and vagrants ; and, when it spreads among populations not suffermg from famme, still chiefly affects those sections of them that are least well-fed. Overcrowding and filth are almost necessary accom- paniments of famine ; but these are not thought to have any special influence in the production of relapsmg fever. At all events, when these conditions exist (as they often do) independently of famine, they are never known to promote the outbreak of the special famine-fever. Season and other climatic conditions appear to exert no inflvience over its development or spread ; and its attacks are probably in no degree determined by age or sex ; although it is true that statistics show a larger proportion of sufferers among males than females. The contagion of relapsing fever is carried by the atmosphere, and also by fomites. But there is good reason to believe that its influence extends but a short distance aromid the patient, that it is readily lost by dilution, and that in order to ensure its action a large dose of poison or a long exposure to it is essential. There can be EELAPSING FEVER. 197 no question that when the disease spreads its source is a specific con- tagium,^ which is evolved by the body akeady diseased and is absorbed by that which is about to suffer. It is a debated pomt, however, whether those who are primarily affected breed in their systems the contagion which they afterwards evolve, or whether they have derived it from some external source where it has lain dormant ; in other words, whether during the progress of starvation the specific poison is engendered within the body, or whether the effects of starvation are such as to render the frame liable to be affected by a poison, which mider other circumstances is uniocuous. The question is one which scarcely yet admits of a positive solution. Those who look especially to the close connection between this fever and famine, and to the long intervals wliich elapse between succes- sive outbreaks, naturally lean to the one view ; those who give weight to the analogies between it and the exanthemata, lean as naturally to the other. A marked peculiarity of relapsing fever, as compared with other diseases of its class, is the fact, that one attack does not confer safety from subsequent attacks ; at all events, many persons have been known duruig one and the same epidemic to suffer from it two or three times at short intervals. It may be remarked, however, that the fact of a patient recovering spontaneously from an infective disease is a proof that he enjoys at least a temporary freedom from liabihty to be affected by it. And hence it may be assmned that immunity is actually conferred by an attack of relapsing fever, but that the period of immunity is mostly of very short duration. Symptoms and progress. — The latent period of relapsing fever varies. Its extreme limits are probably two and sixteen days. Cases, however, are recorded in which the attack seemed to follow ahnost immediately on infection. Dr. Murchison concludes that the period of incubation is, on the whole, shorter than that of typhus. The onset of the disease is for the most part sudden. The patient is seized with a feeling of chillmess or with rigors, attended with severe pains in the forehead, trunk, and hmbs. This condition is soon followed by intense heat and dryness of surface, increased frontal headache, lumbar and other pains, giddiness, frequency of pulse, thirst, and loss of appetite. The latter symptoms continue with some slight variation (the dryness of skin, however, frequently alternating with perspirations) until the third, or more commonly the fifth or seventh day of the disease ; when, often preceded by a slight rigor, a copious perspiration almost suddenly breaks out, which lasts for a few hours, and is then followed by a remarkable reduction in the rate of the pulse and of temperature, and, with the exception of some remainmg lassitude, almost complete restoration to health. The following is a more detailed accomit of the several symptoms which attend the febrile attack. The temperature almost from the com- mencement is very high, often ranging from 104° to 108*5° F. ; the pulse is rapid, generally over 110, and often reachmg 130 or 140 in the minute ; ' For further information on this point, see page 138. 198 SPECIFIC FEBKILE DISEASES. the tongue is thickly coated with a white fur (the tip and edges being red), and occasionally towards the termmation the centre of the organ gets dry and brown ; the teeth are free from sordes ; the patient suffers from extreme thirst, generally from anorexia and often from vomiting ; in rare cases there is slight hsematemesis ; the bowels are mostly constipated ; there is often considerable tenderness in the region of the hver and spleen, both of which organs become increased in size, and in many cases jaundice appears about the second or third day ; the urine varies in quantity, but presents an excess of urea, and occasionally contains albu- men and even blood — towards the later period of the attack suppression may take place ; the pains in the head, trunk, and limbs continue, all being severe, and the latter mainly affecting the joints and presenting, therefore, a rheumatic character ; the patient for the most part retains perfect consciousness, but generally suffers greatly from want of sleep and from frightful dreams when he does sleep ; delirium, which may be maniacal, sometimes occurs about the period of the crisis ; stupor, coma, and even convulsions supervene, though rarely, about the same period, and are then probably due to ursemic poisoning. The patient seldom presents the congested conjunctivas and dull puzzled aspect of typhus fever. The critical perspiration is occasionally attended with, or replaced by, an attack of diarrhoea, or of hemorrhage from the nose, bowels, or elsewhere. No rash is ever seen, except perhaps a few petechi£e towards the end. During the intermission the temperature often sinks below the normal, to 96°, 94°, 92°, or even 90*6°, and it continues low for the first two or three days ; the pulse also drops to 60, 50, or 40 in the minute, though liable to sudden increase on exertion ; the tongue becomes clean, and the appetite often voracious. Occasionally, at the commencement of this period, the patient falls into sudden collapse, or passes into a typhoid state ; but far more frequently, with the exceptions above adverted to, he appears to be restored to perfect health. Sometimes the first paroxysm of fever is the only one. But more commonly, at the end of fourteen days (more or less) from the first accession of symptoms, the patient suddenly experiences a recurrence of his febrile attack. The symptoms which now ensue are as nearly as possible identical with those from which he formerly suffered. The temperature, however, is often higher, and the duration of the attack for the most part shorter. It generally lasts about three days ; at the end of which time, convalescence is ushered in with the phenomena which pre- viously ushered in the remission. Occasionally a third paroxysm takes place on or about the twenty-first day ; and a fourth and even a fifth recurrence have been observed, though very rarely. The danger to life from relapsing fever is comparatively very slight. Dr. Murchison's statistics show a mortality of only 4'75 per cent. The statistics of mortality, however, of an epidemic prevailing in Philadelphia in the winter of 1869-70 seem to show that it is much more apt to EELAPSING FEVEE. DENGUE. 199 terminate fatally in the negro than in the white race. The causes of death are mainly asthenia and collapse (the latter of which may occur suddenly about the period of crisis), coma and other cerebral complications, and its sequelae. Convalescence is generally protracted (the patient very slowly regain- ing strength), but seldom complicated with serious sequelae. Amongst the most common of these are pulmonary affections (more especially pneumonia), diarrhoea, and dysentery. The most characteristic of them all is ophthalmia. It is a remarkable fact that pregnant women affected with relapsing fever almost invariably abort, and this no matter what period of gestation they may have reached. The foetus, moreover, dies ; the mother, as a rule, recovers. Morbid anatomy. — Excepting for the presence of such lesions as are due to accidental complications and sequelae, nothing very characteristic is noticeable after death. The liver is usually enlarged and congested, but otherwise (even if jaundice be present) apparently healthy ; and the spleen is invariably enlarged to several times its normal bulk, and generally softened or diffluent. Treatment. — Li the treatment of this disease it is of course necessary, in order to prevent its spread, to isolate the sick, and to take the ordinary precautions in respect of ventilation and the like. In every case the disease will probably rmi its course, whatever treatment be adopted. It is important, nevertheless, to alleviate symptoms and to avert complica- tions. To diminish heat, cold sponging or the graduated bath may be serviceable ; to check vomiting, ice ; to relieve headache and other pains and to promote sleep, perfect quiet, opium or morphia in medium doses, chloral, and counter-irritant or sedative applications ; to obviate constipa- tion and portal congestion, mild laxatives such as castor-oil, or enemata ; and to encourage diuresis, non-stimulatmg diuretics, such as bland drinks, and medicines containing chlorate, nitrate, or acetate of potash, or acetate of ammonia. If coma, attended with suppression of urine, occurs, it may be necessary to give purgatives, and to apply cupping-glasses over the lumbar region. Emetics are recommended by many to be given early in the disease ; and bleeding has also been strongly advocated. During the febrile attack, the nourishment should be such as is usually proper for patients suffering from febrile disorders. Alcoholic stimulants are rarely necessary, excepting when there is tendency to collapse. XIV. DENGUE. {Dandy Fever.) Definition.— k specific affection, characterised by high fever, inflamma- tion of the joints, a peculiar rash, and a tendency to be continued for a few weeks by intermittent attacks of short duration. Causation and history. — Nothing seems to have been known of this disease until the year 1824, when it broke out suddenly in Eangoon 200 SPECIFIC FEBKILE DISEASES. among a body of troops. Thence it spread ; and since that time it has- occurred in occasional epidemics in different parts of India, and also in the tropical parts of North America and in the West India Islands, into which it was introduced from the East Indies. It does not appear to have extended to temperate regions. Dengue is contagious in a very high degree, and doubtless, like other such diseases, depends upon a specific virus communicated from the sick to the healthy. Its contagious- ness, indeed, is almost as virulent as that of influenza, and it spares neither male nor female, young nor old. Symptoms a7id j^rogress. — Little or nothing is known with respect to the period of mcubation of dengue, or the amount of protection one attack affords. The invasion is sometimes preceded by slight premonitory symptoms, but much more frequently is sudden. Among the early phenomena of the disease are : high fever, with sense of chilhness or actual rigors, alternating with flushes of heat; dryness of skin; severe frontal headache with vertigo ; aching in the eyeballs ; pain along the spine and ni the limbs, but more particularly in the joints ; great rapidity and hardness of pulse ; acceleration of respiration ; furred tongue, and heat and pain at the epigastrium, with loss of appetite and very frequently sickness ; great muscular prostration, restlessness, and inability to sleep. With the advance of the disease, the prostration and the febrile symptoms. undergo aggravation ; the face and the conjunctivae become congested ; the pulse rises to 120, 130, or even 140; the tongue gets coated, except at the tip, with a thick, white, moist fur ; and the pains (especially those in the joints) are augmented — the arthritic pains, indeed, tending to shift about as in ordinary rheumatism, and the affected joints (especially the smaller ones) to swell. In the course of a day or two, however, perspira- tions break out, and the severity of the symptoms seems to abate some- what ; but on the third or fourth day of the disease, or a little later, some increase of pain takes place, and is attended with an evanescent eruption, which, commencing on the hands and feet, quickly spreads over the whole cutaneous surface. This eruption has been likened to that of scarlet fever, measles, urticaria, or erythema. From the descriptions it would seem to be a kind of erythema papulatum, such as is not unfre- quently met with in cases of acute rheumatism. It is said to disappear usually on the second day, to be attended with more or less itching, and to be followed by desquamation. It is not always present. With the subsidence of the rash, or about the fifth, sixth, or seventh day of the disease, the febrile and other symptoms abate, the patient becomes conva- lescent, and is then soon restored to com^Darative health. Li a short- time, however, a relapse almost as severe in its symptoms as the primary attack, but lasting only for two or three days, occurs ; and to this, after intervals of apparent convalescence, a second and perhaps a third relapse succeed. Usually much debility, and not unfrequently pain, stiffness or swelling of the joints, persist after the final cessation of fever ; and health is generally not completely restored under a period of three months. It is important to observe that, notwithstanding the high fever, the extreme- DENGUE. YELLOW FEVEE. 201 pain, and the general severity of the symptoms under which the patient labours, he rarely suffers from delirium, or fails to make a good ultimate recovery. Occasionally death occurs early in the disease (during the period of defervescence) from syncope. Other phenomena which patients suffering from dengue occasionally present are : bleeding at the nose ; swelluag of the parotids with salivation ; swelling of the lymphatic glands, or of the testicles ; jaundice, and ophthalmia. It may be added that the appetite m some cases continues unimpaired, and that pregnant women rarely abort. It is obvious that the phenomena of dengue have a considerable resem- blance, in some aspects, to those of rheumatism, ague, scarlet fever, and measles, with each of which it has been confounded. But it much more closely resembles relapsing fever. It resembles this, m its wulence of contagion, in its sudden access, in its high temperature with headache and arthritic pains, in the rareness of the occurrence of delirium, in its tendency to be continued by several successive relapses, m its little mor- tality, m some of the details of symptoms and sequelae (such as the condition of tongue and appetite, the occasional occurrence of jaundice, ophthalmia, and inflammation of the salivary and other glands), and even in the occasional supervention of death from syncope durmg the period of defervescence. The eruption of dengue (if it be specific) may seem to indi- cate a difference between them, as also may the intensity of the arthritic inflammation which attends it. Of the morbid anatomy of dengue nothing of any importance is known. Treatment. — The treatment must be that applicable to other fevers over whose course we have no control. Emetics and purgatives have been strongly advocated. But, on the whole, it is probably best to ad- minister saline or other cooling medicmes. The headache and arthritic pains may be reheved by local apphcations, or by the use of opiates ; and complications may call for special treatment. During convalescence, quinme or other tonics are indicated. XV. YELLOW FEVER. Definition. — A spreadmg contmued fever, of short duration, charac- terised especially by epigastric tenderness, vomitmg, hsematemesis, and jaundice. Causation and history. — This disease prevails in certain tropical regions, mainly in the West India Islands, which seem to be its home, and in the neighbouring portions of the contments of North and South America. But it occasionally invades countries correspondingly situated in the Old World, and has even been introduced into the seaport towns of England, France, and other parts of Europe. It seems never to spread, however, in these latter places, excepting at times of excessive- .202 SPECIFIC FEBEILE DISEASES. heat. A high temperature appears to be an essential condition of its prevalence. It is said, indeed, that it never spreads when the thermo- meter stands at less than 72° Fahr., and that, even when it is epidemic in a place, it rarely if ever attacks those who Hve more than 2,500 feet above the level of the sea. Outbreaks of yellow fever are probably pro- moted by local conditions of general insalubrity ; and the intensity of the disease is doubtless augmented by them. Its contagiousness is denied by many, especially American, writers. It is admitted, however, that it attaches itself to fomites, and that it may be carried by infected ships -into healthy seaport towns, and there produce local outbreaks. The evidence, therefore, in favour of its contagiousness is very much of the same nature as that in favour of the contagiousness of epidemic cholera and enteric fever. We regard it as contagious, and as the product of a specific virus given off from the bodies of the sick. There is no good reason to believe that it ever arises spontaneously. It spares neither age nor sex ; but one attack confers on the sufferer immunity from other attacks. Symptoms and i^r ogress. — The period of latency of yellow fever is said to vary between two and fifteen days. Most commonly it ranges from six to ten. At the end of this time the patient is generally attacked sud- denly with acute febrile symptoms marked by shivering, increased temperature (101° to 105°), dryness of skin, congestion of face, redness, suffusion and aching of eyes, acceleration of pulse, thirst, anorexia, pains in limbs, and intense frontal headache ; to which are soon added acute lumbar and spinal pains, slight epigastric tenderness, and vomiting of the mucous and other contents of the stomach. The tongue is generally coated with a thick creamy fur, except at the tip and edges, which are preternaturally red. After these symptoms have lasted, with some varia- tion, for a day or two, the febrile condition and the intense frontal and rhachidian pains are apt to subside somewhat. But, for the most part, the epigastric tenderness becomes more pronounced and the vomiting more constant ; and slight yellowness of the conjunctivae may perhaps be recognised. On the third or fourth day, or later, the vomited matters, hitherto colourless or yellow, begin to contain blood (sometimes bright, more commonly in the form of suspended particles of black pigment), and they soon assume from this cause a coffee-ground character, constitu- ing the so-called ' black vomit.' At the same time the motions are often dark or black from the presence of blood. If the patient do not at once «ink, symptoms of a typhoid character are apt to supervene ; the vomit- ing may or may not continue ; the skin probably becomes more decidedly jaundiced and at the same time dusky, the teeth covered with sordes, the tongue dry and black, the pulse quick and feeble ; an eruption of red spots or of petechise often makes its appearance on the trunk ; and drowsiness, convulsions, delirium, maniacal excitement, or coma super- venes. From the second or third day the urine contains albumen, and occasionally a little blood. Later on it is scanty, and sometimes suppressed. YELLOW FEVEE. 203 Convalescence may (according to tlie severity of the attack) conamence from any period of the disease, is marked by the gradual subsidence of the graver symptoms, and is generally completed at the end of two or three weeks. The jaundice, however, is slow to disappear. The fifth day is often regarded as critical. The mortality from yellow fever is very high, and death occurs at various periods in its course. Li some cases the attack is so sudden and so severe that the patient dies in a state of collapse at the end of a few hours. More commonly he sinks at the end of two, three, or four days, during the period of black vomit — his death then being often due to sudden collapse probably determined to some extent by gastro-intestinal hemorrhage. Death is not unfrequently thus produced at this time in patients who have seemed to be going on quite favourably, and even m those who have hitherto suffered so little from the disease that they have not been confined to bed, and have been able to follow their employ- ments. At a later date death is due, sometimes to cerebral complica- tions, probably referrible to uraemic poisoning, sometimes to gradually increasing exhaustion. The symptoms which collectively are most characteristic of yellow fever are, sudden onset with high fever, frontal and lumbar pain, epi- gastric tenderness, hemorrhagic vomiting, and jamidice. But any of them, and more especially the last two, may be absent. Indeed, the symptoms of the disease are liable to great variation, dependent in large measure on the greater or less severity of the attack, and on the relative degrees m which the several parts of the organism are affected. Mild cases of the disease often present no characteristic features whatever, and may be readily confounded with similarly mild attacks of other con- tinued fevers. La its sudden onset with frontal headache, lumbar pain, and vomitmg, yellow fever closely resembles variola, from which, however, it soon be- comes differentiated. Eelapsing fever, again, in its sudden development with fever, headache, pain in the back, and vomiting, followed in a day or two by jaundice, presents a marked resemblance to yellow fever ; but it differs from it widely in its little fatality, in the absence of black vomit, in its sudden cessation at the end of a few days, and in the subsequent relapse. Malarial remittent fevers may also be confounded with yellow fever, but are distinguishable by many features : they are endemic and not contagious ; one attack favours subsequent attacks ; the febrile paroxysms intermit ; there is enlargement of the spleen ; and gastro- intestinal hemorrhages, if they occur, are copious and sudden. Yellow atrophy of the liver may be distinguished by its gradual commencement, without marked fever, pain, or other characteristic symptoms of yellow fever ; at a later period, when the skin becomes yellow, the epigastrium tender, and delirium supervenes, the diagnosis may be difficult. Lastly, it may be remarked that jaundice is not uncommonly developed in the course of various fevers and inflammations, and cannot therefore be re- garded as a distinctive mark of yellow fever. 204 SPECIFIC FEBEILE DISEASES. Morbid anatomy. — The principal morbid conditions observed after deatii from yellow fever are, as might be predicted from the symptoms, to be discovered in the liver and mucous membrane of the ahmentary canal. The liver is generally pale, soft, yellowish or clay-coloured (as it is in many other acute febrile states attended with jaundice), more or less fatty and somewhat enlarged. The mucous membrane of the stomach is for the most part soft and injected, and the cavity of the organ usually contains disintegrated and blackened blood. Similar congestion and similar contents may also be met with in the intestines. Peyer's patches are unajBfected. The spleen is soft, but not enlarged. Hemorrhages are not uncommonly met with in the lungs and various other parts. Nothing else noteworthy has been detected. Treatment. — Many drugs have been recommended and used in the treatment of this disease. Large doses of calomel and large doses of quinine have both been tried. But it seems probable that they have done no good, if not harm. The patient should be confined strictly to bed, and not allowed to make any exertion. He should be kept cool, in an apartment well ventilated and devoid of hangings. The secretions of the skin and kidneys should be encouraged by diluent drinks, and the bowels kept freely open — preferably by enemata. Vomiting should be counteracted by ice, and medicinally by limewater, hydrocyanic acid, spirits of chloroform, bismuth, or other stomach- soothing drugs. Wake- fuhiess and delirium may be treated with opiates ; headache, precordial uneasiness, and lumbar pains relieved by the local application of counter- irritants, cold, or anodynes. Constant vomiting generally precludes the successful administration of food. Under any circumstances, however, this should be bland and unirritating, and given frequently and in small quantities. Nothing can be better than milk, barley-water, rice-water, or gruel. No doubt the great tendency to fall into collapse is suggestive of speedy recourse to alcoholic stimulants. Of these brandy and the effervescent wines have been most recommended. But they should be given diluted and with caution ; for, however beneficial they may prove if absorbed, their local influence on an irritable and bleeding stomach can scarcely be other than injurious. XVI. CEEEBEO-SPINAL FEVEE. [Epidemic Cerebro- Spinal Meningitis.) Definition. — A specific contagious fever, characterised by inflamma- tion of the membranes of the brain and cord, and the symptoms which these lesions induce, and frequently attended with petechias, collapse, and early death. Causation and history. — This disease has only been distinctly recog- nised from the time of its epidemic prevalence in various parts of France between the years 1837 and 1848. Since its first appearance in that CEEEBEO-SPINAL FEVEE. 205 coiuitry, it has broken out at various times in Italy, Algeria, Gibraltar, Portugal, Holland, Denmark, Sweden, Norway, North Germany, and Ireland. In Ireland the disease prevailed between the years 1846 and 1850, and again with considerable severity between 1865 and 1867. In Dantzig a notable epidemic occurred in the years 1864 and 1865. In the United States cerebro-spinal fever became prevalent about the same time as in France, and since then there have been frequent outbreaks m different parts of that comitry. It is by no means clear that there has ever been any prevalence of the disease m Great Britain. Age and sex, social condition, and ordinary sanitary circumstances appear to exert little influence over the origin and spread of cerebro-spinal fever. Nevertheless, males seem on the whole to have suffered in larger proportion than females, and soldiers in garrison, in many epidemics, more severely than other sections of the population. It appears, also, to be indisputable that the disease occurs mainly during the winter months; and Mr. Netten EadcHffe remarks that ' it is noteworthy that the northern and southern limits of distribution in both hemispheres but slightly overlap the isothermal lines 5° and 20°.' Cerebro-spinal fever is certainly epidemic. Is it also mfectious ? Of this we think there can be little doubt. It is important, however, to note that the mode of its epidemic prevalence is not unlike that of cholera or typhoid fever, in the facts that it is marked by numerous scattered and for the most part small out- breaks, rather than by a general widespread diffusion ; and that the disease, like these others, although giving clear uidication of its spread from the sick to the healthy, presents little or nothing of the virulence of direct contagion which characterises most of the exanthemata. Symptoms and progress. — Cerebro-spinal fever is attended in some cases by premonitory symptoms, lasting from a few hours to several days, and comprising mainly feverishness, malaise, headache, and pains in the back, abdomen, and limbs ; but in many cases it comes on quite without warnmg. In either case the first symptoms of the actual outbreak are : severe rigors ; mtense headache with vertigo ; persistent vomiting with more or less severe pam in the stomach ; and pains along the spine and in the muscles of the extremities, often attended with spasmodic con- traction. The patient soon becomes restless or irritable, voluble or taciturn, more or less obviously delirious or the subject of delusions, and not unfrequently drowsy. His head is thrown back and retahied in that position ; not so much from spasm in the muscles of the neck, as from a volmitary effort to relieve pain in that situation ; and his Hmbs become flexed. He probably cries out at times, or screams with the intensity of the pain in his head and back. But gradually his mmd gets more distinctly affected ; he becomes less alive to pain and other subjective phenomena ; he passes into a condition of busy or muttering dehrium or into one of acute maniacal excitement, occasionally has convulsions, and then lapses into profound coma. In many cases a purpuric eruption makes its appearance from the second to the fourth day. Death may occur dming the first day or two (occasionally after a few hours only) 206 SPECIFIC FEBEILE DISEASES. from collapse; or, from this time to the seventh or eighth day, from coma due to the cerebro- spinal lesion ; or at a later period, even up to the sixth or seventh week, from one or other of the compHcations which are apt to ensue. The above is a sketch of the symptomatic phenomena of the disease in its ordinary form ; and, as will be observed, they are mainly those of non-specific inflammation of the membranes of the cord and bram. They vary much, however, in their severity in different cases, and are frequently conjoined with other symptoms which are also for the most part dependent on the cerebro -spinal lesion. We will consider them seriatim, as they are referrible to different conditions and different organs. Fever is not usually a marked featm'e of the disease. The temperature appears in many cases never to rise above 101° ; but it may reach 105° ; and iu cases which are rapidly fatal, with symptoms of collapse, it may even sink below the normal. The skin varies in its condition, but is seldom pungently hot and dry, or profusely perspuing. Besides the petechial eruption which has been described, it occasionally presents patches of erythema or roseola ; or groups of herpetic vesicles appear upon the Hps. Bespiration in severe cases is more or less embarrassed. It is then generally slow and suspirious, but with the increase of depression becomes hurried and shallow. The 2^ulse is much enfeebled, but its frequency is liable to great variation ; sometimes it is preternaturally slow, sometimes exceedingly frequent ; and rapid alterations are apt to occm- without any obvious cause. The g astro -intestinal phenomena, SbYe of some importance. Violent sickness is a noteworthy symptom of the disease during its earHer periods. It comes on without any necessary sense of nausea, and independently of" the ingestion of food. As the disease advances it usually ceases. The severe abdominal pam which commonly occm^s about the same time is also an important symptom ; it appears to be strictly neuralgic, and Iik& the vomiting itself referrible to the condition of the central nervous organs. The tongue may be clean or furred, and with the progress of the disease is apt to become dry. The bowels are for the most part con- stipated. The tirine in some cases contains albumen and blood. The more important symptoms referrible to the nervous system (namely neuralgic pauis, dehrium, and coma) have already been enumerated, and we need not recur to them. We may, however, point out that numerous additional phenomena are apt to present themselves. The patient not only suffers from intense pam in the head, not necessarily Hmited to any one locality, but also from pain in the course of the spine and especially ui its cervical region, and from neuralgic paius in the belly and hi the course of the hmbs. Cutaneous hypersesthesia is sometimes present. We have pointed out that general convulsions are occasionally observed ; but more common perhaps than these are local spasms either of the tonic or of the clonic kind in various groups of muscles, or tremors and sub- sultus. Paralysis, either hemiplegic or limited to a limb or some other portion of the organism, occasionally supervenes ; or there may be anes- thesia. Deafness, loss of sight, squinting, hiequahty of pupils, and the CEEEBEO- SPINAL FEVEE. 207 like, are also occasionally met with ; and sometimes, intolerance of light or somid. With the supervention of coma, and often before that period, there is loss of control over the bladder and rectum. The attitude which the patient assumes is characteristic at all events of cerebro- spinal inflam- mation ; and his asjject generally affords clear indications of the condition of his cerebral and spinal functions. If the case be of long duration, various phenomena, due apparently to irritation of the nerves or of the centres whence they emerge, are apt to ensue : and amongst them, destructive inflammation of the cornea, or other parts of the eye, or of the internal ear ; inflammation, often attended with suppuration, of the large joints ; parotid swellings ; and bed-sores. Inflammatory affections of the thoracic organs are also not imfrequent. The percentage of deaths m cerebro -spinal fever has varied in different epidemics between 20 and 80. Morbid anatomy. — The morbid changes observable after death are definite and simple. They consist in congestion of the vessels of the pia mater of the brain and cord, and inflammatory exudation into the sub- arachnoid tissue and occasionally into the ventricles. This exudation may be transparent and watery, but is more frequently opaque, greenish, and distinctly purulent. The affection is sometimes general, but more com- monly localised to some extent ; and not unfrequently it is confined mamly to the base of the brain (especially its posterior part) and to the- surface of the medulla oblongata and upper part of the spinal cord. There is often, also, congestion of the substance of the brain. It is said that in some cases in which death has occurred speedily from collapse no charac- teristic lesions have been detected. Treatment. — The treatment of cerebro-spinal fever has probably not been more successful in its results than that of any other of the specific fevers. It must, however, be borne m mmd that the mortality of this disease is due, less to the direct influence of the specific poison of the disease than to the cerebro-spinal inflammation which is one of the im- mediate consequences of its operation. If, therefore, meningeal inflam- mation be amenable to treatment, it is reasonable to believe that that of cerebro-spinal fever should be to some extent within our control. Power- ful depletory measures, however, and above all the abstraction of blood, are on several grounds obviously contraindicated. Counter-irritation, or cold to the head and along the spine, and moderate purgation, may possibly be of some benefit, as also may cooling salme draughts. Opium in large and frequently repeated doses, and quinine in large doses, have found much favour with American physicians. The food which is administered should be in the fluid form, and its regulated exhibition should be enforced. When symptoms of collapse manifest themselves, stimulants may be had recourse to, and the surface should be kept warm. •208 SPECIFIC FEBKILE DISEASES. XVII. DIPHTHEEIA. {Membranous Croup.) Definition. — A contagious disease, of which the more characteristic phenomena consist in the formation of whitish membranous pelhcles on certain mucous surfaces (more especially those of the fauces, nares, larynx, and trachea), and on excoriated or wounded arese of the skin; the rapid development of anaemia and extreme debihty ; and the supervention, during apparent convalescence, of temporary paralysis. Causation and history. — This disease, although it has been described by many authors of ancient and modern times, has been known by its present name only since the publication . of Bretonneau's treatise in the year 1826. He designated it ' diphtherite ' (^ since modified into diphtheria) from the Greek word 8i(j>0epa, a skin. Diphtheria, Hke most other infectious diseases, is met with m the sporadic form, and from time to time breaks out into virulent and widespread epidemics. Many of these have been recorded. The last of any serious importance prevailed in France during the years 1855, 1856, and 1857, and was imported thence into our own country, where, from 1859 to 1862, it committed great ravages. It was then regarded by a large number of the most experienced physicians as a disease almost, if not quite, new to the country. They were well acquainted with membranous inflammation of the trachea, or croup — a disease, too, which had been known to occur in an epidemic form ; but they failed to see, as many indeed still fail to see, that between the characteristic forms of croup, from which the classical description of the disease was taken, and diphtheria, there is no essential difference. The Scottish and English physicians of the latter part of the last century, and the early part of this, had their attention particularly directed to the rapidly fatal laryngeal form of the disease, and described it as a local malady. Bretonneau, on the other hand, recognised that the laryngeal affection was only the occasional complication of a general disease, which was infectious, and presented other remarkable features besides the mere formation of a membranous lining to the air-passages. Thus, the same disease, described from different points of view and from different degrees of acquaintance, with its pathology, and receiving different names, came to be regarded as two distinct diseases. And hence as much confusion has arisen, and as much difficulty in recognising the exact truth, as in the converse case of disentangling enteric fever and typhus from the discordant descriptions of the presmned single disease, continued fever. Diphtheria is a disease of all countries and all seasons, and affects both children and adults. It is, nevertheless, far more common among young children, especially between the ages of three and six, than in persons of more mature age, and is both actually and relatively much more fatal to them. There is reason to believe that the sanitary state of houses or localities, and the condition of health of those who are exposed to its poison, have much influence over its development. It is not very DIPHTHEEIA. 201> clear, however, what forms of uncleanHness or what constitutional con- ditions are most influential in this respect ; for we know that those who appear to be in the best of health often take it, while the weakly often escape ; and that it attacks the wealthy and the clean as well as the poor, the filthy, and the overcrowded. Diphtheria is undoubtedly contagious ; the epidemic of 1859-62 was distinctly imported into this country from France ; the introduction of a case into a house, hospital, or other institu- tion containing many inmates, is almost certain to be followed by an out- break of the disease amongst them — and indeed it not uncommonly happens that every child of a large household is thus swept away ; the nurse contracts it from her charge, the doctor from his patient, the mother from her suckling. The contagion is carried by the atmosphere. But it may also lie dormant in fomites, and thus present prolonged vitality ; for it is certain that many cases have been met with in which children, brought into rooms which had been well purified subsequently to the occurrence of diphtheria in them several weeks or months previously, have taken the disease. There is no doubt that it can be imparted by inoculation. Many cases are recorded (such, for example, as that of Professor Valleix, in whom a fatal attack supervened on the reception into his mouth of a small quantity of saliva coughed out by a diphtheritic child) , where accidental inoculation seems to have been efficacious ; yet, on the other hand, both Trousseau and Peter have inoculated themselves without effect. Experiments upon the lower animals have latterly been largely performed, but Avitli results which are not entirely conclusive. The most important are those of Letzerich, Oertel, and Trendelenburg, in which they claim to have given diphtheria to rabbits by the introduction of diphtheritic matter into the trachea. It is generally believed that the virus of the disease may be conveyed by means of sewer gases. It may be presumed that the patient is most apt to impart the disease while the membranous exudations are present ; but it is by no means certain at what period he ceases to be infectious. Convalescent children (children, that is, who appear to be perfectly well and have been ap- parently well for two or three weeks) seem occasionally to give the disease to others. Symptoms and progress. — The period of incubation is not accurately known. Some patients appear to have had the first symptoms of diph- theria a few hours only after exposure to its virus. In others the disease has not manifested itself for eight days. The incubative period probably varies between these extremes. Whether it is ever longer must be regarded as doubtful. The symptoms of invasion vary in some degree in their intensity with the virulence of the attack they usher in. For the most part they consist in elevation of temperature and other evidences of febrile disturbance, together with slight uneasiness or soreness of the throat. But these are often so slight, that the patient makes httle or no complaint, and pursues his ordinary avocations, until perhaps (especially if he be a child) attention is attracted to him by the presence of pallor, languor, and dulness or tendency to mope. Sometimes the febrile 210 SPECIFIC FEBRILE DISEASES. symptoms are mucli more marked, and there may be distinct chills or rigors ; but there is rarely even then any great complaint as to the con- dition of the throat. If, on the first evidence of illness, the interior of the throat be examined, there will probably be observed some degree of red- ness and tmnefaction of the tonsils, pillars of the fauces, soft palate or pharynx, or of all these parts. And very soon afterwards, whitish, greyish or buff-coloured, opaque, well-defined patches will be visible on some parts of the congested surface — often on one or both tonsils. These vary in thickness, are more or less coherent, admitting of removal in shreds or as a whole, and are moderately adherent to the subjacent Suirface, which is left excoriated but not excavated by their removal. They tend to spread rapidly, and hence if multiple to coalesce, and at the same time to become thicker and more adherent ; and may thus, in the course of a few days, form a nearly continuous covering to the whole surface above indicated, including that of the uvula. And, indeed, the throat may be found already in this condition, at the time when attention is first seriously attracted by the general aspect of ilhiess which the patient presents. By this time, the tonsils are often considerably enlarged, and the uvula swollen and oedematous ; there is almost invariably manifest swelling and tenderness of the lymphatic glands about the angles of the jaw ; there is generally, also, more or less mucous exudation and accumu- lation about the fauces ; but rarely, either the total loss of appetite, or the great agony in mastication and swallowing, which attends ordinary tonsillitis. The course which the disease may take from this point is very various. In some cases, the febrile symptoms soon subside, the morbid process ceases to spread, and the patient rapidly convalesces. In some cases, the membranous formation extends along the oesophagus, reaching it may be to the stomach. In some, it spreads to the larynx and trachea, and occasionally thence to the bronchial tubes. In some it invades the posterior nares, extending possibly throughout the whole of the nasal cavity and even along the lacrymal ducts to the conjunctivae. In some, the inflammation spreads in depth, and the glands and other soft tissues in the submaxillary and adjacent regions get swollen and infiltrated with inflammatory matter. And in some, diphtheritic pellicles make their appearance on other mucous surfaces, or on excoriated or ulcerated parts of the skin. We vnll discuss these various cases categorically. 1. The first of the above varieties of diphtheria is often a very mild disorder. The patient (with little or no fever at any time, and scarcely any complaint of soreness of throat, with no material thirst or loss of appetite, and with perhaps a small white patch on one or other or both tonsils, which may even have disappeared before the throat comes to be examined, or which may be detached at the end of three or four days or a little later) becomes convalescent in the course of a week or ten days, and then, except probably for some unusually persistent anaemia and debility, and perhaps for some enduring enlargement of the cervical glands, is soon restored to health. When, however, the membranous DIPHTHEEIA. 211 •exudation covers an exteusive sui-face (especially if, at the same time, the tonsils and uvula are much swollen) the symptoms are far more serious, and the dui'ation of the malady is prolonged ; but even then, if no complications arise, the patient is generally convalescent at the end of ten days or a fortnight. There is commonly under these circumstances ^great and increasing debility, and antemia ; and not unfrequently the patient, who has been perfectly sensible all along, dies from asthenia or in a fainting fit following some slight exertion. Occasionally, and more commonly in adults than children, the breath acquires a fetid and dis- tinctly gangrenous odour, the false membrane at the same time assuming a dirty grey or blackish hue, and a more or less pultaceous consistence. These phenomena are seldom due to actual gangrene, but are generally the result of mere decomposition of the diphtherial exudation. This is perhaps the best place to point out that diphtheritic patches not unfrequently make their appearance on the inner surface of the cheeks and on the gums, especially m the neighbourhood of the pillars of the fauces, and sometimes at the margins of the lips ; and, further, that Bretonneau has described an affection of the gums ( frequently associated with distinct faucial diphtheria and evidently of the same nature) in which an abundance of rust-coloured tartar accumulates about the necks of the teeth, in association with marginal pellicular formations on the gums, and a tendency to the development of similar patches en those parts of the inner surfaces of the lips and cheeks with which the diseased gums are in contact. There is excessive fetor of breath and disposition to gm- gival hemorrhage. 2. Extension of the diphtheritic inflammation along the oesophagus is not very common, nor is it attended with any marked special symptoms. Both difficulty and pain in swallowing, and complete and unconquerable anorexia, are not unfrequent accompaniments of severe cases of simple diphtheria, and hence would not be characteristic of this complication, although they would probably attend it. 3. Diphtheria of the air-passages constitutes one3£ the most frequent, and at the same time one of the most fatal, of the varieties of the disease. In some cases, no doubt, the larynx or trachea is the primary seat of m- flammation and membranous exudation, the fauces remaining healthy. Under these circumstances, croupy symptoms manifest themselves simul- taneously with the first onset of febrile disturbance, and we have in fact •a case of typical croup. In a much larger number of cases, however, the laryngeal mischief supervenes on ordinary pharyngeal diphtheria, the membranous inflammation extending from the one part to the other by contmuity. But since in this case the preceding affection of the pharynx is often exceedingly slight, not to say trivial, and has very likely given Httle or no positive indication of its presence, the laryngeal sequence is very apt to be assumed to be the primary disorder ; and, agam, the case falls in with the classical descriptions of croup. In many cases, however, the pharyngeal affection is severe, and has been recognised before the symptoms of croup appear. Here the sequence of events is obvious. p2 212 SPECIFIC FEBRILE DISEASES. Thus, diplitlieritic affections of the larynx and other air-passages- either may be secondary to pharyngeal diphtheria, or may commence in the lar\T.ix, trachea, or possibly even bronchial tubes, and then either remain limited to these parts or spread upwards to the pharynx. Under any circumstances the symptoms resulting from the laryngeal or tracheal affection are of the same kmd, and of extreme gravity. The child (for although membranous croup occurs in adults, it is mainly children who suffer) is first attacked with a frequent, short, dry, perhaps metallic cough, and slight hoarseness of voice — symptoms in this affection of the worst omen, even if in other respects he appears, as he often does, to be fairly well. But soon, some difficulty of breathing supervenes, com- mencing usually in the night. The symptoms now rapidly increase in severity ; breathing (inspiration more than expiration) becomes noisy, sibilant, stridulous, or metallic, especially after an attack of coughing ; the voice grows hoarser and weaker, or fails ; the cough gets less frequent but more severe — paroxysmal, suffocative, harsh, unmusical, and wheezy, or far less commonly hard and metallic ; and during the paroxysms the child tosses itself about, sits up, clutches whatever is near it, throws its head back, opens its mouth, dilates its nostrils, and struggles for breath ; the general surface and especially the face become \iviA, the eyes staring, and the expression one of intense anxiety. . Even now, in the intervals between the paroxysms of cough, the child often assumes a fallacious appearance of ease and comfort; the breathing may be a little quickened, and, unless under excitement, attended with little noise ; and the best hopes of recovery may arise. But the paroxysms return and increase in frequency and severity ; until at lengih, overcome by his exertions and progressive suffocation, the patient passes into a condition of combined coma, asphyxia, and prostration, in which he dies. Death takes place sometimes in a few hours, rarely later than the fourth or fifth day after the commencement of symptoms. In adults the course of the disease is usually not so acute. During the progress of the attack, the respirations increase in frequency ; the pulse becomes small, weak, and rapid ; the surface, especially that of the extremities, gets cold ; and perspirations break out. Further, consciousness remains for the most part unimpaired almost to the close. The symptoms above detailed are clearly referrible to the gradual growth and extension of false membrane in the larynx and trachea, and are occasionally reHeved by their expulsion in the act of coughmg. The paroxysmal cough is probably dependent chiefly on the occasional blockhig up by mucus of the narrowed rima glottidis or. trachea, and on spasm. The spread of the false membrane throughout the bronchial tubes, and the supervention of lobular pneumonia, are indicated mainly by rapid advance of hvidity and asthenia, increasuag imperfection of the respiratory acts, with falling in of the lower ribs and intercostal spaces durmg inspiration, inefficiency and feebleness of cough, and sup- pression of the auscultatory phenomena of the lungs. Emphysema of the connective tissue of the neck, head, and thoracic parietes, is occasion- ally developed. DIPHTHEEIA. 213 4. Extension of the cTiplitberitic process to the nose, or the deeper tissues of the neck, constitutes an essential feature of the so-called ' mahgnant ' form of diphtheria, and indicates severe concurrent constitu- tional poisoning and an almost certainly fatal issue. Malignant diph- theria often comes on with no more severe symptoms than those which attend the commoner forms of the disease ; and even when local signs indicate the course the malady is taking, and the observant physician foresees and dreads the impending change, there is frequently nothing in the patient's condition to alarm himself or his friends. The spread of the disease to the nose is indicated by catarrhal symptoms, by redness and soreness of the nostrils, and by the discharge of mucus, frequently ■attended early with some degree of epistaxis, and, ere long, with a copious flux of bloody ichor. At the same time the lacrymal ducts become involved, the escape of the lacrymal secretion by the puncta is arrested, the eyes water, and occasionally false membranes form on the conjunctivae. On inspection of the anterior or posterior nares the existence of the false membrane in the nose will probably be clearly recognised. The extension of the inflammation in depth is shown, partly no doubt by progressive enlargement of the tonsils and thickening of the soft palate and uvula, but more especially by rapid increase in size of the lymphatic glands about the angles of the jaw, and by infiltration with inflammatory pro- ducts of the connective and other tissues which intervene between them. By these processes very considerable general tumefaction is produced ; extravasations of blood and suppurating cavities appear here and there m the substance of the mass ; ulceration or gangrene occasionally takes place at the mucous surface ; and the cutaneous aspect, either uniformly or in patches, becomes brawny and congested or livid. In malignant cases, anaemia and prostration come on with great rapidity ; the pulse early becomes quick, irregular, extremely small and feeble, and the sur- face cold ; hemorrhage frequently takes place from the mucous orifices, and petechia and vibices appear beneath the skin ; the patient is restless and occasionally delirious ; and death results from asthenia. 5. Although, in the vast majority of instances, diphtheria commences either in the pharynx or in the mucous cavities which communicate directly with it, cases are occasionally met with (especially durmg epidemic outbreaks and amongst the members of infected households ) in which the diphtheritic inflammation and pellicular formation first make their appear- ance in some other region — occasionally m the vulva or vagina, on the glans penis and foreskin, at the anus, in the external auditory meatus, or on excoriated or raw cutaneous surfaces. The local changes here are identical with those occurrmg in the more usual seats of the disease ; the redness of the affected part is more or less vivid and intense, especially in a narrow zone circumscribing the adherent pellicle ; the pellicle is white, buff, grey, or black, not unfrequently looking like an eschar, and adherent to the surface ; and (when the skin is the part involved) its extension is attended with the formation of vesicles at the margins, which run together, and lead to the development of spreading excoriations which presently get 214 SPECIFIC FEBEILE DISEASES. clothed with the enlargmg pelHcle. Just as in many cases of primaiy phaiyngeal diphtheria false membranes appear after a while on various- parts of the surface of the body, so, in the cases now under consideration, it is not uncommon to find the pharyngeal mucous membrane ultimately involved. There are two or three important points in relation to diphtheria which have been either passed over, or merely touched upon, in the foregoing account, but must not be forgotten. The temperature of diph- theria is never a characteristic feature, and is rarely high. In some, and even severe cases, it scarcely at any time exceeds the normal ; generally,, however, there is distinct elevation during the first day or two ; and occasionally (but more particularly in those cases in which the larynx and trachea are implicated) the temperature rises in the course of the disease to 106° or 107° and upwards. The urine in a large proportion of cases (one-half or two-thirds, according to different observers) becomes- albuminous at an early date, the amount of albumen being sometimes- very great. Occasionally, and more especially in malignant cases, there is hfematuria. Under the microscope will be found, in the former case hyaline and granular casts ; in the latter blood more or less modified in character. These conditions of the urine are rarely of long duration, and scarcely ever usher in dropsy, uraemia, or permanent lesion of the kidneys. Urea is excreted in excessive quantities during the progress of the disease, and diminishes during convalescence. Inflammation now and then extends from the throat to the ear, and may produce suppuration and other serious lesions in that organ ; and occasionally it spreads froni' the conjunctiva to the cornea, causing opacity, ulceration, and perforation.. Delirium is of unusual occurrence, and generally forebodes a fatal issue. The duration of diphtheria varies widely, and relapses occasionally take place. When the disease ends in convalescence it rarely exceeds a fortnight, and it may be as little as a week. Death occurs at very different periods, which, however, are largely determined by the nature of the lesions inducing it. It may take place within the first twenty-four hours, or as late as the end of the second week, or at any intermediate period. The causes of death have been sufficiently considered. The mortuary rate of diphtheria is high ; but it is impossible to make any exact statement on this point ; for while in some epidemics, undoubtedly many mild cases occur of which a large proportion are never suspected to be diphtheria, in other epidemics the fatality of the disease is frightful. The most fatal forms of diphtheria are those in which the air-passages are affected, especially in children, and those which have been spoken of as- malignant. Diphtheria does not always cease with apparent convalescence. In many cases, morbid phenomena of a totally different kind to any which have preceded sooner or later supervene. These are affections, for the most part paralytic, of the sensory and motor nerves. They sometimes commence with the separation of the false membrane, but more com- monly come on from a week to a month after convalescence seems to have DIPHTHEEIA. 215 been established. Usually the first, and not unfrequently the only, part affected is the soft palate. The patient, who had probably regamed his voice and power of deglutition, begins to speak with a nasal tone ; when he attempts to swallow, a portion of his food is apt to pass into the posterior nares ; and on examining the throat, the soft palate is found to be more or less pendulous and motionless — motionless even when me- chanically irritated ; its sensibility also is impaired or annulled. It is worth while pointmg out, as showing that the palatal paralysis is not the result of local inflammatory changes, that it occurs in cases in which pharyngeal or faucial mflammation has been very slight, and even in cases where there has been none. The paralysis, however, does not necessarily stop here ; but soon, it may be, the patient begins to complain of numbness, tingling, and loss of power, in the lower extremities ; then probably the upper extremities are attacked in the same manner ; presently, perhaps, the sensibility of the trunk diminishes and its muscles lose their force, the intercostal muscles and the diaphragm fail, and even the rectum and bladder share in the general paresis. Further, the paralytic condition, commencing in the fauces, may spread so as to involve, on the one hand, the muscles of mastication, articulation, and expression, and on the other the larynx, lungs, and heart, and generally the organs to which the vagi are distributed. In addition, complete failure of sexual power and appetite often comes on, and more or less impairment of the organs of sense. There may be loss of smell or taste, or deafness. But it is chiefly the eyes that suffer : — squinting and double vision, and loss of adjustmg- power by reason of paralysis of the ciliary muscles, are not uncommon ; and temporary amaurosis sometimes takes place. Further, the patient may complain of numbness of the tip of the nose, or of the upper lip, or of both lips, or of the tip of the tongue, or of the chin, or of the penis and scrotum. It is important to note that, although all the forms of paralysis above specified may occur, they rarely all occur in the same individual, and never all at the same time or in the same order. The paralysis, in fact, is progressive, and often tends to get well in one part while it is extendhig elsewhere ; and, like hysterical paralysis, it fre- quently shifts from one region to another. Moreover, it is generally, if not always, symmetrical. In place of paralysis, we sometimes meet with hyper^esthesia and neuralgic pains. Notwithstanding the alarm which the presence of paralysis necessarily creates, the paralytic condition is rarely fatal, and generally ends in perfect recovery in the course of two, three, or at the outside four, months. But it is not altogether devoid of danger. When death occurs from it, it is usually in those cases in which the paralysis is rapidly developed and extensive, and in which the nerves arising from the medulla oblongata and floor of the fourth ventricle are especially implicated. The patient may die from inability to swallow food, or from the accidental entrance of foreign matters into the larynx, or from gradual failure of the respira- tory acts and consequent asphyxia, or from enfeeblement of the heart's action, which is attended vntli remarkable slowness, or rapidity, or irregu- 216 SPECIFIC FEBKILE DISEASES. larity of the pulse, and tendency to syncope. Occasionally death is due to convulsions or coma. In reference to diphtheritic paralysis M. Duchemae points out that sensation and motion are usually simultaneously affected, but that the impairment of sensation tends to preponderate over that of motion. The paralysed muscles retain their electric contractility, their hulk, and their healthy texture, but the tendon-reflexes disappear. In speaking of diphtherial albuminuria we remarked that it is usually one of the early phenomena of the disease. But it sometimes comes on again, or for the first time, during the paralytic stage. Morbid anatomy and i^atliology . — The morbid changes attending diph- theria are almost limited to the circumscribed inflammations which have already been discussed. In most cases the affected parts are congested, swollen, and infiltrated with leucocytes and other inflammatory matters ; and, when the inflammation extends deeply, extravasations of blood and foci of suppuration, terminating in distinct abscesses, occasionally appear. The mflamed surface secretes abundant thin mucus, and soon an opaque layer forms upon it. This increases by additions to its under surface and to its edges, and is attached to the subjacent mucous membrane, partly by general adhesion, partly by prolongations into the mucous and other follicles. In the first instance it consists only in the inflammatory pro- liferation of the epithelial cells, which become cloudy and are apt from the shrinking of their protoplasm to assume a stellate form, the resulting interstices being probably occupied by mucus. This appears to be its permanent condition in the pharynx. But in the air-passages a fibrinous exudation takes place before long at the surface of the membranalimitans, between it and the modified epithelial layer w^iich it displaces, and coagulating there forms a more or less distinctly lammated network of fibres which entangles leucocytes but very rarely distinct epithelial elements. Under these circumstances the superficial cellular lamma undergoes gradual disintegration and disappears, and thus the diphthe- ritic membrane at length becomes purely fibrinous. Many lowly vege- table organisms have, as might be supposed, been detected in it. It is not clear that any of them can be justly regarded as specific. Heuter, Oertel, and some other observers, however, maintain that the contagium of the disease consists in certain forms of bacteria, which they describe as existing in great abundance not only in the diphtheritic exudation, but in the lymphatic spaces of the subjacent corium. The membrane varies considerably in thickness and consistency, and, when very thick, its superficial parts are apt to be pulpy or flocculent. Its detachment often exposes an excoriated surface, and sometimes distinct ulceration. Occasionally gangrene occurs. We have pointed out the localities in "which diphtheritic membranes are chiefly formed. It remains to say that, when they extend into the nose or larynx, they adapt themselves accurately to irregularities of surface, and form complete solid casts of such diverticula as the sacculi laryngis ; and that, when they involve the bronchial tubes, they extend sometimes to their finest ramifications,, forming arborescent laminated casts. It is mainly when the air-passages DIPHTHEEIA. 217 ;are invaded that collapse of lung and lobular pneumonia take place, and, in children, interlobular emphysema, going on, it may be, to general emphysema. The only other organs ordinarily presenting obvious morbid changes are the kidneys. These may be enlarged, and somewhat pale, and on microscopic examination may present granular or fatty deposits in the renal cells, with hyaline casts occupying the canals of some of the tubules. In malignant cases, besides intense local mischief, hemorrhages take place beneath the serous and mucous membranes and into the substance of the lungs, heart, kidneys, and other organs ; and sometimes the muscular tissue of the heart presents granular or fatty changes. The blood has been said to be distinctly modified in character ; but this is •certainly not always the fact ; and even in the worst cases fibrinous clots may be discovered in the cavities of the heart. That diphtheria, like the exanthemata, is a specific disease affecting the system generally, can'scarcely be doubted ; its symptoms and progress, and especially its paralytic sequelae, all attest the truth of this view. There may still, however, be a doubt as to whether the primary diph- therial patch, the formation of which attends the first onset of the disease, is a localised outcome of the general disorder and analogous therefore to the rash of variola ; or whether it is to be regarded as the direct result of inoculation, and analogous therefore to the inoculated variolous pu.stule. In what way the diphtherial poison induces paralysis is a problem which ■does not at present admit of solution. The lesion, however, whatever its exact nature may be, is evanescent, and seems mainly to involve the medulla oblongata and neighbouring parts, and the cord. Treatment. — The treatment of diphtheria is a subject of much interest and importance, and not the less so that great variety of opinion has prevailed even in regard to points of vital moment. One of the most remarkable features in the disease is its tendency to produce anaemia and ■exhaustion, and death by asthenia. Such being the case, it is scarcely necessary to say that depletory measures cannot be adopted without grave risk. Indeed it is now almost universally admitted that the general "treatment should be directed to the maintenance of the bodily powers. To this end, nourishment by appropriate kinds of food, and the use of such tonic medicines as the patient can bear, must be firmly enforced. The liquid or pulpy foods generally administered in acute febrile disorders are suitable here ; for medicine it is fashionable to prefer the solution of perchloride of iron, and doubtless the preparation is a valuable one ; but there is no reason why other preparations of iron should not be giveji, or for the avoidance of quinine and other vegetable tonics. By some, chlorate of potash, or this with the addition of small quantities of hydro- chloric acid, is strongly advocated. For local treatment of the affected mucous membrane various agents have been proposed. Bretonneau, and Trousseau following him, strongly recommend the free application of .undilute hydrochloric acid ; others prefer strong solution of nitrate of .silver or of bicarbonate of soda, or pure tincture of the perchloride of iron, or creasote. Again, other practitioners regard the use of strong 218 SPECIFIC FEBEILE DISEASES. caustics as useless, if not injurious, and prefer to wash out the throat or- have it gargled with solution of chlorate of potash, alum, or the Hke ; and undoubtedly the administration of ice in small lumps is in many case& very grateful. Eemedies to the nose must be applied either in the fluid form by means of a syringe or nasal douche, or as a powder by insufflation. The larynx must be treated, either by insufflation, by ' swabbing,' or by the use of the vaporising apparatus under the guidance of the laryngoscope. Emetics, which were formerly and are still often given for their supposed specific effects on inflammations of the respiratory mucous membrane, have been regarded as remedies of the utmost importance m croup, and therefore in all cases m which the diphtherial membrane tends to pass into the larynx. They are sometimes useful, indeed, but chiefly if not entirely by the mechanical influence of the vomiting which they induce, in promoting the expulsion from the larynx and trachea of the mucus, and even of the false membrane which obstructs them. They must, therefore, be regarded mainly as local remedies. Of emetics it is best to- give those that act rapidly without inducing much depression ; for these reasons, large doses of ipecacuanha or of sulphate of copper are preferable- to equivalent doses of antimony. As soon as distinct implication of the mucous membrane of the larynx or trachea occurs, the question of the performance of tracheotomy will necessarily and properly present itself. The extreme fatality of croup if left to itself, the little influence which drugs exert over its progress, and the fact that death is in the great majority of cases directly due to the affection of the larynx and trachea, render in many cases the opening of the trachea our only hope. It is doubtless generally difficult to decide at what moment the operation becomes imperative. Here the physician must do what he thinks best according to his own judgment, bearing m mind, however, that it is much better to perform the operation too early than too late, and that he ought not to be deterred from doing it by the occurrence of one of those deceptive intervals of calm and tranquil breathing which are so common even while the disease is hastening to its fatal issue. Further, it is better to operate even when life seems ebbing away, or the patient is moribund, and in the face of every discouragement, than to let him die suffocated before one's eyes without making an effort to save him. Trousseau's vast experience of this treatment of croup gives an average of one successful operation out of four ; he points out, however, that tracheotomy in children under two is scarcely ever success- ful . Other writers (chiefly foreign) record results at least equally encouraging. In the treatment of convalescence, and in that of the consecutive paralysis, all efforts should be directed to improve the general health of the patient and to give him strength. With these objects, change of air, tonics (especially quinine and iron), good diet, and a fair proportion of stimulants, are most important. Other agents may be serviceable in promoting the cure of the paralysis, especially strychnia, galvanism, and friction. ENTEEIC FEVEE. 219 Lastly, looking to the established fact that breaches of the cutaneous surface have a great aptitude to become the seat of diphtherial inflamma- tion, it should be regarded as a fundamental rule never to employ blisters or other remedies calculated to produce sores. XVIII. ENTEEIC FEVEE. {Typlioicl Fever. Ahdominal Typlnis.) Definition. — A febrile disorder, characterised by an inflammatory affec- tion of the agminated and solitary glands of the intestines, gastro-intestinal disturbance, and a peculiar rash. Causation and history. — Enteric fever is a disease of world-wide pre- valence, occurring for the most part m an endemic form, but occasionally assuming the proportions and the behaviour of a genuine epidemic. It seems to have no special connection with overcrowding, poverty, or ill- health, and indeed to attack the denizens of town and country, rich and poor, healthy and ailing, with singular impartiality. Sex is without in- fluence over it ; but children and young persons are much more liable to it than adults, and these than such as are of advanced age. Dr. Murchison's investigations show that more than half the total number of cases admitted into the London Fever Hospital durmg ten years occurred in persons between the ages of fifteen and twenty-five ; more than a fourth in persons under fifteen ; one-tenth in persons between twenty-five and thirty ; and that from the latter age onwards the numbers rapidly diminished. Considering, however, how few children attacked with enteric fever are likely to become hospital patients, it seems not improbable that the tendency to contract the disease is pretty nearly equal at all ages up to about twenty-five, and that from that epoch it rapidly and uniformly dimmishes. Undoubted cases have been recorded at various ages be- tween seventy and ninety. Dr. Murchison also shows from the records of the Fever Hospital that enteric fever prevails chiefly in October, November, September, and August, and that it is at its minimum in April, May, February, and March ; and he confirms the general belief that its prevalence is augmented by excessive heat of weather, and diminished by continuous low temperature. There is reason to believe that persons newly arrived in districts in which enteric fever is endemic are more likely to take it than those who have resided there for some time. The confusion which prevailed up to within a recent period in regard to typhus and enteric fevers rendered any exact knowledge of their causation impossible. Since, however, they have been recognised as distinct and specific diseases, much light has been thrown upon the subject. It has been proved, indeed, apparently beyond all cavil, that enteric fever is above all fevers the fever of ftecal decomposition ; that it occurs only among those who are exposed to the influences of defective drams or foul and overflowing cesspools, especially when these are so situated as to pour forth their fetid 220 SPECIFIC FEBKILE DISEASES. gases into tlie interior of houses, or to contaminate by their emanations, their soakage, or their leakage, water and other articles used for food. In opposition to this view, it has been asserted that persons who work in the sewers are never attacked with enteric fever ; but even if this were the fact (which it is not), it would weigh nothing against the positive evidence on the other side, which has been furnished of late years by repeated scientific investigations into the causes and circumstances of local outbreaks of the disease all over the country. Also, several local outbreaks of enteric fever in Switzerland liave been traced to the eating of the decomposing flesh of unhealthy calves.^ But whether the calves were themselves suffering from enteric fever, or their flesh had derived its infectious qualities from some other source, is at present uncertain. The subject of its etiology is not •exhausted in the above remarks. It is admitted by most physicians that enteric fever is not, in the usual sense of the term, contagious ; that it is not conveyed from one person to another person by the touch or by the breath ; and that attendants on the sick rarely if ever take the disease from them ; yet it is quite certain that the immigration of a patient, suffering from enteric fever, into an uninfected locality not unfrequently leads to an outbreak there. We have pointed out that the virus seems not to escape with the breath or from the skin ; and it must be added, that if it escapes with the fgeces in an active form it is difficult to understand how the nurses, and other persons brought into relation with the sick, so con- stantly escape infection. It has been observed, however, over and over again, that the faeces, which are probably at first wholly ineffective, become, in the course of putrefaction, virulent in a high degree, and impart their infectious properties largely to the contents of cesspools and sewers, and thence to well and other waters, with which the former happen to communicate. In many cases, indeed, the source of an enteric-fever outbreak has been distinctly traced to the water of a well, into Avhich there has been percolation from a neighbouring cesspool recently contaminated with the evacuations of a patient sufl'ering from that fever ; and occasionally, also, groups of cases seem to have been distinctly referrible to body-linen and bedclothes befouled with typhoid evacuations, which have been allowed to accumulate and remain unwashed. It seems clear, therefore, that persons sufl'ering from enteric fever discharge in their faecal evacuations (as do cholera patients) some specific but at the time innocuous organised substance ; which, after its escape from the body, and under suitable circumstances, increases and at the same time becomes virulent, diffusing itself throughout the fluid media to which it gains access, and imparting to them its specific properties. The question then arises. Does the specific poison of this disease, which is certainly developed from the stools of patients suffering from it, also arise spontaneously, or rather independently of such stools ? The question is by no means easy to solve. Dr. Murchison especially argues forcibly in favour of its origin independently of the disease which it generates. Dr. W. Budd and others argue with equal vehemence in support of the opposite hypothesis. We adopt the ' Dr. Cayley, Croonian Lectures, British Medical Journal, March 20, 1880. ENTEEIC FEVER. 221 latter view, and, in accordance with it, regard the essential cause of enteric fever not as a mere inorganic or even organic result of decomposi- tion, but (like other contagia) as an organised living particle which has special endowments and unlimited powers of multiplication ; not as the product of healthy bowels or of ordinary decomposing ordure, but as a specific virus yielded by the bowels of patients suffering from enteric fever, and probably by them alone. A further question here presents itself — namely, By what route does the virus gain admission into the system ? It is certain that in many cases it is received into the alimen- tary canal ; it is thus that the disease is imparted by contaminated water, and by milk to which contaminated water has been added. It is generally believed also that it may be inhaled with the breath, and that it is thus that the effluvia of cesspools and drains act in producing the disease. On the whole there is reason to suspect that the virus in all cases enters the system at the surface of the alimentary mucous membrane, and that the intestinal lesions are to be regarded as points of inoculation. One attack of enteric fever is believed to confer immunity against sub- sequent attacks. If, however, this be so, the immunity is much less perfect than in the case of the infectious fevers generally, for many second attacks have been recorded ; and, moreover, true relapses are far more common in this than in any other allied specific disorders. Symptoms and progress.— TYvexe is reason to believe that the incuba- tive stage of enteric fever varies between about six and twenty-four days. The mode of attack and the initiatory symptoms of the disease present great variety. In exceptional cases its invasion is as sudden and well marked as that of typhus, the symptoms moreover resembling those of that disease. But much more commonly it comes on so insidiously, with midefinable feelings of malaise, or slight feverishness, or failure of appe- tite and strength, or some degree of gastro-intestinal disturbance, extend- ing over several days, that the patient is quite unable to fix the date of the commencement of his illness. During the early period of enteric fever, the patient suffers in a greater or less degree from the following- symptoms : — irregular chills and flushes of heat ; increased frequency of pulse, and elevation of temperature ; lassitude and aching in the limbs ; thirst, and loss of appetite, with morbid redness or coating of the tongue and headache or heaviness of the head, with tendency perhaps to drow- siness by day, to wakefulness, restlessness and dreaming at night time. Epistaxis is not uncommon. Vomiting and diarrhoea, with abdominal pain, and tenderness in the cascal region, are generally associated with the above symptoms, and, though sometimes absent, are often the very earliest and generally the most striking of the phenomena which attend the earlier period of the disease. During the first week of the fever, although the symptoms gradually increase in severity, the patient is very often not confined to bed. At the beginning of the second week, however, unless the case be exceptional either in its mildness or in its intensity, the symptoms become more fully developed and assume a more characteristic aspect. The fever reaches its acme ; the skin generally is hot and dry. 222 SPECIFIC FEBKILE DISEASES. but liable to break out in perspirations ; the pulse still increases in fre- quency, as also do the respirations, and not unfrequently there is some degree of cough ; the tongue may continue clean or become coated Avith a moist fur, but generally, whether coated or clean, tends to get dry and to present cracks, mostly transversal, upon the dorsum ; the vomiting has very probably subsided, but thirst and anorexia continue, and there may be some difficulty in swallowing and speaking in consequence of soreness of the throat ; the patient sleeps badly ; and occasionally, but by no means in all cases, delirium comes on, especially at night time and between waking and sleeping. It is about this time, too, that the rash which is peculiar to the disease first makes its appearance. It consists in lenticular rose-coloured spots, distinctly elevated and sensible to touch, disappearing on pressure, and varying when fully formed from half a line to a line and a half in diameter. Though generally rising above the general level in the form of segments of spheres, they occasionally become vesicular in the centre and thus more or less distinctly acuminated. They are rarely numerous, and always appear in successive crops — those of each crop attaining their full development, and disappearing, in the course of two, three, or four days. Thus, spots of various ages are gene- rally present and intermingled at one and the same time. In perhaps one-fourth of the total number of cases no spots are ever discovered, and in the remainder their number may vary from a dozen or less up to many hundreds. They are chiefly developed on the chest, abdomen, and back ; but occasionally are observed on the face and extremities. At this time too the intestinal symptoms usually become pronounced ; the abdomen is tumid ; tenderness and pain manifest themselves more distinctly in the right iliac region, where also on pressure gurgling may be detected ; and the bowels become loose — open three, four, or a dozen times a day, and discharging liquid yellow stools which have been likened, not miaptly, to peasoup. The spleen too has become enlarged, and its edge will probably be felt below the ribs. From the condition above described the patient may gradually recover. But in a large proportion of cases he passes, in the course of the second week (probably towards its close), into a typhoid condition. The elevation of temperature continues ; the rash still comes out ; the diarrhoea persists ; the tongue becomes dry and brown and traversed by deep fissures, the lips and teeth covered with sordes, the pulse quicker and more feeble ; the general prostration increases ; com- plaints of headache and pain cease ; the mind grows dull and apathetic ; drowsiness and delirium (sometimes violent, sometimes busy, sometimes muttering) supervene ; and bed-sores tend to form. Blood, in greater or less quantities, is now not unfrequently passed with the stools. Finally, if the case be going on unfavourably, tremors, subsultus and involuntary passage of the evacuations come on, the somnolence or delirium passes into coma, and death ensues. If, on the other hand, the case be likely to do well, convalescence commences usually in the course of the third or fourth week. The change is in general gradual. The fever abates, the pulse falls, the cerebral symptoms pass away, the tongue cleans, the ENTERIC FEVER. 223 -appetite reappears, tlie diarrlicea ceases, and the strengtli returns. The progress of convalescence is, however, always slow, and the patient often does not regain his former health until after the lapse of many months. Occasionally, when convalescence seems to be fairly established, a relapse takes place, attended with the rash and all the other characteristic spnp- toms and phenomena of the disease. This may be in all respects more severe than the primary attack. A second relapse may follow. The foregoing account apphes, for the most part, fairly well to the ordmary run of well-marked, uncomplicated cases of enteric fever. No disease, however, is attended with greater variety of symptoms, or pre- sents more fi'equent and greater departures from the t}Tpical character. It is desirable, therefore, to discuss briefly the various phenomena of the disease, and its varieties. The pulse varies greatly in frequency. Occasionally, in very mild cases, it scarcely exceeds the normal throughout the whole course of the illness. In other cases, however, it mounts (in dependence very much on the severity of the case) to 90 or 100, and from this to 120, 140, or -even 200, and becomes very feeble. It is generally quicker in the evening than in the morning, and in the typhoid stage than in the earlier period. Other things being equal, rapidity of pulse implies severity of attack. It is curious, however, that even during the presence of marked fever the pulse may at times sink below 50 or 60. In one of Dr. Murchison's cases it fell to 37. The respirations are generally accelerated, especially with the advance of the fever, and not unfrequently some little cough is present. These symptoms are necessarily greatly aggravated when (as not unfrequently happens) bronchitis or pneumonia becomes developed. Then also the surface is apt to get dusky, and the local signs of the complication mani- fest themselves. The character of the tongue varies. In some cases this organ re- mains almost normal throughout the iUness, or is merely a little redder and drier than natural, or presents the sHghtest possible increase of epi- thelium only. More commonly it is covered, except at the margins, with a whitey-bro\\Ti fur which tends to become dry ; or it has a di-y, glazed, morbidly red character ; and in either case is apt to jpi'esent transverse ■cracks which are often of considerable depth. The throat is not mifre- quently congested and sore, and there may even be inflammation of the tonsils at an early period. Sickness is one of the most common of the initiatory symptoms, and is sometimes exceedingly severe. It may last throughout the whole illness. Thirst and loss of appetite are almost invariably present. Diarrhoea is seldom absent, and is often very severe. Not unfrequently it prevails from the beginnmg ; but in many cases it does not come on till the second week, or even later ; and sometimes there is constipation throughout, or the patient has an occasional loose stool only. The motions usually have the appearance and consistence of peasoup, are alkaUne, and offensive ; m the course of the second, third, or fourth week they may contain blood. The progress of the fever is gener- 224 SPECIFIC FEBRILE DISEASES. ally attended witli abdominal pain, tenderness, and gurgling in the right iliac fossa, flatulent distension of the belly, and manifest enlargement of the spleen. In the early part of the disease the urine is scanty, dark- coloured, and of high specific gravity ; later on it becomes pale and copious, and its specific gravity falls. There is almost always a large increase in the amount of urea and uric acid, especially at the commencement ; and the chlorides are diminished. Albumen is not present in more than one- third of the total number of cases, and occurs for the most part in very small quantity and seldom before the third week. The skin, though for the most part dry, is apt to become moist, espe- cially in the morning ; and during the latter part of the second, or in the third, week profuse perspirations may occur. The cheeks, especially after meals or during the febrile exacerbations, are often flushed. The rash, which has already been described, continues by successive outbreaks for . one, two, or three weeks. During convalescence perspirations are often very copious, and sudamina generally appear on the chest. The fever, as indicated both by the thermometer and by symptoms, is always of a remittent character, presenting morning falls and evening exacerbations. The temperature begins to rise about noon and attains its maximum between 7 p.m. and midnight. After midnight it gradually falls, the lowest point being usually attained between 6 and 8 a.m. In uncomplicated cases these daily alternations are almost constant, the difference between the morning and evening temperatures varying from one to two or three degrees, or even more. The rise begins from the first day of illness, and gradually increases by daily waves until, on the fourth or fifth day or about the end of the first week it attains its greatest elevation, which varies in difterent cases between 104° and 106°. From this period up to about the twelfth day there is but little change. Then, if the case be mild, the morning falls become lower and of longer dura- tion, to be followed shortly by a corresponding decline in the evening rises ; and gradually, as convalescence becomes established, the morning and evening temperatures approximate until they attain their normal level, or even sink below it. If, on the other hand, the case be severe and the commencement of convalescence be delayed, the temperature still continues high, and the morning remissions often become less marked than they had been. Again, if in the course of the disease serious com- plications arise, the usual course of the thermal variations is modified. Profuse diarrhoea, epistaxis, or intestinal hemorrhage, causes the tempera- ture to fall ; as also does the condition of collapse, however produced. Pneumonia makes the temperature riee, and modifies its diurnal varia- tions. Sometimes it rises before death to 108° or even to 110-3° inde- pendently of complications (Wunderlich). As regards the organs of sense : singmg in the ears and deafness are not imcomnion ; the conjunctivas are seldom congested ; the pupils are usually dilated ; epistaxis is of frequent occurrence. Most patients com- plain, at the beginning of the disease, of giddiness and headache, and of ENTERIC FEVEE. " 225 paiii and sense of lassitude in the limbs. There is often wakefulness at night ; sometimes, on the other hand, there is somnolence, and this not unfrequently precedes delirium. Delirium is a variable symptom ; in many cases it never occurs ; in many it is slight, and shows itself only between waking and sleeping ; in severe cases it usually comes on about the middle or end of the second week, and is then apt to vary in character and duration. It may present all the characters of the delirium of typhus ; but, as Dr. Murchison remarks, it is more frequently of the violent and noisy kind than in that disease. In rare cases the invasion of the fever is attended with maniacal excitement. Coma occasionally supervenes before death. Convulsions are not usual, but are more com- mon in children than in adults ; they generally come on late, and frequently prove fatal. Muscular weakness is always present, but is not so marked as in typhus ; nevertheless, in the later stages of severe cases, tremors and subsultus are common. Occasionally there is muscu- lar rigidity. Enteric fever presents itself in many forms, and has been and still is frequently confounded with other diseases. It is especially important to know that, for the most part, cases of so-called ' infantile remittent fever,' ' worm fever,' ' gastric fever,' and ' bilious fever,' are cases of this affec- tion. In the mildest form of the disease the patient perhaps complains only of slight feverishness and weakness, with loss of appetite and diarrhoea or irregularity of the bowels, and probably goes about his ordi- nary avocations, or at all events does not take to his bed, and, if no complication supervenes, recovers at the end of three or four weeks. In other cases the disease is much more severe in character, and its progress is more or less distinctly in accordance with the account we have already given ; the attack is one of well-marked enteric fever, but varies according to the relative prominence of certain of the symptoms, such, for example, as vomiting, diarrhoea, thoracic symptoms, hemorrhage, and delirium. In other cases, again, the attack is from the beginning of exceptional severity, and, as in analogous cases of scarlet fever and other like affec- tions, the patient dies, poisoned apparently and in a state of collapse, within the first week, sometimes on the first or second day. Much of the danger which attends enteric fever depends on the com- plications which arise in its progress. The most important of these are intestinal hemorrhage, perforation of the bowels with peritonitis, and pneumonia or bronchitis. It has already been pointed out that intestinal hemorrhage is not un- frequent. It may occur at almost any period of the disease, but is most common from the middle or end of the second week to the end of the fourth. It may be due, in cases where there is a general hemorrhagic tendency, to oozing from the mucous membrane ; but far more com- monly it takes place from the surfaces or edges of the intestinal ulcers. It has no necessary connection with the extent or size of the ulcers, or with the presence or absence of diarrhoea, or indeed with the mildness or severity of the patient's previous symptoms. The hemorrhage may be 226 SPECIFIC FEBEILE DISEASES. scanty, or so copious as to cause speedy death by syncope ; and the blood which escapes may be fluid or clotted, black or of the normal colour of blood. Peritonitis is one of the most frequent causes of death in enteric fever, and, like intestinal hemorrhage, has no necessary dependence on either the severity of the case or the urgency of diarrhoea. In the vast majority of cases it is due to perforation of the bowel in the floor of one of the intestinal ulcers, and is therefore sudden and unexpected in its onset. Not unfrequently perforation occurs in patients who have never taken to their beds ; who are then seized, without warning, with intense abdominal pain, tenderness and distension, together with vomiting, col- lapse, thoracic respiration, and other symptoms of acute peritonitis. In such cases the nature of the complication is manifest. When, how- ever, it takes place in patients who are already in a typhoid condition, the indications are apt to be overlooked. Yet, even in these cases, there may be more or less evident abdominal pain and other local signs of peritoneal inflammation ; but very often the diagnosis must be made to rest mainly on the sudden supervention of collapse, with first a fall and subsequently a rise of temperature, increased rapidity and feebleness of pulse, hurried and thoracic respiration, duskiness of surface, copious perspirations, and flatulent distension of the abdomen or tympanites. Indeed it may be said generally that the sudden occurrence in the course of enteric fever of symptoms of intense collapse, even when no direct evidence of abdominal inflammation is present, points to perforation. Perforation of the bowel may occur in patients of all ages, but is more common in males than in females. It cannot take place until ulceration has commenced, and, as might be supposed, is more common when ulceration is advanced than when it is beginning. Hence, although it occasionally happens during the second week (more especially towards its close), it is much more common during the third, fourth, and fifth weeks ; and, indeed, all risk has not ceased mitil the expiration of two or three months. It may arise, there- fore, during the period of convalescence, and even after apparently complete restoration of health. Death almost invariably follows this lesion ; and generally occurs within a couple of days, sometimes in the course of a few hours. But occasioiially life is prolonged for a week or two ; in which case the peritonitis becomes circumscribed and an abscess forms. A few cases of recovery after the evacuation of such an abscess have been recorded. Dr. Murchison calculates that no less than one- fifth of the total number of deaths from enteric fever are due to. perfora- tion of the bowels. Bronchitis is often present in a slight degree ; but occasionally it gets severe, and may be so at any stage of the fever. The symptoms of bron- chitis are then added to those of the primary disease and mask them. So pneumonia, mainly lobular, may creep on insidiously at any time, but most commonly appears during the third or fourth week. It is usually connected with the hypostatic congestion of the lungs which is generally present in a greater or less degree ; and hence occupies mainly the back ENTEKIC FEVEE. 227 and basal portion of one or both lungs, and may fail to be detected unless the attention of the physician be specially attracted by the presence of symptoms indicating thoracic mischief. Pleurisy ending in empyema is also not unfrequent. Many complications and sequelae are described besides the above ; but they are, for the most part, unimportant or rare or not specially charac- teristic. We will enumerate a few of the more important. Ulceration of the larynx or trachea ; tJirombosis of the veins, especially in connection with the lower extremities, leading to oedema ; bed-sores on the sacrum and other parts exposed to pressure or irritation ; gangrene of the mouth [noma), ears, penis, vulva, feet, corneoe, and especially of parts to which blisters have been applied, or which are already inflamed from other •causes ; inflammation of the parotids ; 2^^^'^ostitis or acute necrosis ; imbecility, mania, or other mental disorders ; prolonged marasmus ; and tuberculosis. Pregnant women not unfrequently abort. But neither pregnancy nor parturition appears materially to interfere with the prospect of recovery. There is probably no other disease in which death threatens from so many quarters, and at which it may occur at such diverse and unexpected times. It is due immediately either to asthenia, asphyxia, or coma, or to combinations of these. It may happen early in the disease, mainly from the intensity of the attack ; in which case there is generally more or less pulmonary congestion. But it more commonly occurs later, either from pneumonia or other pulmonary complication, from perforation and perito- nitis, from intestinal hemorrhage, or from coma coming on in the course of typhoid symptoms. Again, it may ensue during the period of con- valescence, from one or other of the sequela? of the disease, or from sheer exhaustion. Enteric fever in hospital practice is fatal in about the same proportion as typhus — at the rate, namely, of about 15 or 16 per cent. But when we consider how large a number of mild cases occur, which are not only never admitted into hospital, but not even recognised, it becomes obvious that the proportion of total deaths to total attacks must be much smaller than the above figures imply. Excepting childhood, the percent- age of mortality varies little with age ; but, on the whole, the statistics of the London Fever Hospital show that the ""sath-rate is less below the age of 20 than in the later periods of life, md that it is highest in patients above 60. Young children seldom die of the disease. It is not generally difficult to distinguish between a case of enteric fever and one of typhus. The main clinical distinctions are furnished : first, by the invasion, which is generally sudden in typhus, insidious in typhoid ; second, by the rash, which is abundant, general, and of nearly simultaneous origin in typhus, scanty and coming out in successive crops in typhoid ; third, by the abdominal symptoms, which in typhus are usually vague, but in typhoid comprise the discharge of liquid yellow stools, intestinal hemor- rhage, pain and tenderness in the ctecal region and tympanites ; fourth, by the temperature, which does not in typhus present the gradual rise with regular diurnal variations which are so characteristic of typhoid ; q2 228 SPECIFIC FEBEILE DISEASES. and, fifth, by the mode of conyalescence, which is by crisis and rapid in typhus, but slow and followed by long- continued debility in typhoid. Many other distinctions of secondary value might be adduced. But it must not be forgotten that all may fail us, and that the discovery of the typical intestinal lesions after death may alone reveal the nature of the case which has been under treatment. Morbid anatomy. — Enteric fever is always attended with characteristic anatomical lesions, affecting the solitary and agminated glands of the bowels and the mesenteric glands in direct relation with them. These lesions consist in an apparently simple hyperplasia of the glandular ele- ments, in \drtue of which the organs undergo rapid enlargement, and then either slowly subside, reverting to their normal condition, or midergo softenmg, suppuration, ulceration or gangrene. Under the microscope the lymphatic corpuscles are found to be mcreased in number ; and ft'e- quently hypertrophied or giant cells, containing groups of small corpuscles in their interior, may be discovered among them ; later on the cells get granular and fatty, and break down into a granular detritus. The morbid process appears to begin with the first symptoms of the patient's ilhiess ; at all events, it has been found well advanced m those who have died during the first few days. The intestinal lesions are in many cases limited almost entirely to the agminated glands, of which sometimes two or three only, sometimes all, are mvolved. These gradually swell until they form oval plates from a line to ^ inch thick, which present a tumid margin, a reticulated or foveated but oftener more or less mammillated and smooth surface, and a consistence which is sometimes softer but more often denser, though more ftiable, tlian natural. They generally attain their full development by the ninth or tenth day — sometimes a day or two earlier, sometimes a day or two later. And then they either undergo slow resolution or pro- ceed to ulceration. The latter process may commence ft'om the surface at nmnerous points, and thence gradually invade and destroy the whole of the diseased mass ; or, as more frequently happens, the patch sloughs at once m the greater part or the whole of its extent. The resultmg slough, which probably from bile-staming soon assumes a yellow or brown hue, becomes soft, spongy, and tumid, and separated by a line of demarcation from the still living tissues, and after a short time comes away either in mass or in successive fragments. The separation of the sloughs generally cccm-s between the fourteenth and twenty-first day, but may not be fully completed for another week. The resulting ulcer varies in character. Usually its form is oval, or round ; its margin thick and vertical, as if made by a punch, and congested ; its floor pretty smooth and formed of the submucous tissue. Sometimes, however, the edge becomes imder- mined, and then perhaps mtensely congested, and the floor irregularly excavated and flocculeiit, and formed partly of the exposed muscular coat, partly, it may be, of the peritoneal membrane only. Cicatrization does not usually begin before the end of the third week, and probably as a rule is completed in about a couple of weeks more. But the process may ENTEEIC FEVEB. 229 be delayed, either from mere sluggishness, or in consequence of a kind of phagedenic extension of the ulcer, or by other circumstances, and hence may not be accomplished under two or three months. The cicatrices rarely if ever lead to serious contraction. The typhoid process as it affects the solitary glands is precisely similar, excepting that the resulting tumours are much more numerous and much smaller — generally about the size of half a pea ; and that, On the one hand resolution without vilceration is more common, and on the other the ulcers which form are of insignificant dimensions and tend to heal more rapidly. The morbid process, whether it affect only the agminated glands or involve the solitary glands as well, is always most extensive and advanced in the ileum immediately above the ileo-cscal orifice ; whence in both of these respects it gradually diminishes upwards. The solitary glands are rarely affected to a greater distance than two or three feet above the valve ; Peyer's patches seldom above the lower half of the ileum. The disease implicates the solitary glands of the large intestine in about one-third of the fatal cases, and is always most advanced in the caecum, rarely extend- ing below the ascending colon. Perforation takes place only in those ulcers which have already destroyed the muscular wall. But when the floor is formed of peritoneum only, it sometimes hap|)ens that local peritonitis occurs and causes adhesion between the affected portion of bowel and some neighbouring organ, and thus averts the impending cata- strophe. The actual perforation may be due to the forcible separation of such adhesions ; but more commonly, probably, it is the result of the simple accidental laceration of the softened and unsupported serous cover- ing. It occurs in the great majority of cases in the lower two feet of the ileum ; but it has been met with at least six feet above the ileo-cfecal valve, and more rarely in the cfecal appendage or in the colon. The peritonitis which results is in the first instance always general ; but not unfrequently when the rupture is small and but little fsecal matter has escaped this latter and the suppuration which it necessarily excites are found after death to be strictly confined by adliesions to a very limited space. It is this tendency to limitation which gives an element of hope in the treat- ment of these cases, and to which the very few recorded recoveries after perforation are due. Sometimes the laceration is so extensive that large quantities of ffecal matter are discharged at once into the peritoneal •cavity. The mesenteric glands, especially those connected with the lower part of the ileum, enlarge from the beginning with Peyer's patches, and some- times attain the size of a walnut ; they become soft and vascular and. at the end of ten days or a fortnight undergo resolution, or soften, or sup- purate. Under the latter circumstances they not unfrequently dry up eventually ; sometimes, however, they induce peritonitis either by exten- sion of inflammation, or by rupture into the serous cavity. Most other lesions in enteric fever, such as bronchitis, pneumonia, and pleurisy, have no specific character, and need no description. The spleen, how- 230 SPECIFIC FEBEILE DISEASES. ever, is enlarged and congested; and it may be added that when the patient dies during the ulcerative stage of the fever, the contents of the bowels are generally peasoup-like, and the large mtestines inflated ^dth gas.. Dr. Klein's' inquiries show that the smaller typhoid growths do not originate exclusively in solitary glands, but that they often arise in the lymphoid tissue of the mucous membrane. He also shows that the typhoid process, whether taking place in the intestines or mesenteric glands, is attended with hyperemia of vessels, mcreased development of lymphatic cells, and the development from these of giant cells, not milike those of tubercle, and the rarefaction of the fibrous matrix. Further, he calls attention to the presence of a microscopical fungus in connection with the specific intestinal lesions. This is characterised by a distinct mycelial growth, by greenish spherical bodies two or three times as large as blood- corpuscles, and by micrococci or spores of extreme minuteness which occur singly or in couples, strings, or irregular clusters. The fungus exists on the surface of the mucous membrane and within the tubular glands, but it pervades the epithehum and is especially abimdant in the lymphatic spaces and channels, and in the small vems. Similar bodies are discoverable in the diseased mesenteric glands. Eberth also describes a particular form^of bacillus as occurring in the intestinal lesions, m the mesenteric glands and in the spleen, and regards it as the specific cause of enteric fever. Treatment. — Knowing as we now do the source whence the contagium-. of enteric fever enters the system, it becomes our duty, nor is it difficult,, to adopt suitable precautionary measures both against the contamination of water and atmospheric air, and agamst the exposure of persons to the influence of media thus contaminated. Whenever typhoid patients are under treatment their evacuations should be disinfected with carbolic acid, Condy's fluid, or chloride of lime, before they are emptied mto the sewer or cesspool ; and all articles of di-ess soiled by such evacuations should be similarly disinfected and washed. Water-closets and drains should be kept sound, clean, well flushed, and well ventilated, and all communications between drains and the interior of the house cut off by efficient traps. No water should be used for diinldng or culinary purposes which has been exposed to sewage-contamination; hence the water of superficial wells, especially if these be near cesspools or sewers, should be looked upon with grave suspicion, as also should the water derived from streams or ponds receiving drainage, and that from cisterns or butts com- municating by waste pipes with closet-di'ains. If such waters must be drunk, they should first be boiled and filtered. It must not be forgotten that milk, from the presence of water which has been fi-auduiently or otherwise added to it, has on many occasions been the vehicle for the com- munication of the disease. Many remedies have been employed for the cure of enteric fever ;. amongst others mineral acids, antiseptics (such as chlorme, hyposul- phites, carbohc acid and creosote) and emetics. Other remedies have ' Report of Medical Officer of the Privy Council, New Series, Xo. vi., pp. 80 et segi^ ENTEEIC FEVEE. 231 been used with tlie special object of reducing the fever — such are quinine in large doses (10 or 15 grains or more), salicylate of soda, actual refi'igeration, and bleeding. The last practice has properly fallen mto desuetude. The use of cold is often beneficial, especially in cases in which the temperature reaches or exceeds 104° ; it is best applied by means of baths, the temperature of which to begin with should be 10 degrees or more below that of the body, and then gradually reduced to about 68°, immersion being continued for about half-an-hour, or until the patient's temperature, as ascertained in the mouth or rectum, has become sensibly reduced, or shivering comes on. It is held that the reduction of the bodily temperature not only prevents the direct injurious urfluence of excessive heat, but arrests or modifies in a favourable sense the character- istic lesions of the disease ; and there are many physicians abroad, and some in our own country, who mamtain that by the habitual use of the cold or graduated bath in cases in which the temperature reaches 103° or thereabouts, the mortality of the disease is very largely reduced. If this treatment be adopted it should be begun early in the disease, and con- tinued for so long as the temperature tends to rise injuriously : the number of baths administered daily ranging from one. or two to seven or eight according to circumstances. Even if not used continuously, cold bathing may be had recourse to from time to time when the temperature becomes excessive. Our own experience (Avhich has not been very great) leads us to the belief that the persistent use of the graduated bath in this disease is attended with considerable risk, and especially that it is liable to induce fatal collapse and congestion of the lungs. Periodical sponging with cold or tepid water is probably always beneficial. But our chief aims m the treatment of enteric fever must be to guard against and prevent the many sources of danger which attend it, and to relieve symptoms as they arise. The condition of the bowels must be carefully watched, and under no circumstances must drastic purgatives be employed. There is no harm, perhaps, in giving a mild laxative, such as castor oil in small doses or rhubarb, during the first week of the disease and before ulceration has taken place, but even then it is generally suflicient, and on the whole certainly more safe, to employ eiiemata. Subsequently enemata only should be resorted to. When diarrhrea is present it should be restramed either by tannic acid, lead and opium, sulphuric acid, the compound kino powder, or some such remedy, or by opimn or morphia suppositories, or enemata. Trousseau, Dr. George Johnson, and others think that the diarrhoea should not be restrained, regarding it as a curative effort of nature ; that view, however, is not generally accepted, and is, we think, erroneous and dangerous. When hemorrhage from the bowels takes place, measures should be adopted to arrest it. Dr. Murchison has great faith in the use, under such circumstances, of turpentine, tannic acid, ergot of rye, or other forms of astringents. Hemorrhage occurring, how- ever, during the first ten or twelve days is of little importance, and does not usually call for treatment. For the prevention of perforation, the avoidance of purgatives, the arrest of diarrhoea, and the maintenance of a 232 SPECIFIC FEBEILE DISEASES. quiescent condition of the bowels, are of extreme importance ; it is further necessary to prevent the patient from using muscular exertion, and from taking articles of food likely to upset the bowels. If signs of perforation manifest themselves, our only hope lies in keeping the patient under the influence of opium or morphia— the dose and frequency of its administra- tion being determined partly by the patient's age, but chiefly by its effects. Tympanites may be benefited by the use of stimulating enemata or hot fomentations to the belly. Sickness may be relieved by the use of lime- water and milk, bismuth or ice, or by counter-irritation. Pulmonary complications should be guarded a;gainst by the maintenance of an equable temperature, and by the avoidance of draughts. When present they must be treated on general principles. The great tendency there is to the formation of bed-sores makes it very important to keep the patient scrupu- lously clean and diy, to take measures to obviate or relieve pressure, and, if precursory redness make its appearance, to anoint the part with some stimulating and protective application. The diet should consist of fluid and easily digestible food given frequently (every hour or two), and in small quantities. The best aliments are milk, gruel, barley-water, rice- water, and such like ; but arrowroot, sago, chicken-broth, beef-tea, and eggs are valuable. Stimulants are necessary when there is tendency to collapse, when typhoid symptoms are present, or when there is great debility. In many cases, however, though their administration in mode- rate quantities can do no harm, they are by no means absolutely needed at any period of the disease. Much care is necessary during convalescence. The great debility which endures so long demands the use of tonics, and an abundance of nutritious food. But the liability to perforation of the bowel (which may not cease until the end of two or three months) makes it specially impor- tant that the food should be easily digestible, and not of such a character as to derange the action of the bowels. For the same reason it is gene- rally a good rule not to administer solid food until the temperature has fallen to the normal, and has continued normal or sub-normal for a week. Moreover, the liability to the supervention of pulmonary inflammation and of tuberculosis renders exposure and fatigue particularly dangerous. Change of air is often extremely beneficial. XIX. EPIDEMIC CHOLEEA. {Asiatic or Malignant Cholera.) Definition. — An epidemic disease, of which the attacks are very severe and rapidly fatal, characterised by a copious discharge of watery fluid from the alimentary canal, suppression of the urine and other secretions, shrinking of the tissues, cramps, and extreme prostration. Causation and history. — Epidemic cholera has been kno^vn in India for centuries, and probably from time immemorial. It is seldom entirely absent there, but at regular intervals breaks out into wide -spread EPIDEMIC CHOLEEA. 233 •epidemics. The first Indian outbreak which specially interests us is that which, originating in the Delta of the Ganges in the year 1817, soon ravaged the greater part of Hindostan, and during the next ten or twelve years spread over nearly the whole of Asia, including the Burmese empire, China, Tartary, and Persia. In 1829 it commenced its progress through Tartary and Persia into Europe, and in that year it reached Orenburg. It then became temporarily arrested ; but subsequently took a fresh start, and still travelling slowly westwards it appeared in the spring of 1831 in European Eussia and Poland; and in October invaded Hamburg, Berlin, .and Vienna. In the same month cases were imported into Smiderland, and the disease remained endemic in this country for fourteen months. Having thus reached the north-western angle of Europe, the epidemic divided into two branches, one of which crossed the Atlantic and appeared in Quebec in 1832, thence diffusing itself over the North American con- tinent ; the other turned southwards, attacking successively France, Spam, Italy, and the Northern Coast of Africa. The disease did not finally leave Europe until the year 1837. Since the epidemic of 1817, numerous other epidemics have occurred in India, and several times the disease has slowly spread thence to Europe and to this comitry — not, however, always taking the same route as on the first occasion. The first British epidemic was that, above referred to, of 1831-32, the second occurred in 1848-49, the third in 1853-54, and the last in 1865-66. On each of these occasions the disease was distinctly imported into this •country by passengers or sailors coming direct from infected places, and its general prevalence was always preceded by local outbreaks in the seaport towns to which such infected visitors were admitted. The general history of these epidemics, so far at least as relates to England, has been that isolated outbreaks occurred in the autumn of the first year, that the ■disease died out with the approach of winter, and reappeared with extreme virulence in the later spring, summer, or early autumn of the second year, lasting for some two or three months, and then disappearing alto- gether. It might seem from this that its prevalence was largely de- termined by season ; and, indeed, there is strong evidence to show that ■on the whole high temperature is favourable, and cold inimical, to its spread. Yet, on the other hand, the disease has prevailed with the greatest severity in Moscow, Sweden, and other northern regions in the •depth of winter. To what cause or causes is epidemic cholera due ? This is a question which has been the subject of innumerable discussions and investigations during the last fifty years. The horror which the disease occasions, the slowness yet certainty of its onward march, its sudden and capricious out- breaks, and its equally capricious subsidence and then total disappearance, all conspire to invest it with an atmosphere of mystery. Like influenza, it is the very type of an epidemic disease ; and therefore, like epidemic disease generally, has been largely held to be due to some atmospheric or telluric condition, some peculiar ' epidemic constitution ' which, diffus- ing itself from country to country, gives to the prevailing maladies a 234 SPECIFIC FEBEILE DISEASES. choleraic character, and produces where local circumstances are favour- able an outbreak of the fully-developed disease. There is much to be said, no doubt, in favour of this view ; but the questions then naturally arise — ' On what does this epidemic constitution depend ? ' and ' What are the local conditions which favour its operation ? ' These questions are not easy to answer. We may pomt out, however, as bearmg on them : that, although heat and climate have (as has been stated) some influence over the propagation of the disease, there is no good reason to believe that moisture or drought, or excess or deficiency of electricity or ozone, affects it either one way or the other ; that, according to Pettenkofer, localised outbreaks of cholera are determined in great measure by pecu- liarities of soil — the ground must be porous and a superficial layer of it unoccupied by ' ground water ' and penetrable by air ; that, as shown by numerous observations, the disease is much more apt to prevail in low- lying districts than in those which are much elevated above the sea ; and. that vegetable fungi, which have been detected by numerous observers in cholera-stools, have often been assumed to pervade the atmosphere and to be the specific cause of cholera. These latter have been specially investigated by Hallier, who recognises in the stools and vomit a form of urocystis, consisting partly of membranous spore-cases containing yellowish or brownish spores, and partly of cells of extreme minuteness which he believes to have been developed within these spores. This fungus he has cultivated in various ways ; and he believes that he has obtained from it forms of penicillium, mucor, and the Hke, all of which he regards as polymorphous conditions of it. This particular fungus, however, has certainly not been recognised by most others who have been engaged in similar investigations. Lastly, in relation to the subject now under dis- cussion, it may be pointed out that cholera has often been attributed to the accidental or designed poisoning of sprmgs, and to the use of diseased cereals, especially rice, and even of unripe fruit. Again, in favour of the dependence of cholera on some miasm or epidemic constitution was the striking fact that, although cholera affected large numbers of persons within a short time, there was little evidence of its communicability by direct contagion. It was noticed, and has been constantly observed, that nurses and medical attendants seldom, if ever, take the disease from patients under their charge, and that the introduc- tion of cholera patients into a general hospital is by no means necessarily followed by the communication of the disease to other patients. Nevertheless, it has always happened that the spread of cholera epi- demics has followed lines of traffic, showing that human intercourse, not winds, has been instrumental in their propagation. In every invasion of this country, the disease has first been distinctly imported into our sea- port towns by the arrival thither of infected persons from infected locali- ties ; and has been thence carried by like means to other localities in direct relation with them by railways or other lines of traffic, and has thus gradually become distributed throughout the country, not generally, but by local outbreaks. The fact that cholera, though obviously not EPIDEMIC CHOLEEA, 235 directly contagious, or at all events not directly contagious in a high degree, yet had some mysterious relation with the movements of mankind, and never broke out in any isolated country or town without having been distinctly imported into it by human agency, was manifestly opposed to most of the theories of its causation which have been previously referred to and had generally prevailed. Dr. Snow, now some years since, first shrewdly suspected that the cholera contagium was contained m the cholera evacuations, and that the disease was propagated by the entrance of minute quantities of such evacuations, for the most part through the medium of contaminated water, into the alimentary canal. And nume- rous subsequent investigations, some of the most remarkable being con- ducted by himself, have entirely confirmed the correctness of his pre- vision. The matter is so important that we may quote some of the best established and most striking cases. The cholera epidemic of 1849 was specially severe in the south of London, which was supplied with drinking-water mainly from surface wells and by two water companies, the Southwark and Vauxhall and the Lambeth, which derived their water from the Thames (the one in the neighbourhood of Hungerford Bridge, the other in that of Battersea Fields) and supplied it in a very im_perfectly filtered condition. At that time all the sewers of London discharged themselves into the Thames, the water of which was consequently very foul. The cholera epidemic of 1854 also was very severe in South London. But between 1849 and 1854 the Lambeth Company had removed its intake from Hungerford Bridge to Thames Ditton, and consequently furnished an infinitely purer water than it had done in 1849 ; the other company continued to draw its water from the neighbourhood of Battersea Fields. At this time the two companies were acting in rivalry, so that in many streets their mains ran side by side, and houses, under the same sanitary conditions in other respects, received a different water supply. A careful investigation of the distribution of cholera in South London in this year, conducted mainly by Dr. Snow but with the assistance of the Eegistrar- General, gave the following results : — Population in Cholera Deaths Cholera Deaths 1851 in 14 weeks per 10,000. Houses supplied by Southwark Co. . 266,516 4,093 153 „ Lambeth Co. . 173,748 461 26 The facts were even more remarkable when examined in detail, inasmuch as in streets and localities which both companies supplied the disease singled out the houses furnished by the Southwark Company. During the same epidemic a remarkable outbreak occurred within a limited area, in the neighbourhood of Golden Square, London, the facts of which were also examined into by Dr. Snow. There had been a few cases in the neighbourhood during the month of August, including- altogether up to the 30th nine deaths. On the 30th at least eight cases which ultimately proved fatal occurred ; on the 31st, fifty-six ; on Sep- tember 1st, one hundred and forty-three ; on the 2nd, one hundred and 236 SPECIFIC FEBEILE DISEASES. sixteen ; on the 3rd, fifty-four ; and then daily until the 9th, forty-six, thirty-sis, twenty, twenty-eight, twelve, eleven ; after which the disease rapidly disappeared. No less than six hundred and sixteen persons were ascertained to have been attacked fatally with cholera within this area between August 19th and September 30th, of whom at least four hundred and fifteen contracted the disease between August 31st and September 4tli inclusive. It would take much more space than is at our disposal to enter fully into details ; suffice it to say that Dr. Snow's investigations proved beyond the shadow of a doubt that this sudden and evanescent outbreak was distinctly due to the use of the sewage-contaminated water •of the Broad Street pump, occupying the centre of the affected area, the w^ater of which was held in great repute, and was largely drunk by those who lived in its neighbourhood. Again, the epidemic of 1866 was remarkable in the fact that it was almost limited to a circumscribed area in the East of London, includmg Bethnal Green, Whitechapel, St. George's, Stepney, Mile End, and Poplar, together with the suburban districts of Stratford and West Ham. The inquiries of Mr. Eadcliffe, conducted under the direction of the Medical Officer of the Privy Council, demonstrated with almost mathe- matical precision that the localisation of the epidemic was almost en- tirely due to the distribution to these districts of impure and unfiltered water by the East London Water Company. It must be assumed therefore as a fact that the choleraic poison, at all events in a large number of cases, is conveyed through the medium of foul drinkmg-water, and necessarily, therefore, by means of all articles of food or drink to which such water is added. But it still remains to ask — ' How does the poison reach the water, whence does it come, and what is it ? ' It would naturally be supposed that the choleraic poison is con- tained in the cholera stools ; and indeed there is plenty of evidence to show that the drinking of water directly contaminated with small quanti- ties of rice-water evacuations has induced cholera ; and, as regards the local outbreaks above adverted to, it is certain that the incriminated waters were contaminated with sewage, and that there was at least the probabiHty that that sewage contained the evacuations of cholera patients c But, on the other hand, there is good reason to believe that the freshly passed stools are not specifically noxious. Much, however, of what seems mysterious in reference to these matters appears to be explained by the important experimental inquiries first conducted by Professor Thiersch, and since repeated by Dr. Sanderson in this country. The experiments which yielded the most striking results were those performed on mice. It was ascertained by these gentlemen that when, under cer- tain conditions, mice were fed with cholera evacuations, they were attacked with symptoms which proved rapidly fatal, and that both symp- toms and post-mortem appearances had a very close resemblance to those ■of human cholera. The chief points of likeness consisted in the rapidity and intensity of the disease ; in a remarkable lowering of the tempera- ture (sometimes as much as 20 degrees) ; in the accumulation in the in- EPIDEMIC CHOLEEA. 237 testines of thin fluid containing bacteria, other lowly organisms, and abundance of shed epitlielia ; and in the discharge of loose stools from the anus. The method adopted by Dr. Sanderson to infect the mice was to soak pieces of tilter-paper in fresh cholera evacuations, or in the con- tents of the bowels of patients dead of cholera, to dry them, to ascertain by weighing the quantity of solid matter thus added to them, to cut them into pieces an inch square, to soak them in bacon fat, and then to ad- minister them to the mice. The mice under these circumstances ate them greedily. The consequences were : that of mice fed with paper prepared from evacuations, which had not been allowed to stand more than twenty-four hours, or on the first day after passing, 11 per cent. were affected ; that of those fed with paper prepared on the second day, 36 per cent. ; that of those fed mtli paper prepared on the third day, every one ; that of those fed with paper prepared on the fourth day, 71 per cent. ; and that of those fed with paper prepared on the fifth day, 40 per cent. Paper prepared subsequently had no effect. These experi- ments show : that the cholera evacuations have little or no intensity of action when perfectly fresh ; that their virulence increases up to the third day, diminishing during the fourth and fifth days ; and that they lose all specific properties after that date. The evacuations from the diseased mice produced the same effects on healthy mice as did true cholera evacuations ; and, further, all experi- ments made by Dr. Sanderson in the month of November failed abso- lutely, probably, as he suggests, on account of the low temperature then prevailing. The application of the above results in explanation of the pheno- mena connected with the causation of cholera is obvious. And it is fair to conclude from them, and from the other facts which have been ad- duced : that the specific poison of cholera is furnished by the discharges from the alimentary canal ; that these are not operative when completely fresh, but acquire virulent infectious properties in the course of the following two, three, four, or five days, and subsequently lose them ; that the poison of the disease is taken up by, or acts upon, the mucous mem- brane of the bowels, which it reaches through the mouth ; and that, while undoubtedly it may be conveyed to the mouth under uncleanly circumstances from saturated bedclothes, and direct contamination of culinary utensils, food, or fingers, larger outbreaks of the disease are due to the infection of drinking-water (well, pond, or river) with cholera poison derived from cesspools, sewers, or other such sources. There can be little doubt, from the fact of its active powers of multi- pHcation, that the cholera poison is an organised contagium ; that one phase of its normal active existence is passed externally to the body ; but that that phase is commonly of short duration, and probably readily arrested or rendered imiocuous by cold and other agencies. Symptoms and iirogress. — The duration of the incubative stage of cholera is not known certainly. It probably varies generally between a few hours and three days. The symptoms of invasion present consider- ^38. SPECIFIC FEBEILE DISEASES. able variety. In some cases an indefinable feeling of malaise, associated with noises in the ears and lowness of spirits, precedes all other symp- toms. In a large proportion of cases (either in succession to the above phenomena or arising independently) there is more or less looseness of bowels (premonitory diarrhoeaj coming on a few hom's, a day, or even two or three days, before the nature of the disease is distmctly revealed. Premonitory diarrhoea of even longer duration has not unfi-equently been observed ; but in most such cases there is reason to suspect that the rela- tion of the diarrhoea to the subsequent attack of cholera was accidental only. Lastly, in some instances the invasion of cholera is sudden. Omitting the premonitory symptoms which have just been considered, the first indication of an ordinary attack of cholera usually consists in the sudden and uncontrollable evacuation {with or without pain) of an abruidant loose stool, composed mainly of the proper contents of the .alimentary canal in a fluid or semi-fluid state. To this succeeds a con- tinuous or intermittent flux of fluid, at first bile-stained, but subsequently thin, colourless, or opaline, without f^cal look or smeU, and containing in suspension whitish flocculi. The amount of fluid thus discharged is sometimes enormous ; four or five pints, or enough to fill a chamber-pot, may be passed in the course of an hour or two. Sickness for the most part attends the diarrhoea, but generally comes on a little later. The matters first vomited are the ordinary contents of the stomach and of the duodenum ; but after these have been got rid of, the vomited fluid exactly resembles that which is flowing simultaneously from the anus, and may be almost as abundant. Shortly after vomiting and diarrhoea have be- come established, severe cramps, attended with agonising pain, come on in the thighs and calves, in the arms, hands, feet, and parietes of the abdomen. And very speedily the patient falls into a state of extreme collapse — the so-called ' cold ' or ' algide ' stage ; his tissues shrink ; his fingers and toes get shrivelled and corrugated, and his eyes sink into their sockets ; his surface becomes more or less notably livid, and some- times as blue as that of a cyanotic patient — this change bemg specially noticeable in the hands, feet, cheeks, lips, around the eyes, and in the tongue, which looks like a piece of lead ; his respirations are rapid and shallow, and his voice hoarse or squeaking, feeble, and reduced almost to a whisper ; his pulse gets rapid and thready, and soon scarcely, if at all, perceptible at the wrist or even in the brachial artery. At the same time his temperature falls ; his surface becomes cold and clammy, and sometimes covered with cold sweats ; and his tongue and breath also get manifestly cold. The temperature in the mouth and axilla falls rapidly to 95°, 94°, or even 92° ; and much lower temperatures than these have been recorded. But while the general temperature, and especially the surface temperature thus falls, that in the rectum and adjoinhig parts may stand at 101°, 102°, or even 105°. The urinary and bihary secre- tions are totally suppressed. The patient is wakeful and restless, throw- ing his arms about, probably complaining much of intense thirst and burning at the chest, but withal singularly apathetic. When the con- EPIDEMIC CHOLEEA. 239 ■dition of collapse is fully established the vomiting and diarrhcea either ■cease completely or greatly diminish, and the patient lies ghastly and livid like a corpse, with eyes open and pupils dilated, torpid, yet still retaining his senses. During this period the muscular power is ex- tremely enfeebled ; yet occasionally the apparently moribund patient will rise up in his bed, and even get up and walk across the room. The duration of this stage varies from two or three to thirty hours or more, and then ends in death, secondary fever, or convalescence. Death, in ■collapse, sometimes occurs in the course of two or three hours ; more frequently supervenes after the eighth hour — especially between the tenth and fourteenth ; but is seldom delayed beyond the twenty-fourth. The symptoms above described are not all developed in every case of cholera. The muscular cramps are sometimes altogether wanting ; while in some cases, and these perhaps cases of no great severity, they are con- stant and agonising. Again, vomiting and diarrhoea are not invariably present ; and indeed their absence is almost characteristic of some of the most formidable attacks of the disease — those, namely, in which the patient is suddenly struck down with symptoms of extreme collapse, and dies in the course of an hour or two, or less. In those patients who survive the period of collapse a gradual change •of symptoms supervenes. The stage of reaction sets in. This stage is said to be often wanting in the cholera of hot climates. In our own country, however, it is always present ; but its duration, and the severity of its symptoms, depend very largely on the intensity and duration of the cold stage which preceded it. It generally comes on between the twelfth and the thirtieth hour after invasion. Its first indications are slight and vague. A general improvement is visible in the patient ; he becomes less restless, his breathing slower and more natural, his pulse just per- ceptible at the wrist ; the lividity of surface slowly disappears ; the shrunken tissues expand ; the temperature rises ; perspiration breaks out ; and not improbably he falls into a comfortable sleep ; urine begins to be secreted ; and the motions are again stained with bile. The tem- perature, however, generally rises somewhat above the normal, and more or less obvious febrile disturbance takes place. In some cases the reac- tionary symptoms remain mild and end in convalescence in from twelve to twenty-four hours ; but more commonly they undergo aggravation, and may then be prolonged (unless cut short by death) to between four and twelve days, sometimes longer. The general symptoms have some resemblance to those of enteric fever ; the face becomes flushed, the eyes injected, the skin hot and sometimes studded with roseolous patches, the pulse increased in power and volume and accelerated, the respirations a little more rapid than natural, the tongue furred, sometimes dry and brown, and the temperature one, two, or three degrees above the normal ; the patient may also present more or less delirium, or lie in a torpid or comatose condition. The motions, according to Dr. Sutton's observa- tions, often consist on the first establishment of reaction of a thin, yellowish fluid, which looks like, and may be mistaken for urine, and 240 SPECIFIC FEBRILE DISEASES. often contain a kind of gelatinous substance ; but soon they get green from contained bile, next peasoup-like, and then, consolidating, gradually acquire the normal character. Occasionally, early in the stage of reac- tion, the stools contain blood — the quantity varying from a mere trace, just sufficient to impart to them a pale pink tinge, up to a flux sufficient to undergo very complete coagulation. The stools of the reactive period are often very fetid. The re-establishment of the urinary secretion is a most important element in the progress of the disease. In mild cases it sometimes takes place in twelve hours or less ; but it is more common on the second or third day, and may be delayed until the fourth, fifth, or sixth day. The urine first passed is in extremely small quantity, and often, during the first twenty-four hours, remains far below the healthy average. Subsequently the patient may pass four, five, or six pints daily. At first it is a little turbid, contains traces of albumen, casts of the urinary tubules, and epithehal cells from other parts of the urinary passages, but presents a very small amount of urea and uric acid, as also of chlorides, phosphates, and sulphates. The colour varies. Sub- sequently, while during the progress of fever the urine becomes more copious, the amount of urea in it increases, and may even exceed the healthy standard. Urocyanogen is sometimes found in the urine. The causes of death in the stage of reaction, and the phenomena which precede it, present considerable variety. Sometimes cough and difficulty of breathing, with pulmonary engorgement or consolidation, carry the patient off. At other times he seems to sink mider the con- tinuance of intestinal flux, especially when hemorrhage accompanies it ; or symptoms much like those of enteritis supervene. In some cases con- vulsions, coma, or other cerebral symptoms, which there is good reason to believe are not mifrequently due immediately to ursemic poisonmg, precede and apparently cause death. Lastly, the patient sometimes sinks from mere asthenia, arising directly out of his primary symptoms, or supervening on his typhoid condition. In the description of cholera above given we have adverted to some of the varieties which its attacks present. Especially we have pointed out, or incidentally mentioned : that in some cases the patient is struck down by the disease, and dies in extreme collapse at the end of perhaps two or three hours, without ever having passed an evacuation ; that in a still larger number of cases the characteristic vomiting and diarrhoea are pre- sent, the stage of collapse gradually supervenes, and the patient dies in this stage at the end of from (say) ten to twenty-four hours ; that in many cases again, even of considerable severity, the patient emerges from the condition of collapse into one of febrile reaction, during which he may perish in one of the modes above enumerated, or from which he may glide into convalescence ; and,, lastly, that in some cases, notwith- standing the presence of rice-water stools and other quite characteristic signs of the disease, the patient scarcely becomes collapsed at all, and very speedily regains health and strength. This enumeration leads up to the important questions, as to how far cholera may be so mild as to simu- EPIDEMIC CHOLERA. 241 late ill its attacks mere summer or autumnal diarrhoea, and how far also it is possible that the latter which (in this comitry, at all events) concurs with the epidemic prevalence of cholera is influenced by the choleraic poison. As to the former question, there can be no doubt, we think, that, just as enteric fever, tyx^hus, scarlatina, and other like affections are sometimes so mild and shghtly developed as to be (except it may be from associated circumstances) mcapable of identification, so cholera may be so mild and so shorn of everything characteristic as to be unrecognis- able as cholera ; and hence that cases of undoubted cholera may simu- late, and be taken for, cases of ordinary unspecific diarrhoea. As to the latter question, it may be remarked that those who regard cholera as being the outcome of some ' epidemic constitution ' of the atmosphere, or of some all-pervading miasm; might reasonably believe that all morbid conditions tend during the prevalence of cholera to take on a choleraic character. Those, however, who believe the choleraic poison to be a form of contagium, and accept those views of its operation which we have endeavoured to uphold, would necessarily discredit its general in- fluence, excepting in the face of overwhelming evidence in favour of the existence of such influence. But no such evidence, we think, exists. It seems to us, uadeed, a fundamental and mischievous error to regard the diarrhoea which precedes and accompanies epidemics of cholera as having any other than a fortuitous connection with them. The mortality of cholera is very great ; it varies in different countries and in different epidemics, but m round numbers may be estimated on the average at about 50 per cent. It is said to be less fatal towards the close of an epidemic than at its commencement ; and further to be more fatal to the very young and very old than to those whose age lies between these extremes. Any affections attended with sudden and extreme collapse, especially if there be at the same time gastro-intestinal disturbance, may be mis- taken for cholera. Among those most liable to be thus confounded are arsenical poisoning, and poisoning by croton oil ; severe summer cholera ; perforation of the stomach or bowel ; extensive enteritis ; and the onset or cold stage of severe remittent fever. Morbid anatomy and pathology. — The appearances found after death from cholera differ according as death takes place in the stage of collapse or in that of reaction. In the former case, the body retams much of the shrivelled character and hvidity which it presented during life, and the dependent parts are often deeply congested. The muscles not unfre- quently contract for some little time after death, causing movements of the limbs ; and for the most part rigor mortis is well marked and pro- longed. The tissues of the body are preternaturally dry, the muscles firm and dark-coloured, and the systemic veins loaded with blood which is manifestly thicker and perhaps darker than normal. For the most part the serous cavities are empty of fluid and their surfaces sticky to the feel, and they not unfi'equently present subserous petechial extravasations. The right cavities of the heart are always full of dark-coloured, imper- 242 SPECIFIC FEBEILE DISEASES. fectly coagulated blood. The left ventricle is sometimes firmly contracted and empty, sometimes contains a little fluid blood or clot. The left auricle also presents a small quantity of blood, The lungs are usually much diminished in weight, pale, anemic, and dryish on section. Some- times, however, they are congested and cedematous below, and they may even-be congested and oedematous throughout. The pulmonary arteries are usually gorged with blood, the veins nearly or quite empty. The liver presents no decided departure from health, and the gall bladder is full of bile. The spleen generally is reduced in size. The outer surface of the bowels is often injected or of a diffused rosy tint. Their mucous membrane is sometimes of a nearly uniform pink tinge, increasing in intensity towards the csecum ; or it may present irregular patches of con- gestion, with submucous extravasations ; or it may be quite pale. It often exhibits a corrugated and sodden appearance ; and the solitary and Peyer's glands are for the most part enlarged. The contents are an opaline or gruel-like fluid, which is sometimes white, sometimes pink from admixture with blood. The mucous lining of the stomach is often congested and mammillated, and the contents generally resemble those of the bowels. The kidneys are congested on the venous side, so that the medullary portions and the superficial veins are mjected, while the cor- tical substance remains more or less pale. The urinary bladder is firmly contracted, and empty or containing a little pus-like fluid. The brain presents numerous puncta cruenta. IP death occurs during reaction, the tissues are found moist ; blood occupies, perhaps in equal degree, both sides of the heart, and not mifre- quently thick fibrinous coagula are prolonged thence into the aorta ; the lungs are congested and oedematous ; and the contents of the intestines present the appearance of pea-soup. Besides which changes pneumonia is sometimes met with, sometimes distinct inflammation of the intestinal mucous membrane. Other pathological facts of great interest have been ascertained with respect to this disease. Although, as has been stated, the blood is inspis- sated, it is not by any means so much so as is commonly beHeved ; but (according to Dr. Thudichum) it is more adherent to the blood-vessels than natural. The proportion of albumen and salts to its other solid constituents is diminished ; and the white corpuscles are often increased relatively to the red. The rice-w^ater fluid, as found in the intestines, is alkaline, in a state of rapid decomposition, evolves gases (chiefly nitrogen and carbonic acid), and contains, besides bacteria, shed epithelium in abundance, mucine, albumen, and also butyric acid, acetic acid, ammonia, leucine, and inorganic salts. It does not, however, contain urea. There is no doubt that after death the mucous surface of the bowels is found to have lost its epitheHal covering, which is thrown off in flakes and sus- pended in the intestinal contents. But it is uncertain whether this is merely a post-mortem change or a lesion occurrmg during life. It is probaijly the latter, however, for there appears to be a similar tendency to shed the epithelium in almost every other part in which epithelium EPIDEMIC CHOLEEA. 243 exists, especially in the bladder and urinary passa.ges, in the bronchial tubes, and in the ducts of the liver and salivary glands. Dr. Thudichum's observations show that during the period of collapse the blood and the tissues contain very little urea, but that its quantity increases during the period of reaction, and soon, if urine be not secreted, becomes excessive. It remains briefly to discuss the relations between the post-mortem appearances and the vital phenomena of the disease. It is obvious that we here have an affection which is characterised primarily and mainly by a sudden and profound impression on the mucous surface of the ali- mentary canal ; in dependence on which, active destructive changes take place (as evidenced by the raised temperature of the parts) and large' quantities of imperfectly filtered blood, with tendency to rapid decomposi- tion, are poured forth with sudden impetuosity. This rapid and profuse discharge tends to cause inspissation of the circulating blood, and conse- quently indirectly, but very thoroughly, to drain the tissues of their inter- stitial fluid, and to cause them to shrivel up. Anasarca, indeed, if present, becomes thus temporarily cured. The absorption of extra-vascular fluid into the blood-vessels tends, of course, to maintain the fluidity of the blood ; but, notwithstanding this, the blood almost invariably becomes thicker than natural, and less easy of transmission through the minuter vessels. On these conditions follow : contraction of all the smaller arteries, excepting, probably, those connected with the bowels; general failure of the circulation ; arrest of normal destructive changes, and therefore of formation of urea ; arrest of urinary, biliary, and salivary •secretions ; and diminution of the normal action of the lungs, with cyanosis, lowering of temperature, and generally collapse. All the above phenomena flow directly or indirectly from the eftects of the cholera poison. But how and where does the poison act ? Some believe that it acts simply on the intestinal mucous membrane as a violent local irritant, just as croton oil or elaterium acts, and that all the symptoms which ensue are the result of this irritation of the mucous membrane and of the ■ discharge which takes place from it; and there is no doubt that symptoms almost identical with those of cholera may be produced by the local action of irritants and irritant purgatives. But if it be true, as it seems to be, that the fcetuses of mothers dying of cholera themselves give clear indica- tions of being aflected with the disease, it is clear that the poison must be diffused throughout the system in addition to being contained in the ;:alimentary canal. And, indeed, it is most consonant with all we know of similar diseases to regard cholera as a systemic affection. But whether we are therefore to assume, with Dr. George Johnson, that the choleraic yirus is contained in the blood ; that by its presence there it causes cramp of the voluntary muscles on the one hand, and of the capillary arteries of the lungs on the other, so as to prevent the passage of blood through them ; that the general collapse, loss of temperature, and suppression of secretions are due to this mechanical obstruction ; and, lastly, that the discharge from the bowels is an effort of nature (which should be en- "Couraged) to eliminate the poison from the blood, is quite another matter. E 2 244 SPECIFIC FEBRILE DISEASES. We confess that, in our view, the intestinal flux is not eHminative, but connected, as is the eruption of small-pox, with the local growth and multiplication of the poison ; and that there is ample explanation in the processes going on in the bowels of nearly all the subsequent phenomena of the disease, including collapse. It is obvious, however, that the pre- sence of inspissated blood in the vessels, the drying up of the moisture of the tissues, the contraction of the smaller branches of the pulmonary artery (assuming it to take place), must all co-operate to maintain the patient in the condition of collapse. Treatment. — The value of precautionary and hygienic measures in 'preventing or limiting the outbreak of cholera has never been better shown than in the history of our own epidemics. Pure water, well filtered, and carefully guarded from fscal contamination ; thorough domestic clean- liness ; and, when cholera is present, the immediate disinfection by car- bolic acid or Condy's fluid of all evacixations, and contaminated articles, are conditions of the utmost importance in preventing the spread of the disease. The medicinal treatment of cholera resolves itself into that of the prodromal stage, that of the period of collapse, and that of the stage of reaction. It is commonly beheved that the treatment of the premonitory diarrhoea is a matter of vital importance to the patient ; and the assump- tion that the diarrhoea, which so often prevails when cholera is epidemic, is actually cholera, or simple diarrhoea modified by choleraic influence, has led to a general belief in the importance of treating at such times all diarrhoeal cases with the object of preventing their development into the graver malady. But mifortunately, while the majority of physicians laud astringents for this purpose, others prefer castor oil, and aU refer to statistics in proof of the efficacy of their respective modes of treatment. We have asserted our o^m behef that, if a case be one of simple diarrhoea, it will not run on to cholera under any form of treatment ; and we may add that, if the case be one of commencing cholera, there is no more ground for believing it can be cut short than for believing that typhoid fever or hooping cough can be cut short. We do not believe that either castor oil or astringents have any such influence. In the period of collapse all sorts of remedies have been adopted ; some have given calomel in large doses, some opium, some brandy, some castor oil ; but it seems clear that drugs administered by the mouth must in such cases be inoperative. And this is certainly the opinion of nearly all except the enthusiastic supporters of some special di'ug. During this stage the patient should be kept in the horizontal position ; he should be allowed cold or ice-cold water to relieve his insatiable drought ; and his surface should be kept warm by the appHcatioii of hot bottles or flannels, or by friction. The placing of the patient in a bath, two or three degrees above blood heat, is often very comforting and apparently of much service. The vapour bath is equally beneficial. It is in this stage that the injection of saline fluids into the veins has been so frequently tried, and occasionally with success. The immediate eftect of the injection is HYDEOPHOBIA. 245 ■often marvellous, the moribmid patient regains his healthy appearance, his respirations, pulse, and voice resume their normal characters, and he sits up in bed conversing cheerfully. But the improvement is generally • of short duration ; he falls agam into collapse, and probably dies. The solution employed should resemble as nearly as possible the serum of the blood, and should be injected slowly and cautiously, in quantities varying, accorduig to its effects, between 10 oz. and one or two pints. Schmidt recommends the following : — chloride of sodium 60 parts, chloride of potassium 6, phosphate of soda 3, carbonate of soda 20 ; of which mixture 140 grains are to be dissolved in 40 oz. of distilled water, and filtered. The temperature of the fluid as it enters the veins should be a little over that of the blood. Cramps may be relieved by hiction, or the inhalation of chloroform. Great care must be taken of the patient durmg the reactionary stage. He should be kept cool. Diarrhoea and vomiting must be restrained : the former by astringents, such as Dover's powder, compound kino powder, or the aromatic powder of chalk and opium ; the latter by lime-water, bismuth, and the like, or the use of ice or the application of counter- irritants. The food should be fluid, nutritious, and mistimulating : milk, broth, arrowroot, sago, barley-water, and eggs are the most appropriate. It is questionable whether stimulants are beneficial. If resorted to they should be given m small doses much diluted. It is of essential importance that the urinary secretion be restored, but it is unwise to employ stimulant dim'etics for the purpose. Saline eftervescents may relieve sickness and at the same time promote urine. Cupping glasses and counter-irritation to the lumbar region are believed to be serviceable. If dysenteric or ■enteritic symptoms come on, opium must be freely used. XX. HYDEOPHOBIA. (Babies.) Definition. — A disease special to dogs, wolves, foxes, and animals closely related to them, among which it spreads by direct contagion, and from which it is imparted (but by moculation only) to other animals and to human beings. Its most characteristic features in man are the spasms and terror which are induced by the attempt to swallow fluids, or even by the thought of swallowing, and its invariably and rapidly fatal issue. Causation and history. — There is no evidence to show that this disease ever arises spontaneously among dogs any more than small-pox does among men ; and, fm-ther, there is reason to believe that it spreads .among them by inoculation only, or rather, perhaps, by the introduction of the sahva of diseased animals into the tissues of those which are healthy, by whatever process that introduction is effected. The cause of the disease is evidently a specific virus which resides mainly in the viscid secretions furnished by the mucous membrane of the mouth and fauces and by the salivary glands. The prevalence of rabies, like that of other 246 SPECIFIC FEBEILE DISEASES. infectious diseases, varies very greatly at different periods ; sometimes ifc is scarcely seen for many years together, at other times it prevails widely ia an epidemic form. The circumstances on which these differences depend are obscure ; for climate, season, dearth of water and of food, and other such conditions, do not seem to have any influence over it. It is important, however, to know that the virus never inoculates when it is apphed to the sm-face of the sound skin ; and that only a small proportion of those who are bitten by rabid dogs become hydrophobic. This propor- tion has been variously estimated at fi'om 5 to 50 per cent. One main reason doubtless of the immunity, which so many who are bitten enjoy, is the fact that they are wounded through their clothes, and that the fangs are thus cleansed from all moisture before they enter the skin. Symptoms and progress. — After a man has been inoculated with the saliva of an animal suffering from rabies, the wound in most cases heals as readily and quickly as a wound not so inoculated would heal ; at all events, there is nothing in its x^rogress to indicate the existence of any- thing unusual. A period of latency follows, which is generally remarkable for its long duration. Li most cases the first symptoms show themselves between the fourth and eighth week, but they have appeared in the course of a few days, and have been delayed for months, and even it is asserted for several years. They rarely, however, appear after four months. The outbreak of hydrophobia is in some cases preceded for a day or two by heat, tmgling, or pain at the part on which the injury was uiflicted, the pain sometimes being intense and extending upwards in the course of the sensory nerves. There is occasionally also renewed inflammation and suppuration or ulceration. In many cases, on the other hand, no such phenomena present themselves. The period of invasion, which is sometimes termed the melancholic stage, is attended with a variety of symptoms, most of which have no particular significance, and which gradually merge in those of the fully developed disease. The patient complains of feverishness and shivering,, with dryness of mouth and thirst, want of sleep, epigastric uneasiness, and mdefinable anxiety. He is pale, anxious, but distraught in his aspect, with restless eyes and dilated pupils, restless and fidgety in his movements, garrulous, but speaking m short sentences and in a jerky, abrupt manner. He suffers also from uicreased frequency of the heart's action and loss of appetite, perhaps nausea and vomiting ; and not improb- ably has even now some feeling of constriction about the fauces with a disinclmation to swallow fluids, quickened and sighing respiration, general hyperaesthesia, and a tendency to priapism and seminal discharges. At the end of two or three days the next stage has become fully deve- loped. This is sometimes termed the stage of excitement, and in it the disease assumes all its typical features. The strange agitation of the patient has become more marked ; his eyes are bright, mobile, wild, and glance with suspicion or terror about him ; his hair is rough, his skin pale, his brow contracted, his aspect indeed closely resembles that of a patient with acute mania ; he is still inclined to be talkative, fi'equently making. HYDKOPHOBIA. 247 odd but pertinent remarks ; he is probably quite sensible, and capable of understanding and reasoning ; at the same time he is obviously under the domination of some indefinable but great horror ; and occasionally perhaps he has hallucmations, and is liable to outbreaks of violent maniacal excite- ment m which he may endeavour to mjure himself or others. The thirst has increased ; his mouth and fauces are congested and dry ; and a quan- tity of tenacious saliva accumulates, which he is constantly hawkmg up and spitting about him T\dth a noise which has often befen taken for a bark. But, above all, the disinclination to swallow fluids has now become an almost perfect mability to swallow them, and a dread of makmg the attempt. He will still perhaps resolutely try to drink, will take the glass of water in his hand, prepare himself with strange calm and dehberation to make one supreme effort, put the vessel hurriedly to his hps, make a sudden gulp, and then, with or without swallowing a little of it, eject the bulk of it spasmodically and violently from his mouth and throw the glass away. A conviilsive attack has been induced, marked by general tremors or shuddering, and violent spasmodic action of the muscles of deglutition and respiration, which lasts for a few seconds, and leaves the patient for a mmute or two in a state of pamful agitation. The fear of the recurrence of these terrible con\-ulsions is constantly before him, and their actual recurrence is soon induced, not merely by the attempt to swallow, but even by the sight or sound or thought of fluid. The general hyperesthesia, which has already been adverted to, becomes more acute. The patient will often complain of the mere weight of the hand, or of his bed-clothes ; and a draught of cold air upon the surface suffices to induce a convulsive attack. Bright objects, and loud, harsh, or unaccustomed sounds are painful to him, excite a feeling of terror, and not unfrequently also pro- voke con\'ulsions. The sexual excitement, of which the patient complains bitterly, may also continue. He passes urine frequently. As the disease progresses all the symptoms become more severe ; the patient gets feebler, his pulse quick, irregular, and small, his skin clammy, hig voice hoarse ; the tenacious mucus which is secreted by the mouth and fauces accumulates and becomes more difficult of expulsion ; the paroxysms of general convulsive action and of spasm of the respiratory muscles increase m severity and frequency ; and at length he dies either of sudden asphyxia in one of these convulsive attacks, or of slow asphyxia induced by their rapid recurrence, or of exhaustion, aided possibly by a general paralytic condition. The most remarkable phenomena of the disease are : first, the hyper- esthesia of the skin and organs of sense ; second, the tendency which impressions on these organs, and attempts to swallow or thoughts of swallo-vsang liquids, have in producing clonic and tonic spasms of the respiratory muscles ; and, third, the wakefulness, horror, and tendency to yield (while apparently still quite rational) to insane impulses. The last condition is occasionaUy absent ; or the patient only rambles shghtly immediately before death. The disease is invariably fatal, and generally terminates between the second and fourth day. 248 SPECIFIC FEBEILE DISEASES. Eabies in dogs presents in great measure the same symptoms as hydrophobia in man. There are, however, one or two important pomts of distinction : — namely, dogs are not afraid of water, and will indeed bm-y their muzzles in water while at the height of the disease ; cutaneous hyperesthesia seems to be absent in them ; and towards the close a paralytic condition supervenes, involving especially the hinder extremities and the lower jaw. Morbid anatomy has not yet thrown any important light upon the phenomena of hydrophobia. The muscles retain their rigidity for some time after death, and there is congestion of the posterior surface of the corpse, and of the fauces, pharynx, oesophagus, larynx, trachea, and lungs. Investigations ' by Drs. Coats, Gowers, Greenfield, and others have demonstrated the presence of hyperasmia of the central nervous organs, with accumulation of leucocytes around the smaller vessels and capil- laries of the cerebral convolutions, the ganglia at the base of the brain, the grey matter of the cord, and especially that of the medulla oblongata. Small extravasations of blood have also been found in the grey matter of the dorsal and cervical regions of the cord. Dr. Coats further describes extravasation of leucocytes into the salivary glands, mucous glands of the larynx, and kidneys. There can be little doubt that the hydrophobic virus exerts its influence mainly on the sensory and emotional regions of the central nervous organs. Dr. Marochetti, in 1820, described the formation of small vesicles beneath the tongue in persons bitten by mad dogs. These vesicles, which have also been described subsequently by one or two other physicians, are said only to occur during the second week after inoculation. Treatment. — Whenever a patient has been bitten by a rabid animal, or one suspected of having rabies, the wounded part should at once be excised and the remaining raw surface freely treated with caustic potash, nitric acid, the acid nitrate of mercury, the actual cautery, or some equally efficient destructive agent. No remedy has been discovered competent to arrest the progress of the once established disease. Drugs producing narcotism and anaesthesia might seem to offer some chance of benefit, but it is doubtful if any has been fomid of service, except perhaps in the relief of suffering. It should be observed, however, that a case of recovery is said to have occurred in 1874, in the practice of Dr. Offenburg, of Winkrath, under the use of injections of curara, of which about a third of a grain was administered every fifteen minutes or so. The patient was well on the eighth day. Any drug that may be employed should be administered by inhalation, by the rectum, or by subcutaneous injection. Tracheotomy has been suggested in the hope of averting death by as- phyxia. Great care should be taken to prevent the patient from doing violence either to himself or to those about him, and especially to prevent inoculation of wounds by the saliva which he disperses. ^ Lancet, vol. ii. 1877, p. 882. GLANDEES. FAECY. 249 XXI. GLANDEES. FAECY. {Equinia.) Definition. — A specific disease, special to the horse, and animals of the same genus, but communicable to man, and characterised by a peculiar tubercular afi'ection of the nasal and respiratory mucous membranes, and of the skin, lungs, lymphatic glands, and other parts of the body. Causation and history. — Whether or not the disease originates spon- taneously in the horse is a matter of dispute. It is certain, however, that it spreads readily among horses, and from them to man by contagion — mainly by the virus contained in the secretions of the nasal mucous membrane ; and, further, that it is similarly transmissible from man to man. Symptoms and progress. — The period of incubation probably varies generally between one and fifteen days ; but it is said to be occasionally much prolonged. Two varieties of equinia are met with, which go by the respective names of glanders and farcy : the difterence between them • dependmg mainly on the seat of inoculation and on the absence or pre- sence of early affection of the nose and air-passages. These varieties run into one another even in the horse ; in man they are generally combined. The symptoms of invasion are those of intense febrile disturbance — heat of skin, rigors, acceleration of pulse, headache, febrile urine, pains in muscles and joints, and often nausea and vomiting, and profuse perspira- tions. The' specific phenomena of the disease soon follow. These con- sist in an affection of the nasal mucous membrane and of the mucous surfaces which are continuous with it, and an eruption on the skin. The mucous surface of the nostrils becomes congested, and secretes a thm, acrid, watery fluid, which soon gets thick, tenacious, and profuse, and probably assumes at length the characters of sanious pus. The cutaneous eruption is thmly and irregularly scattered, and chiefly on the face, extremities, neck, and abdomen. It consists at first of red points ; but these soon increase in size, ultimately perhaps attaining the bulk • of peas, and feehng hard and shotty between the fingers, and not unlike syphilitic chancres. A vesicle or pustule soon makes its appearance on the summit of each spot, enlarges, bursts, exudes a more or less abundant purulent fluid, and leaves an irregular sloughy ulcer, with a livid margin. A little later, other phenomena manifest themselves : the conjunctivae yield a purulent secretion ; sores arise on various parts of the mucous surface of the oral cavity and pharynx ; bronchitic, pulmonic, or pleuritic symptoms are added ; erysipelatous redness and swelling of the eyelids, nose, cheeks, and forehead become developed ; and subcutaneous or deeper- seated tubercles and abscesses (the latter often of considerable size) appear in various parts, but mainly in the face and in the vicinity of joints. Whilst these symptoms are in progress, the patient becomes weak and prostrate, his pulse quick and feeble, his muscles tremulous, his tongue dry and brown, and delirium ■ comes on ; in a word, typhoid symptoms rapidly develop themselves, on 250 SPECIFIC FEBEILE DISEASES. which coma supervenes, and death soon follows. During this period the breath is fetid, perspiration is profuse, there is often diarrhoea, and gan- grene sometimes attacks the nose, eyelids, and other parts. The course of the disease is generally acute ; the temperature may rise to 104° or even to 106° ; and death occurs, sometimes during the first few days, but more commonly between the seventh and fifteenth or sixteenth. Occasionally in man (but much more commonly in the horse) the disease is chronic. The invasion is then more gradual, the various phenomena follow one another at longer intervals, and the eruption is often absent ; but the subcutaneous abscesses which form become larger, the resulting ulcers are often attended with sloughing, and the affection of the nostrils extends and leads even to the exposure and destruction of the bones. The patient passes into a hectic condition, and lingers for weeks, months, or years. The blood is said by Colin to be greatly surcharged with white corpuscles. Farcy is generally dependent on the inoculation of a wound of the trunk or limbs. The inoculated part gets inflamed and painful, and the absorbent vessels and glands in relation with it soon become similarly affected. Then supervene more or less of the febrile disturbance that characterises glanders, and the formation of subcutaneous lumps (farcy- buds) and abscesses ; often, too, the absorbent glands become generally inflamed, and suppurate. The cutaneous rash is not so frequently pre- sent in farcy as in glanders, and the nasal inflammation is often absent. Occasionally, however, all the special symptoms of glanders supervene. This variety of equinia may be either acute or chronic. In the latter case it is sometimes exceedingly ill-marked and difficult of diagnosis. Equinia is generally a fatal disease. The chronic forms are most likely to be followed by recovery, and farcy more so than glanders. In its early stage, and in the absence of rash or nasal implication, equinia may be readily mistaken for acute rheumatism or pyaemia. Morbid anatomy. — The anatomical phenomena of equinia consist mainly in the formation of tubercles, presenting to a great extent the structural features of true tubercles, and like these tending rapidly to undergo caseous degeneration and liquefaction or suppuration. When superficial, they speedily form unhealthy-looldng ulcers. When deeper seated they become converted into abscesses, which then gradually enlarge and ultimately burst. The tubercles vary from the size perhaps of a pin's head to that of a pea or bean. It is to their development in connection with] the mucous membrane of the nose that the peculiar symptoms referrible to this organ are due. They also form in the mouth and fauces, in the larynx, trachea, and bronchial tubes ; and they appear in the substance of the lungs, producing a condition not unlike that of ordinary lobular pneumonia, and often inducing pleural inflammation. The cutaneous eruption is due to the growth of these tubercles in the skin ; and the subcutaneous lumps and abscesses, and those which arise in the substance of muscles, are of the same nature. The kidneys, spleen, testicles, and other organs are also occasionally affected. Implication of SYPHILIS. 251 the lymphatic glands is not mifrequent, but must be regarded as generally, if not always, secondary to specific lesions occurring in parts with which they are connected. More or less of simple inflammation is generally associated with the specific lesions. Treatment. — It is impossible to lay down any authoritative rules for the treatment of equinia. No specific is known, and no drug which has any favourable influence over its course. Iodine, arsenic, and strychnia have each been recommended. All that can be done, probably, is to support the patient by nourishment, stimulants, and tonics ; to reheve pain and other symptoms ; and to cleanse, and treat with stimulating or astringent lotions, or other applications, the nasal mucous membrane and other inflamed and ulcerated parts which are within reach. During convalescence change of air and good diet are of course important. XXII. SYPHILIS. Definition. — A specific disorder, communicable only by inoculation, resembling the exanthemata in the facts that it presents a period of latency, and a period during which characteristic eruptions make their appearance, and ,that ^one attack confers protection ; but differing from them in the remarkably long duration of these periods, and in the tendency to the recurrence, it may be for many years, of specific lesions. Causation and history. — Syphilis has occasionally prevailed in the form of widespread and severe epidemics. One such epidemic passed through Europe during the latter part of the fifteenth century ; and it was probably in great measure omng to this fact, that, for a time, it came to be assmned that the disease first made its appearance in Europe after the discovery of America, and had been imported from that continent. There is no doubt,, however, that this was an erroneous assumption; and that, just as syphilis prevails now, so it has prevailed fi-om the earliest times both in Europe and in the other quarters of the Old World. Like many other diseases, syphilis was long confomided with aflections which, though often associated with it or arising under analogous circumstances, are essentially distinct from it. Hunter regarded gonorrhoea as one of its manifestations, and even until quite recently other forms of circumscribed mflammation of the surface of the fgenital organs !have been confused with the true chancre — the sore which arises at the point of syphilitic inoculation. But, thanks to the labours of Piicord and other recent observers, including Mr. Henry Lee, the phenomena of syphilis apparently have now been fully disentangled from those of the maladies which simulate it, and our knowledge of syphilis is as accurate as is our knowledge of scarlet fever or small-pox. The symptoms of syphilis are quite characteristic, and when fully developed can rarely escape ready recognition ; yet the disease, though maintaining its identity and typical features, has varied very greatly in its virulence at diflerent 252 SPECIFIC FEBEILE DISEASES. times and in different countries, under circumstances the nature and relative importance of whicli it is not easy to estimate. Of the specific nature of syphiHs, therefore, there can be no doubt. There is equally no doubt that it spreads by means of a specific contagium, and that there is no evidence to show that it ever originates spontaneously. Klebs claims to have discovered a specific bacillus in syphilitic growths. The specific poison of syphilis is never imparted, like that of typhus, by atmospheric conveyance, or, like that of cholera, by means of diffusion through water; it acts only when directly introduced by inoculation. For the most part it is imparted in the act of sexual intercourse by the secretions which are furnished by primary or secondary sores — the thin cuticular covering of the glans penis and inner surface of the prepuce, and the mucous mem- brane of the urethra, and the corresponding parts in the female, becoming readily inoculated even when no breach of surface exists. It is also not unfrequently transmitted from the sucking child to its nurse, or from the nurse to her suckling, either from the mucous membrane of the mouth to the nipple, or conversely, or from mouth to mouth. But, indeed, inocula- tion may take place at any part, provided only the cuticular layer be not too thick, or there be an excoriation or wound ; thus syphilis has not un- frequently been accidentally inoculated on the hands of medical men, and occasionally has been imparted by the operation of vaccination. And, lastly, it is a common thing for syphilitic parents to procreate children who also are syphilitic. Thus a syphilitic mother may have a syphilitic child, the father remaining uncontaminated ; or a syphilitic father may beget a syphilitic child, and may infect the mother either directly, or mdirectly through the foetus. The contagium of syphilis resides in its most virulent form, doubtless, in the primary syphilitic sores, and in the indurated glands which succeed to them ; but the contagious influence persists dur- ing the secondary phenomena of the disease, and also durmg the period of so-called ' tertiary ' manifestations, as is distinctly proved by the fact already adverted to — namely, the transmission of the disease in its later stages from parents to their offspring and from these to healthy wet-nurses. Experiments have been made which seem to prove that the blood of syphilitic patients possesses contagious properties : but there can be no doubt that, as well in the latter as in the earlier stages of the disease, the virus is mainly concentrated in the specific lesions. The secretions of syphilitic patients, more especially the milk, semen, and products of the mucous surfaces, have been supposed to possess infectious properties. But Mr. H. Lee is probably right when he insists that only those organs yield infectious discharges which are either distinctly implicated in the syphilitic process or are in a condition of inflammation. The protective influence of one attack of syphilis has only been fully recognised since the true disease has been disencumbered of the maladies whicli had grouped themselves with it. It is now established beyond doubt : that syphilitic inoculation affords as secure a protection against subsequent attempts at inoculation as does one attack of small-pox or scarlet fever against sub- sequent attacks of either of these affections ; that a person fully under SYPHILIS. 253 tlie influence of the syphilitic poison, or who has had an attack from which he has recovered, very rarely acquires a chancre even when inocu- lated under the most advantageous circumstances, and even more rarely suffers in consequence from the secondary symptoms which so surely follow on the primary inoculation ; and, further, that a person inoculated a second time, during the period which elapses between a primary inocu- lation and the matm-ation of the primary chancre, has as the result of his second inoculation a modified chancre — a chancre which runs its course with exceptional rapidity, and attains its full development concur- rently with its elder brother. Symptoms and 'progress. — 1. Primary symptoms. When a successful inoculation has been effected on an unprotected person, the virus remains apparently quiescent for a period of uncertain duration, but which is estimated by Lancereaux at from eighteen to thirty-five days, with a mean of twenty-eight days. At the end of that time a minute dusky red papule makes its appearance, which for the most part is unattended with pain or itching, and slowly enlarges. Soon a thin greyish crust, the result of superficial necrosis, forms on its most prominent part. Whilst the papule gradually increases in area, successive crusts are formed and shed from its surface, which thus becomes more and more eroded ; so that before long the papule, which has now become a tubercle, displays an elevated dusky red margin surrounding a concave excavation, with a grey dry surface. Almost from the begmning the papule has a remarkably indurated character, and appears imbedded, as it were, in the substance of the skin. These characters it retains, the induration extending a little beyond the area of elevation, and presenting a very obvious edge, so that the mass can be readily grasped between the finger and thumb. At the end of about six weeks the tubercle has attained its complete development, and is perhaps of the size of half a pea, or somewhat larger. It then begins slowly to subside, and after a while cicatrizes, generally however leaving behind more or less dusky dis- coloration, induration, and permanent depression. This is the course of the true Hunterian chancre. But, just as the inoculated cow-pox vesicle presents many deviations from its natural course, so does the pimple which results from syphilitic inoculation. For a description of these reference must be made to surgical works. It should be stated, however, that inoculation sometimes takes place without the development of any appre- ciable local sore, and that a sore may have existed, and yet no visible cicatrix remain. A week or two, usually, after the first appearance of the chancre, the lymphatic glands in relation with the affected part begin to enlarge. If, therefore, the chancre be on the genital organs the glands of one or both groins suffer. Their enlargement is slow and painless. For the most part several glands are affected, and each probably attains the size of an almond shell. They remain freely movable under the integuments, and are characterised, like the chancre itself, by extreme induration. They seldom undergo suppuration, but remain with httle change for months or years. 254 SPECIFIC FEBEILE DISEASES. The period, to which the above phenomena belong, corresponds exactly to the incubation of the exanthemata, and consequently to that period in the inoculated small-pox during which the primary pustule attains maturity, and which precedes the general variolous outbreak. 2. Secondary symptoms. — From six weeks to three months, generally perhaps between sixty and seventy days, after inoculation, the eruptive stage, or stage of secondary symptoms, supervenes. The mvasion of this stage is often indicated by slight febrile symptoms, attended with recurring exacerbations, increased frequency of pulse, loss of appetite, weakness and emaciation, cachexia, restlessness, want of sleep, and pains, more or less variable but augmenting towards night, in the head, jomts, and back. Shortly afterwards, or sometimes concurrently with the febrile disturbance, phenomena of a more characteristic kind manifest themselves. Among the earliest of these are certain affections of the skin and mucous membranes, and inflammations of the joints, bones, and eyes. The cutaneous affection, which is a form of roseola, generally first appears on the trunk, but before long involves the face and extremities, includmg the palms and soles. It is in the begmning a mere subcutaneous rash of romidish dusky-red spots, varying from one to two or three Hues in diameter, and fading at the edges. But they soon become sHghtly elevated and lenticular in form. They are variously scattered, but are not unfrequently grouped m segments of circles or in circles. The rash comes out in successive crops, and may continue off and on for some two or three months. In association with it the hair not unfrequently gets dry and loses its gloss, and presently begins to fall out ; and thus more or less complete baldness is apt to ensue. This roseola may be the only rash to make its appearance, but very commonly it constitutes the first stage of some other variety of skin-disease. Thus, sometimes the individual roseolous spots, or the patches formed by the coalescence of several, gradually enlarge, and fading away in the centre form circles or irregularly rounded marginated tracts of erythema circinatum ; sometimes as they enlarge they get covered with thin scales, and acquire a close resemblance to lepra or psoriasis ; sometimes they assume the form of dis- tinct but flat tubercles ; sometimes they become the seat of vesicles or blebs, and occasionally even of pustules. And hence the secondary eruption may acquire an erythematous, scaly, papular or tubercular, vesicular or pustular condition, or may present several or all of these characters at the same time variously combined. But besides this peculiar polymorphous character, which of itself points to syphilis, there are generally certam peculiarities about the eruption which, apart from all other considerations, indicate its specific character. In the first place, it often presents a peculiar dusky-red or coppery tint, which is due to some pigmentary deposit in the substance of the cutis, and tends to persist long after the actual eruption has disap- peared. Occasionally the course of the superficial vems in the extremities, and especially along the shins, becomes mapped out by similar dusky pig- mentary stains. This condition is not peculiar, however, to syphilis. In the second place, syphilitic eruptions have a singular aptitude to affect those parts which the non-specific eruptions they resemble specially avoid ; they are common on the flexor aspects of the joints, about the forehead, where SYPHILIS. 255 they often cause tlie so-called ' corona veneris,' and especially in the palms and soles. It may be added that, in syphilitic lepra, the formation of scales is usually much more scanty than m the non-specific variety of the disease ; that it is almost impossible to make any real distinction between the several s^-philitic aflections of the palms and soles, inasmuch as all are generally attended with desquamation ; and that scabs, due apparently to the inter- stitial effusion of serum or pus, sometimes form on leprous or tubercular patches, which thus pass by easy gradations into the truly vesicular and pustular conditions. The morbid processes of the mucous membranes first show themselves in the fauces and pharynx, generally upon the tonsils. On the last, which then present an inflammatory blush, shallow ulcers, for the most part reniform in shape, make their appearance ; they are generally unattended with pain or even uneasiness, and disappear after a few weeks. Similar sores are also apt to form on the palate and internal surface of the cheeks, on the tongue and lips. In addition, condylomata or mucous tubercles often become developed in the mouth, fauces, and pharynx, about the anus, upon the mucous or dehcate cuticular surface of the genital organs, and in those parts of the skm which are in constant apposition and consequently always moist. Mucous tubercles are roundish, oval, or irregular congested tabular elevations, not fibrous, warty, or villous, but uniform in texture and soft, with a tendency to be covered with a greyish or yellowish film, to exude abundant moisture, and to secrete pus, or undergo ulceration. Similar formations may arise in the rectum, oesophagus, nose, larynx, trachea, and bronchial tubes, and not improbably in other parts of the mucous tracts. The pains in the jomts and bones are of a rheumatic character, and are apt to be especially severe at night. There may be no visible change in the parts affected ; sometimes, however, there is ob^^ous periostitis, or arthritis and effusion into the joints. True nodes are comparatively seldom developed at this time. The affections of the eyes are twofold. The more obvious is a form of iritis, attended with httle pain, uneasiness, or mtolerance of light, but with more or less of the ordinary form of sclerotic injection which ac- companies iritis. Exudation of rust-coloured lymph occurs at the surface of the iris, mainly, however, at its inner margin, and, though much less frequently, at its outer margin. In the former situation the lymph may form a uniform tumid ring, and in either situation a series of reddish beads. At the same time the iris becomes sluggish or immovable, and probably adheres to the surface of the lens, and the aqueous humour gets turbid and yellowish from admixture with inflammatory products. The less obvious but more serious form is retinitis, coming on msidiously without external congestion, pain, or intolerance of light, but marked by increasing haziness of vision and indications of retinal congestion and extravasation. 3. Tertiary symptoms. — The period of secondary symptoms, after lasting for a few weeks or months, terminates for the most part in spon- taneous convalescence, and the patient may possibly remain hence- 256 SPECIFIC FEBEILE DISEASES. forward free from disease. But more commonly, after the lapse of an mrcertain period, generally from six months to two years, but sometimes twenty years or more, other characteristic lesions manifest themselves, distinctly referrible to the syphilitic poison, and usually termed tertiary symptoms. Although, however, there is generally a distinct interval between the subsidence of the secondary and the onset of the tertiary symptoms, they do occasionally, and perhaps not unfrequently, become intermmgled, or pass without break one into the other. The chief characters by which tertiary symptoms are distinguishable from those of earlier occurrence are : first, their dependence on a specific overgrowth of tissue — the formation of gummata ; second, their great inveteracy and tendency to recur ; third, their involvement of internal organs as well as of parts that are superficial ; and, fomih, their want of symmetry. We will consider the more important of these lesions seriatim, and in refer- ence to the organs Avhich they affect. a. Shin. — The most common form of skin disease is characterised by the appearance of dusky red or coppery flat tubercles, which differ little, if at all, in the first instance, from those described among the secondary symptoms ; they are, however, generally larger, more prominent and more indurated, and occur sometimes widely scattered, sometimes collected into irregular groups, sometimes arranged in the form of crescents, circles, or sinuous lines. In the first case they gxadually increase in number, and coalesce ; in the second, the groups tend to grow in area, and not unfrequently also in thickness, so as to form irregular tuberculated elevations of considerable extent and thickness ; in the last case the affection tends to spread centrifugally, slowly invading the healthy surface by a line of ever-new tubercles, while the parts primarily affected return to a state of comparative health. In some instances the tubercles become scaly on the surface, the affection presenting a certain amount of resem- blance to some forms of lepra ; in other instances they undergo super- ficial molecular necrosis, they get more or less deeply eroded, and a scab forms without a vesicle or pustule having ever been developed ; in other cases each papule undergoes suppuration, and a thick adherent ecthyma- tous scab results ; and, lastly, ulceration is not unfrequent. But, which- ever of these processes takes place, the disappearance of the active lesion is always followed by the formation of indelible depressed cicatrices ; and the progress of the serpiginous form can always be traced by the cicatri- cial surface which it leaves in its wake, and the pre-existence of large patches always recognised by the persistence of a corresponding cicatrix. The tubercular eruptions here described, although essentially identical with one another, are often denominated, according as one or other pecuharity predominates, tubercular, pustular, or serpiginous sylphide, or syphilitic lupus, or psoriasis. They affect almost any part of the body, but are perhaps especially common on the face, neck and shoulders, buttocks and extremities. When they occur, as they frequently do, on the palms and soles, there is httle to distinguish them from secondary lepra. Another well-marked form of skin-affection is that known by the SYPHILIS. 257 name of syphilitic rupia. It consists in the scanty formation, indiscrimi- nately on various parts of the body, of isolated blebs, each of which arises on a congested indm-ated base, and may attain the diameter of a fom-- pennypiece. Their contents are clear and limpid, or tm-bid and sanious, and soon concrete into scabs, each of which, from constant additions to its edges and base, rapidly attains large dimensions : a thickness, for example, varying from a quarter to three-quarters of an inch, and a form which may resemble that of a limpet-shell or oyster-shell, or may be merely irregular and rocky. The base at the same time becomes deeply excavated, and on removing the scab a deep unhealthy slow-heahng ulcer is revealed. These rupial sores leave remarkably deep cicatrices. Very frequently, altogether independently of any primary cutaneous disorder, hard nodules, from the size of a pea to that of a filbert, appear singly or in groups in the substance of the subcutaneous connective tissue. They are unattended with pain, and very slow in their progress ; but after a while they adhere to the skin, which then becomes somewhat prominent over them, assumes a dusky red tint, and gives to the fingers a sensation of elasticity and resistance, or of ' bogginess.' Before long the central portion of the involved skin becomes perforated in one or more points, and a viscid, turbid, or sanious fluid escapes, together with shreds or a mass of subcutaneous slough. In this way a deep cavity results, the bomidaries of which are formed of ragged greyish or yellowish tissue. If groups of these masses soften, we get a number of such cavities side by side, the skin appears irregularly honeycombed, and the bridles which intervene between the adjoining openings get undermined by the co- alescence, beneath them of the contiguous cavities. Thus extensive and deep destruction of skin and subcutaneous connective tissue takes place, which is very slow of repair, and followed by deep cicatrices. 6. Mucous membranes. — The affections of the mucous surfaces have much resemblance to those of the skin. They are chiefly superficial and tubercular, or sub -mucous and gummatous. The former are especially frequent on the tonsils, fauces, soft palate, pharynx, tongue and other parts of the mucous surface of the oral cavity, and in the larynx ; are followed by deep unsymmetrical and obstinate ulceration ; and lead to extensive destruction with permanent loss of tissue and contraction. Thus, the uvula and soft palate may be more or less perfectly destroyed ; the isthmus of the fauces may be narrowed ; stricture of the oesophao-us may ensue ; or destruction of the epiglottis, vocal cords, or other parts of the cartilaginous skeleton of the air-passages may take place ; and, following upon these several lesions, loss of voice, difiiculty of swallowing or breathing, and other serious or fatal consequences. Gummatous tumom's also appear in the same parts, frequently in the tongue, where they may attain the size of a hen's egg, and sometimes in the connective- tissue and muscles of the larynx. These not unfrequently assume many of the superficial characters of epithelioma, and undergo the same processes as do subcutaneous gummata. Similar affections to the above take place in the male urethra and in s 258 SPECIFIC FEBEILE DISEASES. the vagina and os uteri, as weU as in the external parts of the organs of generation of both sexes ; they also occur within the anus and in the lower part of the rectum ; and may in all of these situations, in addition to other forms of mischief, lead ultimately to more or less serious contrac- tion or stricture. c. Organs of locomotion. — Voluntary muscles are occasionally affected in the same way as the subcutaneous connective tissue. Gummata invade their texture, separatmg from one another their fibres, which then undergo degeneration. Such growths occur quite irregularly and may be mistaken for tumours of a far more serious character. We have already pointed out that they may form among the muscles of the larynx ; they have also been obsers^ed imphcatmg the masseter, the muscles of the scapula, and indeed those of most other parts. The bones are sometimes affected with diffused periostitis ; but more commonly nodes are developed on various parts of the long or flat bones, including the ribs, sternum, and bones of the face and skull. Nodes are gummatous growths in connection chiefly with the periosteum. They are usually extremely painful and tender, of various extent and prominence, more or less hard and unyielding at the periphery, but elastic or even fluctuating in the centre. They seldom end in suppuration, and generally on healing leave some irregularity behind. Nodes do not usually result in caries or necrosis. A more frequent cause of these conditions is the extension of syphilitic ulceration in depth until subjacent bone is involved. But from one or other of these causes caries or necrosis may attack any bone ; the bones most frequently thus affected, however, are those of the nose, palate, and skull, to which may be added the cartilages of the larynx and trachea. The bones of the ear also may suffer. Syphihtic affections of the skull are generally limited to the outer surface and diploe, but occasionally involve the inner table as well, and are then apt to cause more or less serious cerebral symptoms. The joints occasionally suffer, the surrounding soft parts becommg thickened and infiltrated, and the ca^dties distended vvath fluid effusion. d. Viscera. The affections of the internal organs are scarcely so well known as those of the parts which have abeady been considered, but they are even more serious. The Hver is perhaps their most frequent seat. The chief conditions which have been recognised here are, flrst, a more or less general h^-perplasia of the connective tissue, especially of the capsule of Ghsson, leadhag to a variety of cirrhosis ; and, second, the for- mation of gummy tumours which rapidly undergo degeneration, and by then' contraction cause puckering and fissm-ing of the surface of the organ. Either of these conditions may lead to the development of symptoms identical with those resulting from ordmary cirrhosis. The organs of ckculation also are frequently imphcated. The muscular tissue of the heart is occasionally the seat of diffuse fibroid infiltration or of more or less extensive gummatous formations, exactly Hke those involving the voluntary muscles. These induce degeneration of the tissue, mdm-ation, adhesion of pericardium, and the ordmary symptoms of progressive cardiac incompetence. There is good reason also to believe that some forms of SYPHILIS. 259 arterial disease, and especially that form in which the inner coat under- goes a land of nodular hypertrophy antecedent to the supervention of degenerative changes, are in many cases the result of syphilis. It is at all events certain that arteries frequently assume this condition m those who are the subjects of syphilis, and who are suffering from gummatous tumours in other organs. And it is also certain that some of the lesions observed in the brains of sj^philitic patients are essentially due to arterial changes of this kind, invohing, however, not only the internal coat, but the adventitia, and to some extent also the middle coat, and leading to obstruction either directly or by thrombosis. Syphihtic affections of the lungs (gummata and fibroid infiltration) are described ; nevertheless, their recognition is attended with much uncertainty. We have already adverted to the fact that the bronchial tubes, like the larynx, may be distinctly impKcated. But, besides bronchial lesions, there are not un- frequently found in the lungs of old syphihtic patients scattered masses of hard greyish or blackish fibroid induration, or caseous masses imbedded in such tracts of induration, which, although in many particulars resem- bling affections of tuberciilar or inflammatory origin, are almost certainly gummata. The most grave of aU tertiary syphihtic affections are those which involve the nervous centres. Gummatous tumom-s are developed in connection sometimes with the mner layer of the dura mater, sometimes with the pia mater, or the connective tissue of the brain-substance. In the latter two cases the growths, which may attain the size of a pigeon's egg or even of a hen's egg, are, even if of peripheral origin, for the most part imbedded m the substance of the brain. Their most frequent site is the basal portion. Similar gro^^hs occur, though much less frequently, in connection with the spinal cord. The symptoms due to them are those of cerebral or spinal tumours. The cranial nerves and even the brain-substance are occasionally the seats of syphihtic infiltration. Specific affections of the kidneys have been less thoroughly investigated ; never- theless, it is certain that these organs are sometimes attacked, sequentially to syphihs, with diffused inflammatory processes, which induce atrophy, and that they are sometimes studded with distinct gummata or with patches of cicatricial tissue, attended vrith corresponding linear or stellate contractions of the surface, and having imbedded m them small caseous masses. The testes are frequent seats of gummata, and also of diffused inflammatory processes. They are apt to become much enlarged ; occasionally suppurate ; and not unfrequently are associated with hydro- cele. The lymphatic glands, as has already been pointed out, get enlarged and indm'ated secondarily to local sjqphilitic lesions ; but occasionally, here and there in groups, they acquire such enormous dunensions as to simulate the enlargement of these organs due to scrofula, lymphadenoma, or cancer. Among other organs hable to syphilitic disease may be enumerated the spleen, stomach and bowels, mammse, and organs of special sense. The effects of syphilis do not end here. The long persistence of ter- tiary symptoms, with then- frequent tendency to relapse, leads gradually 260 SPECIFIC FEBEILE DISEASES. but surely to a marked cacliectic state of the system, indicated by sallow- ness and anaemia, with relative increase of wliite corpuscles, emaciation and loss of strength, and lardaceous or amyloid degeneration of the liver, spleen, kidneys, and other parts, together with the additional symptoms to which such complications give rise. And finally may follow, tubercu- losis, or insidious but non-specific inflammations of various mternal organs. 4. Inherited syphilis presents some peculiarities which make it neces- sary to give the subject a brief separate consideration. It may be derived from father or mother, or from both. The effects of parental syphihs are not unfrequently manifested in the death of the foetus, and consequent abortion, at the latter period of pregnancy. The child is born dead, and more or less decomposed, but usually without distmct evidence of specific tamt. In some instances, however, the placenta is affected with syphilitic disease. In other cases the mfant is born alive, but shrivelled, puny, and unhealthy looking ; and large bull® appear on the palms, or wrists, or the corresponding parts of the lower extremities. These blebs give rise to miliealthy sores, and the infant almost invariably dies speedily. In the majority of cases, however, the babe appears to be healthy at birth, and first gives evidence of disease after an interval of three or four weeks. The symptoms are mainly those of the secondary period of acquired syphilis ; but there are some features which are specially characteristic and important, and to these alone attention will now be drawn. Among the earliest of these are, congestion and swelling of the nasal mucous membrane, with abundant secretion, giving rise to snufQes and other symptoms of chronic coryza ; diffuse inflammation of the mouth and fauces, with sores at the angles of the mouth ; mucous tubercles about the anus and similarly constituted parts ; and a roseolous rash. The rash is generally most abundant on the buttocks, privates, and neighbouring parts of the abdomen and thighs, on the face, and on the palms and soles. It consists in circular patches from a Ime to half an mch in diameter, which either form lenticular elevations, or are slightly concave or cupped, and present therefore a more or less tumid marginal ring. They vary in colour, are sometimes dusky red, sometimes brown or yellow, sometimes of a more or less coppery tint. They may be smooth or scaly, or may present superficial excoriation or erosion. The eruption on the palms and soles assumes a scaly character, and is attended with a tendency to crack and exfoliate. In association with the above phenomena the child becomes emaciated, its face assumes an old and weird character, its com- plexion grows sallow and unhealthy lookmg, its skin dry and shrivelled, its hair scanty and thm, and not mifrequently it suffers from diarrhoea. These symptoms last probably for a few months, and have generally disappeared by the end of the first year. Somewhat later, generally from the age of four or five up to that of puberty, the tertiary series of symptoms manifest themselves. These differ Httle from those which characterise the common tertiary stage. There are two or three, however, of peculiar and special mterest, which now become apparent or develop SYPHILIS. 261 -themselves for the first time. One of them is flattening of the bridge of the nose, from sinking in of the subjacent cartilages. Another is en- largement of the lower end of the hmnerus between the epiphysis and shaft. A third is a peculiar form of atrophy of the permanent incisor and canine teeth. This is generally most marked in the upper two central incisors, and is often limited to them ; they are atrophied, peg-like, and present towards their free edge a reniform or cordate character — the notch occupying the centre of this edge. This condition is traceable to the effect, on the tooth-germs, of the stomatitis from which the children have previously suffered. The last of them is interstitial keratitis, that is, an interstitial inflammation of the cornea, marked by increasing cloudiness and opacity of the part, and attended with a vascular zone in the sclerotic, and intolerance of light. There is no vesication or PlO. 3S.— llALFORlIATIOIf OF PEEMANEiSTT TEETH IN INHERITED SYPHILIS (HtttchiuSOn). ulceration, and the opacity speedily diminishes under appropriate treat- ment. The recognition of the last two affections is due to Mr. J. Hutchinson. It would be impossible in a brief space to discuss the differential diagnosis of syphilis. It must be sufficient to say that the manifestations of syphilis simulate a vast range of different diseases ; and further that syphilis necessarily often occurs in persons who are the subjects of skin- affections and various other disorders, and often exerts a modifying influence over these ; and that hence it is frequently quite impossible to form an exact diagnosis, without going fully into the history of the patient's case, and taking into careful consideration all the facts of his past history and present condition. Morbid anatomy and patliology. — Li the foregoing description of the phenomena and sequelfe of syphilis we have necessarily, to a large extent, discussed the pathological processes of the disease and its morbid ana- tomy. It remains, however, to give a brief connected account of these subjects. The morbid poison which enters the system at the time of inoculation is doubtless a living entity or contagium, which imparts specific properties, primarily to the growth which it directly induces, and secondarily to the vital constituents of the enlarging lymphatic glands situated next above that growth. Possibly from the primary sore, more probably, however, from the group of morbid lymphatic glands, as a centre, is shed into the blood- stream newly manufactured contagious matter (probably particulate) ; which in its turn infects in different pro- portions and in different order the various organs and tissues of the body, producing in them specific processes which have a more or less close resemblance to those out of which they arose, and which like them are infectious certainly to other persons, and probably like carcinoma to the 262 SPECIFIC FEBEILE DISEASES. individual. The early series of general phenomena (those for the most part which belong to the period of secondary symptoms) differ scarcely at all in their anatomical characters and in their local results from simple inflammatory processes. There are congestion, proliferation of connective- tissue imitative of granulation-tissue, and a tendency in the new forma- tion, after a temporary persistence, to subside altogether so as to leave no trace whatever behind, or to merge into the tissues in relation with which it appears : if in relation with connective-tissue into connective- tissue, if in relation with bone into bone, if in the matrix of the Hver, kidney, Imig, testicle or brain, into nucleated fibrous tissue, and to pro- duce therefore in these organs indm-ation, contraction, and atrophy. The latter phenomena (those which belong chiefly to the tertiary stage) consist in the formation of adventitious gi'owths, termed gummata, which are identical m structure with primary chancres and the primarily indurated glands. They consist hke them of cell growth, differing Httle microscopically from ordhiary granulation-tissue, and in this respect therefore httle fr'om the secondary lesions, but presenting certain special featm-es. Thus they do not so much displace as infiltrate or involve the tissues among which they arise ; they have a remarkable tendency to midergo speedy caseous degeneration, and to cause molecular or fatty dis- integration of the higher elements which are mixed up with them ; if developed in internal organs, they acquire for the most part permanence as caseous lumps, earthy concretions, indurated fibrous patches, or morbid tracts in which all of these conditions are variously combined ; and if they be developed m superficial parts, such as the skin, mucous mem- branes or superficial bones, then degeneration results in the formation of crusts, ulcers, abscesses or sloughs, with more or less serious destruction of tissue. Gummatous tumours, while in process of development, vary in their physical characters ; thus, sometimes they are greyish, firm, trans- lucent or opaque ; sometimes (especially when they form beneath the skin and mucous membranes) they are uifiltrated with a mucus-hke fluid, which oozes away when they are laid open. There is undoubtedly a resemblance both anatomically and func- tionally (at all events as regards their infectiveness) in all the congestive or prohferatuig lesions which depend for then origia on the syphihtic vnus. And although a line may be drawn, both on clinical grounds and for the purposes of description, between secondary and tertiary pheno- mena, and although it is quite true that the later lesions are far more serious and virulent than those which precede them, there is no doubt that they pass one into the other, that they shade off' the one hito the other by numerous gradations, and that they are often blended ; so that while, on the one hand, gummatous tumours may occur dm'ing the secondary period, secondary eruptions may be met with late in the pro- gress of the disease. Treatment. — For the prophylactic treatment of syphihs, and for the treatment of the primary affection, reference must be made to sm'gical works. The inoculation of syphihs upon healthy persons, which has been SYPHILIS. 263 so extensively practised by Boeck, and advocated by others, in order tliat by giving them the disease it might affect them in a mild form and prevent any future attack in a graver form, seems to us, we confess, not only dangerous but altogether mijustifiable. It is now generally admitted that syphihs, like other specific febrile diseases, is incapable of absolute cm-e, and that it will run a definite course in respect of duration, no matter what steps are taken to arrest its progress. It is nevertheless certain that we have at least two remedies which exert a remarkable influence over its various localised manifestations, which subdue them almost to zero if they do not absolutely aimul them, and which keep the general disease m abeyance even if they fail (as they probably do) to extinguish it altogether. These remedies are mercury and iodine in their various preparations. The value of mercury was early estabhshed, and has indeed only lately been regarded with suspicion. But this suspicion arose doubtless out of the mjurious mfluences which the abuse of mercury engendered dming the early part of this century, and was supported by the recognition of the fact that the free use of mercury failed in many cases to prevent the supeiwention of secondary symptoms. It is admitted now that mercury does not prevent either secondary or tertiary symptoms from coming on ; but nevertheless it is certain that it has a maiwellous influence in causing the removal, in turn, of the primary, secondary, and tertiary lesions of the disease. The form, the dose, the mode, and the length of time in which the drug should be admmistered are points on which there is much difference of opinion. Some prefer to introduce it by the inunction of strong mercmial ointment on the imier aspect of the thigh or other parts in which the integuments are thin : in this case from haH a drachjin to a drachm of the ointment may be rubbed in every night before the fire. Others affect the practice of fumigation by means of volatihsing calomel with the heat of boiling water. The drug may by this means be inhaled, or applied to the general surface, or to particular regions, with little difficulty. For inhalation, not more than four or five grains of calomel should be employed. Others again recom- mend that the mercury should be administered by the mouth. For this pm-pose any mercurial preparation in an appropriate dose is appli- cable. But the most convenient, and possibly the best, is corrosive subh- mate or the red iodide of mercury, of which from -sV *o s" S^'- ^^J ^^ given three times a day, or equivalent doses of the liqiior hydrargyri perchloricli. The treatment should be contmued until the lesions have disappeared under its influence, and even for a week or two longer, and the quantity should be regulated by its effects on the system, shght sore- ness of the gums only bemg maintained. Iodine is almost equally valuable with mercmy ; but it seems to have a special value dm-mg the later periods of the disease, in which (when the lesions prove intractable) it may often be beneficially combined with the mercurial treatment. The usual, and probably on the whole the best, form is the iodide of potassium m from 5 to 10 grain doses three times a day, combined with a tonic. The syrup of the iodide of iron is very valuable in many cases, and especi- 264 SPECIFIC FEBEILE DISEASES. ally for young children. Bromine has an antisyphilitic power similar to that of iodine, and is sometimes substituted for it. Among other anti- venereal remedies which have acquired and stiU enjoy a wide reputation are sarsapariUa, and nitric acid in large doses. They have probably no specific virtues at aU, Tonic medicines (quinine, iron, cod-liver oil and the like) are often of immense value in the treatment of the cachexia which attends the later stages of the disease. The value of local appHca- tions to syphihtic lesions is imdoubted : the most important of these are the merem-ial and the iodic, among which may be enumerated powdered calomel, black-wash, mercurial, citrine or iodine ointment, iodide of starch paste, and localised calomel fumigations — one or other being employed according to the nature of the lesion, and the convenience and relative safety of its applicability. XXIII. PYEMIA. (Septiccemia.] Definition. — By ' pyaemia ' is understood a febrile and generally acute disorder, due to the entrance into the blood of certain poisonous or septic matters, for the most part in connection with unhealthy inflammations, and usually characterised by the blocking up by clots or emboli of the arterioles of the lungs and other organs, and by the consequent occur- rence therein of scattered patches of congestion, hemorrhage, inflammation, suppiu'ation or gangrene. The terms ' septic poisomng ' and ' septic in- fection ' have been applied to those cases in which, while septic matters are absorbed and cause febrile symptoms, no blocking of arterioles ensues, and the secondary lesions characteristic of pyaemia are not developed. Causation. — The conditions out of which pyemia arises are very numerous and various. First, it is a frequent sequela of accidental fractures, especially of the long bones, and of the bones of the head and pelvis. Second, it frequently ensues on surgical operations, especially those attended with the formation of extensive raw surfaces, such as amputations of the larger Hmbs, and also those mvolving bone, bladder, prostate, urethra or rectum. To these must be added operations on veins, such as phlebotomy and operations for the cure of varicose veins and hemorrhoids. Third, pyaemia occurring after parturition constitutes one of the most common and fatal forms of so-called 'puerperal fever.' Fourth, pyaemia not very unfrequently originates in acute suppm-ative inflammation taking place at the surface or in the substance of bones — cases in which, as a rule, the periosteum becomes extensively detached, and the bone necrotic. Fifth, many varieties of so-called unliealthy inflammation, such as erysipelas, diffuse cellular inflammation, carbuncle, and dissection-womids, are often fatal on account of the supervention of this complication. When pyasmia manifests itself after injuries or opera- tions, it is generally preceded by some obviously unhealthy condition of .the imphcated tissues. Also it is far more Hable to originate in affections of PYiEMIA. 265 certain organs and tissues than in those of others. Among' these maybe included the connective tissue generally, the bones, the male and female pelvic organs, and the veins. That pyemia is in a large number of cases imparted by contagion is beyond dispute. It is thus that it often spreads in the surgical wards of a hospital, and among the puerperal inmates of a lymg-in mstitution. In all such cases there is good reason to beheve that it is transmitted from patient to patient by direct inoculation at the raw surfaces of wounds or of the placental area ; or rather, not so much pyaemia is transmitted directly from patient to patient, as some form of erysipelatous or other unhealthy inflammation is thus transmitted, of which pyaemia is a common accident. It is certam, on the other hand, that even when it complicates the puerperal state and surgical womids, it often arises, so far as we can discover, de novo. It still remains to con- sider whether there are any special conditions of system and of a patient's surroundings which render him peculiarly liable to become pysemic. In reference to this point it may be remarked that age and sex have no distinct influence ; that patients, apparently m the best of health, are often stricken with pyaemia ; and indeed, that when pyaemia pervades a ward, it by no means selects the weakly and the cachectic in preference to the robust and healthy-looking ; and, again, that it does not arise with special frequency m connection with simple overcrowding, bad ventilation, or common filth. So far as we know, the related conditions included under the term septicaemia, namely septic poisoning and septic infection, originate under the same circumstances as pyaemia itself ; and all are due, as we have previously shown, to the mfluence of septic bacteria. Morbid anatomy and pathology. — The poist-mortem phenomena which characterise the presence of pysemia are (as stated in our definition of the disease) patches of congestion, hemorrhage, inflammation, suppuration or gangrene, disseminated more or less abundantly throughout the organs and tissues of the body. These are most common in the lungs, and are often confined to them. We find here, irregularly scattered but mostly abutting on the surface, circumscribed patches ranging from the size of a pea to that of a walnut. These are sometimes distinctly apoplectic, in which case they may be reddish black or more or less decolourised, solid or partly broken down into a puriform pulp ; sometimes they present the orduiary characters of lobular pneumonia ; sometimes they are simple abscesses or gangrenous cavities. These different characters depend in part no doubt on the stage at which death has taken ]3lace, but are often due to individual peculiarities. There is usually more or less congestion and oedema of the general lung-tissue, and occasionally diffused pneumonic consolidation and secretion of mucus into the bronchial tubes. There is probably always a deposit of pleural lymph over and around each pyaemic lump which involves the surface of the lung ; and not unfrequently general pleurisy ensues. Sub-pleural petechi^e are common. The surface of the heart, like that of the lungs, is often studded with small extravasa- tions of blood ; as also are the substance of the cardiac walls, and the 266 SPECIFIC FEBEILE DISEASES. sub -endocardial tissue. And sometimes, generally in relation witli these extravasations, small yellowish patches of disintegratmg tissue or abscesses may be discovered. When these reach the inner or outer surface of the heart they are apt to provoke inflammation of that surface. Neither pericarditis nor endocarditis is of rare occurrence. Of the abdominal organs, the liver, spleen, and kidneys most frequently suffer. In the liver, generally in connection with patches of congestion or of ansemia, we sometimes find small buff-coloured spots of disintegrated tissue, some- times abscesses of considerable size full of greenish purulent fluid. The morbid conditions presented by the spleen and kidneys are almost exactly such as are met with in embolism or thrombosis of the vessels of these organs. In the spleen we observe apoplectic or fibrinous blocks of various sizes, which have often undergone more or less disintegration and softening, or even conversion into abscesses. The kidneys are sometimes studded (chiefly in the cortex) with small abscesses, grouped for the most part in lines perpendicular to the surface and surrounded by a halo of congestion. Occasionally no abscesses have formed, but almost the whole of their tissue is mapped out by tracts and bands of deep congestion, which alternate with and surromid patches of which the colour is un- naturally pale. Spots of hemorrhage, patches of inflammation, or small abscesses may be present in any other of the abdommal organs, some- times, for example, hi the intestinal wall ; and the peritoneum may be affected exactly in the same way as the pleurae and pericardium. The brain is not very commonly the seat of pysemic changes ; extravasations of blood are generally small in amornit and limited to the surface ; patches of softening exactly like those due to embolism, exceptmg that they rarely exceed the size of a horse-bean, and may occur in any part of the organ ; abscesses containing greenish -yellow glairy pus attain a much larger size. Meningitis also occurs. The bones and joints are frequently involved. The secondarily affected bones rapidly become denuded of periosteum, and fetid pus accumulates upon their surface and probably in their substance, and rapid necrosis ensues. The synovial frmges of the joints get intensely congested, and the synovia increased in quantity or replaced by pus or puriform fluid. The cavities of the joints become distended, and the parts around inflamed. It is important to bear in mind that suppura- tion may occur in the neighbourhood of joints without involving them, and that pyfemic inflammation of joints is not always suppurative. It must be added to the foregoing account that secondary mflammations, suppurative or not, frequently manifest themselves in the connective tissue and among the muscles ; and that of organs which have not been specially named, the eye, the prostate, and the testis are very apt to suffer. The skin never presents any characteristic change ; but it is often slightly jaundiced, and occasionally presents petechise ; sudamina are common. The condition of the blood and blood-vessels in pyaemia is a matter of great interest. The bulk of the circulating fliiid, and the vessels in the greater part of their extent, have usually the aspect of perfect health. The PYEMIA. 267 coagula, indeed, which are found post mortem in the heart and larger vessels usually differ in nothing from coagula found under other circum- stances ; very rarely a few soft masses of disintegrated fibrine or of cor- puscles resembhng pus may be found imbedded in them. But, with this exception, it is only in the arteries which lead to the secondary morbid patches, and in the vems involved in the primary lesion, that visible morbid phenomena are present. The minute arteries distributed to each patch of pulmonary disease are always found filled and obstructed either with ordinary thrombi or with a soft yellowish material, consisting of dismtegrated fibrine and corpuscles, or m some cases of these mingled with what appear to be groups of pus-cells. Similar coagula have been detected in the small vessels leading to the diseased patches occurring in the heart, spleen, and kidneys, and doubtless are always present in the arteries, which are comiected with the generalised pysemic lesions. The vems which are involved in the prhnary inflammatory process are in a very large proportion of cases obviously diseased. It is true that, even after careful dissection, they have in some cases appeared to be entirely healthy. But when we bear in mind that in other cases the presence of diseased veins has only been detected after hours of minute investigation, we shall see reason to suspect their existence in cases where they have been reported to be absent. When diseased, their parietes are thickened and mdurated ; they may be entire, or may communicate by orifices resulting from ulceration or some other cause with the morbific elements in which they are imbedded ; and their mterior is occupied by coagula. These are mostly adherent, and more or less decolourised ; they may be solid throughout, but more commonly are reduced in their interior into a reddish or yellowish pus-like pulp or fluid. This appears generally to consist of disintegrated fibrine, but is in some cases true pus. It is mostly separated from the venous walls by a layer of fibrine, and shut out from the proximal portion of the venous channel wherein it lies by a continuation of this layer of fibrine, which forms a kind of diaphragm or septum between them. In some cases no mechanical impediment whatever exists to prevent the free admixture of the pus contained in the vein with the general circulation. We are now in a position to discuss the proximate cause of pyemia. It was formerly supposed that the secondary inflammatory patches were mere deposits of pus which had been absorbed as such by the vems and carried to the localities in which abscesses were found. But, unfortu- nately for this view, pus as such is not found to circulate with the blood, and the secondary patches of disease are never in the first instance, and not often at any time, distmctly purulent. The theory of embolism, how- ever, here comes to our aid. There is no doubt that the secondary foci of disease are almost exactly such as would be produced by embolism of the arteries leading to them ; and we find, in fact, that these arteries are really plugged. But we find further, that these plugs are identical in composition and appearance with the coagulated material which blocks up the vems of the primarily inflamed region. It is reasonable, therefore, to assume that the diseased veins are really the sources of emboli, which be- 268 SPECIFIC FEBEILE DISEASES. coming impacted in the pulmonary arteries induce characteristic changes in the parts beyond, and that the phenomena of pyaemia are, therefore, in large measure due to the dissemuiation in pellets of the morbid matters (pus, disiutegrated clot, and the Hke) which these veins contain. In favom' of this ^dew are the facts that such pellets have been recognised in transitu, and that pyjemia is especially Hable to occur where veins have been the subject of operation, and where inflammation attacks parts in which the veins are abundant and large, thin-waUed, or incapable of col- lapsing — such parts, for example, as the contents of the pelvis, the uterus after parturition, the cancellous structure of bones, and the meninges of the brain. There can be little doubt indeed of the correctness of the above explanation, so far as it goes, and little doubt also that the quality of the emboH has a marked influence over the quality of the processes which they induce ; and that hence whether these latter be gangrenous, suppu- rative, or simply inflammatory, depends in no small degree on the special nature of the process going on in the prunary seats of disease. But will embolism alone explain all the phenomena of pyemia ? To this question Virchow repHes in the negative. He considers pyaemia to be a two-fold disease, comprising, ui the first place, phenomena due to embolism, and, -in the second place, phenomena due to the absorption of some more subtle poison. The latter, which he regards as the more important, have been collectively termed septicamia, and he considers that these two groups of phenomena may occur independently of one another. A very strong argument in favour of this view is the fact that patients occasionally die with many of the ordinary symptoms of py£emia, arismg from some un- healthy wound, in whom no morbid conditions whatever can be discovered post mortem, save congestion of various internal organs, small extravasa- tions of blood beneath the serous membranes and elsewhere, and tendency to rapid decomposition. Such cases, which are very acute in their pro- gress, are not unfi-equently met with in the course of the endemic prevalence of pyaemia, and are regarded by many as cases in which death Las supervened before the specific lesions have had time to develop them- selves. The discovery of bacteria in the blood and morbid tissues of pygemic patients is a matter of deep interest. Indeed, there can be no reasonable doubt that in these organisms we have the specific cause of the disease ; that it is to their abundant presence in the part primarily affected that local unhealthy action is due ; and that it is to then distribu- tion, in association to a large extent \ni]x emboli, that the secondary lesions owe their specially unhealthy features, and the general symptoms of disease assume so grave a character. In conclusion we may say, so far as our present knowledge goes : that septic bacteria (at present indistuaguishable fi'om one another) are the causes alike of true pyaemia, of septic infection, and of septic poisoning : that (as we have already shown) in septic poisoning the bacteria grow only at the primary seat of disease, and evolve there a fluid poison which undergoes absorption ; that m septic infection ( as we have also sho'RTi) the bacteria infect the organism and multiply in the blood and in the PYEMIA. 269 tissues ; and that in true pyemia we have not only bacterial infection, as in the last case, but disseminated foci of inflammation due to arterial obstruction. It is easy to understand from this view how it is that, when pyfemic processes are present, the lungs are, as a rule, affected both earlier and more extensively than other organs. Sijmptoms and progress. — The symptoms which usher m an attack of pyaemia are generally well marked, unless the condition of the patient or the nature of the disease under which he is labouring at the time confuses them. The first symptom to attract attention is almost without excep- tion a sudden, severe, and prolonged rigor, followed by profuse perspiration. The patient may recover from this, and for a time appear to be restored to health. But before long, it may be the next day, or at some earlier period, the rigor returns with its after sweating stage ; and agahi and again, at varying intervals, rigors and sweats recur. In the course of a day or two the conjmictivfe and sMn assume a sallow tmge ; the patient becomes dull and heavy, or it may be restless, and acquires very much the manner and aspect of a person suffering from some form of continued fever. In company with the above symptoms, or in succession to them, others of more or less importance show themselves. The pulse becomes rapid, weak, and perhaps mtermittent. The tongue becomes glazed and fissured, or coated, and after a time dry and brown, the hps parched, the teeth covered with sordes. The patient is thirsty, loses appetite, suffers often from nausea and vomitmg, and not unfrequently from diarrhoea. The resph'ations become shallow and frequent, and the respiratory acts attended with dilatation of the nares or separation of the Hps, and a sniffing, sipping or sucking somid. Cough often supervenes, attended probably with pains in the chest, and evidences of pleurisy or consolidation of the lungs, and of excessive secretion into the bronchial tubes. The skin, in the intervals between the perspirations and rigors, is often dry and harsh, and may present sudamina. The sallowness generally in- creases, and often amounts before death to well-marked jaundice. Pam and swelling in or aromrd joints, or m other parts of the connective tissue, often present themselves, and pus may form rapidly m these situations. As the disease advances the patient becomes excessively prostrate, his face shrmiken, and for the most part pale, his mental fmictions distm'bed ; slight delirium comes on, sometimes coma, sometimes con\'TJsions ; and death ensues usually in from four to ten days. Sometimes pyaemia takes a more chronic com'se : the symptoms are then altogether less strongly pronounced, the fever assumes the characters of hectic fever, abscesses form m comiection "s^dth bones, in the joints and other superficial parts, and the patient sinks from exhaustion at the end of a few weeks or even a few months, or in rare cases recovers after a protracted convalescence. In these cases there is a curious tendency to the occurrence of sup- purative pericarditis ; and in these especially joints are apt to hiflame fr'om time to time, and to subside without suppurating, as in acute rheumatism. We will consider some of the symptoms of pyemia more in detail. 270 SPECIFIC FEBEILE DISEASES. The patient's aspect may at first be healtliy-looking or nearly so, but soon becomes dull and oppressed. The face is sometimes flushed, some- times paHid, and often these conditions alternate. Towards the close of the disease pallor generally becomes estabHshed, and the countenance shrunken and anxious, or of that dull expressionless aspect which is common in the last stage of many febrile disorders. Eigors, though occasionally absent, constitute one of the most strikuig phenomena of . pygemia. They vary in number and frequency, sometimes occurrmg at short and irregular intervals, sometimes assuming a quotidian character, and generally ceasing after the first two or three days. Their duration ranges from a few mmutes up to haK an hour. The temperature of pyaemia has a good deal of resemblance to that of ague ; the rigors are always attended with a rapid rise, which is followed by an almost equally rapid fall. Dmdng, or after, the first rigor, the temperature may reach 104°, 105°, or even 107°, or more, and the subsequent fall carries it down probably to a little above the normal, occasionally even below it. Subse- quently, according to circumstances, the temperature may X3i'esent a succession of similar elevations and depressions, or maintain a nearly uniform level. Death may be preceded by a normal, low, or even very high temperature. The skia, which is often harsh and dry, perspires profusely after the rigors, and copious perspirations recur from time to time during the progress of the malady, and attend its last stage. The resphatory acts, as the disease advances, become frequent, independently of the presence of pulmonary compUcation, and not micommonly reach 40, 50, or 60 in the minute ; and the breath is said to acquire a pecuhar sweet odour. The plemitic exudation, the pulmonary lesions, and the excessive formation of bronchial mucus aggravate the symptoms due to the respiratory organs ; and induce dyspnoea, cough with various forms of expectoration, pleuritic stitches, and friction, crepitation, rhonchus, or other auscultatory phenomena. The feebleness of the pyemic pulse is remarkable. It is generally rapid from the begimiing, or, if not rapid, variable, so that the shghtest exertion of body or mind raises it 20, 30, or even 40 beats in the minute. As the disease advances, it frequently rises to 140 or 160 in the minute, and may even reach 200 ; it then tends to become irregular and almost imperceptible. Pericardial friction or other signs of cardiac impHcation may of course arise. Abdominal pain and tenderness may be caused by the presence of hepatic or splenic congestion or uiflammation, or of circumscribed peritonitis m connection therewith. The jaundice, which is so common in pyaemia, appears to be quite independent of the presence of pyemic deposits and abscesses m the Hver. Frerichs remarks that, ' to aU appearance the jamidice is here the result of an impahed consumption of bile m the blood, arising from an abnormal condition of the metamorphic processes which go on m that fluid.' Urea is largely mcreased, and often the urine contains a small quantity of albumen. PYEMIA. 271 Arthritic, periosteal, and other superficial abscesses are far more common in the chronic than in the acute form of pyemia. Their formation is mostly indicated by the usual symptoms which attend such inflammation. Sometimes, however, they come on rapidly and with little or no pain. The nervous symptoms are much Hke those of typhus and some other specific fevers. They vary, but comprise in the first instance either rest- lessness or apathy and drowsiness, and later on delirium, which may be violent, but is generally muttering, and often passes into coma. Muscular debility is always well marked from the beginrdng, and soon becomes extreme. There are often tremors or subsultus, and sooner or later loss of control over the bladder and rectum. The time at which pyaemia arises in relation to the morbid condition on which it supervenes varies. In accident and operation cases, and in those •of carbuncle and erysipelas, it may come on at any moment from the com- mencement of suppuration down to the period of complete recovery. In cases of acute suppuration connected with bone, and acute necrosis, pyemic symptoms are sometimes present almost from the first. In puerperal women pyaemia usually manifests itself between the third and the tenth or twelfth day after labour. The prognosis of pyaemia is exceedingly unfavourable. There is little doubt that recovery occasionally takes place ; at the same time it rarely happens that this event ensues in cases which, from the severity of their symptoms, are distinctly recognised as pyemic during life. The cases of recovery are usually those in which the symptoms from the beginning are mild, and which would probably not be recognised as pyaemic but for the fact of their occurrence during the endemic prevalence of the disease m the wards, say, of a lying-in hospital. There is generally not much difficulty in the diagnosis of i^ysmia when it arises after surgical injuries or parturition. There is much more difficulty when it occurs in patients who are already prostrated by acute inflammatory affections, such as carbuncle or erysipelas, the symptoms due to which are not unlike those of pyemia itself. And it is particularly apt to be misunderstood when it arises out of some deep-seated suppura- tion. The diseases for which it may be especially mistaken, and for which it has been mistaken over and over again, are typhus and enteric fevers, internal acute inflammations (especially of the lungs), urethral and bladder affections in which the kidneys have become involved, glanders and acute rheumatism. It is a good rule when a case comes under treatment in which typhoid symptoms with great prostration have developed themselves very rapidly, and in which from the absence of any specific symptom the physician hesitates to form a definite diagnosis, to examine the limbs and surface of the body carefully. It has more than once happened to us in such cases to recognise, by the increased bulk of a thigh or arm, the source of the symptoms in the existence of a sub- 3)eriosteal abscess. It is difiicult, if not impossible, to distinguish clinically between the 272 SPECIFIC FEBEILE DISEASES. different forms of septicemia on the one hand, and true pyaemia on the other. The symptoms are, in the main, alike in both cases ; but in simple septicaemia there is necessarily absence of symptoms referrible to the secondary inflammatory lesions characteristic of pyaemia. It is well to bear in mind, however, that constitutional symptoms suggestive of pyaemia, coming on suddenly in the course of unhealthy ulceration, may be due simply to septic poisoning, and may subside as the ulcerated surface cleans. In these cases there may or may not be an initial rigor ; but among the more striking phenomena are, mental apathy or delirium, vomiting and diarrhcea, dryness of tongue, feebleness and rapidity of pulse, perspirations, extreme muscular debility and rise of temperature. And further, it may be noted, that cases (such as are met with in puerperal women) resembling pyaemia in their onset and main symptoms, proving rapidly fatal, and presenting post mortem no secondary lesions, are probably to be regarded as cases of true and uncomplicated septic infection. Treatment. — Very little, unfortunately, can be done medically for a case of pyaemia. We cannot cure the complaint ; we cannot arrest it ; we cannot, so far as we know, eliminate from the system any poisonous matter to which it may be supposed to be due. Quinine has been ex- hibited with the object both of checking the periodic rigors, and of reducmg excessive temperature ; cold baths also have been used with the latter object ; hot baths have been employed to promote perspiration, purgatives to aid elimination from the bowels, antiseptics of various kinds to obviate the supposed putrefactive tendency of the disease. But all to little pm'pose. Our mam aim must be, on the one hand, to support the patient's strength by regulated and suitable diet and the moderate em- ployment of stimulants, in aid of which vegetable tonics in combination with the mineral acids are often useful ; on the other hand to relieve, as far as may be, all distressing symptoms and injurious complications, for which various purposes no drug is so generally useful as opium or morphia. Where symptoms suggestive of pyaemia show themselves, it is of the utmost importance to attend to the condition of the part which is its supposed source ; not so much, however, for the purpose of arresting pyaemia in actual progress as of preventing the occurrence of what may perhaps only threaten. Unlaealthy wounds should be freely laid open, deep-seated abscesses freely incised, and, if deemed necessary, antiseptic or caustic injections or applications freely employed. In surgical and obstetrical practice, especially that of hospitals, the question of the prevention of the spread of pyemia is one of the highest interest. No doubt pyemia very frequently occurs sporadically among both surgical and obstetrical patients. But, whenever either pyemia or erysipelas, no matter how it has originated, appears among groups of such patients, we know that there is a remarkable tendency for it to spread. To obviate this tendency, extreme cleanlmess, ample ventilation, scrupulous nicety with respect to the treatment and dressing of raw surfaces, and especially .the utmost care not to allow infection to be LEPKOSY. 273 conveyed from one to another by tlie fingers of the medical and other attendants, are essential. The extreme value of Professor Lister's anti- septic method of operating and treating raw sm'faces is now almost miiversally acknowledged. XXIV. LEPEOSY. {Elephantiasis Grcecorum.) Definition. — A specific disease, endemic in many parts of the world, characterised by the slow development of nodular growths in connection with the skin, mucous membranes, and nerves, and (in the last case) by the supervention of anesthesia, paralysis, and a tendency to ulcerative destruction and gangrene. Causation and history. — Leprosy has doubtless been largely con- fomided with other maladies, such as elephantiasis Arabum, syphilis, and various affections of the skia, but has yet been recognised from the earliest times, has been described under various names, and has been re- garded with perhaps more general superstitious awe and dread than any other known disease. It was probably not uncommon throughout Europe during the first two-thirds of the Christian era ; but it underwent a marvellous increase during the twelfth and thirteenth centuries. An epidemic wave seems then to have spread slowly from the south-east to the north-west ; and it was assumed, indeed (though probably errone- ously), that at that time it was imported into Europe by the returnhig Crusaders. The disease prevailed generally with great severity during the succeeding two or three hundred years, then began to subside, and had finally disappeared from the greater part of Europe by the end of the seventeenth century. This subsidence of leprosy was closely related in time with the asserted introduction of syphilis ; and hence it has been maintained (in spite of the clearest proof to the contrary) that these diseases are co-related, and their manifestations mere modified results of the operation of the same virus. But although the greater part of Europe became thus free at the date above assigned, the disease hngered m the Faroe Isles up to the commencement of the present century, and still prevails in certain parts of Italy, Greece, Spain, Portugal, and Eussia, and with especial severity in Norway, Sweden, and Finland. At the present day, however, leprosy is mainly a disease of tropical and sub- tropical climates, and among these its chosen habitats are, perhaps, Central and Southern Africa, India and China, the West Indies, and South America. The etiology of leprosy has been largely discussed. Temperature, climate, soil, race, habits, food, have all been regarded as predisposing, if not exciting, causes. That temperature has no obvious specific influence is manifest from the fact that the disease prevails alike in Norway and in India. That soil and climate are equally inoperative is shown by the fact that it occurs both on marshy soils and at high T 274 SPECIFIC FEBEILE DISEASES. elevations, both on the sea-coast and m ualand regions, both in continents and in islands, and in nearly all latitudes. At the same time it is worthy of note that a large nmnber of the localities which it specially affects are low-lying and marshy, and on the sea-coast or banks of rivers. That race and habits are not specific causes is clear from the prevalence of the disease amongst races of the most diverse kinds, and amongst persons of the most opposite habits. Yet it may probably be admitted, and has been asserted, that of several races living associated together and under many similar conditions, some are more prone to leprosy than others ; and also that the disease is on the whole more common among the poor and filthy than among the well-to-do and cleanly. As regards the in- fluence of diet, it may be pointed out that it has been attributed to the use of decomposing fish ; but, unfortunately for this theory, the disease is met with where not only fish is never eaten, but where the diet is mainly vegetable. It follows necessarily that if the cause of leprosy reside in any of the conditions which have been enumerated, that con- dition has at all events as yet escaped recognition. Formerly the disease was regarded as highly contagious, and consequently all communication between the sick and the healthy was rigorously interdicted. At the present day, however, its contagiousness is almost universally denied by scientific medical men ; and it is beyond doubt that the attendants on the sick apparently fail to take it, that children live habitually in the same house with leprous members of their family without becoming affected, and that even sexual cohabitation may go on for years without the disease being transmitted from the diseased person to the healthy one. On the other hand, it seems to be clearly established that the dis- ease is to a considerable extent hereditary — hereditary, that is to say, in the same sense as tubercle and carcinoma are hereditary, but not in the sense in which syphilis is hereditary. In other words, it appears, not that children are ever born with leprosy, but that the children of leprous parents are more likely to become affected than are the children of healthy parents — a fact which probably explains the supposed influence of race. It must indeed be admitted that the causes of leprosy, of its generally endemic character, and of its occasional epidemic prevalence, are alike unknown. That the disease has a specific character is quite clear ; and that the tendency to it (if not the disease itself) is trans- missible from parent to child, is equally clear. But whether it belongs to that class of diseases which is represented by tubercle and carcinoma, or whether, like ague and goitre, it is the result of some obscure telluric condition, or whether, like scurvy and ergotism, it is due to some default or error of diet as yet unrecognised, or whether, like cholera, enteric fever, or syphilis, it is imparted in some special way by the sick to the healthy, are matters in regard to which we have no accurate knowledge. Certain recent statements in respect to the introduction of leprosy into the Sandwich Islands and into Australia, and its subsequent spread in those countries (assuming them to be correct), go far to establish its communicability. Dr. Liveing concludes that, if not contagious in the LEPKOSY. 275 ordinary sense of the word, it is capable of propagation by the imbibition of the excreta of lepers. The suspicion that leprosy is directly or indirectly contagious derives some confirmation from the discovery of bacilli, apparently specific, in persons suffering from the disease. They were first recognised by Dr. A. Hansen, in 1874. Since that time the fact of their presence has been confirmed by numerous observers ; and recently, Cornil and Suchard in France, and Majocchi and Pellizzari in Italy, have given descriptions and •drawings of the organisms, which accord in every essential particular with those of Hansen. Kobner of Berlin has yet more recently published a paper on the subject. It appears from these researches that the bacillus lepr^ (which like the bacillus of tubercle is stained by methyline blue) is found, both in the granular and in the elongated form, in the blood and tissues of leprous patients, but mainly in the specific leprous growths ; that it is found in the blood, specially at the periods of eruption, and more abundantly in growing tubercles than in those which are undergoing atrophy. Symptoms and progress. — Leprosy is a disease of both sexes and all ages, but commences most commonly in early adult life. It is usually preceded by premonitory symptoms which continue for weeks, months, or years, before the specific signs of the disease manifest themselves. These consist in the first instance in lassitude and depression, attended with more or less febrile disturbance, rigors, nausea, and loss of appetite. After a time livid blotches make their appearance here and there on the surface of the skin, remain out for a few days or weeks, and then subside, to be followed at irregular intervals by other similar outbreaks. They are tender, elevated discs, or rings, or more or less irregular patches, varying perhaps from half an inch to two or three inches in diameter. In the course of time the blotches become more persistent, and their subsidence is followed either by brownish pigmentary stains, or by an •unnatural whiteness and opacity of the skin, associated with more or less ■ contraction and depression. The central area of a patch not unfrequently assumes one or other of these conditions, while its periphery is still extending in the form of an elevated livid ring. During the earlier of these stages the affection has often some resemblance to psoriasis, lupus, or acne rosacea, and is sometimes termed macular leprosy ; during the later of them the condition of skin is sometimes designated nnorplicea nigra or alha, according as the cicatricial area is pigmented or colourless. The specific phenomena of leprosy now begin to develop themselves, a,nd these vary according as the skin and mucous membranes on the one hand, or the nerves on the other, are principally affected. Many cases no doubt occur in which all of these tissues are implicated simultaneously or in succession. But in a large number the specific morbid processes rare almost accurately limited to one or other tissue ; and the disease hence assumes two distinct and easily recognised types. They are known as Utbercular and anesthetic leprosy respectively. t2 276 SPECIFIC FEBEILE DISEASES. In tubercular leprosy, wliicli is relatively most common in temperate climates, nodular elevations slowly develop themselves in the stibstance- of the cutis, and mainly on the site of the macular eruption. These are attached by broad bases, become more and more prominent and some- times pedunculated, and not unfrequently coalesce with one another so as to form irregular nodulated masses. They vary at length individually from perhaps the size of a hazel nut to that of a walnut. They are for the most part hard and resistant, of a dusky reddish or brownish hue, smooth and sometimes polished on the surface, and often, like those of lupus, present a certain degree of translucency. They are attended with little inherent pain or uneasiness, but are more or less tender, and are remarkable for their permanence and the little tendency they manifest to undergo degeneration or ulceration. Nevertheless they do occasionally, after a long time, become the seat of some partial fatty change, grow softer and almost fluctuating, and acquire a dirty yellowish hue ; and not unfrequently also, Avhen irritated by exposure, filth or injury, they become excoriated or ulcerated, or covered with thin scabs, and exude a serous or ichorous fluid. The growth of the tumours is attended with atrophy of the cutaneous glands and of the hair. The latter first becomes thin and dry and loses its colour, and then disappears entirely. The loss of hair, how- ever, is not, as in syphilis, general, but simply limited to the situations in which there is obvious disease. The tubercles of leprosy occur mainly on those surfaces which are most exposed to the air, namely, the face, hands and feet, but they are common also on the extensor aspects of the limbs. On the face they chiefly affect the eyebrows and eyelids, the nose and lips, and the lobes of the ears. The nodulated thickening of the eye- brows and adjacent parts of the forehead gives a peculiar morose character to the expression ; and the thickening of the nose and lips with the associated bronzing of the parts imparts to the European the appear- ance of the mulatto. When the face is thus affected the term leontiasis is sometimes applied to the disease. In the hands and feet the back or dorsum is chiefly involved. In addition to the cutaneous growths which have just been described, nodules of the same kind appear in the sub- cutaneous tissue. The morbid process is limited to the skin and subjacent tissues for a longer or shorter time ; but at length certain of the mucous membranes become implicated, especially those of the nose, mouth and larynx. The affection here is of the same kind as that in the skin ; it consists in the formation of nodules, which increase in size, run together, and sometimes form flattened elevations. The growths, however, are softer, more readily ulcerate, and on healing leave deep and dense cicatrices. In the progress of the disease the cartilages of the nose not unfrequently become exposed, the tongue large, nodulated, and seamed with cicatrices, and the different parts of the larynx thickened and stiff, and its channel contracted. In association with the affection of the larynx a peculiar cough and hoarseness of voice become developed which are very characteristic of the disease. Accordmg to Daniels- LEPROSY. 277 sen and Boeck the trachea and bronchial tubes may undergo the same changes as the larynx. The conjnnctivte are apt to >be similarly affected, and inflammation, suppuration, and perforation of the cornete to ensue. In ancEsthetic leprosy, which is specially common in hot climates, it not imfrequently happens that no tubercles are ever developed. And the cutaneous affection may be either that which has been described as among the prodromal phenomena of leprosy, or so slight that attention is first called to it by some impairment or change of sensibility. There may even be no structm-al change whatever. We will first consider the nervous phenomena, and afterwards the local processes going on in the skin and subjacent parts. In the first instance there may be a combina- tion of hyperesthesia and anaesthesia, some parts being numb or insensible while others burn or tingle and are excessively tender, and not uufre- quently arete of numbness are surromided by rmgs of increased sensibility ; these conditions, moreover, replace one another, so that parts which were byperaesthetic become anaBsthetic ; and, further, they may occupy numer- ous scattered spots or pervade separately or in combination extensive tracts of skui. They are often connected, though by no means necessarily so, with the cutaneous maculas. The affection of the sensory nerves is generally associated with affection of the motor nerves, and indeed the latter (although it seems to come on later) occasionally preponderates. Thus there are often tremblmgs and jerkiugs of the limbs ; but especially there soon supervenes muscular paralysis. The anesthetic and paralysed regions gradually shrink, the fat, the muscles, and even the bones waste, and the skin contracts over them, becoming white or pigmented, and assuming a cicatricial character. The parts which are generally first affected, and which suffer most severely, are the hands and forearms, feet and legs : in the upper extremity mainly the districts supplied by the ulnar nerve, and m the lower extremity the regions correspondingly situated on the outer side of the leg and foot. It will be recollected that the rdnar nerve, besides giving sensory branches to the^muer side of the lower part of the arm, to the inner side of the hand, and to the ring and little fingers, supplies motor nerves to the flexor carpi ulnaris, the inner half of the flexor profundus, the muscles of the baU of the little finger, the interossei, the adductor muscles of the thumb, and the palmaris brevis. And the consequence of their wasting and loss of fmiction is that the palm becomes flattened, the thumb separated from the other fingers, and these powerfully extended at their first joints, and flexed at their second and third joints : conditions which impart to the hand the well-known claw-like, form which always results fi-om paralysis of the ulnar nerve. Bulls not unff-equently form and burst, sometimes healing quickly and well, at other times leading to obstinate ulcers, which leave hard depressed cicatrices behind. After a time gangrene occurs in the affected parts, more especially the hands and feet. This sometimes begins from the surface, and gradually deepens, until the bones are exposed ; sometimes begins among the deeper tissues, and involves the skin secondarily. It 278 SPECIFIC FEBEILE DISEASES. often ends in tlie separation of tlie bones, in the loss of fingers or toes, or even of a hand or foot. It is remarkable, however, how rapidly and' perfectly wounds thus made heal up. The duration of leprosy is very uncertain : that of the anfesthetie variety is, on the average, sixteen or seventeen years, that of the tuber- culated form eight or nine. Death is due partly to gradual impairment of nutrition, but mainly to the supervention of complications, especially phthisis, dysentery, and kidney affections. Morbid anatomy and ])atliology. — The morbid process on which the chief phenomena of leprosy depend consists in the infiltration of the^ affected tissues with innumerable small cells containing comparatively large nuclei. These, in accordance with Virchow's views, are probably due to proliferation of the connective-tissue corpuscles ; and collectively form more or less extensive masses of new growth which are almost iden- tical microscopically with granulation-tissue and with the tissue of syphilitic gummata, and lupus. The leprous growth differs, however, from the latter two especially by its permanence and comparatively little tendency to undergo degenerative changes. The new growths present, at all events during their earlier progress, a greyish, yellowish or brownish tint, are firm, translucent and homogeneous in texture, and contain few blood-vessels and little blood. In tubercular leprosy the tumours commence in the skin around the hair follicles and glands, which in their progress they gradually compress and destroy, together with the majority of the other textures which they involve ; the epidermis, however, remains for the most part normal, and the muscles of the hairs, in the beginning at all events, become hyper- trophied. The tubercles do not usually admit of being enucleated, but. are connected by processes with the subcutaneous connective tissue. Their formation beneath the skin and in connection with the mucous membranes essentially accords with the above description. Both in the macular stage and in the anesthetic form, the cutis, however slightly it may appear to be affected, is the seat of specific proliferation. In anaesthetic leprosy the nerves are always implicated : the smaller branches being mainly involved, and of the nerve-trunks those portions which are most superficial and most obnoxious to injury. They swell to several times their normal bulk, sometimes uniformly, but more frequently irregularly, so as to present something of a beaded character. They become at the same time firm, greyish, and translucent. The change is due to a proliferation of the cells of the connective tissue of the nerve - bundles (mainly of that which separates the individual nerves from one another, and of that which bounds and isolates their different strands),, and exactly resembles what occurs in the skin and mucous membranes.. At first the essential elements of the nerves suffer but little from the adventitious growth which surrounds them ; eventually, however, they undergo degeneration. Dr. Vandyke Carter ^ shows that, in anaesthetic leprosy, the affected. • On Leprosy and Elephantiasis, 1874. AGUE. 279 muscles become converted into fibrous tissue ; and that the bones es- pecially of the hands and feet waste ; that the carpal and tarsal bones suffer thus to some extent, but that the metacarpal, metatarsal, and phal- angeal bones are chiefly affected, and in an increasing order from the first of these to the last phalanges ; that their shafts become attenuated, and their distal extremities disappear. He shows also that these conditions involve mainly the fourth and fifth fingers and the corresponding toes, and that here the last phalanx not unfrequently disappears wholly, the skin and nail then shrinking on to the top of the second phalanx. We have already adverted to the statement of Danielssen and Boeck that leprous patients are liable to the development of specific tubercles throughout the bronchial tubes ; they describe them also as occurring in the substance of the lungs, liver and other organs. These statements have not, however, been fully verified by subsequent observers. In all forms of leprosy the lymphatic glands become largely hypertrophied, especially those in immediate connection with diseased districts. The glands which chiefly suffer are those of the groin, neck, and submaxillary region. Distinct leprous infiltration, with degeneration, of the testicles is recorded by Virchow. The ulceration, gangrene, and other inflammatory processes, which are so common in the course of leprosy, seem to be due, not so much to any special tendency which leprous formations have to pass into such con- ditions, as to what may be regarded as accidental circumstances. Thus in the case of tubercular leprosy, ulceration seems to result from the effects of exposure, cold, dirt, and other sources of irritation ; and, in the case of anaesthetic leprosy, the ulceration and gangrene are probably mainly dependent on the irritative implication of the nerves. Treatment. — By common consent leprosy is an incurable disease ; nor does it admit of alleviation or arrest by medicinal treatment ; but it is doubtless well, when the case admits of it, to remove the patient from a locality in which the disease is endemic, to protect his surface as far as possible from injurious influences of all kinds, and to maintain his strength by appropriate food and various tonic adjuvants. XXV. AGrUE. {Intermittent and Bemittent Fever.) Definition. — A specific non-contagious fever, produced by malaria ; cha- racterised by enlargement of the spleen, and recurring attacks of fever, attended each with a cold, a hot, and a sweating stage ; and having an in- definite duration, and a tendency to recur which may last for many years or during the whole of life. Causation and history. — Ague is undoubtedly not contagious. It is not communicable from man to man, nor does it spread from a centre, successively invading town after town and country after country. It is 280 SPECIFIC FEBEILE DISEASES. strictly -an endemic affection, belonging to certain districts and induced in them by some poisonous influence which pervades them. Ague-districts are scattered more or less irregularly over the whole non-aqueous surface of the globe, excepting apparently that of the frigid zone. And the viru- lence of the poison which they yield increases for the most part as they approach the equator. They generally present certain common features : they are tracts of loAV-lying marshy ground, often situated upon rivers or lakes or in the vicinity of the sea, often presenting a luxuriant vegetation, and always a porous soil which is commonly composed to a large extent of decaying vegetable matter. But, however fever- stricken such places may be, the malaria which they breed is evolved at certain seasons only. In our own country and probably in all temperate climates, the dangerous periods are spring and autumn, especially autumn ; in the tropics, the season of heat and drought which follows upon the periodical rams ; and in all cases, it would seem that the poison is produced only or v/ith special intensity, not when the marshy ground is thoroughly soaked, but when, after it has been thus soaked, the surface to a little depth has under- gone a rapid process of drying. What, it may be asked, is the condition common to all the variously situated aguish regions which causes ague ? Is it high temperature '? Clearly not ; for many of the hottest regions of the earth are completely blameless. Is it the presence of water ? The answer must be No ; for, if aqueous vapour could cause ague, all who frequent the sea, or live in the vicinity of rivers, should contract ague ; and especially, aguish districts should be most dangerous at those very times when they are now most free. Is it the presence of decaying veget- able matter ? Again the answer must be No. Decaying vegetable matter exists abundantly in places where ague never occurs ; and more- over, as Sir Thomas Watson remarks, if such matter could cause ague, Londoners ought at least to be occasionally infected by the contents of their dust-bins and by the neighbourhood of Covent Garden Market. But the specific influence of decaying vegetables in the causation of ague is disproved by the fact that ague prevails in certain places where no such matter exists. ' In August 1794, after a very hot and dry summer, our army in Holland encamped at Eosendaal and Oosterhout. The soil in both places was a level plain of sand, with a perfectly dry surface, where no vegetation existed, or could exist, save stunted heath plants. It was universally percolated to within a few inches of the surface with water, which, so far from being putrid, was perfectly potable. Here fevers of the intermittent and remittent tjqDe appeared among the troops in great abun- dance.' (Watson.) Again, the soil of Hong Kong consists of disintegrated granite, containing, according to Dr. Parkes, less than 2 per cent, of or- ganic matter ; yet ague, which had not previously prevailed, became rife and fatal at a time when the soil was being extensively excavated for building purposes. The last quotation illustrates another point of con- siderable importance in relation to the causation of ague, namely, the influence in this respect of upturning of the soil — of soil, at any rate, which has long been untouched. The malarious affections which prevailed AGUE. 281 in the armies before Sebastopol are referred by Trousseau to this cause ; and lie also points out that in Paris, where ag-ue is almost unknown, epidemics of hmited dm-ation have on several occasions been distmctly traced to the formation of extensive excavations. It would seem, therefore, that neither heat, water, nor decomposing organic matter is alone capable of evolving the malarious poison ; but that for its production there must be a certain porous character of soil, a certain degree of saturation of this soil with water (the surface having recently undergone desiccation) and a certain elevation of temperature. Nothmg is more certain than that aguish districts may be rendered healthy by drainage. In London, most of which is built on land which was formerly marshy, and where ague was once largely prevalent, the disease is now rarely if ever met with unless it be imported. The malarious poison appears to be manufactured in the soil of the malarious district, and to be exhaled from the siu'face in company with the moisture which rises from it, and by night far more abundantly than by day. It forms over the infective area a khid of invisible mist, which is denser and more potent in proportion to its proximity to the groimd, and which extends to no great height above it. Indeed, it is well known that the ground-floors of houses in aguish districts are more dangerous to sleep in than are the upper stories ; and that the miasm rarely ascends to any great height the sides of mountains which adjoin such districts. Dr. Parkes considers that the upper limit in temperate climates is 500 feet, in tropical climates from 1,000 to 1,600 feet. As might be supposed, the miasm may be carried by the wind and atmospheric currents beyond the limits of the area in which it is produced ; and thus, under certain cir- cumstances, places which are miles away, and in all other respects healthy, not unfrequently become affected. It seems, however, that the miasm is absorbed in its passage across water, so that the mtervention of a river three-quarters of a mile or a mile broad, or of a similar breadth of sea, gives perfect safety. Even a belt of trees, acting probably as a kind of filter, often forms an efficient barrier. For the latter reason it is dangerous to sleep under trees in malarious places. It is also dangerous, according to some, to drink the water, however pure it may seem to be, which is furnished by the soil of such localities. What, then, is this miasm? Is it a gas, is it some decomposing organic substance, is it a Hvmg thing ? No absolute proof has yet been adduced of the truth of either of these alternatives. There is, however, much, both in the behaviour of the miasm and in its eflects on the human body, to mdicate a generic relationship with the contagia of infectious fevers, and to render it probable that the last of the alternatives above expressed is entitled to acceptance. Dr. Salisbury, of Cleveland, indeed, beheved that he had discovered the specific cause in the sporules of certain algfe, species of palmellfe ; and more recently il879) Professors Klebs and Tommasi-Crudeli ^ state, from investigations conducted at Piome, that ^ ' Arehiv fiir experimentelle Pathologic,' July and October, 1879. 282 SPECIFIC FEBKILE DISEASES. they are enabled to obtain from the soil and air of marshy districts, and to cultivate, a microphyte having a close resemblance to the bacillus anthracis, and termed by them the ' bacillus malaria,' by the inoculation of which they can produce ague in rabbits. Further, it is stated that the bacilli may always be found post mortem in the spleen, marrow and blood, of men and other animals dying during an attack of ague ; and that they are present in abundance in the blood at the commencement of the febrile paroxysm, but disappear as it attains its height. There are certain facts m reference to the causation of ague, besides those which have been considered, to which attention should be dra^ai. It seems to be well ascertained that the denizens of malarious districts become, in a greater or less degree, acclimatised, and hence less readily contract ague than persons newly arrived. It is remarkable how little the negroes suffer in districts which are fatal to Europeans. Another well-ascertained fact is that persons suffering from fatigue or privation are much more liable to take the disease than those who are well fed, strong, and in robust health. Again, contrary to all we know of most other fevers, especially of the exanthemata, one attack of ague, so far from being protective, renders its subject more than ever liable to be again attacked with it on exposure to its exciting cause. Symptoms and progress. — The period of latency of miasmatic affec- tions varies within wide hmits. Authentic cases are recorded in which persons who have been exposed to the paludal poison have manifested the first symptoms of fever within the ensuing four-and-twenty hours. On the other hand, it not unfrequently happens that persons who have been residing in aguish districts at the time of year when ague chiefly prevails have their first attack of ague many months after they have removed thence to some perfectly salubrious locahty. Thus we frequently meet with persons, residing in healthy parts of London, who are attacked during the spring or summer with symptoms of ague, the poison of which was taken into the system during the previous autumn, in Essex or Kent,^ and had lain dormant during the whole of the intermediate period. Ague presents itself clinically in two well-marked extreme forms, which, however, pass one into the other by insensible gradations. The first of these is the mtermittent fever, which is especially common in temperate climates, and comparatively mild ; the second is the remittent fever, which occurs chiefly in the tropics, and is of gi-eat severity and danger. We will describe first the phenomena of intermittent, and then those of remittent fever. A. Intermittent fever is characterised by the occurrence of febrile- attacks of some hours' duration, separated from one another by periods of apparently, or, at all events, comparatively, good health. The patient is attacked suddenly, or after having complained for some indefinite time of lassitude, headaclie, and general malaise, with a sense of chilliness, and weariness, headache, muscular pains, and epigastric discomfort. The chilliness rapidly increases until the patient feels and looks as if he were suffering from intense cold. He begins to shiver — the sensation of AGUE. 288 shivering commencing in the back and extending thence to the rest of the body. The shivering is speedily converted into a severe rigor, attended with violent chattering of the teeth and convulsive tremblhags of the trunk and limbs. At the same time the skin is di"y, and assumes the j)apular condition known as ' goose's skin ; ' the face and the hands and feet acquire a dusky hue, the face also looking pmclied, the hands and feet shrunken and wrinkled. Whilst this condition lasts the pulse is small, frequent, and often kregular ; the respirations are quick and sigh- ing ; there is loss of appetite, thirst, and epigastric op^Dression, not un- frequently associated with sickness ; the tongue is perhaps bluish, and sHghtly furred ; headache and pains in the back and limbs are often present, and sometimes torpor or drowsiness ; and the urine is pale, abundant, and passed frequently. The length of this, which is termed the cold stage, presents great variety. In some cases it is represented by a slight sensation of chilliness of a few mmutes' duration only. It more commonly lasts from half an hour to one or two hours, and is occasionally prolonged to three or four hours, or even more. During the whole of this stage the temperature of the patient is above the normal, and rises rapidly. The elevation begins m fact before the patient himself recognises the commencement of his attack, and rises quickly and uniformly mitil towards the close of the stage ; at which time, even though he be still trembling violently with the feeling of intense cold, the thermometer placed in his axilla probably marks 105°, 106°, or even 106"3°. After a time the cold stage subsides, and the next, the hot stage, com- mences. The rigors and aspect of chilliness gradually disappear — slight flushes at first alternating -^ith the diminishing rigors, and then by de- grees replacing them. The patient begins to feel comfortably warm, and the shrunken and Hvid surface assumes the smoothness and hue of health. But gradually the feeling of heat gets mtense ; the patient looks excited and flushed ; the skin feels dry, harsh, and pungently hot ; the pulse becomes fuller, stronger, and soft, but maintains its frequency ; the respirations get more rapid and deeper, and the thirst more severe ; anorexia contmues ; the urme is still abundant, but of a darker colour and higher specific gravity ; and the headache, which differs in character from that previously complained of, becomes extreme ; mental confusion is not luicommon, and occasionally there is slight delirium. During this stage the temperature contmues high ; sometimes during the early part attaining a higher elevation than was reached during the cold stage, sometimes, on the other hand, falling somewhat below it. The hot stage lasts from one or two hours up to four or five, but is occasionally pro- longed to eight or ten hours. The hot stage is succeeded by the third or siceating stage. The ap- proach of this is indicated by the supervention of a general feeling of comparative comfort ; the intense heat of skin diminishes somewhat, and moisture appears on the face, and rapidly involves the whole surface of the body ; soon the patient is bathed in profuse sweats ; the temperature rapidly falls ; the pulse becomes less frequent and softer ; the respirations 284 SPECIFIC FEBEILE DISEASES. resume their normal rate ; the lieadaclie disappears ; the loss of appetite and the thirst abate ; the urine gets scanty, but of variable colour, and deposits a sediment on cooling ; and not unfrequently the j)atient falls into a gentle sleep. The duration of this stage is very various, but is generally shorter than either of the other two. On emerging from it, the patient may still be languid and listless, but on the whole appears to be restored to more or less perfect health. The duration of the febrile paroxysms and that of their different stages present considerable variety. The whole paroxysm may be completed in an hour or two, or may be prolonged to eight or ten, or even twelve hours. The cold stage, as has been pointed out, may last from a few minutes to some hom^s, and not unfrequently the shorter cold stage is followed by the longer and more intense hot stage. Again, the hot stage, wliich is often of some hours' duration, is occasionally absent — the sweating stage in such cases following immediately upon the cold stage. And lastly, the sweating stage may be so slight as almost to escaxDe notice, or may be protracted for many hours. The period which intervenes between the cessation of one attack and the commencement of the attack next following is called the intermission. In it the patient seems not unfrequently to be in the best of health. Sometimes, however, he suffers from more or less malaise, the degree and character of which depend on various circumstances which need not be specially considered. The period which elapses between the commencement of one attack and that of the attack which is next in sequence is termed the interval. And it is mainly in accordance with the length of this interval that we determine the different varieties of ague. In one variety the interval is twenty-four hours, or thereabouts, and there is consequently a daily febrile paroxysm. This is termed quotidian ague. In another variety the interval is forty- eight hours, more or less, and the paroxysm occurs every other day. This should strictly be called ' secundan ague ; ' but those who framed its name chose to reckon the day of the first attack as one day, the day of freedom as another day, and the day of the next attack as the third day, and consequently attached to it the inaccurate but now well-known name of tertian ague. In another variety the febrile paroxysms occur every third day ; and this, which should strictly be named tertian ague, has received the designation of guartan ague. In addition to these three prmcipal varieties, others which are much rarer are occasionally met with. Thus, in some cases the fits recur every fourth, fifth, or even sixth day ; and in some cases we have what are termed double tertians or double quartans. In the double tertian the patient has febrile paroxysms occiu-ring every day ; but, while those of the odd days correspond with one another, in time of commencement, duration, and probably also other features, those of the even days, though presenting a like agreement among themselves, differ markedly from those of the other series. In the double quartan the patient suffers, as it were, from two series of quartan attacks, the first series of similar AGUE. 285 paroxysms occurring, say, on the first, fourth, and seventh days ; the second series occurring on the second, fifth, and eighth days. In quotidian ague the febrile paroxysm usually commences earlier and lasts longer than in either of the other common varieties — often persisting for ten or twelve hoiu"S. In the tertian variety its duration is usually six or eight hours ; in the quartan four or six. On the other hand, the cold stage is shortest in quotidian, longest in quartan ague. The interval, as has been pointed out, is rarely exactly twenty-four, forty-eight, or seventy- two hours ; when it falls short of either of these periods each successive febrile attack commences earlier in the day than that which immediately preceded it, and is said to anticipate ; when the interval is prolonged, the periodical paroxysms become later and later, and are said to postpone. In the former case the disease is generally becoming more severe ; in the latter case there is usually a tendency towards improvement. Tertian ague is, at any rate in Europe, more common than either of the other varieties ; none of them, however, is rare, and they readily and not un- frequently pass into one another. B. Bemittent fever (the form of ague most common in tropical cli- mates) is much more serious and dangerous to life than the intermittent forms of ague which have just been considered. Its distinguishing feature is that the febrile paroxysms, which come on once or twice a day, are not separated from one another by intermissions of complete apyrexia, but are rather to be regarded as exacerbations of an abiding febrile state. Further, the cold stage of each exacerbation is always of short duration, sometimes indicated by a few minutes only of shivering or chilliness, and sometimes escaping recognition ; the hot stage is much prolonged, lasting from six to twelve hours ; and the sweating stage is imperfectly developed, and merges into the period of remission from which it is undistinguishable. The attack of remittent fever is sometimes sudden ; but is more commonly preceded by premonitory symptoms, such as chilliness, lassitude, loss of appetite, nausea, epigastric uneasiness, and pains in the head and limbs. The actual febrile paroxysm begins with a rigor or slight chilliness, to which the hot stage speedily succeeds, and after some hours ends in per- spiration and the period of remission — -the remission, like the hot stage, varying in length from two or three to twelve hours. The paroxysms usually increase in intensity day by day for a few days. The symptoms which the patient presents are for the most part like those which attend intermittent fever, but some of them are much more severe. The tempe- rature attains no greater height, but it never falls during the remissions to the normal standard ; there is no difference as regards the respirations and pulse, except perhaps that the latter with the progress of the disease tends to become quicker and weaker. Sickness is much more severe during the hot stage of remittent fever than in the corresponding period of intermittent fever, is often very distressing, and sometimes attended with hfematemesis (black vomit) ; the tongue is drier, and occasionally there is slight, jaundice ; headache and pains in the limbs are more in- 286 SPECIFIC FEBEILE DISEASES. teuse ; confusion of intellect is more common, and drowsiness, delirium, and coma are not xmfrequent. The patient often passes into a distinct typhoid condition, witli dry brown tongue, sordes on teeth, muttering dehrium, subsultus tendinum, and other symptoms of the kind. Eemittent fever presents at first sight an ahnost closer relationship, in the type of its fever, with enteric fever and hectic (which usually also are distinctly remittent), than with the varieties of intermittent fever. And indeed enteric fever and hectic were formerly, in many of their forms, termed remittent, and regarded as of malarious origm. It is certain, however, that the so-called remittent fevers of temperate climates have no affinity with ague. And, on the other hand, it is equally certain that there is no essential difference between the remittent and intermittent forms of ague. For not only do they arise from the operation of the same miasm, and present symptoms essentially alike, but their varieties shade into one another by insensible gradations, and they alternate with one another or replace one another in the same individual. The effects of the ague -poison are not always in accordance with the above description. Thus there are described : some cases in which the paroxysm consists in a violent and prolonged cold stage only, during which the temperature is actually lowered (the patient suffering from extreme anxiety and intense thirst, and looking like a corpse), or in which, independently of any other peculiarity, he falls into a condition of exhaus- tion, and lies torpid, motionless, and as if asleep, for many hours ; others, in which the sweating comes on early, is exceedingly profuse and of long duration, and during which the temperature falls rapidly, and the patient lies in a condition of extreme coUapse ; others, in which the patient presents coma or delirium, or has epileptiform or tetanoid convulsions coming on in the hot or cold stage, and continuing until the establishment of the sweating stage ; and again others, m which hemorrhage takes place from the nose, stomach, bowels, bladder, or into the substance of organs. Further, there are various neuroses which are distinctly forms of ague, the more important of them bemg neuralgic affections of one or other of the branches of the fifth pair. That invohdng the supra-orbital constitutes one form of the malady known as ' brow-ague.' These may be recognised as being malarious, partly by their periodic character, partly by their occasional supervention on a more or less distmct cold stage, partly by their occurrence in a malarious district, partly by the fact that the patient has already been the subject of ague. There are one or two points in reference to the paroxysms of ague to which we have hitherto only very briefly alluded, but which are neverthe- less of considerable importance. In intermittent fever, durhig the cold and hot stages the m-ine is usually secreted in considerable abundance, is pale and of low specific gra\'ity, and the patient generally has very frequent desire to mictm'ate. He passes an excess of urea, uric acid, and chloride of sodium, Avhile phosphoric acid is diminished. During the sweating stage the urine becomes scanty and darker coloured, and the amount of the AGUE. 287 •excreted solids wliicli was previously in excess, undergoes diminution. Li the intermission urea and uiic acid fall below the normal standard. In the remittent form of ague the same pecuharities exist, but are necessarily somewhat less marked. In both forms there is occasionally albummuria or hsematuria, with renal casts. The spleen is invariably enlarged during the paroxysms, becomes especially swollen during the cold stage, and may generally be easily recognised by palpation or percussion ; it then subsides, and during the intermission may return to its normal bulk. If, however, the ague persists, the splenic enlargement tends to become permanent. The duration of ague presents great differences. An attack will pro- bably always subside (unless death supervenes) after some mdeterminate .period ; especially it will subside if the patient be removed from the district in which he contracted it. But this subsidence is rarely final. In the great majority of eases the patient remains for months or years, or for his life-time, liable to fresh attacks of ague, even if he never again ventures into a malarious district. The attacks then recur at irregular intervals, and are generally determined by some accidental circumstance, such as over-fatigue, an attack of cartarrh or indigestion, or the occurrence of other ailments, whether mild or serious. In other words, the malarious poison becomes a portion of his being, and seems to tinge and quahfy any morbid condition which happens to arise. Death from the ordinary inter- mittent fevers is rare ; but remittent fever, unless it be promptly treated, is a very fatal disease. The patient dies for the most part in the typhoid condition, and seldom (according to Dr. Maclean) before the eighth day. If ague assumes a chronic form, and especially if the patient has been long resident in an agxiish climate, or has had periodical attacks for many years, organic changes take place in the liver and spleen ; their fmictions become impaired or perverted, and chronic conditions of disease are sooner or later developed. Among the more important of these are various forms of cachexia and dropsy. In some cases the patients simply pass into a condition of debility and angemia, on which general dropsy may supervene after a time ; in some cases jaundice becomes associated with this anaemia, and from the same affection of the liver that causes this, ascites or haematemesis and melfena may eventually come on ; in some eases, again, degeneration of blood-corpuscles takes place in the spleen, and their con- version there into brown or black pigment -granules, and the diffusion of this pigment thence throughout the system, give a peculiar dirty or bronzed hue to the complexion. Some degree of such discoloration, indeed, is often seen in persons who have had repeated attacks of ague. In conclusion, it is not uncommon for the denizens of malarious regions to become the subjects of the visceral lesions and cachexiae which supervene on ague without ever having experienced a distinct attack of ague — the malarious poison appearing to affect the system slowly and insidiously, and without even the warning wliicli an occasional febrile ^paroxysm might afford. Morbid anatomy and pathology. — The pathology of ague is very ob- 288 SPECIFIC FEBEILE DISEASES. scure ; and morbid anatomy throws little light upon it. We know that a poison (probably li-^^ng) is taken into the system, and that this remains incorporated with it for an indefinite period, giving rise at irregular intervals to more or less distinctly periodical attacks of well-marked fever, attended with rapid destruction of tissue, high temperature, and conges- tion of internal organs, more especially the spleen. But where the poison lurks, why it acts periodically, and on what organ or organs it acts chiefly, are matters concerning which we do not positively know anything. There is, however, good reason to believe, on the one hand, that it is not dis- charged from any surface, and on the other that (whether it acts directly or indirectly thereon) its main efl'ects are wrought through the agency of the sympathetic system of nerves. It is scarcely probable that the enlargement of the spleen and associated changes in the liver, important though they be in many respects, are anything more than secondary phe- nomena. The only constant lesion discoverable after death is enlarge- ment of the spleen. This organ becomes distended with blood, and often to many times its normal size ; and if the patient die when the attack of ague is recent, it is found large and congested. The Hver, too, is commonly to some extent engorged and increased in bulk. Congestion of the neighbouring parts of the alimentary canal has also been observed ; and in hermorrhagic cases traces of hemorrhage at mucous sm'faces and beneath the serous membranes may be discovered. Enlargement and induration of the spleen and liver are among the common results of long-continued or repeated attacks of ague, or of long residence m malarious districts. Another change to which these organs are liable is a XDeculiar dark or slaty discoloration, due to disintegration of blood-corpuscles and their conversion into pigment-granules. In the hver, this is generally referrible to the changes which occur in minute extravasations of blood into the capsule of Glisson and hepatic parenchyma ; in the spleen, to sunilar changes going on in the blood which occupies the intermediate blood-passages. The pigment is apt to escape from the spleen, to enter the general circulation, and to become arrested m the capillaries of different organs, more especially the Hver, bram, and kidneys, and thus not only causes them to be pigmented, but interferes with their nutrition, and induces various organic changes and functional disturb- ances. Treatment. — What the prophylactic treatment of ague should be may be surmised from the foregoing account of the disease. First, when practicable, malarious districts should be thorouglily dramed and cleared of miderwood or jungle. Second, those Avho are compelled to remain in them should take ample precautions ; should not go out in the evening, night, or early morning ; should sleep in the higher rooms of the house they occupy ; should not drink the water of the locality unless it be well filtered or boiled ; especially should not expose themselves to the mala- rious influences when they are ill or fatigued ; and on going out should, as Sir T. Watson suggests, wear charcoal respirators, and also regularly take such remedies as are efficacious in curing ague. And third, persons who AGUE. 289 are actually attacked with tlie disease should be removed to some healthy locahty. In treating ague medicinally we have to consider, first, the treatment of the paroxysms, and next that of the disease. It is reasonable to sup- pose that the ague-patient will experience some actual benefit if we assuage some of his discomforts, and hence that he vnll be benefited, during the cold stage, by the application of warmth, by packing, warm bottles, hot- air baths, or warm- water baths ; durmg the hot stage by the maintenance of a cool atmosphere, by the use of light clothing, and by tepid or cold sponging ; and, during both, by the admmistration of diluents. Little or nothing, hi fact, is necessary beyond such simple measures. Other remedies, however, have been employed, and some reputedly with con- siderable success. Thus emetics have sometimes been given pre\dous to the fit ; and bleeding has been much lauded as a means of relief durmg the cold stage. The most valuable, however, of such special modes of treatment seems to be the exhibition of opimn in largish doses (about thirty minims of the tincture) during the cold or hot stage. It is of infinitely greater importance to attack the disease itself, and fortunately ague is one of those maladies for which we have almost unfail- ing remedies. Cinchona, indeed, its alkaloids, and arsenic are true specifics. There is no difference of opinion as to their efficacy ; the only diflerence which can exist is as to the mode of their administration and the dose. Of the several cinchona alkaloids, quinine, in the form of the sulphate, is undoubtedly the most efficacious, and it is certainly much more convenient of administration than cinchona itself. There are two principal modes in which quinuae is admmistered ; by some physicians it is given m a single large dose before each paroxysm is expected, by others in small doses at comparatively short intervals. According to the former mode from twenty to thirty grams may be given for a dose to an adult. The time of its administration here, how- ever, becomes important. By some it is thought best to give it just before the paroxysm, by others just after it and even during the sweating stage. The immediate object being prevention, it certainly seems most reasonable that the quinine should be given so long before the expected occurrence of the paroxysm as to allow of its being fully absorbed into the system ; and hence, of these two alternatives, the latter should be preferred. The plan, indeed, of giving the larger dose during the sweating stage can scarcely be improved upon either in the case of remittent or m that of quotidian ague. When, however, the paroxysms are separated by longer intervals, it is probably best either to divide the large dose into two smaller doses and to give them at intervals, or to give the full dose between six and twelve hours previously to the expected attack. The other method, which is frequently pursued, is that of giving the quuiine in smaller doses (three, four, or five grains) three or four times a day without reference to the times of occurrence of the paroxysms ; and indeed it may be given freely even while a paroxysm is in progress. In some cases, owing to extreme irritabihty of the stomach, the quinine (in u 290 SPECIFIC FEBEILE DISEASES. proportionately increased doses) must be given in tlie form of enema, or (in proportionately diminished doses) by subcutaneous injection. The time during whicli the administration of tbe remedy should be persisted in must necessarily vary with the case. It should be given for at least a week or two after all symptoms have disapx3eared ; and should be at once renewed if a recurrence manifests itself. It is important, however, to observe that quinine (and the same is true of arsenic) does not, by con- tinuous use, even for many months, necessarily eradicate the disease. Arsenic is equally efficacious with quinine in the treatment of ague, and indeed sometimes effects a cure when quinuae has failed. The liquor arsenicahs may be given in doses of from five to ten minims three or four times a day. It is generally considered advantageous to keep the bowels freely open, and uideed it is asserted that quinine and arsenic are occasionally ineffica- cious mitil a purgative has been administered. The complications and sequelae of ague must of course be treated according to their nature ; and the diet (in regard to which no special rules need be laid down) must be regulated by the condition and the tastes or desires of the patient. 291 Chap. II.— DISEASES OF THE SKIN. I. INTEODUCTOEY EEMAEKS. MoEBiD conditions of the skin are of great interest and importance, partly because they are very common, partly because they are in many cases a valuable aid to us in the determination of the nature of internal maladies, partly because their presence so largely affects, not only the health, but the comfort and happiness of those who suffer from them. Further, their position renders them comparatively easy of observation. For all these reasons they have been repeatedly investigated and described with extreme care, and have been distinguished with a degree of minuteness, and classified with an amount of ingenuity, which have been surpassed only in the distinction and classification of the members of the vegetable kingdom. The resvilt has undoubtedly been largely to increase the range and exactness of our knowledge of skin diseases ; bat it may be questioned whether this result has not been to a great extent counterbalanced by the confusion which the introduction of a large number of names to designate trivial and often fanciful varieties of disease, and the pains taken to dis- criminate between conditions which are essentially identical, have tended to create. But there is considerable excuse for mmuteness of description and complexity of nomenclature of skin diseases, in the facts : that the skin is an extremely complicated organism, any one or all of the constituents of which may become the seat of almost any of the various morbid processes which have been considered in a former section of this work ; that it differs greatly in character in different parts of the body, and is hence not equally liable everywhere to the same affections, or even to present identical appearances under the mfluence of the same disease ; and, lastly, that it subserves various important functions, all of which are liable to modification or impairment in the presence of morbid processes. A. Classification and Definition of Terms. We shall not classify skin diseases either according to the anatomical elements of the skin which are involved, as has been done by Erasmus Wilson ; or according to their visible features, which constitutes the essence of Willan and Bateman's system ; nor indeed shall we follow any u2 292 DISEASES OF THE SKIN. strictly logical sclieme of classification. But we shall group them mainly in accordance with their mutual pathological affinities, not hesitatmg, however, to depart from this arrangement whenever it seems of practical utility, or convenient on any other grounds, to do so. There are certam terms in common use in the description of skin diseases, which we proceed in limine to enumerate and explain ; the more especially as there will thus be afforded a suitable opportunity for uidi- cating the principles of Willan's artificial, but nevertheless very simple and useful, classification. 1. Macula. — By this term is generally meant a spot or patch of dis- colouration which does not fade on pressure, and in which, therefore, there is some obvious and more or less persistent deposit or change of texture. Freckles, moles, and port-wine marks are good examples of maculEe. Under the same term may be included the circumscribed discolouration s due to escape of blood into the tissue of the skin. But these are better known by special names. Extravasations, from about a line in diameter downwards, aire (from their supposed resemblance to flea-bites) designated 2)etechice ; larger effusions, such as may result from the coalescence of several petechise are called v ibices ; and those presenting the ordinary characters of bruises are known as bruises or ecchymoses. The term stigma is sometimes employed to indicate small patches or spots of vivid but readily effaceable redness, due merely to congestion, which appear suddenly, and often precede the development of vesicles, papules, or the pocks of vaccinia or small-pox ; and the term areola or halo is apphed to the ring, more or less broad, of redness which so often surrounds a definite spot of inflammation. Willan's eighth order of skin diseases was that of the mciculce, and included, amongst other affections, freckles and the various forms of birth-mark. 2. Exanthema, or rash. — These words are employed in reference, not fo individual spots of disease, but to a more or less general eruption of spots or patches, which are inflammatory, and variously grouped, and, in the first instance at any rate, red, faduig on pressure, and but httle elevated above the general surface of the skin. The exanthemata formed the third of Willan's orders ; and he included in it measles, scarlet fever, nettle-rash, roseola, pm-pura, erythema, and erysipelas. It is ob-sious, however, that he has here grouped together affections of the sldn some of which have little in common with the others, and that he has excluded several which should really be regarded as exanthemata. Thus purpura is in no sense an exanthem, and erysipelas and erythema have no more right to that name than has acute eczema or impetigo. On the other hand, the erux3tions of varicella and small-pox, and especiallythat of typhus, should certainly be regarded as exanthems. The term ' exanthem ' should, indeed, be applied exclusively to the several eruptions which attend and characterise the mfectious fevers. 3. Pajmlct, ox pimple. — This is a small elevation at the surface of the skin, generally acuminated or pointed, but sometimes rounded, and rarely DEFINITION OF TEEMS. 293 exceeding the size of a large pin's bead. It is very commonly congested, but by no means invariably so, and often attended with much itching. Papules are produced in various ways. In the condition known as ' goose's skin ' there is a temporary production of them at the orifices of the hair-follicles in consequence of the contraction of the arrectores pili ; and in the same situation papules often arise from the concentric accumu- lation of epidermis and sebaceous matter entangling young hairs. The pearly concretions so common in the sebaceous glands of the eyelids con- stitute another form of papule. Typical papules, however, originate either in enlargement of the normal papillae of the skin, or in inflam- matory exudation into the substance of the cutis. The paindce, constituted Willan's first order, and comprised the various diseases known as strophulus, lichen, and prurigo. 4. Tubercles are sohd elevations of the cutis, ranging roughly from the size of a hazel-nut to that of a papule, varying considerably in form and texture, and presenting more or less permanence. In form, they may be hemispherical, spheroidal and attached by comparatively narrow bases, conical, lobulated or warty ; and not unfrequently neighbouring tubercles coalesce, and thus extensive surfaces may become irregularly thickened and lobulated. As to texture, it is sufficient, perhaps, to say that tubercles are sometimes cancerous, sometimes sj^philitic, sometimes lupoid, sometimes due to inflammatory changes in sebaceous glands, sometimes simple warts. The ^;«&erc?^Za formed Willan's seventh order, and included boils, warts, molluscum, vitiligo, acne, sycosis, lupus, elephantiasis, and frambtesia. A ivheal may be regarded as a species of tubercle. Its special pecuHarities are that it is of very transient duration, and that it forms a flat, generally circular, elevation, rarely exceeding a quarter or third of an inch m diameter. It sometimes presents a more or less vivid rosy tint, but is frequently pale, and in either case generally surrounded by a halo of congestion. It is usually attended with much itching. A wheal re- presents an early stage of inflammation ; and the swelling which charac- terises it is due to eflusion from the vessels of the part. Wheals may run together, and thus form bands or patches of considerable extent. 5. Vesicles are small accumulations of fluid, generally between the horny layer of the epidermis and the rete mucosum. Individually they vary, for the most part, from the size of a pin's head downwards ; but they may be larger than that, and by mutual coalescence may form con- tinuous tracts of considerable extent. They generally stand out promi- nently from the surface ; but where the horny layer of the cuticle is thick, as on the palm and sole, they often present no elevation whatever, are imbedded, and can be recognised only by the peculiar greyish or bluish tint which they present. The amount of fluid relatively to the solid con- stituents of vesicles varies very much ; and especially this is so if the vesicles are of mflammatory origin, inasmuch as the fluid effusion is then often associated with manifest thickening of the subjacent cutis and with overgrowth of the involved epidermis. Indeed, owing to this circum- 294 DISEASES OF THE SKIN. stance, the distinction between vesicles and certain forms of papules becomes pm-ely arbitrary. Certain vesicles (sudamina) appear to be due simply to accumulation of sweat between the layers of the epidermis, and their contents are pellucid and acid. Generally, however, vesicles are the result of inflammation, spring up on a congested surface, and present contents which are alkaline, and, according to their age or other cir- cumstances, transparent, milky, or tinged with the colouring matter of the blood. The vesicula formed Willan's sixth order, and were made to embrace varicella, vaccinia, herpes, rupia, miharia, eczema, and aphthae. 6. BullcB, or blebs, may be regarded as having the same relationship to vesicles that tubercles have to papules. The line of separation between vesicles and bullae is quite artificial ; generally speaking, however, a vesicle as large as a split pea would be termed bulla. Bulls usually vary between this size and that of half a walnut. Occasionally they attam the bulk of an orange. But when thus large they are very often elongated and even sinuous as to their base, and their elevation is proportionately reduced. Their contents are identical with those of vesicles. The biillcB were Willan's fourth order, and comprised pemphigus and pompholj-x — affections now regarded as identical. 7. Pustules are accumulations of pus within or beneath the epidermis. They vary in size and form, and also in the degree in which they involve the deeper tissues of the skin. They sometimes commence as vesicles, the contents of which gradually suppurate ; but very frequently they are purulent from the begimimg. They are generally covered, as vesicles are, by the horny layer only ; sometimes, however, by the whole thickness of the epidermis. The inflammation attending the formation of a pustule is much more intense than that which causes a vesicle or bulla, and con- sequently we find, as a rule, much greater congestion, thickening, and induration of the surrounding and subjacent parts in the former than in the latter case. The imstula were Willan's fifth order, and mcluded impetigo, porrigo, ecthyma, variola, and scabies. 8. Furfura, or scurf, is the name given to the thin bran-like scales, which separate from the surface of the skin on the subsidence of many of the exanthems, and which so commonly form upon the scalp. Scurf consists either of thin plates of epidermis or of a mixture of epidermis and sebaceous matter. 9. SquamcB, or scales, differ from scurf only in the fact that the plates of detached epidermis which constitute them are of larger size. They vary considerably, however, in size, thickness, colour, and consistence. Thus, they may be as much as a square inch m area, or even larger ; they may be as thin as flakes of scm'f or several lines in thickness — in the latter case being always more or less distmctly laminated ; they may have the colour of the skin, or present various tints of yellow or bro-«-n ; and they may be soft or hard, friable or tough. Some of these pecu- liarities depend on the amount of fluid which has been diffused amongst DEFINITION OF TEEMS. 295 the epidermic laminae during tlie x^i'ocess of tlieir formation. The detach- ment of scurf or scales is called ' desquamation.' WiUan's second order was that of sqtiamce, and comprised lepra, psoriasis, pityriasis, and ichthyosis. 10. A scab, or crust, is the concretion formed upon a diseased surface by the drying up of the exudation which has taken place from it, and generally comprises therefore some of the normal elements of that surface, namely, epidermis and sebaceous matter. The exudation may be serum, pus, or blood, alone or combined in various proportions ; and it is obvious that, according as these occur smgly, or intermixed, or combined with sebum or epidermis, will the colour and other physical characteristics of the resulting scabs vary. Serum alone dries into thin yellowish or brown translucent flakes, pus alone into greenish scabs of some thickness, and blood mto crusts which are black or nearly so. The admixtm-e of seba- ceous matter with serum or pus imparts to the resultuig scab the colour and general aspect of gum or honey, and that with blood a bro^ni or red tint. When many particles of epidermis are mixed with simple serous exudation, as in cases of acute eczema, the concreted product often assumes a powdery character and the colour of brimstone. Crusts vary in thickness, and are occasionally conical. It is needless to discuss the meanings of the terms * excoriation,' 'fissure,' 'ulcer,' 'cicatrix,' and many others which are in common use and generally understood. B. Tendency of Spots and Patches of Skin Disease to assume a Circular Form. Before proceeding to the description of the different diseases it may be worth while to point out that, while eruptions present great varieties of groupmg or arrangement, the individual spots or patches almost invari- ably have at first a rounded shape, and that as they grow they maintain that shape, unless the form of the surface on which they are situated, or the direction of its grooves, or the union of neighbouring patches with one another, interferes with their regular development. Thus a vesicle, bleb, pustule, papule, or tubercule is almost mvariably circular m the first instance ; so is a patch of erythema, lepra, or pityriasis ; and so also are the vegetable parasitic affections. In many cases, moreover, there is a tendency for the central part of the inflamed patch to resolve whilst its periphery is extending ; and then it not unfrequently happens that the enlarging ring breaks up into fragments, and that some of these form the startmg-points of other circles or segments of circles. It is easy to miderstand from this statement how the sinuous, serpentine, and other curious forms which skin diseases frequently assume are produced. 296 DISEASES OF THE SKIN. II. EEYSIPELAS. Definition. — An acute inflammation of the skin, originating for the most part in the neighbourhood of wounds or sores, attended with much redness and infiltration and severe febrile disturbance, and characterised by a marked tendency to spread over the surface, and (especially in the presence of wounds) to become contagious. Causation. — Erysipelas is either traumatic or idiopathic : that is, it either occurs in connection with wounds, or arises apparently spon- taneously on surfaces which were previously sound. The former variety may be developed, therefore, on any part of the body on which wounds have been inflicted, or wherever conditions equivalent to wounds exist, as, for example, in connection with other forms of cutaneous disease, and about the umbilicus in new-born children ; further, erysipelatous inflam- mation, or a modification of it, may attack parturient women. Idiopathic erysipelas occurs most frequently on the face. That erysipelas is highly contagious among surgical patients, and that its presence in a lying-in hospital induces a rapidly fatal form of puerperal fever among the mothers, and erysipelas of the new-born infants, are facts entirely beyond dispute. It is obvious that in these cases the disease is propagated by the trans- mission from the sick to the healthy of some poisonous matter capable of reproducing it ; and from the circumstance that the inflammation always begins at the very spot where a wound or rawness exists, it is reasonable to assume that the poison has been inoculated at that spot. It is by no means clear that erysipelas spreads in the same way to those whose skin and mucous involutions are sound. No doubt many, and apparently very striking, examples of such spread are recorded, but, on the other hand, good authorities deny its occurrence, and certainly it is far from common. Li close relation with the subject just considered is the question, whether erysipelas is to be regarded as a specific fever or a mere local inflammation. The former view is generally entertained, at all events in this country ; and the chief grounds on which it rests are : first, the mani- fest contagiousness of the disease under certain conditions ; second, the existence, which is obvious in idiopathic cases, of a distinct, though short, stage of incubation ; third, the affirmed enlargement and tenderness of lymphatic glands prior to the appearance of the skin affection, indicating that the erysipelatous inflammation is secondary to constitutional disturb- ance ; fourth, the discovery of bacteria in great abundance in the inflamed tissues and in the lymphatic spaces and vessels connected with them, and the fact that these bacteria may be propagated, with the inflammation which they accompany, by inoculation upon the lower animals ; and lastly, the close resemblance which exists between the general morbid anatomy and symptoms of this disease and those of the specific fevers. The ar- guments in favour of its being a non-specific and local disease are chiefly the following : — first, the fact that the disease appears in many cases to arise from exposure to cold and various other non-specific causes ; second. ERYSIPELAS. 297 that a pre%'iou3 attack, so far from precluding subsequent attacks, as is generally the case with the infectious fevers, encourages them, as is the common rule with non-specific inflammations ; third, that contagiousness is not an attribute of the specific fevers only, for many varieties of simple inflammation (catarrh, ophthalmia, and the like) are apt to spread by con- tagion ; and lastly, that the symptoms and morbid processes which attend erysipelas can be fully accomited for as being the consequences of the local inflammation. "\Ye agree with Hebra in the behef that erysipelas is not a specific fever, but a local disease ; that is, a local disease in the same sense that inflammations of the lungs, kidneys, and other organs are local diseases. Apart from contagion, to which, as we have shown, erysipelas is largely due, the causes of the disease seem to be identical with those of other forms of inflammation, especially exposiu'e to cold and atmospheric changes generally, and local mitations of various kinds. The causes which predispose to it are partly breaches of surface, partly constitutional conditions, such as may result fi'om long- continued indulgence in drhik, and poor hving. Morbid anatomy. — The earhest local changes consist in a circum- scribed blush of more or less ^i"^-id redness, which fades on pressure, and the accumulation of inflammatory products (lymph and corpuscles) in the substance of the cutis and subcutaneous connective tissue. The inflamed patch consequently becomes thickened, hard, and brawny. Its margin is well defined, and obvious to eye and touch. The character of its surface varies according to the part aflected. If the skin be originally smooth and dehcate, it becomes yet smoother, andshming ; if it be coarse, all its markings are apt to get magnified, and its coarseness therefore exaggerated. The inflammation gradually spreads by continuity to the surromading healthy parts, and thus extending may ultimately mvolve a very large area — the entire surface of a limb, for example, or that of the head and face, and occasionally (it is said) that of the whole body. As it spreads, however, the parts first affected undergo changes, their tension diminishes, their redness becomes less vivid and assumes a yellowish or brownish tint, and resolution, preceded by desquamation, presently takes place. Thus all stages of the disease may be present at the same time. Occasionally erysipelas (then termed erratic) disappears from one part and breaks out elsewhere, and may thus be prolonged by successive out- breaks. The intensity and results of the inflammatory process vary consider- ably in different cases. In some the degree of inflammation present is no greater than that attending the affections which we shall shortly describe under the name of erythema. In some the effusion is so abundant that it infiltrates the subcutaneous connective tissue, and well-marked cedema is developed. This is common wherever the cutis is thm and the sub- cutaneous connective tissue lax, as they are in the eyelids and scrotum. In some cases the inflammation goes on to the formation of pus, which, like the oedema, occupies mauily the subcutaneous tissue. The suppura- 298 DISEASES OF THE SKIN. tion is frequently diffused ; but sometimes, and especially in the eyelids and elsewhere about the face and head, forms circumscribed abscesses. In some cases again, and mainly in connection with suppuration, the con- nective tissue sloughs, or the skin itself becomes gangrenous. When oedema, suppuration, or sloughing is in progress, the inflamed surface becomes paler and duller, perhaps livid, and acquires a soft ' boggy ' feel, or pits on pressure. Vesicles and bullae not unfrequently form on erysi- pelatous surfaces, and may become converted into pustules. Subsequently excoriations and scales or crusts necessarily make their appearance. Bullffi also, containing sanious fluid, attend the progress of superficial gangrene and subcutaneous sloughing. Although erysipelas is commonly limited in depth by the fasciae, it is not invariably thus limited; and hence subjacent organs are apt to get involved. Thus erysipelas of the trunk may produce inflammation of the peritoneum, pleurae, or pericardium ; erysipelas of the neck oedema of the larynx ; and erysipelas of the head meningeal inflammation. Again, it not unfrequently creeps from the skin into the mucous orifices : into the auditory meatus, causing inflammation of the ear, or into the nose or mouth, and thence to the fauces and larynx. On the other hand, cutaneous erysipelas may result from extension of faucial, aural, and other such inflammations. There is a marked tendency in erysipelas for the veins, and especially for the absorbents, to sufi^er. As regards the absorbents, indeed, it is not only common to trace red Knes from the seat of inflammation to the nearest glands, which get enlarged and tender ; but some authors go so far as to maintain that a patch of erysipelatous inflammation is always preceded by inflammatory enlargement of the neighbouring lymphatic glands. Phlebitis, again, with suppuration in or around the veins, and pysemia, occasionally take place. Eepeated attacks of erysipelas lead to permanent thickening and in- duration, and sometimes to very considerable overgrowth, of the skin, and subjacent connective tissue. Indeed, according to Virchow, it is to such attacks frequently repeated that the hypertrophy of these parts in elephan- tiasis is mainly due. There is no special affection of internal organs in erysipelas. In the early stages of the disease the blood contains an excess of fibrine and white corpuscles ; but subsequently it tends to assume the characters commonly observed in the later stages of febrile disorders. Post mortem it is gene- rally found dark, and fluid or pitchy, with little tendency to coagulate, and still less to the separation of fibrine. It stains the inner surface of the heart and vessels. The organs are generally soft, and the lungs, liver, kidneys, and especially the spleen, congested. Pneumonia is not uncommon. Decomposition is rapid. Symptoms and progress. — The symptoms of erysipelas are mainly those of the local process and of inflammatory fever ; but they are often complicated with those of intercurrent lesions ; and they vary in their severity, both actually and relatively, according to the intensity of the EEYSIPELAS. 299 inflammation, its extent, and its situation. In icliopatliic erysipelas the local signs are generally preceded by an interval, varying from a few hours to two or three days, in which the patient experiences slight febrile symp- toms, sometimes rigors ; and in which, according to certain authors, some swelling and tenderness of lymphatic glands may be detected. At the end of this time an inflammatory blush appears, generally on some part of the face, attended with heat and tingling, and tenderness on pressure. With the appearance and extension of this, the febrile symptoms in- crease ; there are headache and pains in the limbs, rise of temperature with dryness of skin, rigors, increased rapidity of pulse, furring of the tongue, with thirst, loss of appetite and nausea or sickness, generally some constipation, occasionally, however, diarrhoea, and scanty high coloured urine. There may be some degree of drowsiness, but sleep is restless and disturbed by dreams. If the case be mild, the symptoms may subside and the patient become convalescent in the course of two or three days. But if the inflammation continue to spread, or in any way to increase in severity, the pulse gets rapid and feeble, the respirations hurried, the tongue more thickly coated and dry ; and delirium, at first only when the patient is dropping to sleep or waking, but subsequently constant, comes on. Sometimes at this period diarrhoea occurs ; and the patient's evacua- tions may be passed into the bed. At this point also (that is, at the end of six or seven days) the patient may begin to amend. When, however, from the inherent severity of the attack or other circumstances, the case takes an unfavourable course, the symptoms assume a more distinctly typhoid character : marked mainly by great failure of muscular power, tremulousness of limbs, dry black tongue, want of control over the evacuations, and delirium, which is generally low and muttering, some- times busy like that of delirium tremens, and occasionally violent and maniacal. As the fatal end approaches the temperature often rises, the skin becomes bathed in sweat, the pulse rapid, perhaps irregular, and almost imperceptible, the respirations quick and noisy, and the delirium passes into coma. The temperature in erysipelas is always above the normal, but rarely exceeds 106° ; and, although it is liable to considerable variation, there is a general tendency to an evening rise and a morning fall. The urine is always scanty, presents an excess of urea and diminution of chlorides, and often contains small quantities of albumen between the fourth and seventh or eighth day of the disease. The motions are generally dark-coloured, watery, and fetid. The course and event of the disease are often modi- fied by the association with it of some one of the various complications which have been previously enumerated. Thus, CBdema of the larynx and congestion of the lungs will each add symptoms and dangers of its own. And similarly inflammation of the membranes of the brain, phle- bitis and pyaemia will each bring its characteristic indications. Further, the health and circumstances of the patient at the time of seizure for the most part largely modify the character and severity of his attack. Erysipelas which seems to affect only the cutis is termed simple 300 • DISEASES OF THE SKIN. erysipelas ; wlien the subcutaneous connective tissue is largely involved as well, tlie affection is called iMegmonous erysijjelas ; wlien oedema, suppu- ration, or sloughing supervenes, the erysipelas is often termed edematous, suppurative, or gangrenous, as the case may be. But these distinctions are essentially artificial, for the various forms of erysipelas run into one another, and several, or all of them, may be present at the same time ui the same case. Treatment. — Having regard to the tendency which erysipelas has to become contagious, it is always important that erysipelatous patients should be removed from the neighbourhood of those who are especially liable to take it ; and that, in fact, all such precautionary measures should be adopted as have been already recommended in relation to the mfectious fevers. The local treatment in mild cases is of little importance ; and, even m severe cases, has perhaps little influence. Collodion, nitrate of silver in saturated solution, solution of sulphate of iron, tincture of iodine, and mercurial omtment, have each been strongly advocated. Flour, dusted thickly over the surface, is also recommended. There is an obvious disadvantage in employing anything which conceals or masks the diseased surface ; for which reason several of the above applications are objection- able, even if useful on other grounds. Mild astringent lotions and oint- ments, such as those of lead, zinc, and iron, are probably as useful and convenient as any. Cold-water dressing, which has commonly been dis- countenanced in this country, is strongly recommended by Hebra, and is undoubtedly useful. Warm applications and poultices are not generally desirable. It is rarely needful to abstract blood locally, or to make incisions, except for the purpose of lettmg out matter, or relievmg tension. In reference to the internal treatment of the disease, we must recollect that mild cases get well spontaneously, and that more serious cases very soon present symptoms indicative of great debility and of blood-poisoning. For these reasons it seems obvious that depletion can never be necessary ; but that, as a rule, the strength of the patient should be sustained, and the free action of his excretory organs encouraged. To support strength, such nourishment as he can take should be administered frequently and in small quantities, milk, eggs, beef-tea, arrowroot, sago, and the like, are most suitable for the purpose ; to which, if the pulse be failing and the tongue dry, brandy, wine, or ale (if the patient prefer it) should be added. To promote the action of the emmictories, purgatives should, if necessary, be from time to time administered, and the patient may be put on a course of mild diuretics or diaphoretics. Ammonia, camphor^ iron, quinine, have all been employed in the treatment of erysipelas. It is questionable, however, whether any one of them is of material use in the early stages of the disease. But stimulant medicines are clearly indicated when typhoid symptoms are present ; and tonics are, of course, highly valuable during convalescence. Hyoscyamus and opium are not generally indicated, and must always be given with caution. But in cases where there is great irritability, or persistent want of sleep, they, chloral hydrate, or other sedatives are valuable. CAKBUNCLE. BOIL. 301 III. CAEBUNCLE. {Anthrax.) BOIL. (Furuncuhis.) Definition. — A boil or carbuncle is an intense inflammation occupying, within a well-defined area, the entire thickness of the skin (inclusive o£ the subcutaneous connective tissue), and attended almost always with circumscribed suppuration and the formation of a slough. Causation. — Boils and carbuncles are usually considered to be consti- tutional disorders ; and midoubtedly they are common in persons of broken- down constitutions, and in those who are recovering from diseases of various kinds. Diabetic patients are said to be specially liable to them. But, on the other hand, they are common in those who appear to be otherwise m perfect general health ; often occurring in connection mth acne and other forms of skin disease, or induced by local irritation, such as arises from friction, poulticing, the contact of unhealthy discharges, and (as pathologists know to their cost) the soakage of dead bodies. It cannot be denied that there is, in many cases, a predisposition to boils and car- buncles, and that this predisposition may be induced. We are disposed, however, to regard the disease as essentially local, and due to the operation of local causes ; and to believe that, like acne, it is mainly an affection of . the sebaceous glands and their surroundings. Morbid anatomy. — The morbid process commences with circumscribed thickening and induration of the deeper tissues of the skin, attended from the beginning, or soon followed, by a little elevation and redness of sur- face. The resulting nodule increases in area and thiclmess, and conse- quently in prominence, until, at the end of a few days, it has attained its full development. It then presents a more or less circular base, varying in diameter from half an inch to three or four inches or more ; is intensely congested, and surrounded with an areola of congestion and often much cedema ; and forms a considerable elevation, which is conical or flat, according as the area involved is small or large, and presents on its summit a vesicle or group of vesicles, containing serous or sanious fluid or pus. Each vesicle soon bursts, discharges its contents, and exposes in its floor a small round orifice, from which, even at this time, an ash- coloured slough protrudes. When there are more vesicles than one, they generally soon run together ; and then by sloughing of the intervening papillary layer of the cutis the subjacent orifices coalesce, so as to form a more or less extensive irregular excavation, the floor of which is formed as are the floors of the primary orifices by underlymg sloughy tissue. The slough thus exposed has been gradually forming during the progress of the disease, and mvolves the deeper structures of the skin and some- times subjacent parts ; mainly, however, it consists of connective tissue saturated with pus, and presenting a yellowish or greyish colour, and a resemblance to w^ash-leather. It now gradually becomes detached from its bed, and is at length discharged through the orifice which has formed over it. After its separation the excavation which it leaves granulates, the inflammatory thickening of the surrounding tissues subsides, and the parts gradually return to their normal condition, except that a permanent 302 DISEASES OF THE SKIN. scar remains. The distinction between a boil and a carbuncle is arbi- trary ; a boil is comparatively small, generally conical in shape, and opens by a single orifice ; a carbuncle is characterised by its size and flatness, and particularly by the formation of more orifices than one, and the presence of superficial gangrene. Carbuncles very often arise in the median line of the trunk behind, and especially in the nape of the neck. They sometimes attack the lips (more particularly the upper lip), and are then characterised by great malignancy. The lymphatics and veins are very apt to get inflamed in these affections ; and, of carbuncle especially, pyaemia is a common sequel. Symptoms. — The local symptoms are heat, tingling, and aching, with throbbing and great tenderness, which are often followed by pain and redness of the lymphatic vessels and glands in relation mth them. There is generally, even with a boil, some amount of febrile disturbance ; and with a carbuncle the febrile symptoms may be very severe. Indeed, in the latter case, the general symptoms are almost exactly like those which attend the progress of erysipelas, and may be at least as serious as those of the worst forms of that disease, and the consequences may be fully as grave and fatal. Treatment. — The general treatment of carbuncle is identical with that of erysipelas. For local treatment free incisions are generally recommended, which, if the carbuncle be large, should be crucial. Pain and tension are greatly relieved by them ; but it is doubtful if they check the progress of the disease or materially modify its course. Caustic applications, and especially the free use of caustic potash, are recom- mended by some. Poultices and warm water dressings are generally of service. Hebra strongly advocates the employment of cold in the form of compresses saturated with ice-cold water, to be applied so long as they are not disagreeable to the patient. In the treatment of boils, which often show a tendency to recur, many internal medicines (among others yeast, quinine, and mineral acids) have been recommended, with the object of preventing that recurrence. But it is more than doubtful whether any of them has a specific influence. It is, of course, always desirable to treat any associated malady which may tend to keep up a condition of system favourable to the development of boils. Boils may be dealt with locally on the same principle as car- buncles ; and some authorities believe they may be made to abort by the early application to them of strong ammonia, caustic potash, acid nitrate of mercury, or some other such agent. EEYTHEMA. 303 IV. EEYTHEMA. EOSEOLA. UETICAEIA. PITYEIASIS. Causation and description. — The above affections embrace a consider- able number of morbid states of the skin which resemble one another in the facts : that they are for the most part slight, superficial, and essen- tially short-lived inflammations ; that they have little or no tendency to suppuration, ulceration, or gangrene, but end usually in furfur aceous des- quamation ; that they are often variously figured and distributed ; and that they are never contagious. There is great confusion amongst dermatologists as to the distinctions between erythema and roseola. Dr. Willan describes the former as a nearly continuous redness of some portion of the skin, and the latter as a rose-coloured efflorescence variously figured. But even he includes under the head of ' erythema ' affections which, according to his definition, should be varieties of roseola ; while, on the other hand, several condi- tions are now universally termed roseola which, according to the same definition, ought to be regarded as erythema — we refer to so-called ' roseola cholerica ' and ' roseola vaccina.' The formation of wheals is the special characteristic of urticaria ; but wheals arise under so many different conditions, and so closely resemble some of the eruptions which are termed erythema, that it is impossible to draw any sharp line between them. For these reasons we propose to discuss erythema, roseola, and urticaria together ; and, although we shall preserve the names, we shall regard them as indicating trivial, and in some cases imaginary, distinc- tions between things which are essentially the same. Pityriasis we look upon as simply the desquamating stage of the different forms of ery- thema. Some of these affections are of local origin, due to the action of direct irritants ; but many of them, as is shown by attendant circum- stances, and by their simultaneous development in different parts, are distinctly traceable to causes acting from within. The former, if exten- sive, may be attended with febrile disturbance. The latter are generally so attended ; and, indeed, not unfrequently appear in the course of some rheumatic, gouty, or other inflammatory or febrile attack. The local symptoms are, for the most part, more or less intense itching, burning, stinging, and occasionally aching. A. Erytliema simplex iQ a pretty uniformly diffused redness, occupyin» an area of irregular size and form. The redness is generally bright, dis- appearing on pressure ; is attended with slight thickening and elevation of the skin ; and presents a fairly well-defined margin. It often spreads from its primary seat over the neighbouring skin, and is not unfrequently erratic. There is a very close resemblance between certain varieties of erythema and the simplest form of erysipelas ; between which, indeed, it is impossible in many cases to distinguish. One variety of erythema is produced by the direct operation of local irritants, as by the application of a mustard plaister, or by the constant flow of catarrhal secretions 304 DISEASES OF THE SKIN. from the nostrils or of saliva from the moutb, and in children, when from want of cleanliness the urine is allowed to fret the thighs, groms, and other neighbouring parts. Intimately related to this is the condition known as e. intertrigo, in which inflammation is induced, either by attri- tion of opposed surfaces of the skin, or by the effect on such surfaces of the decomposing and fetid sweat which accumulates between them. This is common, in children and fat adults, in the groins and between the ripper parts of the thighs and external genital organs; and, in fat women, between the pendulous mamma and the surface with which it lies m contact. The persistence of the cause in e. intertrigo tends to keep up and intensify the irritation ; and consequently excoriation and ulceration are apt to supervene. Another variety of erythema is termed e. lave. This is the superficial inflammatory blush which often appears in limbs, and especially in legs, which are the seat of anasarca. The redness is generally somewhat ununiformly distributed, and is attended with tenderness and itching, tingling and aching. Vesicles, which rup- ture and allow of the escape of the dropsical fluid, are apt to form on the surface; and not unfrequently the inflammation passes into distinct erysipelas, or superficial gangrene ensues. A further variety of erythema is known by the name of lyityriasis simplex. This occurs on various regions of the body, but is especially common in the form of circular or oval patches on the lips, chin, and other parts of the face, in children and persons of dehcate skin. The patches present a slight degree of redness, and are early covered with thin branny scales, or scurf, whence the name ' pityriasis ' has been given to them. This affection is also of common occurrence in the hairy scalp, when it is usually called j3. capitis or dandriff. In this case the branny scales, which form pretty abundantly, and, owing to the presence of hair, tend to accumulate, contain, as might be expected from their soil, a large admixture of sebaceous matter. B. Erythema multiforme.— \Jndiex this term, which we owe to Hebra, are included e. paimlatum (in the sense in which Hebra employs that term), e. circinatnm, e. iris, e. marginatum, and e. gyratum. The earhest stage of the affection is characterised by the appearance of small, flat, circular, congested elevations of the cutis, attended with itching, and differmg little if at aU from wheals [e. papulatum). Their development may cease at this point. But in most cases they pass on to a second stage : the wheal gradually increases in area mitil perhaps it measures half an inch or an inch in diameter ; and while thus increasing, its central portion probably subsides, its periphery formmg a congested tumid ring [e. circinatum) ; or the enlargement of the inflamed patch is effected by the development of successive concentric rings of inflamma- tion, separated by zones of fairly healthy skm, and the affection known as e. iris results. Further, the spots of e. iKtindatum, and the patches of the circulate form of the affection, which may attain much larger dimen- sions than have been above assigned to them, tend in the coiirse of their development to coalesce with one another, and thus to cover with more EKYTHEMA. 305 or less uniformity round, oval, or sinuously margined are^e of several square inclies, which, like the spots from which they sprung, are still for the most part characterised by a tendency to central subsidence, and marginal extension by a broad band of congestion. In their progress these ' fairy rings ' not unfrequently break up into segments, and hence after a while curved or sinuous erythematous bands alone remain. These latter forms of the affection constitute e. marginatum and e. gyra- tum respectively. The several varieties of erythema above described occur on different parts of the body and are sometimes very extensively distributed ; they are most common, however, on the backs of the hands and ■v\T:ists and corresponding parts of the lower extremities. They are generally attended with febrile symptoms, which, if the eruption be extensive, may rmi high — the temperature rising temporarily to 104° or more ; and they are apt to be associated with rheumatism or gout. Individually the inflamed patches seldom last more than a week or ten days, sometimes not longer than two or three days, and terminate in desquamation. But the eruption may be continued by successive crops for several weeks. Occasionally it assumes a chronic form, and the patient remains for years liable to more or less frequent outbreaks. It sometimes happens : that the wheals or rings become the seat of intra- cutaneous hemorrhage (lywyura urticans ?), which generally occurs in the form of minute coalescing points, and is for the most part limited to their central arese ; and that this leads to the death of the involved cutis and separation of the eschars, or to the development of sanguinolent blebs, and unhealthy ulcers. Further, vesicles or bullfe, containing limpid fluid, not unfrequently arise in more or less abundance upon the surface of the erythematous patches, constituting varieties of herj^es and 2Jevi2:)higus. C. Erythema nodosum is characterised by the appearance of round or oval red patches, varying, roughly speaking, from i inch to 1^ inch in dia- meter. They rise in a lenticular form above the surface in relation with which they are developed, and are consequently most elevated at the centre, where also their redness is most intense ; and in both of these respects they fade away gradually at the margms. They are hot, hard, and tense to the touch, and to the patient tender and attended with aching. They occur chiefly scattered over the anterior aspect of the leg, between the ankle and knee, but sometimes on the lower part of the thigh. They occasionally appear also on the corresponding parts of the arms, and in rare cases stud the whole of the surface of the body, including, fingers, toes, and face. The patches generally increase in number for a few days — each one lastmg perhaps a week. They get dusky in colom- after a day or two, and generally acquire a bluish aspect when exposed to cool air ; they present successively the greenish and yellowish tints of fading bruises, and end with desquamation. E. nodosum is for the most part preceded by and attended with febrile symptoms, and not unfrequently associated either with rheumatic pains or Avith distinct rheumatism. It is most common in young persons, especially females, above the age of puberty. The affection X 306 DISEASES OF THE SKIN. described by Willan under the name of e. fuherculatum is merely a modi- fication of e. nodosum. We believe, too, that the roseola autumnalis of the same author is essentially the same disease ; and may add that there is httle, if any, difference between a chilblain (pernio] and a iDatch of e. nodosum. D. Erythema fugax is the name given to the evanescent patches of redness which appear on the face, neck, chest, and other parts, in hysterical and dyspeptic patients. This is closely related to the patches of redness, termed roseola, which are sometimes observed in cholera, small-pox, and other fevers, and may be held to mclude those which are so commonly associated with the vesicular and other inflammatory sMn diseases of young children. E. Boseola, as has been already explained, is a name of common and somewhat mdefinite application. This, or still better perhaps the name r. rubeoloides, may properly be appHed to an affection of the skin, of which Willan seems unnecessarily to make two varieties, namely r. cestiva and r. infantilis. This rash seems generally to be preceded for a day or two by shght febrile distm'bance, and, like so many other rashes, to make its appearance first on the face and neck, whence it quickly spreads over the general surface of the skin. It consists of rcse-colom-ed flatly elevated circles, fading at the periphery into the surrounding healthy skin, and disappearing on pressure, varying perhaps from |- to ^ inch in diameter, and often running together over extensive tracts so as to form an imperfect network ^\-ith scalloped mterstices. There is often some general but shght tmnefaction of the sm-face, and a passing chill is apt to render the rash temporarily of a peculiar violet tint. Itching is frequently complained of, and the fauces are sometimes impHcated. The affection disappears within four or five days after the first appearance of rash. It is unattended with danger, and of Httle importance, but for its resemblance to measles and rotheln or epidemic roseola on the one hand, and to mticaria on the other. F. Urticaria or nettle-rash has been subdivided by dermatologists into numerous varieties. It seems unnecessary, however, to make more than two, namely, u. acuta or febrilis, and ?/. chronica or evanida. The more common form of the disease is u. febrilis. In it the appear- ance of the ei-uption is often, if not always, preceded by febrile disturbance, with probably some degree of gastro-intestinal derangement ; and these symptoms continue dm-ing the prevalence of the eruption, which rarely exceeds a few days or a week. The rash, which is attended with much local heat and itchmg, generally comes out in the evening or night, and disappears in the morning, and is continued for a few days by successive nocturnal outbreaks. In many causes, however, it appears at irregular intervals both night and day. The wheals arise quickly, seldom remain out longer than a few hom-s, and on subsiding sometimes leave behind them a shght yellowness of skin and a tendency to desquamate. They may appear simultaneously or in successive crops on any or all parts of the bodv ; but are most common on the face, back, front of the chest, EOSEOLA. UETICAEIA. 307 and flexures of the joints. The lips, tongue, and interior of the mouth are occasionally afi^ected. The wheals are sometimes scattered, but are more generally clustered and running together, and may then cover large tracts. Their presence is often attended with subcutaneous oedema, and stiffness of parts. Scratching and other forms of local irritation tend to increase their size, number, and duration. Occasionally febrile urticaria is due to the use of certain alimentary substances, such as shell-fish and pork, which, either from some acquired poisonous quality, or from some idiosyncrasy in the subject, act in a special way on the system. In severe cases the symptoms come on rapidly, are very grave, and indeed may prove fatal. They are mainly rigors, failure of circulation, fainting, precordial oppression, vomiting, and difficulty of breathing. They generally subside, however, in the course of a few hours. Chronic urticaria, which supervenes in some cases on the acute form, is generally unattended with marked fever. It shows itself for the most part like that in successive crops of eruption, which come out daily or at irregular intervals, for weeks or months, sometimes for many years. A curious sub-variety of chronic urticaria is that which Sir. W. Gull has termed factitious urticaria. Here the eruption, although it may come out as in other cases in successive crops, is also readily produced by pressure or irritation. And thus the application of a ligature, or the passage of the finger-nail, is followed in a few seconds by the appearance of a line of confluent wheals, with an areola of congestion, which remains out for a minute or so and then disappears. Wheals, resembling those of urticaria, are often due to the operation of local irritants. They are common in prurigo, scabies, and phthiriasis. They result from the prick of the ordinary stinging-nettle, and from the action of some species of jelly-fish. And they follow the bites of many insects, such as gnats, fleas, and bugs. In this last case, however, the wheals are persistent, and often last for a week or ten days. They pro- bably constitute Willan's urticaria loerstans. The causes of urticaria are not well understood. Some of its severer forms are caused by poisonous matters received into the stomach, and acting through the medium of the circulatory system. It is natural, therefore, to assume that other forms of urticaria must be due to gastro- intestinal disturbance. That in many cases it really is so is probably beyond doubt. But it is equally certain that, in a large number of in- stances, especially of the chronic variety of the disease, there is no indica- tion whatever that the digestive functions are at fault. Mental emotion, hysteria, and uterme affections are sometimes assigned as causes of urticaria. Treatment. — Most of the erythematous mflammations just described need little or no special treatment, either local or general. Many of them must be regarded as parts, and indeed trivial parts, of more serious diseases, such as rheumatism ; and their treatment must merge in that of the more general malady with which they are associated. For most of them cooling or astringent lotions, such as cold water or lead-wash, are service- x2 308 DISEASES OF THE SKIN. able and agreeable ; but for some of them, more especially e. intertrigo and pityriasis, careful local treatment is generally essential. In e. inter- trigo the affected parts should be kept perfectly clean and free from acrid moisture, and opposed surfaces separated, if necessary, by a piece of lint anomted with some appropriate ointment. Dusting the surface with starch, oxide of zmc, fuller's earth, lycopodimn, or violet powder, and applying astringent lotions or ointment, are often valuable measures. In pityriasis cleanliness is equally essential, and the cure is often aided by the use of mild mercurial ointments. When the lower extremities are affected "s^^ith e. nodosum or e. Icsve, the patient should keep the recumbent position, with the legs elevated. The general treatment of these various affections when acute should be mildly antiphlogistic, and comprise cooling drinks and gentle laxatives. Li e. nodosum, however, it is frequently necessary to have recourse to tonics. In e. multiforme, when it has assumed a chronic form, tonics are also mdicated. And in urticaria, if it be either severe or persistent, special measures must be adopted. If, for example, there be reason to suspect its dependence on poisonous substances taken into the stomach, an emetic or a purgative may be necessary ; if there be much abdominal pain, opiates ; if collapse, ammonia, brandy, or other stimulants. In the chronic form of the disease few remedies have been found generally useful ; but arsenic, mineral acids, alkalies, tonics, and change of air have often been recommended. V. PSOKIASIS. [Lepra.) PITYEIASIS EUBEA. Causation and description. — We have shown that one of the events of the different forms of erythema is the formation of scurf; we pass, therefore, naturally from their consideration to that of psoriasis, which is essentially also a superficial inflammation of the skin, attended with the development of scales. It is thus closely related to pityriasis and cannot always be separated from it. Willan and his followers have distinguished psoriasis from lepra, but their distinctions are artificial ; and we shall therefore, with Hebra and others, combine them in a com- mon description. A. Psoriasis is characterised by the presence of defined, mostly cir- cular tracts, in which the cutis is somewhat congested and raised ; while the epidermis over it is thickened and opaque, and tends to come away in large flakes. These, on their separation, leave behind a congested, irri- table, and sometimes slightly excoriated surface, on which squamae are speedily reproduced. Psoriasis commences with spots or discs of slight congestion, over which, almost from the earliest moment, the cuticle assumes a scaly character ; but at first, and while they are in process of enlargement, the area of congestion usually extends beyond that of desquamation. The patches vary in size and shape. In some cases they are mere papules, a line or less in diameter ; in some they have a discoid form, PSOEIASIS. 309 measurmg between ^ and ^ incli across ; in some they form rings between (say) the size of a shilling and that of a crown-piece, enclosing a central area of comparatively healthy skin, which (especially if they become large) tend to break up into segments ; in some cases, agam, partly by coalescence of adjoining patches, partly by innate irregularity of growth, they form tracts of large size and irregular outline, covering, it may be, an entire limb or even the whole surface of the body. The squamffi also vary in colour, consistence, thickness, and form. These pecuharities are mamly due to the different degrees of rapidity with which they are developed, and to the fact that they result from an ex- cessive formation and exfoliation of epidermis, among the cells of which mflammatory exudation and even the contents of the involved cutaneous glands are diffused in various proportions. The scales are sometimes white and glistening, like mother-of-pearl ; sometimes yellow, and more or less waxy in appearance ; sometimes brown or black ; sometimes close and dense in texture ; sometimes friable and flaky, or even powdery. In some cases they form an extremely tlim layer, in others they are a quarter of an inch or more in thickness ; and occasionally, when a ^drgin patch has been slowly enlarging, the accumulated scales on its surface assume the form of a limpet-shell. The general outlme of the crust will neces- sarily be determined by that of the patch on which it is produced. The subjacent skin is always more or less distinctly congested and thickened ; and generally, when the disease is in an aggravated form and has existed for some time, tends to get excoriated and fissured, and then to exude serum and blood, which, minghng with squanife, form distinct scabs. The eruption of psoriasis is peculiarly liable to attack the extensor surfaces of the knees and elbows. But it may occur on any part of the person, though it is comparatively rare on the face, and still rarer on the palms and soles. The hairy scalp is a common seat of the disease. The nails also are not mifrequently mvolved, becommg thick, rough, and coarse in texture. It is very apt to be symmetrical. Psoriasis presents, as may be supposed from the above account, many varieties of character, some of which it maybe useful to remember, if only for descriptive purposes. Thus, when it consists of an eruption of nmne- rous small spots, it is called p. guttata ; when of small discs covered thickly with white scales, lepra alplioicles or alphas ; when of rings, I. vulgaris ; when of segments of circles which have coalesced with similar segments of adjoinmg circles, I. gyrata ; and when of irregular patches occupyuig a large area, p. diffusa. The progress of psoriasis is occasionally remarkably acute ; thus, it will sometimes come out and become general in the course of a week, and disappear with almost equal suddenness at the end of two or three weeks. At other times, and much more commonly, it is a chronic malady ; some- times remainmg for years in two or three situations, as, for example, on the Imee or point of the elbow, and presenting periodical exacerbations in 310 DISEASES OF THE SKIN. the spring or autumn ; sometimes occupying large tracts of surface per- sistently ( 2^- inveterata) for many years, or for life. The general health of patients suffermg fi'om psoriasis is rarely materi- ally or even obviously impaired. Occasionally, however, febrile symptoms attend its acuter manifestations, and sometimes debihty and emaciation supervene in the course of long-continued severe attacks. Yet the re- markable tendency of the eruption to break out simultaneously in corre- sponding situations on both sides of the body, and its undoubtedly heredi- tary character, together \vitli the fact that an almost identical eruption attends the constitutional operation of the syphihtic virus, pomt very strongly to the dependence of psoriasis on constitutional causes. Its development and disappearance are indeed often manifestly influenced by constitutional modifications. Thus it occasionally shows itself only during pregnancy, disappearing with the birth of the child ; and, on the other hand, those who are subject to it may lose it entirely during the period of child-bearing. It is remarkable how little local discomfort, comparatively, psoriasis produces : a little stiffness and a Httle itching are often the only inconveniences complained of. B. Pityriasis rubra. — This term was apphed by Willan to a variety of that form of pityriasis already briefly considered under the head of erythema. Hebra, and m this respect we follow him, employs it to designate a specific form of skin disease, of rare occurrence, and having a close affinity with psoriasis. So far as is known, it appears to commence with universal congestion of the skin, soon followed by general tendency in the epidermic layer to separate in scales. Its progress is slow, and it is doubtful whether a cure is ever effected. The redness of the cutis, when once established, persists, but is attended with little thickenmg or discomfort ; and the epidermis continues to desquamate, the scales, how- ever, sometimes accumulatmg in considerable quantity. When fully developed, there is nothmg except the history and progress of the malady to distinguish it from universally diffused psoriasis. Patients suffering from it remain apparently healthy in other respects for a long time ; but (accorduig to Hebra) they ultunately emaciate, become cachectic, andsmk from, exhaustion. Treatment. — The local treatment of psoriasis consists, first of all, in the removal of the scales, which may be effected by warm baths or poul- tices, or by thorough inunction of oil or ointments of various kinds ; and then in the application of special remedies, among which may be included iodine paint, nitrate of silver, strong solution or ointment of subacetate of lead, and especially tar ointment, or other equivalent empyreumatic pre- parations. The persistent use of warm baths for several hours daily is often of great value. The constitutional treatment most generally resorted to is the exhibition of arsenic in small repeated doses. Tar is often ad- ministered internally with the same object ; as also are tincture of cantha- rides, copaiba, iodide of potassium, and phosphorus. Tonics and cod- liver oil are occasionally useful. The disease, however, is very apt to resist all treatment ; and even when a cure seems to be effected it is very ICHTHYOSIS. 311 often only apparent, and the result of the normal periodic retrogression of the malady. The treatment of pityriasis rubra may be conducted on the same principles as that of psoriasis. VI. ICHTHYOSIS. [The fish-shin disease.) Descrijjtion. — Under this term are included certain affections of the skin, characterised by dryness of the epidermis, with tendency to crack and scale, deficiency or absence of the sebaceous secretion, and more or less horny conversion of the epithelium of the sebaceous follicles. A. Ichthyosis simplex, or xeroderma, is the commonest variety of the affection. It is for the most part congenital, and its presence is generally first recognised by the parents during the first year or two of life, in con- sequence of the harshness and dryness of the general surface of the skin, and the difficulty they experience in keeping certain parts of it, such as those covering the elbows and knees, in a cleanly condition. In quite yornig children, indeed, it only manifests itself by the characters just enumerated, and by the tendency of the epidermis to come away in flakes. As life advances, the condition of the skin becomes more characteristic. The affection is then seen to be general, but differing in severity in dif- ferent parts. It is usually least marked on the palms and soles, and on the niner aspects of the wrists, arms, and thighs. Here the skin may be a little dry only, and scarcely differing in appearance from healthy skin. The face is generally rough and dry, and slightly furfuraceous ; and the lobes of the ears and the palpebral orifices are occasionally deformed. But the greater part of the rest of the surface of the limbs and trunk is mapped out mto irregular polygonal arete, the limits of which are, for the most part, determined by the normal creases and folds ; and the epidermis of these arete, dry, hard, brittle, and somewhat nacreous, becoming par- tially separated at the edges, and sometimes undergoing complete separa- tion, gives that scaly character to the surface which allies this disease anatomically to psoriasis. Occasionally the creasings on the trmik are so coarse and deep, and the arete of epidermis between them so large, symmetrical, and thick, that the patient's body presents a striking resem- blance to that of an alligator. But the places in which ichthyosis mvolves the most striking results are generally the knees, elbows, and those other parts of the surface which are naturally apt to get thickened under the influence of pressure or friction. Here the epidermis becomes extremely thick and hard, generally brown or black from impregnation with dirt, and divided even more manifestly than elsewhere into polygonal arese. Wilson states that in this affection many of the sebaceous glands are filled with a dry hard substance, which often projects from their orifices. A condition of skin closely resembling ichthyosis is often met with in the course of chronic wasting diseases, such as phthisis, and is sometimes developed with advancing years. 312 DISEASES OF THE SKIN. Persons wlio suffer from ichtliyosis are said to be, for tlie most part, feeble and emaciated. But tbat is certainly not a universal rule. Tliey are often liable to eczema and impetigo. B. Ichthyosis cornea is a m.ucli rarer affection than the last, and often arises at a later period of life. It is seldom general, but usually appears in scattered patches, which have a tendency to spread. It is characterised by the development of prominent, hard, dry, horny processes of epidermis, which often have an exact resemblance to those occupying the surface of the knee in the simple variety of the disease. These are usually grouped together, and hence individually often assume an irregular prismatic form; and they project sometimes half an inch or more above the general surface. They are partly due to a mere overgrowth of epidermis m patches, corresponding to the normal polygonal arete of the skin, but are largely connected with the horny conversion of the epidermic lining of the sebaceous follicles. In the latter case the horny outgrowth first appears as a comedo-like body, which distends the orifice of the follicle, and then rises above it in form not unlike a caraway seed. Presently this gets detached or broken, but the horny matter, still growing upwards and in breadth, distends the sebaceous follicle and its orifice more and more, until they form a mere shallow pit, surrounded by a tumid ring. With the progress of the disease, the pit is effaced ; what was the inner aspect of the follicle becomes level with the surface of the skin or projects above it, and still i^roduces (but now from a larger area) its horny growth. Finally, the tendency to horny development extends from the follicle to the epidermis immediately surrounding it. These bodies absorb dirt, and consequently become more or less opaque and black. They are often shed, and then occasionally leave the surface from which they sprang tolerably healthy. Although for descriptive purposes it may be desirable to divide ichthyosis, as has been above done, into two varieties, it must be borne in mind that there is no essential difference between them, and that not unfrequently patients whose general condition of skin is one of simple xeroderma present patches of greater or less extent, in which the corneous character is developed in the highest degree. It is desirable also to remark that, although in the general form of the disease the regions chiefly affected are those which have been pointed out, it occasionally happens that the hands and feet are much more seriously diseased than other parts. We have recently had a child under our care whose hands and wrists, feet and ankles were covered, as with gloves, with horny growths varying from nearly an inch in thiclmess downwards. Treatment. — The simple form of ichthyosis is incurable ; but it may be much benefited and rendered tolerable by cleanliness, frequent baths, and keeping the surface anointed with oil or grease— olive oil, neat's-foot oil, and the like. The horny variety also is uninfluenced by medicine. But it sometimes dies out in certain situations while it advances in others, and hence it is conceivable that it might occasionally subside altogether. But although a cure is not to be expected, the horny growths ECZEMA. 313 may generally be removed, and the chief discomfort and offensiveness of the disease kept in abeyance, by the frequent use of warm baths, and application of poultices or oil. VII. ECZEMA. {Lichen. Stro]3}iulus.) Causation and descrij^tion.— The first of these affections is vesicular, that is, characterised by the development of vesicles upon an inflamed base ; the second of them is generally regarded as papular— in other words, as due to the formation of solid pimples on an inflamed surface ; the last is simply the lichen of children. Many modern authorities, how- ever, now regard the various forms of eczema and lichen as merely varieties of the same disease, and strophulus a fortiori as a variety of eczema. We adopt this view, and combine them in a common description under the general name of eczema. Eczema is an inflammation of the skin, for the most part much more acute in its phenomena than psoriasis, and attended with much more violent local irritation. It often commences with itching; but this is soon followed by [^the appearance of minute acuminated papules, which are more or less red from congestion, which may be either grouped in patches, or scattered, and which sometimes (but not by any means invari- ably) originate at the points from which hairs emerge. The papules gradually increase in size, sometimes retaining the solid form, sometimes being obviously vesicular almost from their first appearance. In the former case they may attain a line or more in diameter, when their acuminated character probably disappears ; but more frequently perhaps they reach the average size of a millet-seed ; and then, after they have remained out for a few days or a week or two, their redness fades, their surface desquamates, and they gradually subside. When the eruption is essentially vesicular, each papule (which is generally intensely inflamed) is occupied or cro^vned by a circumscribed accumulation of serum between the horny and the mucous layers of the epidermis. The vesicles are rarely larger than a poppy-seed, excepting when they are closely aggre- gated and neighbouring ones coalesce ; under which circumstances a considerable area may get covered with a low undulating bleb, pinned down, as it were, here and there to the subjacent surface by the remains of the party- walls between adjohnng vesicles. In this case also, the eruption may subside at the end of a few days ; but the appearances which attend its subsidence vary. Sometimes the contents of the vesicles become absorbed, and simple desquamation follows. More commonly the vesicles burst ; and the exuded serum, mingling with the separating epi- dermis, coagulates into a scab, the character of which depends on a variety of circumstances — such as the part of the skin affected, the cessation or persistence of exudation, the entanglement in it of dirt or other foreign matters, and the admixture of blood or pus due to the effects of scratching or other local violence. In the simplest case the scab is often of a sulphur- 314 DISEASES OF THE SKIN. yellow line, and more or less powdery. More commonly perhaps it is of a dark colour, scaly or gmnmy, and adherent to the siu'face. On the scalp the crusts are apt to accumulate and to form thick dirty laminae. Eczema is liable to become chronic. In some cases, especially in the papular form, the eruption then loses its vi^dd redness, and the surface gets thickened, rough, scurfy, and fissured. In some cases, and mainly such as are vesicular, large tracts of skin become red, excoriated, and moist, and on close examination may be found to be covered in patches with a thin, opaque, soft, epidermic layer which is studded more or less abundantly, especially at the edges, with pits (very much hke the perforations by which postage-stamps are separated from one another), at the bottom of which a red weeping surface is visible. These pits are excoriations, and correspond to vesicles ; and in such cases are probably the only representatives of vesicles which can be recognised. Again, even m vesicular cases, the inflamed surface often after a time loses its vesicular character, becomes uniformly inflamed, brittle, and scaly, and assumes characters which, apart from the history of the case, are identical with those of chronic psoriasis or pityriasis rubra. The vesicles or papules of eczema may be scattered and discrete, or collected into circular or oval groups of small size, or aggregated m larger irregular clusters, which tend to rmi together — the intervenmg skin being at the same time studded with isolated spots. In the first of these cases, the papular form of the disease constitutes lichen simi^lex or stroi^liulus intertinctus {red gown or red gum) ; in the second, lichen circumscriptus or strophulus volaticus ; and in the third, lichen agrius, or strophulus confertus [rank red gum). Eczema may be aciote or chronic : the former lasting for a week or ten days, or more ; the latter often consistmg in successive outbreaks of the acute disease, but uacluding those cases in which the skin assumes the features of psoriasis diffusa, and also the form commonly known as eczema rubrwn. In the last there is general excoriation with intense redness, abundant exudation of serum, and the formation of numerous red oozing points in place of distmct vesicles. It is most frequently seen m typical completeness on the lower extremities of elderly persons. No part of the surface of the body is free from liability to eczema. It attacks some parts preferentially, however, and then often receives a local epithet. Thus it frequently occurs upon the haky scalp [e. ccqjitis), con- stituting a very troublesome and chronic affection ; on and in the ears (e. aurium) ; at the edges of the eyelids {e. palpehrarum) ; and on the cheeks [e. faciei). It is common in the axilla and bend of the elbow, about the anus, pubes, and outer part of the thigh, and m the bend of the knee. The nipples of suckling women and the umbilicus of the new-born babe are frequently affected. And it is not uncommon on and between the fingers. The affections known as grocers' itch, bakers' itch, and loare- housemen's itch, are all of them eczema or lichen agrius of the backs of the hands and wrists. Not unfrequently, when the eczematous inflammation is severe, spots ECZEMA. 315 of suppuration appear, mtermiiiglecT with tlie original vesicles and papules ; and the scales viiiich result are thicker and darker than those of simple eczema. Eczema then approximates in its characters to impetigo, and is often termed c. impeticjinodes. Eczema, in its various forms, is the most common of all skin diseases. It is frequent hi babes and young children ; but no period of hfe is exempt ; and it may break out for the first time in extreme old age. It is not an mifrequent attendant on pregnancy and lactation. It is sometimes distinctly hereditary ; and a previous attack generally predisposes to subsequent attacks. Its causes are not very obvious ; occasionally, however, it is clearly produced by local irritation : m the head by the constant use of hard brushes ; in the nipples by the irritation of sucking : between the thighs and buttocks and analogous parts by the effects of the local secretions and by attrition ; and in bakers and others by the irri- tating substances among which they work. Eczema is also frequently induced by the presence of scabies or pediculi. These, however, are not the only causes. It is often idiopathic, and then not unfrequently preceded for a day or two by febrile symptoms. It is often ascribed to gout, dyspepsia, uterme complamts, teethmg, and the mfluence of weather and climate. Excepting in the case of the extensive diffusion of the acute disease, eczema is rarely attended with constitutional symptoms. Locally it is characterised by the presence of itching, tingling, or bm-ning. The itchmg m some cases, indeed, is unbearable. Treatment. — -There is no specific treatment for eczema. It is therefore especially important in every case to ascertain, if possible, the cause on which it depends, or whether or not the patient have any associated malady affect- ing the general health ; and to treat it. Thus the constitutional treatment of eczema may resolve itself mto the treatment of gout or mdigestion ; the local treatment into the destruction of msects, or the cessation from certain kinds of manual labour. Alkalies, such as liquor potass^ or the bicarbonate of potash or soda, in combination ^ith vegetable tonics, are often resorted to. But the remedy on which most reliance is placed is arsenic. This is generally given in the same manner as in the treatment of psoriasis, and is by most physicians regarded as being most efficacious in the chronic forms of the disease. When febrile symptoms are present, mild laxatives and cooling medicines are desirable. Tonics are often beneficial in its later stages. It is well to pay attention to the diet. Alcoholic drinks are generally injuri- ous, as also rich food and hot condiments. The local treatment must vary ^\itli the stage of the affection, its intensity, and extent. In the acute stage, and always when there is much inflammation, cold-water dressings or evaporating lotions, or even the cold douche continued from ten minutes to half an hour at a time, are very useful. Under the same circumstances lead-wash and such-like applications are beneficial. At a later period, when there is much accumulation of scabs, it is important to remove them either by washmg with soft soap and water, or by poulticing, or by the saturation of the part with olive-oil. Then the surface must be kept clean ; and mild 316 DISEASES OF THE SKIN. mercurial ointments, or ointments containing lead or zinc, may be gently- applied after each washing. In the dry and scaly condition of eczema which simulates psoriasis, the treatment applicable to the latter affection may be employed. Hebra recommends for some cases the rubbing in of liquor potassEe mitil it acts chemically on the diseased structures, for the purpose both of remo^dng the morbid surface and of promoting more healthy action. The caustic is applied once a week, the parts being treated with water-dressmg in the intervals. Over limited areae of disease, the appHcation of the solid nitrate of silver sometimes effects a cure. As a rule, however, we think that soothmg local treatment, com- bined with cleanliness, will be found most efficacious. And although soap may be occasionally employed to aid in the removal of scabs, persistence in its use is generally injurious. The patient should use, instead of it, bran, oatmeal, starch, milk, or yolk of egg. VIII. IMPETIGO. {Ecthyma.) Causation and description. — The affections comprised under these names are essentially pustular ; we regard them as identical, and shall describe them as varieties of impetigo. Impetigo is a disease which consists m the formation of pustules at the surface of the skin, either between the cutis vera and epidermis, or between the corneous layer of the epidermis and the rete niucosum. The develop- ment of pustules is attended with more intense inflammation than that of vesicles or papules ; and pustules are, for the most part, sm-rounded by weU- marked congested areol®, and situated upon more or less thickened bases. They occasionally commence in vesicles or papules ; and thus eczema or lichen may pass into impetigo. Most commonly, however, they originate in spots of mflammation (stigmata, papules, or tubercles) in which sup- puration is manifest almost from the beginning. Thus pustules vary m size from that of a pin's head (or less) to that of a spht pea or bean. They are generally round or oval in outline, but sometimes irregular and angular, and project in the form of an oblate hemispheroid. At the end of a day or two they break, or their contents concrete, and scabs are formed, which are generally thicker and darker than those of eczema ; but which, nevertheless, vary much in colour and consistence, being some- times softish, translucent, and honey-like, sometimes dark, opaque, and tough. If the progress of the pustules be favourable, the scabs separate after a few days, lea^dng reddish spots behind them, which are soon effaced by the completion of a normal layer of epidermis. Very often, however, the scabs become detached while the subjacent surface is still secreting pus ; and not mifrequently, when the scab seems fully formed, suppuration still goes on beneath and around it, leading on the one hand to a deeper erosion of the skin, on the other hand to the lateral extension of the pustule by the gi-adual underminmg of the surrounding epidermis and the incorporation of the successive ch'cles of suppuration thus formed. IMPETIGO. 317 In the latter cases the local progress of the disease may be mamtamed for a long thne ; and in these alone, but rarely even here, is there danger of the production of permanent cicatrices. The long continuance of impetigo sometimes leads to persistent harshness, muddiness, and deterioration of the skin. The lymphatic glands in relation with the part affected by the disease generally get inflamed, large, and tender, and occasionally suppurate. The pustules of impetigo sometimes come out singly [i. sjKcrsa), some- times in groups {i.figurata) ; and the groups may be of considerable extent. In the former case the pustules are generally larger than those of the grouped variety, and if the subjacent thickening and surrounding inflam- mation be considerable (as they are apt to be when the pustules are seated on the buttocks, or lower extremities, and in adults), the affection is often termed ecthyma. In the latter case the congestion connected with the several adjoining pustules blends, and thus forms a common area of inflammation which may be very intense [i. erysijpelatodes). The scabs also, under such circumstances, are apt to run together and form a continuous mass or lamina [i. scabida). Impetigo occurs on all parts of the surface. It is common on the head and face, especially of young children, and when abundant and confluent in the latter situation is sometimes called porrigo larvalis. Occasionally it attacks the hairy parts of a man's face, constituting one variety of the affection termed sycosis. It is then very intractable, owing probably to the root-sheaths of the hairs being specially involved. It is frequently met with about the buttocks, and indeed on all parts of the trunk and extremities. Impetigo is liable to spread by moculation : thus it may be conveyed from the child's head or face to the fingers with which it scratches itself; or from the nursling's face to the mother's bosom or hands ; or, again, from child to child in families or schools. Sometimes it arises idiopathically, and is preceded by feverish symptoms, lasting for a day or two ; it may be a subsequent development of lichen ; and it is often produced by local irritation, due to pediculi, acari, and even mechanical causes. It is common during dentition. The duration of impetigo is very various, depending partly on the cause, partly on the health of the patient, and partly upon hygienic conditions. The acute form may subside at the end of a week or two ; but the disease is very apt to become chronic, and to be kept up for months, and even years, by successive acute outbreaks. Those who have had previous attacks are liable to suffer from relapses. The constitutional symptoms are generally trivial; hut there is often some degree of fever when the affection is extensive and acute, especially if the lymphatic glands are implicated. There is generally itching and tingling of the parts affected. Treatmemt. — The local treatment of impetigo differs but little from that of eczema. In quite the early stage the application of cold or tepid water, or cooling lotions, is useful. When scabs have formed it is always important to effect their removal, and this may be accomplished in the 318 DISEASES OF THE SKIN. same way as in eczema. After their removal, the use of lead or zinc lotions, combined with glycerine, or of mild mercurial ointments, is generally sufficient. Caustics are rarely beneficial, or even admissible. When the hairy parts are affected it is well to have the hair cut short ; and in the case of sycosis it is generally necessary to resort to epilation. It is important to treat any associated malady under which the patient is labouring, and which may be affecting his general health. But as a rule tonics are indicated, especially iron, mineral acids, quinine and other vegetable bitters, and cod liver oil. Change of air is often of great benefit. IX. SUDAMINA. MILIAEIA. Description. — These names are employed to designate the minute vesicles which appear scattered over the surface of the chest, back, flanks, and sometimes upper arms and thighs of persons who are perspiring pro- fusely, or more frequently perhaps of those who, having had a dry skin for some time, begin again to perspire. Thus we meet with them in rheumatism, pneumonia, and many fevers at the commencement of con- valescence. They form at the orifices of the sweat-glands, and are due mainly to the imprisonment of minute drops of sweat by the horny layer of the cuticle. They are generally about as large as pins' heads, round or irregular in shape, containing a colourless acid fluid with leucocytes, and quite unattended with inflammation. They can be easily felt as small, prominent, hard bodies, but very often escape the eye unless care- fully looked for, and then appear like minute drops of melted white wax. They end in branny desquamation. Occasionally their contents are opaline and of alkaline reaction, and each vesicle is surrounded by a narrow halo of congestion. It is to sudamina presenting these characters that the term miliaria is sometimes, but mmecessarily, applied. No treatment is required. X. HEEPES. PEMPHIGUS. [Pomjjholyx.) Causation and description. — Herpes and pemphigus are vesicular or bullous affections, yet there is a close affinity between them and erythema, especially erythema multiforme ; and indeed it is questionable whether it might not have been best to discuss them all under the same heading. Both herpes and pemphigus become developed upon erythematous patches ; and not unfrequently these patches are papulate, discoid, circinate, gyrate, or marginate, and consequently the vesicular or bullous eruption assumes corresponding characters. Indeed, in no inconsiderable pro- portion of cases erythema, herpes, and pemphigus represent simply successive stages of the same affection. Various causes have been assigned for herpes and pemphigus, and among them one of great interest — ^namely, some affection, probably irritative, of the sensory nerves. One species of herpes (herpes zoster) is, as we shall presently HEEPES. 319 show, always limited to the area of distribution of some one or more of the nerves of common sensation, and usually attended with intense neuralgic pain ; and, moreover, erythematous, vesicular, and bullous eruptions are shown by various authors, and especially by Charcot, to be common accompaniments of pachymeningitis of the cord and of other conditions causing equivalent irritative effects in the cord or nerves con- nected with it. A. Herpes. — By this term we understand an affection characterised by the development of clustered vesicles, varying between the size of a small pin's head and that of a split pea, and seated on an erythematous base. A circumscribed area of redness, round, oval, or irregular in shape, first makes its appearance. This soon becomes thickly studded with papules, which speedily acquire a vesicular character, and in the course of twenty-fours hours or less attain their full dimensions. The vesicles are close-set, and not unfrequently run more or less together, so as some- times to form large bullae. Their contents are in the first instance limpid and pale ; but they often become dark from admixture with blood, or opaque and yellow in consequence of suppuration. After two or three days they dry up, and form thinnish dark-coloured or gummy scabs, which in a few days more become detached, leaving a whole but slightly reddened surface behind. There is always much heat and tingling or stinging during the earlier stages of the disease. Its total duration is rarely more than two or three weeks, and often considerably less. Several forms of herpes are enumerated by dermatologists. We pro- ceed to discuss the more important of them : — 1. Zona or herpes zoster {shingles.) — This is the most important and striking affection of the group. It is characterised by the formation of clusters of vesicles on inflamed patches of various forms, and ranging from the size of the palm of the hand to that perhaps of a split pea. The clusters appear almost simultaneously, and irregularly scattered, over the area of distribution of one of the cutaneous sensory nerves. Hence they always occur within certain definite limits, and on one side of the body only. In addition to the general characters of herpetic affections, zona is apt to be attended with certain special peculiarities. Thus it is often associated with severe neuralgic pains in the neighbourhood of the part affected, which sometimes precede, sometimes accompany, and sometimes follow the cutaneous eruption, and often last for many weeks, occasionally for years ; and again the inflammation is apt to be intense and to penetrate deeply, and hence to be slow of disappearance and to leave permanent scars, and sometimes (especially in the old and weakly) to become gangrenous. The most frequent seat of zona is the chest or abdomen, where it takes the course of the cutaneous branches of one of the intercostal nerves. But it is not luicommon elsewhere, though it is very often then not recognised as zona. Von Barensprung enumerates nine varieties, and it would be possible, but is not necessary, to enlarge their number ; they are as follows : — z. facialis, where the parts supplied by the fifth nerve 320 DISEASES OF THE SKIN. are affected, the surface of the conjunctiva being sometimes involved ; z. occipito- collar is, foUowuig the distribution of the occipitaHs minor, auri- cularis magnus, superficiahs colli, and occipitahs major ; z. cervico- subclavicularis, corresponding to the descending superficial branches of the cervical plexus (supra-sternal, supra-clavicular, and supra-acromian) ; z. cervico-brachialis, affectmg surfaces supplied by branches of the brachial plexus — namely, the shoulder, upper-arm, fore-arm, and hand ; z. dorso- pectoralis, corresponding to the third, fom'th, fifth, sixth, and seventh dorsal nerves ; z. dorso-abdominalis , corresponding to the eighth, ninth, tenth, eleventh, and twelth dorsal nerves ; z. lumho-inguinalis, corre- sponding to the branches of the upper lumbar nerves, and extendmg from the lorn to the linea alba, mvolvhig also the pubes and genital organs, the gluteal region and outer aspect of the thigh ; z. lumho-femoralis, correspondhig to the cutaneous branches of the second, third, and fourth lumbar nerves, more especially the external cutaneous, genito-crural, and obturator, and affecting therefore mainly the anterior and lateral surfaces of the thigh and the inner aspect of the leg and foot ; and lastly, z. sacro- ischiatica, which follows the cutaneous branches of the sacral plexus. Zona attacks persons of all ages, but chiefly, it is said, young adults. It is held by some to be most common in sprmg and autumn, and also to occur only once in a lifetime. It is questionable, however, whether either of these statements be true. Its connection with ner\'ous irritation has already been referred to ; but nothing more in reference to its causation is known. 2. Herpes simplex. — This name may be conveniently used of those cases m which a group of vesicles or several such groups appear, so to speak, casually in some limited area, which then commonly gives a specific name to the affection. Thus we have h. labialis, affectmg the Hps and neio-hbourmg parts ; h. palpehralis, the eyelids ; h. auricularis , the puma of the ear ; and h. prcep^itialis and pudendalis, respectively the prepuce and the labia. In these cases the patches of disease are identical in appearance and progress ^\ith those of zona. But there is nothing to indicate that they have any connection with sensory nerves. Moreover, some of them (especially h. labialis) are very apt to attend an ordinary catarrh, and to come on in the course of acute pnemnonia. 3. Herpes iris is the designation of an eruption of vesicles which arise m series of concentric rings upon a gradually enlarguig erji;he- matous disc. It is most frequently obsers'ed on the backs of the hands and wrists, feet and ankles, but is sometimes much more generally dis- tributed. 4. Herpes circinatus is the name applied to an inflamed disc, which gradually increases in size, and whose enlargement is accompanied by the formation of a ring of vesicles at the circumference, while the centre for the most part gradually returns to a state of health. It is obvious, as we have abeady pointed out, that there is no essen- tial difference between the last two varieties or between them and erythema multiforme ; and that h. iris and h. circinatus are simply HEEPES. PEMPHIGUS. 321 later phases of e. iris and e. circinatum. It may be added that mter- mediate papular conditions are sometimes observed, to which the names of lichen iris and I. circinatus might (unnecessarily indeed) be applied. It is important, however, to bear in mind that the name ' herpes circmatus ' is often given to the specific eruptions of favus and ringworm, and that the multiform erythematous and vesicular affections which have just been considered (though not themselves parasitic) are very apt to be simulated by and confounded with these vegetable parasitic diseases. Lastly, cases are occasionally observed in which erythematous patches, irregular in form and size, appear almost simultaneously over the whole cutaneous surface, and become speedily covered with herpetic vesicles which tend to run together. The patches individually are like those of herpes zoster ; and, moreover, like herpetic patches generally, run through all their stages m a week or two ; but they differ from them in their wide distribution. Herpes iris, h. circinatus, and the form of herpes last described resemble in their symptoms the corresponduig forms of erythema multi- forme. They are usually of trivial importance, but occasionally, when of extensive distribution, are attended with much febrile disturbance. B. Pemphiqus. — This term comprises most of the inflammatory afiections of the skin attended with the formation of buUte or blebs. These sometimes attain the size of a hen's or duck's egg, and are deve- loped on romid, oval, suiuous, or irregular surfaces. But associated with such blebs we often find single or grouped vesicles, no larger than those of herpes. Hence the blebs of pemphigus may be considered to vary between these hmits. There is nothing specific, however, in the forma- tion of a bleb ; any patch of erythema, or other forms of inflammation, or of gangrene, may become studded with vesicles, and any number of contiguous vesicles may run together and form a common cavity. It follows almost necessarily that there is nothing specific in the conditions to which the term pemphigus is applied, and that the limits between them and affections receivmg other names are to a great extent arbitrary. Pemphigus is not unfrequently (as has been pointed out above) the fully developed stage of herpes iris, h. circinatus, and other forms of gene- rally distributed herpes. The stages of the disease are then well-marked : the first being the appearance of a disc, rmg, or irregular patch of erythema ; the second, the formation of small vesicles, sometimes in a ring at the circumference, sometimes in the centre, sometimes generally over the surface ; and the third, the extension or blending of these vesicles and the evolution of a prominent bulla, the edge of which becomes, for the most part, contermmous with that of the erythematous redness. Owmg to the coalescence of neighbouring patches of erythema, neighbour- ing bullfe may coalese into sinuous or gyrate bullous bands several inches in length. Further, the eruption may be sparse or limited in extent, or it may be general and abundant. The full development of the disease may occupy three or four days, or more, but is often much more rapid. In cases of this kind it sometimes happens that extensive tracts Y 322 DISEASES OF THE SKIN. of surface become erythematous and remain so for some considerable time, vesicles and bullse from time to time appearing here and there upon them. In other cases of pemphigus, the formation of bullae is almost coetaneous with the appearance of the erythema, which may then indeed escape recognition as a separate stage of the affection, both generally being preceded by violent itching, stinging, or burning. The bullae of pemphigus are generally plump and distended with a pale straw-coloured serum, which, after a while, gets darker in tint, or milky and opalescent. After a few days the contents begin to disappear by evaporation and absorption, or the bullae rupture and they escape. Then a thin dry pellicle, con- sisting of the epidermis which has been raised up and of coagulated exudation, forms upon the affected surface, and after a few days more becomes detached, leaving a sound but somewhat reddened area behind. Sometimes, especially if the part have been irritated by scratching or otherwise, or if the general health of the patient be bad, the scab more resembles that of eczma or impetigo, probably re-forms after removal, and convalescence may be much protracted. Ulceration or even gangrene may ensue. As will be gathered from the foregomg account, pemphigus presents a good many varieties. Sometimes it is acute, its entire duration bemg comprised within a period of three or four weeks. More frequently it is chronic (chronic, however, in the sense in which urticaria evanida is chronic), that is prolonged by successive acute attacks, and may thus be continued for many years. It is then often termed _/;. vulgaris. Some- times a smgle bulla breaks out suddenly, to be followed on its subsidence by a second, and then by a third, and so on [2^. solitarius) . A form of the disease, termed -p. infantilis, is occasionally met with in new-born children ; large buUffi form on the neck, behind the ears, on the buttocks, genitals, wrists, and other parts, and for the most part progress unfavour- ably, endmg in suppuration, ulceration, and gangrene. A further variety is that called by Alibert _p. foliaceus. It is characterised by the succes- sive formation of bullae of small size, which are generally flat and flaccid, and the contents of which become more or less distinctly purulent, and dry up into thick yellow flaky scabs. These on separation leave a deeply congested weeping surface. P. foliaceus is said to spread gradually until it occupies the entire surface of the body, and never to be cured. The causes of pemphigus are not clearly known. There is reason, however, to believe that in some cases, especially in that of p. infantilis or when it occurs on the soles or palms, the origin is syphilitic. It not infrequently arises in persons suffering from mental worry or distress, or who are in feeble bodily health. And, as we have already pointed out, it appears in some instances to be comiected with affections of the spinal cord or sensory nerves. The symptoms which attend its progress vary. There is often some degree of fever — sometimes high fever, the tempera- ture reaching 104° or 105° ; and, when the affection is much prolonged, debility and emaciation may ensue. This latter is especially the case in the foliaceous form. New-born children affected with pemphigus generally succumb speedily. In many cases the patient's health remams apparently unimpaired throughout the whole course of the malady. EUPIA. 823 Treatinent. — Whatever its form may be, herpes seldom requires •special treatment. Coohng lotions, simple ointments, and protection of the affected parts against rubbing, include all the local measures that are usually necessary. The only important object to aim at in the treatment of zona is the relief of the severe neuralgic pain which is so often associated with it. For this various measures may be tried, such as the local apphcation of blisters or other comiter-irritants, the inunction of belladonna, or of aconitia ointment, and the use of leeches ; and, besides, these, morpliia or other sedatives administered by the mouth or hypoder- mically. The bullae of pemphigus require little local treatment. They may be punctured and their contents permitted to escape ; but it is unadvisable to allow the cuticular pelHcles covering them to get detached. For this reason, among others, it may be necessary to protect the parts with simple ointments spread on hnt. For mterual treatment iodide of potassium and mercurial preparations should be employed when syphihs is suspected. Arsenic is much lauded by some. Li most cases, however, tonics are sooner or later indicated. XI. EUPIA. Causation and description. — Eupia is described as beginning with flat bullae, rarely, if ever, exceeding hah an inch m diameter ; first contaiiung clear serum, then producing very thick greenish browTi or dark-coloiu'ed scabs, and deep destructive ulceration. In some respects, therefore, the disease resembles pemphigus ; but it differs h-om all ordinary forms of pemphigus in the fact that its bullse are the result, not of superficial, but of deep-seated disease. Eupia, indeed, is to be distinguished less by the occurrence of bullae than by the character of its post-buUous stages. The rupial bulla slowly increases in size, is surromided by a halo of conges- tion, and seated on a slightly thickened base. A scab soon forms, but while it is forming the bulla spreads at its margm, and fi-esh matter, which also soon coagulates, is produced around and under the first- formed scab. In this way the rupial sore increases in diameter, the scab increases in thickness and prominence, and the subjacent ulcer becomes deeper and deeper. The resultmg scab is always very thick, but some- times flat and flaky, somethuig like an oyster-shell [v. simplex), some- times conical, like a Hmpet-shell [r. prominens), sometimes irregular and rocky in shajDe.. On its removal, a fL*esh scab usually forms. Eupial ulcers are always deep and unhealthy-lookmg, and cause much destruc- tion of tissue, and permanent cicatrices. In some cases, and especially in. childi'en, the ulceration extends rapidly, assuming a phagedasnic character ir. escharotica), or becoming distinctly gangrenous, when it is some- times termed pemphigus gangranosus. Eupial sores are generally scat- tered and few in number, and are not limited to any particular part of the person. They are, perhTlps, most common on the buttocks and lower extremities. Y 2 824 DISEASES OF THE SKIN. Eupia occurs rarely, if ever, in persons wlao are not obviously weakly and cachectic, and most frequently in those who have previously had syphilis. Indeed, there is some reason for regarding true rupia as essen- tially a syphilitic disease. Treatment. — In the constitutional treatment of rupia, tonics of various, kinds, iron, mineral acids, vegetable bitters, cod-liver oil, together with good diet and change of air, are all-important. Anti-venereal remedies; must not, however, be forgotten, especially if there be a clear syphilitic history. For local treatment, poultices are necessary to aid in the detachment of the scabs ; and the resulting ulcers must be treated not only with poultices but with stimulating or detergent ointments or washes, and even in some cases with undiluted caustics, such as nitrate- of silver, nitric acid, acid nitrate of mercury, or other such agents. XII. STEAEEHCEA. ACNE. Causation and description. — By acne is meant an inflammatory affection of the sebaceous glands, dependent on, or at all events con- nected with, retention of their secretory products. In most inflamma- tions of the skin the sebaceous glands of the parts affected share in the inflammation ; and always in acne there is more or less tendency for- inflammation to extend from them to the contiguous structures. Hence, as might be supposed, acne occasionally (and especially in some of its forms) passes into other recognised varieties of inflammation of the skin. Further, inflammation of the sebaceous glands is sometimes attended, not with retention of secretion, but with increased production and flow, so that we may have an inflammation of them which is not acne. This is. sometimes named stearrhoea. A. Stearrhcea. — The secretion of sebum in some persons is naturally exceedingly profuse, but it is not therefore morbid, and becomes seriously inconvenient only in the absence of scrupulous personal cleanliness. In some cases, however, an excessive production of sebum occurs over cer- tain limited arese, attended with distinct hypersemia of the parts, and more or less obvious hypertrophy of the glands. The increased produc-. tion is limited in fact to patches of distinct erythema. This affection is not unfrequent in the scalp and on the face, especially in children. The secretion is usually more solid than sebum should be, and with the super- ficial epidermis concretes into greasy flakes, which adhere to the surface. A condition is thus produced which differs little, and not essentially, from pityriasis of the same parts. More rarely the secretion is quite fluid, and may be seen, after cleansing the surface, to form a minute drop at each glandular orifice. This condition, which is occasionally observed on the cheek and nose, is apt to be chronic, and sometimes becomes, permanent. • B. Acne. — The unnatural accumulation of sebaceous matter in the: ACNE. 325 :sebaceous glands is extremely common. It may be met with in glands "which are still patent, as well as in those whose mouths are obliterated. In the former case the orifices are dilated and prominent, and occupied by the dirt-blackened superficial portions of the accumulated sebum, the whole of which may, by squeezing, be removed in the form of small, inaggot-like bodies {comedones). In the latter case no orifices generally are detectable, the sebum retains its normal yellowish hue, and concretes into hard, pearly, laminated masses. This condition was termed by Willan strophulus albidus. A small incision is generally necessary for their removal. Sebaceous tumours or loens differ little, except in size and i}he consistence of their contents, from the bodies last named. When such accumulations of sebum are associated with inflammation of the parts immediately surrounding them, we have that condition present to which the term acne is generally applied. Acne, therefore, may occur in two forms. In the one there is circumscribed inflamma- tion, attended with induration, prominence, and duskmess of tint, but the cause of inflammation is rendered obvious by the fact that at the most prominent part of the tubercle there is a dilated sebaceous orifice, choked with the secretion of the gland. In the other form the orifice of the gland is undistinguishable, the accumulation is deep-seated, mflam- matory products are diffused around, beneath, and superficial to it, and thus an indurated congested prominent tubercle is produced, which yields on inspection no visible proof of its connection with sebaceous accumula- tion. The tubercles of acne vary in size, and are sometimes as large as a horse-bean. They often suppurate, but, especially in the latter form, suppurate very slowly, leading before they discharge their contents to a good deal of localised disorganisation, and eventually to the production of permanent scars. Their contents are scanty but thick, and consist partly of sebaceous matter, partly of pus. Different forms of acne are described, of which the majority are mere varieties of the same condition, and are generally combined in various proportions in the same case. The term a. punctata is often applied to that very common condition in Avhich the sebum simply accu- mulates in the follicles, and leads by its accumulation to the production of a series of black-tipped papules. By a. simplex is generally under- stood a. punctata associated with inflammation and suppuration : the papules being surrounded by congestion, and often gouag on to the forma- tion of small superficial abscesses, which in a short time discharge their ■contents, and then after a few days, or a week or two, heal up. The name a. inclurata \q e,iYen. to those cases which are marked by general enlargement and induration with dusky or livid discoloration, and slow deep-seated suppuration. One form of sycosis is distinctly a. indurata of the hairy regions of the face. Any part in which sebaceous glands exist may be the seat of acne. But it is most common on the face, especially the forehead, cheeks, nose, and chin ; and on the trunk, mainly betw^een the shoulders and on the chest. It rarely occurs in young children, excepting in the form of 326 DISEASES OF THE SKIN, strophulus cdhidus. It is most common iii both sexes about the period- of puberty, and from that time onwards to two or tbree-and-twenty. It is frequently met "s^dtb, however, and then especially m its indurated form,, in persons of middle and even advanced age. The causes of acne are obscm'e. It is certain, however, that the tendency to it rmis in families,, and that it has a special connection with the period of development and maturation of the sexual fmictions. C. Acne rosacea. — The condition to which this name is commonly given has been regarded by most modern authors as a mere variety of acne. Hebra, however, maintams that it is essentially distinct from acne, although fr-equently associated mth it. It generally consists in more or less extensive patches of inflammatory redness, associated \dt\i slight infiltration of the affected cutis and visible dilatation of the super- ficial vessels, and also with the presence here and there upon the inflamed patches and in their neighbourhood of tubercles corresponding precisely to the description already given of those of acne mdurata. The affection is really therefore an inflammatory condition of certain parts of the skin, in which there is a special tendency for the sebaceous glands to be im]DH- cated. Acne rosacea is limited to the face, affecting sometimes the nose, sometimes the cheeks, sometimes the forehead, sometimes the chin, but generally several of these regions at the same time. It is for the most part symmetrical in its distribution, and tends gradually to extend. It usually begins "ttdtli circumscribed hyperemia of the nose or cheeks, often attended with an increased secretion of sebaceous matter, and generally with a more or less obvious development of dusky red tubercles, which may or may not suppurate. This condition, variable at first, soon becomes permanent, the cutis getting infiltrated and thickened, the small veins of the part dilated and tortuous, the tubercles more abundant and larger, and the face consequently much disfigured. In this latter state the disease may remain for many years, or for life, T\-ithout material change. But in some cases, and more especially in elderly men who have been addicted to alcoholic excess, the affection, which is then almost invariably limited to the nose and its immediate neighbourhood, assumes a hypertrophic character ; the parts which were origmally affected with a simple form of acne rosacea become swoUen and tuberculated, mitil in some mstances the nose forms a huge misshapen, lobulated, pendulous mass. These changes are due to inflammatory hyperplasia of the cutis vera, the tissues subjacent to it being rarely, if ever, imphcated. The sebaceous glands, however, are hivolved and hypertrophied, sametimes still discharging their products through the yet patent ducts, sometimes fr'om obstruction allowing accumulation of sebum, and perhaps midergomg suppuration. The affected parts become deeply congested, and the dilated varicose vems larger and more numerous. Beyond heat and flushhig, which are hable to fr-equent exacerbations,, little local inconvenience or discomfort attends acne rosacea in any of its forms. Acne rosacea, in its simpler variety, is an affection of adult hfe. ACNE. 327 coming on generally between 25 and 30, but sometimes making its appearance for the first time after the age of 40. It is far more common m women than m men. The hypertrophic variety of the disease, on the other hand, is rarely observed in women ; and it attacks the opposite sex for the most part in middle age or the declhae of life. The causes of hypertrophic acne rosacea are not m all cases obvious ; there is no doubt, however, that in large proportion it is traceable to long continued habits of intemperance, or over-indulgence in spirituous liquors. The difficulty of assignmg a cause to the other form of this affection is still greater ; nevertheless, it is certain that many of those who suffer from it are dyspeptic or liable to uterine disturbances, and that when any of these complications are temporarily present there almost invariably occurs marked exacerbation of the facial inflammation. Treatment. — In stearrhoea plentiful ablution with soap and water, and the use of astringent lotions, contaming acetate of lead or sulphate of zinc, or of mercurial preparations, are the chief measures to be employed. Constitutional treatment is generally useless. In treating acne it is of great importance to insist on frequent and thorough washing with soap and warm water, to be followed by the friction of a rough soft towel, or flesh brush. These measm-es, however, are even more unportant to prevent than to cure. All black spots should be removed, either by squeezing the papules in which they are contained between the nails, or by pressing down upon them a ring a little larger than the black spot, and including it. The mouth of a watch-key answers the purpose very well. Superficial collections of matter should be punctured, and discharged. The chronic tubercles of acne indurata should be opened with a narrow-bladed knife, and have their contents expressed, or should be touched at the summit with the acid nitrate of mercury, or some other equivalent escharotic. The local mflammation may be allayed to some extent by the use of lead-wash, or lotions con- taining from two to four grains of sulphate of zinc, or from half a grain to two, three, or even four grains of bichloride of mercury to the ounce. Mild mercurial ointments are sometimes useful. Sulphur, in the form of ointment or lotion, is strongly recommended by most dermatologists. Beyond local treatment we can aim only at improving the general health, and must be guided, therefore, solely by the general symptoms which the patient presents. Li sycosis it is important to have the hair of the affected parts kept closely cut, and to remove the hairs rmniing through the tubercles or pustules by frequently repeated epilation. Hebra insists on the necessity for keepmg the surface constantly shorn, for the application of sulphur and other stimulating . ointments, and for the incision of the inflamed tubercles. The treatment of acne rosacea differs little from that of simple acne. But it is especially important here to attend to the general health and habits of the patient, to remedy indigestion, to remove anemia, to prescribe a wholesome unstimulating diet, and to maintain the healthy functions of 328 DISEASES OF THE SKIN. the skin and otlier organs. The local treatment is absolutely that of acne simplex ; but it generally needs more persistent employment. XIII. LUPUS. {Noli me taiigere.) Causation and description. — The term ' lupus ' is applied to a series of affections characterised by a specific overgrowth of the cutis, for the most part of chronic progress, and resulting in the formation of indehble cica- trices, or in more or less extensive destruction of tissue. Lupus usually commences with congestion and hypertrophy of a limited area, which, in a large proportion of cases, is studded with solitary or grouped lenticular tubercles a line or two in diameter, and presenting a slightly translucent aspect and a dull red or pale salmon colour. The patch of congestion slowly increases in area or the tubercles in number, until hi many cases a large extent of surface after a while becomes involved. AVhile this extension is in progress various changes take place. In some instances, the parts first implicated, without attaining any further stage of development, gradually lose their inflamed and hypertrophic character, but, mstead of simply reverting to the healthy condition, become pale, depressed and contracted, and assume a cicatricial character. In some instances, previously to the attainment of this cicatricial termination, their surface yields adherent scales or crusts. In some, the tubercles, almost from the begmning, are the seat of suppuration, and become crowned with thick adherent scabs. In some, extensive ulceration ensues, with grievous and irremediable destruction of parts. In its morbid anatomy lupus appears to consist in the development of a kind of tissue, resem- bling granulation-tissue, composed of small cells, imbedded, according to the density of the growth, in a greater or smaller quantity of fibrous material ; of tissue, indeed, closely resembling that of tubercle. Lupus is generally regarded as a ' scrofulous ' disease ; and it not unfrequently occurs in those who are suffering or have suffered from scrofulous sup- puration of the cervical glands, or who are otherwise out of health ; moreover exacerbations seem not unfrequently to be induced, in those who are already its subjects, by temporary conditions of general ill-health. Females suffer from lupus much more frequently than males, children than adults, and the poor ^tlian the well-to-do. The local symptoms which attend its progress are for the most part trivial ; often the patient makes no complaint, or if he complains at all, complains only of itching or tingling. Ltl accordance with the different peculiarities of character and progress which have been above referred to, several varieties of lupus have been described, the more important of winch we shall now briefly discuss. A. Luinis erythematosus, which was first described and named by Alibert, is the least severe form of the disease. It occurs mainly on the cheeks, nose, forehead, and scalp, but is not limited to these parts ; and it makes its appearance there in the form ol rounded, erythematous patches, which slowly increase in diameter, and may at first be readily mistaken LUPUS. 329 for patches of simple erythema. But sooner or later they get covered mth either thin scales or thick crusts, composed largely of sebaceous matter, and continuous by their under surface with processes of the same material prolonged into the dilated orifices of the subjacent sebaceous glands. In the former case the affection simulates psoriasis ; in the latter, that morbid condition of the knuckles caused by dissection, to which Dr. Wilks has given the name of verruca necrogenica. The progress of lupus erythematosus is very chronic, and scarcely attended with any abnormal sensations, but when it subsides it leaves behind it permanent changes in the condition of the skin. It usually begins in adult life, and affects women more commonly than men. B. Lupus exedens and non-exedens [tubercular hqms). — Lupus non- exedens, like the last, may occur on any part of the surface of the body, but usually originates on the nose or cheek. It commences with the appear- ance of small tubercles, such as have been above described ; which slowly increase in number, sometimes assuming an annular arrangement, and involve more and more of the contiguous cutaneous surface, extending, it may be, to the mucous membranes, and especially to that of the nose. Their course is very uncertain. Sometimes, after making but little pro- gress, they slowly subside. More frequently they advance irregularly, noYi remaining quiescent for a while, now midergoing comparatively rapid extension, and thus, continuing for years, ultimately involve extensive tracts of skin. These become seamed and puckered, and of a greyish white colour in those parts which have undergone involution, and present groups of reddish tubercles in those which are still extending. In the progress of tubercular lupus, the tubercles not unfrequently become covered with scales or crusts, below which gradual erosion is going on, or undergo actual suppuration or ulceration with the formation of scabs. In some cases the tendency to suppurate or ulcerate, and to scab, forms a special feature in the disease, which then receives the name of lupus exedens. This leads to more or less rapid and extensive destruction of tissue, and when occurring (as it most frequently does) in connection with the nose, often involves the gradual loss of the septum nasi and cartilages which bound the nostrils. The cicatrisation to which lupus non-exedens, and still more that to which the exedent form leads, is not merely in a high degree disfiguring, but often induces serious consequences. The eyelids become retracted, the nose curiously thin and pointed, the alae contracted and the nostrils altered in shape, the mouth distorted, and the lower lip and chin drawn down upon the chest, as they sometimes are after extensive burns. The forms of lupus here described usually begin in early life, and are often prolonged by successive outbreaks to an ad- vanced age. C. Pustular lupus. — This variety of the disease simulates impetigo. It is sometimes limited to the face, and has then been termed by Mr. Startin 'impetiginous lupus.' Sometimes, however, the whole surface (head, face, trunk, limbs) becomes more or less thickly covered with it. The eruption consists of tubercles, which are mostly discrete, but are here 330 DISEASES OF THE SKIN. and there collected into confluent patches, vary from 5- to ^ inch in. diameter, tend to suppurate scantily at their most prominent points, and. presently become crowned with small dark, hard scabs, deeply imbedded, and remaining fixed (miless detached by violence) for weeks or months. The detachment of one scab is liable to be followed by the formation of another ; but sooner or later each tubercle gets absorbed, leaving behind, it a temporary livid discolouration and a permanent depressed cicatrix. Pustular lupus is often associated with the presence of suppurating scrofu- lous glands. Treatment. — In the treatment of lupus, constitutional remedies hold an important place. Among these the most efficacious are cod-liver oil, quinine, iron, and other forms of vegetable and mineral tonics, and arsenic. If there be a suspicion of syphilis (and it is often extremely difficult to distinguish non-specific lupus from some forms of tubercular syphilide) the ordinary anti-syphilitic remedies must not be omitted. Change of air is often valuable. Local remedies are very variable in their effects ; sometimes they seem to do more harm than good, sometimes their use appears to be followed by rapid amendment. In the tubercular form of the disease, especially if the tubercles be attended with ulceration or any other kind of destructive process, the use of solid nitrate of silver, potassa fusa, acid nitrate of mercury, or arsenical paste (made according to Mr. Startin's formula with three parts of arsenious acid, two parts of bisul- phuret of mercury, and one part of calomel, together with water) is often highly advantageous. The caustic, however, needs to be repeated from time to time, and previous to its application the surface should be freed from scales and scabs. In the milder cases less severe local applications are usually indicated, such as nitric acid lotion, iodine paint, blistering fluids, or mercurial, lead, or zinc ointment. XIV. KELOID. {Kelis.) Causation and descrii)tion. — This affection was first described and named by Alibert. It is characterised by the gradual formation of roundish, elongated, linear, branching, or reticulate patches, which are elevated a line or two, or even more than that, above the general surface, and appear to be mainly a hypertrophic condition of the cutis. The patches vary in colour, but are usually either white and shining, or of a. more or less rosy hue, and are often marked with vascular ramifications. They present for the most part a smootli and rounded surface, and gene- rally send out here and there claw-like processes or spurs which gradually lose themselves in the surrounding healthy skin. It is from this peculi- arity that their name was derived, and that they acquire their generally recognised resemblance to hypertrophic scars. They are dense and firm in consistence, and never become covered with scales or crusts, or undergo ulceration or other such destructive changes. They are some- times attended with tingling, itching, or burning, and are often tender ta- KELOID. XANTHOMA. 331 pressure. Tlieir progress is slow; they usually extend gradually for a time, and then become stationary ; occasionally they midergo involution,, and disappear. In the early stage of their development they consist largely of fusiform cells, and are by Virchow and others regarded as sarcomatous ; at a later stage they become almost entirely fibrous. Keloid commonly occurs in isolated patches of various sizes on the chest or back ; but it may be multiple, and may be met with on any part of the surface, even the face, ears, genital organs, and extremities. Occasionally it mvolves nearly the whole of the trunk. The causes of the disease have not been clearly determined. It occurs, however, mainly in adults, and seems not unfrequently to be induced by local irritation or injury. Indeed, one form of it, generally termed false keloid, is clearly due to hypertrophic changes occurring in connection with ordinary scars. A remarkable case ^ in which the face became affected to an extreme degree after small-pox has been recorded by Dr. Goodhart. The treatment of the disease is misatisfactory. The growths, when large, have occasionally been removed with the knife, but the results have not been encouraging. Local applications, such as iodine paint, blister- ing fluid, and various forms of stimulating ointments, have been tried and recommended ; but, again, the benefit resulting from them has rarely been very decided. XV. XANTHOMA. {Vitiligoidea. Xanthelasma.) Causation and description. — This affection was first clearly described by Drs. Addison and Gull under .the second of the names given above. It has since been carefully uavestigated and described by various dermato- logists, and more especially by Dr. Hilton Fagge. It consists mainly in a kind of fatty or atheromatous change in the texture of certain portions of the skin, and in this respect has a very close affinity to atheroma of the arteries. The affected parts appear on section to consist of fibrous tissue (mainly the normal fibrous tissue of the partj studded more or less abun- dantly with groups of oil-globules. It occurs in two forms, namely x. l)lamtn and x. tuberosum. In the former, the affected portions of skin present an opaque, yellow, or buff colour, are distinctly marginated, and although perhaps appearing to be elevated, are actually level with the general surface and undistinguishable from it in consistence and feel. In the latter variety, papules or tubera arise, varying from the size of a pin's head to that of a hazel-nut, which sometimes by their aggregation form nodulated masses of considerable extent. These are generally yielding, elastic, and but little indurated, are of the normal colour of the skin or of a reddish hue, and frequently studded, especially in their more prominent parts, with opaque yellow spots. Xanthoma is often unattended with local uneasiness ; in the tubercular form, however, there is not unfre- quently some degree of itching or tingling, and tenderness. Its course is for the most part progressive ; but sometimes it becomes stationary and. ' 'Path. Trans.' vol. xxxi. 332 DISEASES OF THE SKIN. occasionally disappears. It never undergoes ulceration or other such destructive changes. Xanthoma may occur on almost any part of the surface ; on the eyelids, nose, ears, cheeks, head, neck, shoulders, nates, back of elbows and front of knees, about the wrists and ankles, on the palms and soles, and on the knucldes of the fingers and toes. When occurring in the neighbourhood of joints it seems to be connected with the tendons. It has also been observed in the mucous membrane of the nose, gums, lips, tongue, and larynx. The plane form of the disease is met with mainly in connection with the eyelids, ears, and other parts of the face, and with the mucous membranes. This, if the affection be at all largely distributed, occurs concurrently with the tuberous form ; but it is not unfrequently alone present and limited to the face, and more particularly to the eyelids. In the latter case it usually commences in the skin of the upper lid near the internal canthus, and may gradually extend thence until it involves the greater part of both lids. It is occasionally seen in the neck, flexures of joints, and especially on the palmar surface of the hands and fingers, feet and toes, to extend along the deeper creases, and mainly in the form of two narrow parallel bands, one on either side. The tuberous form may be met with in the same situations as the other, but is most commonly ■observed upon the extremities. When occurring in the palms or soles, the tubercles are usually of small size, but very numerous, and give a mottled aspect to the affected surface ; and on the wrists and ankles the affection may assume a good deal of the typical appearance of keloid. Although the causes of xanthoma, like those of so many other affec- tions, are obscure, some curious facts -have been observed which seem to have some relation with its aetiology. Many recorded cases, probably half, have laboured during the development of the disease under jaundice, due to organic disease of the liver ; and many also, as Mr. Hutchinson has pointed out, appear to have suffered from sick headache. Li the very few published cases in which the disease appeared in a tubercular form on the palms and soles, the patients were suffering at the time from diabetes : and, moreover, the eruption got well eventually, or underwent -considerable improvement. It is an affection of adult life, and attacks ^women more frequently than men. Treatment. — No efficacious treatment is known. XVI. LICHEN EUBEE. Description. — This is the name given by Hebra to an affection which is to some extent, no doubt, papular, but has no affinity whatever with the eruptions commonly included under the name of lichen. It begins with small colourless or reddish solid papides, for the most part unattended with itching. These increase in number, but very little in size, and presently coalesce at their margins so as to form smooth patches of uni- form thickening and induration, the effect of which is to smooth away the finer furrows or creasings of the skin, to interfere with the free movement SCLEEODEEMA. 33S of parts, and to render the patient hidebound. The indurated skin is. often thickened apparently to two or three times its normal thickness, and it loses its sensibility in a greater or less degree. The disease begins symmetrically on different parts of the body, and may remain limited in its range, or may gradually spread over the whole surface. But there are certain situations in which its effects, however wide its distribution, are most obvious : these are the hands, feet, face and neck. The hands are affected mainly on their palmar aspects, but the convex surfaces of the metacarpo-phalangeal and phalaiigeal joints are also involved, and, in a less degree, the remainder of the backs of the fingers, which are apt to remain papular. The hands get stiff and almost useless, the fingers are kept widely separated and semiflexed, and cracks are apt to appear over the convexities of the joints. The feet and toes are similarly affected. The skin of the face becomes smooth and hard, the delicate wrinkles about the eyelids, forehead, and cheeks undergo more or less complete obliteration, and much of the patient's mobility of features and natural expression is lost. The primary papules and the infiltrated skin are said by Hebra to be red, and to have a tendency to yield thin scales. They are, however, sometimes pale, or of a pale dead- leaf colour, and free, or almost free from desquamation, Hebra points out, also, that the nails get brittle, and either thin or thick ; that the hair is maaffected ; that the disease rarely undergoes amendment or cure ; and that the patient tends to emaciate, and in the course of years to die from exhaustion. He further states that the papillte of the skin have been fomid after death to be hypertrophied, and the root-sheaths of the hairs thickened. Treatment. — Arsenic in large doses, and cod-liver oil by inunction, are the only remedies which have been found beneficial. XVII. SCLEEODEEMA. {Scleriasis. Addison's keloid. Morphcea.) Causation and description. — Under the above series of designations have been described a number of morbid conditions of the skin, which are now generally admitted to be closely correlated, if not absolutely identical with one another. They are very rare, and consequently, although in- teresting, do not claim any lengthened consideration. They are all characterised by the appearance of patches of induration and thickening ; which vary in extent and shape ; tend gradually to increase in size ; are attended often with tingling, sometimes with anaes- thesia ; are white and ivory-like, or of a pale yellowish or brown hue, sometimes mottled, sometimes surrounded by a halo of congestion or dis- colouration ; are for the most part of long duration, and in their progress apt to become faintly tubercular, or to desquamate, or even to ulcerate, and, when they finally disappear, to leave behind them more or less brownish discolouration, with atrophy and cicatricial seaming of the surface. The affected parts are for the most part smooth, scarcely, if at all, elevated above the general level, and incapable of being pinched up in a fold ; and the thickening, although generally limited to the skin, some- ■334 DISEASES OF THE SKIN. times involves also the subjacent connective tissue. The affection appears to consist anatomically in an overgrowth of dense connective tissue, ^associated with the accumulation of cells, resembling lymph-cells, in the sheaths of the small vessels. A. It is comparatively not uncommon to meet with a patch or group of patches of scleroderma on one side of the forehead, in the area of distribution of the fifth pair. The affection then usually remains limited to this region. It commences insidiously, perhaps as a mere discolour- ation, gradually increases in size, and occasionally spreads to the hairy scalp, where it causes circumscribed alopecia. It is very chronic in its progress. B. Another variety of the affection (Dr. Fagge's ' circumscribed •scleriasis ' (scleroma) is that which Dr. Addison described under the name of ' true keloid,' deriving the word keloid from ktjXIs (a spot pro- ■duced, as it were, by burning). In this, which is also a very chronic affection, the patches commence variously, sometimes as a mere loss or change of colour, sometimes as a mere depressed smoothness, sometimes :as a simple induration, attended or unattended with itching or tingling. The patches differ in shape : are round, oval, band-like, irregularly poly- gonal or stellate, and not unfrequently send out promontories, as it were, or peninsulas, into the surrounding healthy skin. They vary also in size : are sometimes no larger than a sixpenny-piece or shilling, but tend to increase, and thus sometimes involve ultimately very extensive are®. They are usually multiple, and new spots are apt to arise from time to time. Beyond the itching and tingling, the main source of discomfort to the patient is the interference with the free use of parts which any con- siderable extension of the disease involves. He becomes hidebound, and his fingers, hands, arms, or other parts which are affected, more or less distorted, fixed, and useless. This immobility is increased when (as often happens) the skin becomes adherent to the subjacent tissues, and when (as also occasionally takes place) subjacent muscles waste. The mucous mem- brane of the tongue, lips, and guins is sometimes involved in the disease. C. A third form of the disease, which Dr. Fagge designates ' diffused scleriasis ' (scleroma), is that to which the names ' sclerema,' ' scleroma,' ' scleriasis,' and the like, are more particularly given. It appears to have been observed almost exclusively on the Continent, and is mainly charac- terised by the rapid extension of scleroderma over large parts of the surface of the body. It seems frequently to have begun at the back of the neck, and thence to have spread to the face, back, and front of the trunk, arms, and even over the whole surface. The tongue may be involved. The integument becomes thick, hard, ivory-like, and smooth, the arms, hands, and fingers stiff and immovable, the face an expression- less mask. The aspect and feel of the affected regions have been likened to those of a frozen corpse. None of the above varieties of scleroderma appears to be associated with any indications of constitutional suffering ; and the secretion from the kidneys ^nd even that from the affected portions of the skin remain ELEPHANTIASIS. 335 normal. They are all more or less chronic in their course : the first two lasting, as a rule, for years, and leaving on their subsidence marked signs ■of their pre-existence behind ; the last, however, often disappearing entirely in the course of a few months. Women appear to suffer much more frequently than men. In some cases (especially of the diffused form), the attack is said to have originated in exposure to cold or wet ; but little or nothing further is known with respect to the causation of the disease. There is some obvious resemblance between scleroderma " and the later stages of lichen ruber, and still more between it and true leprosy, of which disease some authors regard its circumscribed forms as mere varieties. Treatment. — No local measures seem to have been useful in the treatment of scleroderma. The constitutional remedies which have been employed include cod-liver oil, quinine, iron, arsenic, and iodide of potassium. XVIII. ELEPHANTIASIS. {Elephas. Pachydermia. Barhadoes Leg. E. Arabum.) Causation and description. — The condition to which the above names have generally been given is mainly a disease of tropical climates, and more especially of certam parts of India. Its chief characteristic is hypertrophy of the connective tissue of certain parts of the body, asso- ciated with early implication of the lymphatic glands and vessels. A. Elephantiasis commences with an erysipelatoid inflammation of the part about to become permanently affected, attended with febrile symptoms, and mdicated by superficial redness, and general and deep infiltration. At the same time the superficial veins and lymphatics generally form red painful indurated cords, and the corresponding lym- phatic glands midergo considerable acute tumefaction. If an incision be made at this time, a large quantity of yellowish transparent fluid, coagu- lating spontaneously, and having all the characters of lymph, escapes. After a few days, probably, the inflammation subsides, but more or less swelling remains. Subsequent attacks of inflammation, excited by various causes, supervene at irregular intervals — each attack adding to the mis- chief, and leaving behind it a tendency to still further hypertrophic change. The final result is that the affected part becomes largely, some- times enormously, increased in bulk, and altered in aspect. In some cases the hypertrophic condition occupies mainly the sldn and subcutaneous connective tissue ; in some it involves the whole of tne connective tissue between the skin and bone. In either case, but chiefly in the former, the sldn is liable to be much modified in texture and form ; sometimes it becomes coarsely papular or warty, sometinies studded with nodular elevations, sometimes undergoes ulceration ; and the epidermis, though often remaining normal, may desquamate, or get thick or horny, or acquire the characters observed in ichthyosis, or become more or less deeply coloured from deposit of pigment-granules in the rete mucosum. The affected surface, moreover, may be anemic, congested, or livid. 336 DISEASES OF THE SKIN. When the disease extends deeply, fat, muscles, and nerves get compressed and waste, but the bones undergo hypertrophy — new layers and irregular outgrowths forming, by means of which adjoining bones occasionally become organically united. Elephantiasis appears to consist primarily in an inflammatory hyper- plasia of the cellular elements of the connective tissue, in connection with which (according to Virchow) there is reason to believe that the roots of the lymphatic vessels are specially involved. Inflammatory overgrowth of the elements of the lymphatic glands next ensues, with obstruction to the passage of lymph through them. Then this fluid stagnates in the lymphatic vessels, which sometimes dilate even to their radicles in the cutaneous papillffi ; and it presently accumulates in the interstices of the affected tissues, adding to their bulk and at the same time stimulating them ta overgrowth. It is only in the early stage of the disease that the dilated condition of the lymphatics admits of ready detection. At a late period the morbid tissues are characterised mainly by the presence of a dense accumulation of white fibrous tissue. The lymphatic glands also, after a time, become the seat of fibroid change. The regions most frequently attacked with elephantiasis are the lower extremities and genital organs. But other parts may become afiected, and especially the female breast. In the first of these cases the disease may commence in the toes or about the ankle, and gradually involve the whole leg up to the knee. It rarely, however, rises above that point. In extreme cases the form and appearance of the affected member remind one of those of an elephant's leg, whence the common name of the disease. When the scrotum or labia are involved they often reach enormous dimensions ; the scrotum, which is sometimes also the seat of hydrocele, may attain a weight of 50 or even 100 lbs. Elephantiasis is a disease mainly of adult life, and is more common in men than women. Its progress is slow, but is largely governed by the conditions under which the patient lives, or the care he takes of himself. Fatigue and exposure to weather, or of the affected part to anything provo- cative of irritation or inflammation, are apt to aggravate it ; while, under opposite conditions, the disease may. make but little progress, or remain stationary. There is nothing in it necessarily inimical to life ; but want of cleanliness or other accidental circumstances may give rise to ulceration or gangrene, and thus imperil life or cut it short. Elephantiasis does not appear to be a specific disease. Swellings and indurations of precisely the same kind are apt to occur in the vicinity of old ulcers, and especially in parts which have undergone repeated attacks of erysipelatous inflammation. Only in these cases the hypertrophy rarely, if ever, goes on to that inordinate extent which characterises the endemic elephantiasis of tropical countries. B. Elephantiasis lymphangiectodes. — A condition, closely related to elephantiasis, if not identical with it, occasionally arises independently of inflammation, at all events of inflammation of the parts chiefly impli- cated. It is due sometimes to the continued application of a tight ligature ELEPHANTIASIS. 337 round the upper part of one of the extremities, sometimes to obstructive disease in the lymphatic glands or lymphatic vessels, either arising during adult life, or of congenital or infantile origin. In all of these cases the morbid condition appears to be chiefly, if not wholly, due to obstruction of lymphatics, with consequent dilatation of those below the seat of obstruc- tion, accumulation of lymph in the textm-es, and overgrowth of the con- nective and other tissues. The lesions closely resemble those of elephan- tiasis Arabum ; and the resemblance is not unfrequently enhanced by the occasional supervention of attacks of mflammation. The disease appears to be not uncommon in tropical climates ; and is attributed by Dr. Lewis to the presence of filarige, and to obstruction of the l}'mphatics by these entozoa. This form of elephantiasis generally first reveals itseKby simple increase in bulk of the part affected. This increase goes on more or less insidiously, until it becomes considerable : the tissues gettmg indurated and dense, and 'the surface pale, congested, or otherwise modified in colour, and either smooth, papular, or tuberculated. After a time groups of vesicles make their appearance, sometimes widely distributed, sometimes in an nregular patch, sometimes in a linear series, and generally imbedded, as it were, in the solid tissue. These, which are really dilated lymphatic spaces, are apt to rupture from time to time, and then to exude considerable quantities (sometimes several pints) of lymph, which coagulates after its escape, and is either yellowish and transparent, or milky fi-om the presence of molecular fat. This affection is usually limited to one of the lower extremities, or to the upper part of the thigh and contiguous part of the abdomen, or to the genital organs and perinteum ; and it may be added that there is good reason to believe (as is elsewhere pointed out) that chyluria is due to a similar condition involving the mucous membrane of the bladder or other parts of the urinary tract. When the lower extremity becomes affected in infancy, not only does the limb increase generally m bulk, but the bones, relatively to those of the opposite member, become manifestly hypertrophied — augmented both in thickness and in length. Treatment. — The treatment of elephantiasis should be mauoly prophy- lactic ; the patient who is suffering from it should be careful to avoid all causes of renewed inflammation ; he should keep the affected parts clean and cool, should not expose himself to cold or vicissitudes of temperature, and should avoid all over-fatigue and exposm-e of the parts to irritation or injm-y. Moreover, these should not be allowed to be pendulous. During the inflammatory stage antiphlogistic remedies may be had recoui'se to ; fomentations or cold lotions should be applied locally, with the object of preventmg hypertrophy, and it may be of promotmg absorption ; and the affected region should (if its form or position permit) be kept evenly and firmly bandaged. Hebra recommends that the bandage be of cotton, and dipped in water at the time of application. He further recommends that, previous to the use of bandages, scales and crusts be removed by cataplasms, baths, or greasy applications, and that afterwards mercurial ointment be rubbed in. 338 DISEASES OF THE SKIN. XIX. MOLLUSCUM CONTAGIOSUM. Causation and description. — This is an affection occurring mainly among children, and characterised by the development of small globular or sub -globular outgrowths from the skin, usually varying from the size of a pea downwards, but occasionally attaining larger dimensions. They are sessile, though sometimes attached by constricted bases. They differ little if at all in colour from the surrounding skin, but have a slight degree of translucency. They are unattended with pain or itching. Each tumour for the most part presents a distinct central depression, from which can often be expressed a little milky fluid or wax-like substance. On section it is found to consist of a lobulated gland-like body, the crypts of which are lined with columnar epithelium, and filled with rounded cells of large size. All these crypts communicate with a central duct, which for the most part is full of cells containing fatty matter. The growth appears in fact to be in some sense a kind of epithelioma. Molluscum has been supposed to be due to some abnormal development of the seba- ceous glands ; but both Beale and Virchow regard it rather as takmg its origin in the hair-follicles. We believe, however, that we have seen molluscous tumours in the palm of the hand. Whatever the nature of the disease may be, we consider that it has been clearly proved to be contagious. It frequently occurs simultaneously among the children of a family, and under such cirumstances even the adult members occasionally become affected. The parts on which the tumours chiefly appear are the face, head and neck, and trunk ; but they occur also on the limbs. Treatment. — Local measures only are of use. If the tumours are attached by narrow bases they should be snipped off ; if by broad bases, they should be effectually cauterised with nitrate of silver, potassa fusa, acid nitrate of mercury, or the like, previous to which it may be well to lay them open with a scalpel. XX. SAECOMA AND CAECINOMA. A. With few if any exceptions the varieties of mahgnant disease originating in the skin are epithelioma and melanotic sarcoma : the former arising mainly where mucous membranes and skin meet, but often also in regions exposed to long -continued irritation ; the latter springing up for the most part in pigmented nsevi or warts. B. The skin is often involved in the extension of malignant disease from subjacent parts. When sarcoma or cancer attacks the breast or bones or subcutaneous connective tissue, it usually sooner or later impli- cates the skin lying over it. The skin in such cases first becomes adherent to the growth below, and probably protruded by it; then it becomes infiltrated by it or incorporated in it ; and soon convex or hemispherical SAECOMA AND CAECINOMA. 839 nodules of various sizes, and irregularly distributed, spring from the surface. These tend to run together and to spread, and after a time to ulcerate or slough, and thus to terminate in characteristic area of sloughy- excavation, surrounded by fungating margins. Such extension, however, is not limited to malignant growths occurring in the limbs or organs superficially placed. Malignant disease of the oesophagus or trachea occasionally implicates the over-lying skin. Mediastinal and other intrathoracic tumours not unfrequently involve the walls of the chest. Even peritoneal cancer at times makes its way to the surface, mainly at or in the neighbourhood of the umbilicus. And similar disease, whatever be its origin, developed in the venter of the ileum, tends to invade the integuments of the lower part of the abdomen or the upper part of the thigh, and to form outgrowths. C. The most interesting cases, from the medical point of view, are those in which disseminated malignant tumours of the skin and sub- cutaneous connective tissue arise secondarily to similar disease originally developed in organs or tissues which have no direct connection with the parts thus secondarily affected. Such cases are rare ; and hence, instead of venturing on a systematic description, we shall give brief details of two or three typical cases we have had the opportunity of observing. In one, a melanotic sarcoma affected secondarily the glands in the groin, and shortly afterwards large numbers of melanotic tumours appeared in the skin and subcutaneous connective tissue of the upper half of the front of the thigh, and lower part of the abdomen. The tumours were hemi- spherical and in some instances umbilicated, and varied when we saw them from the size of a pin's head to that of half a marble. The patient died of visceral melanosis. In another, a young woman had scirrhus of the breast, and of some of the abdominal organs. But, besides, she had numerous (probably two or three hundred) scirrhous tumours of the skin. Some of these existed on the face and in the extremities, but the great majority occupied the surface of the trunk. They were mostly hard plates, round, oval, or sinuous in outline, from an inch and a half in diameter downwards, of variable thickness, slightly elevated, presenting a very definite margin, and occasionally a shallow central depression. Some were beneath the skin, which was movable over them ; but most of them involved the skin in its whole thickness. Some of these presented a dusky or brownish hue, but otherwise their colour differed but little from that of the surrounding parts. The patient remained for two or three years mider observation, finally dying of internal cancer. But during this period, while numbers of fresh cutaneous tumours made their appearance, several of the older ones underwent manifest atrophy. None (not even the cancerous breast) ulcerated. A third case was that of an elderly lady who had, in her history and in the presence of growin» abdominal tumours, clear indications of the gradual development of malignant disease. After her symptoms had continued for about six months, enlargement of some of the lymphatic glands above the clavicles and elsewhere was detected. Shortly afterwards, and about three months z2 340 DISEASES OF THE SKIN. before her death, numerous small roundish hard growths appeared in the substance of the skin, and in the subcutaneous connective tissue. These were scattered irregularly over the arms, legs, and abdomen, but were as abundant on her face as the vesicles in confluent small-pox. They increased gradually m size until most of them were about as large as half a pea, and some as large as half a marble. At this time they tended to run together, and on the forehead and cheeks produced slightly irregular tracts of infiltration of considerable extent and thickness. The patient's aspect was not unlike that of leontiasis. The growths on the face were pale and greasy-looking ; but many of those on the limbs and trunk were more or less deeply pigmented. A few pigmented excrescences appeared also on the fauces. The growths in the arms were mostly subcutaneous, and became so abundant that finally the arms felt almost like bags of peas. The disease was probably in this case, as in the first, sarcomatous. As to the treatment of the above affections there is little to be said. The first group belongs wholly to the surgeon. The second group demands no local treatment until ulceration and sloughing have occurred ; and then only such applications as relieve pain and neutralise or prevent offensiveness of discharge. In the third group superficial destruction is uncommon, and there is for the most part absence of pain or even marked uneasmess. Generally, therefore, no topical remedies are called for. XXI. PHTHIEIASIS. (Lousiness.) Causation and description. — Lice, the presence of which gives rise to the affection sometimes termed phthiriasis, are of common distribution as parasites throughout the animal kingdom. Three varieties affect man, namely, the pedicidus ca^ntis, the pediculus vestimenti, and the phthirius (or pediculus) pubis. The first of these as a rule inhabits the head only ; the second Uves in the underclothing, and feeds on those parts of the body which are uncovered with hair ; the last infests the hair of the pubes and armpits, and less frequently the eyebrows, eyelashes, whiskers, beard, and moustache. A. The pediculus capitis or head-louse is generally of a grey colour, like that of the scurf, and hence is very readily overlooked ; it has, however, a dark streak (alimentary canal) along the central Line of its body, the presence of which may aid in its detection. It lives among the hairs close to the scalp, feeding for the most part on the scurf and even on the hairs, and running along the latter with considerable agility. The female, which is larger than the male, deposits her eggs or nits upon the hairs, attaching each one thereto by a tough transparent sheath. These, which may be readily mistaken for particles of scurf, are fixed upon the hairs much as are the cocoons of some moths upon the stalks of grass, are furnished with a hd, and measure about half a line in length. The female, according to Kiichenmeister, begins to lay eggs at the end of eighteen days, and lays about fifty. They are hatched in six days. PHTHIEIASIS. 341 Pediculi always cause more or less itching and consequently a tendency to scratch the head with the nails. This may be all. But iii many cases the irritation which they produce leads to the development of eczema or impetigo, and the formation of thick scabs. As Mr. B. Squire has pointed out, impetigo in children limited to the back of the head is often of pedi- cular origin ; and impetigo affecting the nape of the neck in adults (especially females) is also commonly attributable to lice. There is good reason to believe that the affection termed 'plica Polonica is nothing more than a combination of filth, lice, and entanglement or felting of the hair. Pediculi (then termed p. tabescentium) are very apt to accumulate in the heads of patients suffering from long and wasting illnesses. But there is no sufficient reason for regarding them as distinct from the common head-hce. B. The pediculus vestimenti or body-louse is scarcely distinguishable from the last, excepting by its larger size, and its habits. It lives in the under-clothing, and attaches its eggs to the superficial projecting fibres. It is not always easy to detect its presence, for it is only occasionally dis- covered crawling upon the skin, or even upon the plane surface of the shirt or chemise. It almost always lies concealed in the folds or pleats ; and it is in these situations also that its eggs are deposited. The eggs, moreover, though almost exactly resembling those of the head-louse, have generally so much the colour of the garment to which they adhere that they are seen with considerable difficulty. Body-Hce, like the last, often cause itching only ; but often after a time the constant irritation of their presence leads to the development of an indistinctly papular condition of the skin, and bleeding points and lines, the consequences of violent scratching. This state of skin closely corresponds with the ordinary descriptions of prurigo. And indeed there can be no doubt that the great majority of cases of so-called prurigo senilis are essentially cases of phthiriasis. The presence of body-lice not unfrequently also causes urticaria, lichen, aud eczema. C. The pediculus pubis or crab-louse is very different in form from the other species of louse. It presents a much broader thorax and abdomen, and its chitinous claws are much more elongated and massive. It never affects any other parts than those which have already been named as its ■habitat ; always nestling close to the skin, and biting deeply into it. It fixes its eggs, which resemble those of the head-louse, close to the points of emergence of the hairs. The pediculus pubis causes violent irritation, and fr'equently induces an impetiginous eruption and the formation of abundant scabs. Treatment. — It is usually not difficult to get rid of lice. The thorough use of soap and water, and thorough personal cleanliness, are of course essential, but alone are not generally sufficient. Many local applications wiU destroy them, but none probably is more elficacious than daily washing with decoction of staphisagria seeds, or the munction of the parts (as recommended by Mr. B. Squire) with oil of stavesacre diluted with olive- oil, or the application of mercurial ointments, such as the ammonio- 842 DISEASES OF THE SKIN. cliloricle. The remedy must of com'se be contiiiiTecl until all iiits fas well as lice) are removed or dead. It is often desirable, in order to promote certainty and rapidity of cure, to hunt out and destroy the pediculi one by one, to pluck or cut out the nit-bearing hairs, or even to shave the head or other hairy parts. The applications which have been enumerated are useful even in the treatment of the pediculus vestimenti, but the chief treatment here must be directed to the clothes. Not only, however, must these be frequently changed and washed, but the bed-clothes must be similarly treated, as also must the clothes of any one sharing the patient's bed. XXII. SCABIES. (Itch.) Causation and description. — Itch is a skm-disease dependent on the presence of the acarus scabiei, and marked by the development of a papular, vesicular, or pustular eruption, with intolerable itching, which is especially violent in the evenmg and at night. The acarus scabiei is not unhke a cheese-mite, both m general form and in colour, and is visible to the naked eye as a mmute ovoid speck. Fig. 37. Female Acabus Scabiei x 100. a. Ventral aspect, b. Dorsal aspect, c. Ova. Its body has a short oval form, is convex above, somewhat flattened below, studded with numerous spines and bristles, and furnished (in the adult state) with eight legs. In the female the four front legs end in stalked suckers, the four hind legs in bristles. In the male the hinder- most pair of legs, as well as the four front legs, present suckers. The acarus just escaped from the egg has six legs, the hhadermost, or fourth pair, only making their appearance after the first change of skui. The male is little more than half the length and breadth of the female. The egg, which is oval, measures about one-third the length of the adult female. The acari live for the most part in burrows (cuiiiculi) which they make for themselves in the substance of the epidermis, beneath its horny © ■ (^ 4 ^ s| $ ^ b 'IG. 38. CtmicuLi The dotted cii-cles cles or pustules. (natural indicate size). ! vesi- SCABIES. 343 layer. According to Hebra, about a fortnight elapses from tlie time of liatcliuig iintn the complete development of the animal. At the end of that time the impregnated female penetrates the corneous layer of the skin, and then slowly tmmels beneath it in a straight, zigzag, or curved line. In its onward progress it deposits eggs, sometimes as many as fifty, in a Hnear series ; and at the end of two or three weeks, or it may be six (Hebra), it dies at the further end of its burrow. This may then have attained the length of half an inch, or an inch, or even more than that. It is generally quite obvious, on careful examination, as an irregular line studded with subcuticular black matter (f£eces); presenting at its com- mencement, in consequence of the gradual desquamation of the skin, a groove with retreatmg sides (a kind of calamus scriptoriusi and at its opposite extremity a minute papule, ui which the white body of the animal can generally be pretty readily dis- tinguished. The formation of the burrow and its full development may be unattended with any visible signs of inflammation ; but not un- frequently papules, vesicles, or pustules rise up in its immediate neighbourhood, the burrow then passing over them, or alongside of them, but very rarely forming any commmiication with them. Sometimes strings of vesicles, running perhaps together, mark its whole length. The eggs contauied within the burrow hatch there, and the young speedily migrate. The male acarus is difficult of detection, partly from its mmuteness and comparative infre- quency, and partly from the fact that it either simply imbeds itseK m the skin without burrowmg, or rambles over the general surface. The acari mostly burrow about the wrists and the hands, especially on the palmar aspect, and between the fingers, and in the corresponding- situations in the lower extremities ; they also infest the nipples and organs of generation, the flexiu'es of the elbows and knees, the axillae and the buttocks. No part can be regarded as necessarily exempt from their ravages. The face and head, however, are rarely attacked. The presence of the acari causes intolerable itching, which increases at night-time, and provokes "sdolent scratching. It also gives rise to inflammatory eruptions (papules, vesicles, blebs, or pustules) which are to be looked for especially on those parts of the sm-face which the acari chiefly afl'ect ; and occasionally it induces urticaria, eczema, or impetigo, which is not necessarily limited to the neighbourhood of the burrows, and may become general. The papular variety shows itself for the most part in persons who are out of health or possess peculiarly susceptible skins. Sometimes the mflammation becomes excessive, and produces not only pustules but considerable inflam- matory exudation and infiltration. This condition may often be observed in the penis and the nipples. The disease has naturally httle or no tendency to spontaneous cure ; but can certainly be kept m abeyance by personal cleanliness. Under opposite conditions, however, it is apt to become greatly aggravated. Occasionally the tips of the fingers and toes. 344 DISEASES OF THE SKIN. with the nails, get destroyed, partly by the direct operation of the acari, partly by the ulceration which they induce. A very severe form of the disease, common in Norway (and hence termed scabies Norvegica), but not confined to that country, is characterised by the formation of thick tough crusts extending over the palmar surface of the hands and fingers, and the corresponding surface of the feet and toes, the parts beneath being excoriated or ulcerated. The crusts contain innumerable acari and ova, both living and dead. From the different degrees of severity which it presents, and from the various eruptions to which it gives rise or with which it may be associated, itch is a disease which, on the one hand, is apt to be overlooked when present, and, on the other hand, is liable to be assumed as present when the patient is entirely free from it. The appearance of a papular, vesicular, or pustular itching eruption between the fingers and about the wrists, and in other situa- tions which itch affects, is no doubt an important indication ; but similar eruptions, not due to the acarus, occur in the same localities. The trans- ference of the disease to a bedfellow, or to those with whom the patient has similarly close relations, is also a point of great significance ; but it must not be forgotten that one member of a household may have itch for months and yet fail to infect any of the other members. The only real proof of its presence is the discovery of the acari, their eggs, or their burrows. The burrows are sometimes marvellously well seen, presenting all the characters which have been already described ; but they are often incipient, and very difiicult of recognition. When they are distinct the discovery of the female acarus is easy. It can generally be seen, even with the naked eye, at the further extremity of the burrow, or apparently a little beyond that point, as a very minute whitish papule. If the surface of this papule be torn with a pin, the acarus may readily be removed from its bed on the point of the instrument. In performing this operation it is well to avoid wounding any neighbouring vesicle or pustule. Even in cases where no obvious bur- row exists, the acari may be occasionally detected in the neighbourhood of some of the itching papules by the presence there of the minute whitish elevations which they cause. Sometimes, even when distinct burrows are present, there is some difficulty in detecting the acari at their extremities ; in such cases one of the burrows may be broken down, and its contents re- moved on the point of a pin or lancet, or still better, a whole burrow may be cut out. By these means the ova may be readily obtained. A further plan is to remove the scabs, if there be any, to boil them in a solution of caustic soda until they become limpid, and after allowing the fluid to stand for a time in a conical glass, to examine the deposit with a microscope. Dead acari, including males, and six-legged grubs, and eggs, can often be obtained by this process. Treatment. — The essential object in the treatment of scabies is the destruction of the acari and their ova. For this purpose it is necessary, not only to apply an appropriate parasiticide, but to soften the skin and remove its superficial epidermis, so as to expose the burrowing mites to its influence. The patient therefore should have daily hot baths, use soap abundantly, and SKIN-AFFECTIONS CAUSED BY ANBL\LCULES. 345 rub the surface thoroughly with a flesh-brush or a rough towel. All scabs should be removed. Then sulphur omtment, either of those of the Phar- macopoeia, or that of Helmerich, which contains carbonate of potash, should be rubbed well into the skin, especially in those parts which seem most affected, and should remain upon the skin until the next bath. Treatment of this kind will generally cure iteh in the course of a few days or a week, but may not improbably induce eczema or some other form of superficial inflammation, which will need other remedies for its cure. No doubt less active measures will suffice to cure scabies, but the cure will probably then be long delayed. On the whole, however, when a per- son has itch it is better for himself, in the long run, and better for those with whom he associates, that he should recognise his condition, retn-e for a few days from pubhc life, and adopt the measures which will most speedily work a cure. Tincture of benzoin and balsam of Peru, far more agreeable applications than sulphur, are said to be more efficacious than it in the cure of itch. They should be rubbed well into the affected parts. The purification of the patient's clothes and bed-clothes forms an essential part of the treatment. XXIII. OTHEK SKIN-AFFECTIONS CAUSED BY ANIMALCULES. Causation and description. — Fleas, hugs, and gnats do not of course come under the category of parasitic animals. So many persons, however, suffer from their bites, and the effects of their bites are so often misinter- preted, that it seems desirable to make a remark or two in reference to them. A recent flea-bite always exhibits a pmictiform subcutaneous ■ extravasation of blood, surrounded by a comparatively broad rosy areola. The latter soon disappears ; the former may persist for several days. People, and especially children, of the lower classes are often thickly covered with such petechial spots in different stages of their progress ; and their sldn, when seen for the first time (especially if they be suffering from some febrile disturbance), is very apt to suggest the presence of the typhus eruption. The smalhiess, however, of the spots, their uniformly petechial character, and the probable detection in them on close inspection ■of the puncture made by the insect, will alone, for the most part, enable a careful observer to distinguish the eruption due to fleas from that of any of the specific fevers. In some persons flea-bites produce considerable irritation and the development of wheals or tubercles, sometimes associated with a large amount of subcutaneous effusion of serum. The effects are then not unlike those which commonly arise from the bites of gnats and bugs. In all these cases there is generally in the first instance vio- lent itching, which is followed presently by the formation of a wheal or tubercle from the size of a split pea downwards, and often by more or less considerable subcutaneous oedema. The latter pretty soon subsides ; but the wheal probably continues for a week or fortnight, and is generally 346 DISEASES OF THE SKIN. attended with itching during the whole of that time. In its progress (owing in some measure to scratching) punctiform extravasations of blood often take place into its central part, and these are sometimes succeeded by vesication, or the formation of a pustule. Sometimes the wheals gradually subside and disappear ; but in many cases their subsidence is attended with the separation of a squama, or the formation and detachment of an eschar, or, when there has been vesication or suppuration, the pro- duction of a scab. It need scarcely perhaps be said that gnats generally select exposed parts of the skin, fleas those regions which are protected by clothing, and that bugs are more indiscriminate in their attacks. There is no doubt that the bites of these insects, especially in children of delicate skin, produce eruptions the source and nature of which are often entirely overlooked. Many attacks of so-called ' strophulus,' ' lichen,' and ' impetigo,' ascribed to dentition, dyspepsia, and other causes, are really due to the operations of the above animals. Mosquito-hites are almost identical with gnat-bites in their effects ; they are generally, however,, much more numerous and individually more venomous. The leptus autumnalis, or harvest-hug, which is common in the autumn in grass and cornfields and among gooseberry bushes, is very apt to imbed itself in the skin, and to cause much irritation there. The effects pass off in about a week. The mite, which is just visible to the naked eye, is of a red colour and presents six legs. It is probably the immature condition of an unrecognised eight-legged animal. The pttlex penetrans {chigoe) is a native of South America and the West Indies. It is so small as to be seen with difficulty, and is character- ised by the possession of a proboscis as long as its body. Only the impregnated female attacks man. It penetrates the skin of the feet, and toes, generally in the neighbourhood of the nails, where its impregnated body quickly develops itself into a white vesicle the size of a pea. This enlargement is due to the rapid growth of the larvse, which, if the cyst be ruptured, escape into the surrounding tissues and cause in them severe inflammation with suppuration. The recognised mode of treatment is to dilate with a needle the orifice by which the intruder entered, until it is large enough to allow of its extraction without rupture. On the Island of Bulama and its neighbourhood, on the West Coast of Africa, a pimple ultimately attammg the dimensions of a boil, and then attended with much pain and surrounding inflammation, and even affection of the neighbouring lymphatic glands, is attributable to the grub of some insect, which is deposited doubtless in the egg beneath the skin, and attams its full growth in that situation. The perfect insect is unknown. The acarus {demodex) folliculorum resides in the sebaceous follicles, for the most part in the duct or about the spot at which the sebaceous follicle opens into that of the hair. It is sluggish in its habits, and lies imbedded in the sebimi with its head pomted inwards. The number of acari in a follicle varies from one upwards. As many as thirteen have been discovered at one time (Kiichemneister). They differ in size, and in some degree in form, with age. In the earlier period of their development they present TINEA TONSUEANS. 347 six, and subsequently eight legs. They are most commonly found in the comedones of persons suffering from acne punctata, but do not cause this affection, or apparently aggravate it. In order to find them the expressed sebum should be diluted with oil, and then submitted to microscopic exammation. This parasite causes no distinctive symptoms in man ; but is said to produce serious and sometimes fatal consequences in the dog. XXIV. TINEA TONSUEANS. [Porrigo scutulata. Bingicorm.) Causation and description. — Eingworm depends upon the presence of a fungus, termed trichophyton tonsurans, which chiefly affects the roots and shafts of the hairs, but also invades the epidermis and nails. Its mycelium B. Hair from head sliowing m3-oelium. Fig. 39. Trichophyton Tonsurans x 500. consists of filamentous jointed branchuig tubes, which in the hair run in groups parallel with its long diameter, but in the epidermis and nails form an irregular interlacement. The spores are minute oval or rounded bodies, formed, in the first instance, in linear series at the extremities of the mycelial filaments ; but soon so abundantly developed that this relation is entirely lost. Spores form both m the epidermis and in the nails, but their chief seat is the shafts of the hairs within and a little external to the skin. The fungus spreads superficially, as do most fungi, in gradually enlarging circles, which, however, from various accidental circumstances, are apt to expand irregularly, and often, when large, break up into irregular segments and often, moreover, present fits of alternate quiescence and growth. 348 DISEASES OF THE SKIN. When ringworm occurs in the non-hairy skin, it reveals itself first as a sHghtly raised roundish uniformly erythematous patch, a line or two in diameter. This slowly increases in size, becoming at the same time more distinctly circular ; and when it attains perhaps half an inch in diameter the inflammation at the centre begins to subside, and the patch thus becomes a ring. In its further progress the rmg may enlarge to the size of half-a-crown, or a crown, and still extending (but then for the most part irregularly) may creep, for example, over the whole side of the face or front of the chest. The margin of the patch is always red and elevated, but varies in breadth, and often presents papules or vesicles ; and hence the affection has been called indifferently erythema circinatum, lichen circinatus, and herpes circinatus. The central area, even if all inflamma- tion appears to have subsided in it, still retains a yellowish or brovsmish discolouration, and a tendency to scale. Moreover, fresh spots of inflam- mation are apt to appear here and there upon it. Occasionally, patches of ringworm present two or three concentric erythematous rings, separated hy rings of fairly healthy integument. This variety has often been termed erythema, lichen, or herpes iris. When the nails are attacked, which is rare, they become in the affected parts irregular, thick, softer than natural, and at the same time more or less opaque and of a yellowish tint. The fungus penetrates them gene- rally from the root, and not unfrequently the adjoining surfaces of the fingers, and the hands, are at the same time involved. The most important, if not the most common, seat of ringworm is the head. Here the circular form of the affection and its erythematous or vesicular margin are seldom distinguishable. The patches, however, are generally well-circumscribed, and are indicated : partly by an abundant formation of adherent glistening scurf, which clings around the bases of the hairs, is continuous with the Immg of the hair- sheaths, and, by its pecuHar scaly character, has given to ringworm one of the names, porrigo scutulata, by which it was formerly known ; and partly by the condition of the hairs, which become swollen, dull and opaque, limp and lacerable, so that they break off either at the surface of the scalp, or a hne or two above it. This breakmg off of the hairs produces a marked resemblance to a stubble-field, and has suggested the common name of the disease, t. tonsurans, or tondens. This stubbly character may be concealed, and the surface rendered apparently bald, by accumulation of scurf. On re- moval of this many of the broken hairs are removed with it. Eingworm sometimes in men attacks the beard, moustache, and whiskers, producing one of the varieties of sycosis. It there excites (as it does occasionally in the scalp) considerable inflammation, causmg deep- seated suppuration about the sebaceous glands and roots of the hairs, and is very intractable. Eingworm is generally attended with itching, especially if the head be the part affected. It is highly contagious, and is particularly liable to spread amongst children. Adults, however, especially those who are m attendance on affected cliildren, often take it. But in them it is limited TINEA FAVOSA. 349 for the most part to the nails and fingers, and other non-hairy parts of the skin. Many suppose that it attacks mainly those who are in enfeehled health. But this is doubtful. When confined to the general surface it can, for the most part, be easily cured. In the head, beard, or nails, how- ever, its eradication is extremely difficult and apt to be long delayed. Children may suffer from it for several years ; and we have known it to persist in the finger-nails of an elderly lady for at least seven years, never dm'hig that time extending to other parts of her body. Tmea tonsurans affects the horse and some others of the lower animals. Treatment. — The treatment of tinea tonsvu'ans is purely local, the main object bemg to destroy or remove the fungus which produces it. Many substances are recommended as parasiticides, the most important being the sulphurous acid of the Pharmacopoeia, and empyreumatic sub- stances, such as ungtientum ])icis liquidum (diluted or not), unguentum creasoti, oil of cade, and the like. In the treatment of ringworm of the head or beard, it is of great importance that the surface be kept close clipped or shaven, and, by washing with carbolic soap and water, free from scales or other kinds of exudation. Further, it is desirable that all affected hairs be removed from the morbid patches by daily diligent epila- tion. After each daily washmg and epilation the specific medicament should be apphed and kept applied : sulphurous acid by means of several folds of Hnt saturated with the solution and covered with oiled silk or paper ; ointment by being rubbed in and then left in a thick coat on the surface. In the case of ringworm of the body, the same measures as to cleanliness and specific applications may be pursued ; but here it is often advantageous to destroy the affected surface of the skin with some caustic, such as nitrate of silver, strong acetic acid, iodine pauit, or blistering fluid. When the nails are involved, the surface should be removed in sHces and sulphurous acid or creasote ointment fr-eely and constantly applied. Kingworm of the head and beard is very apt to reappear weeks or even months after apparent cure. The reason of this is of com'se obvious. It is important therefore that the treatment should be prolonged far beyond the period of apparent cure, and that the hairs of affected areas should be from time to time carefully examined. Dr. Duckworth has pointed out that if a few drops of chloroform be dropped on suspected portions of the head, diseased hairs acquire an opaque yellowish- white colour, the healthy hafrs remaming unaffected. XXV. TINEA FAVOSA. [Favus. Porrigo Favosa and Luinnosa.) Causation and description. — The cause of favus is the growth in the skm of the fungus known as the achorion Sclionleinii. This consists in a jointed mycelium, differing little from that of the trichophyton tonsurans, and like it invading the epidermis, nails, and hairs. It differs essentially, however, from the trichophyton in the seat and character of its fr'uctifica- 350 DISEASES OF THE SKIN. tion. The formation of sporules begins with the development of short rounded joints or sporules at the extremities of certain of the mycelial tubes, and a complex development of other sporules from them by budding. The first evidence of fructification to the naked eye consists in the ap- pearance of minute disc-shaped sulphur-yellow spots beneath the horny layer of the epidermis, or of minute yellow cups at the points of emer- gence of hairs. These gradually increase in size, until they form yellow cupped discs from ^ to ^ inch in diameter, through the centres of which hairs not unfrequently pass. On breaking these masses up they are found to be white within and brittle, and microscopically to consist of sporules seated in a finely granular matrix. The early stage of favus, which is commonly overlooked, and is most obvious when the disease attacks the smoother parts of the body, consists, A. Fine hau- from trunk sliowing mycelium. B. Mycelium and spores from neiglibourhood of a lavus cup. Fig. 40. AcHORioN ScHONLEiNn X 500. like that of ringworm, in the appearance of small circles of erythema, which soon enlarge and become rings, and may then be studded with papules or vesicles. These rings of herpes or lichen circinatus rarely grow larger than a sixpence or a shilling and are at first absolutely undis- tinguishable from those of ringworm ; but soon there appear here and there at the edges or over the surface of the discs the characteristic yellow points of fructification ; and these rapidly attain their full dimensions. The mature favi, if discrete, maintain their characteristic form and ap- pearance ; but where many of them are developed in close contiguity with one another they are apt to blend, and before long to form a promi- nent, irregular, mortary mass crossed superficially by an imperfect net- work of undermine! epidermis, and presenting collectively an appearance not altogether unlike that of a rupial scab. Not unfrequently the progress TINEA VEESICOLOE. 351 of faviis is attended with considerable inflammation, and even suppm^a- tion, the products of which blend with those of the vegetable growth. Under these circumstances the neighbouring lymphatic glands also become inflamed. As a rule, however, favus is attended with little local irritation, and little itching. It is characterised generally by a peculiar mousy odour. Favus most frequently attacks the head, and leads to the falling out of the hair, and the growth in its place of thin, colourless, woolly hairs, and often causes eventually total destruction of the hair-follicles, and per- manent baldness. The affected hairs, however, are not rendered brittle, as in tinea tonsurans, and therefore do not break off. Nails attacked with favus do not differ appreciably from those which are the seat of ring- worm. Favus is rare in England, but in Scotland appears to be somewhat common. It is limited almost entirely to persons of filthy habits, and generally begins m childhood. When treated in its early stage it is easily cured ; but when it has infected a large area it is exceedingly intractable, and will often (notwithstanding careful treatment) persist for many years. That this, like other parasitic diseases, is infectious, is beyond doubt ; nevertheless, it is remarkable how rarely (compared with tinea tonsurans) it spreads among children, or from one member of a family to another. Favus is a common and fatal disease in mice. Cats also sometimes suffer from it. Treatment. — The principles and details of the treatment of favus are as nearly as possible identical with those of the treatment of ringworm. Li the first place all the favi should be removed by washing, poulticing, or the employment of oleaginous applications. Then the surface should be kept scrupulously clean, and treated with such parasiticide remedies as are useful in ringworm. Persistent epilation is of essential importance. In severe cases it is necessary to continue the treatment for many months, a year, or longer. Yet even when thus apparently cured, it not unfre- -quently breaks out again as soon as treatment is discontinued. XXVI. TINEA VEESICOLOE. {Pityriasis Versicolor. Chloasma.) Causation and description. — This disease is caused by the growth among the epidermic cells of a fungus, termed the microsporon furfur. The mycelial tubes are about equal in thickness to those of the fungi which have been above described, but their texture is more delicate. They form an interlacement in the substance of the epidermis, but do not in- vade the hairs or nails. The spores are developed in microscopic clusters, somewhat resembhng bunches of grapes, scattered here and there among the mycelial tubes, and seem to originate within buds springing from the sides or ends of certain of the cells of the mycelium. Chloasma is characterised by the formation of light-brown or liver- 352 DISEASES OF THE SKIN. coloured spots which are shghtly elevated above the general surface of~ the skm, covered with a more or less abundant branny scurf, and attended with slight itching. The primary spots have a circular outline, and vary perhaps from the third or fourth of an inch in dia- meter downwards. In the first instance a few such spots appear here and there. These increase in size, and soon other similar spots arise in their vicinity. By degrees neighbouring spots blend, and thus more or less extensive tracts of skin become pretty uniformly covered, the edges still presenting a sinuous cha- racter, and the neighbour- hood numerous outlying sohtary and coalescmg islets. Chloasma seems never to attack children, and very seldom persons of cleanly habits and among the better classes of society. It is a disease of adult life, and not unfrequently appears in those who are consumptive or otherwise out of health. It usually commences on the chest or between the shoulders ; and thence may spread, over the abdomen and back, to the shoulders, upper arms and even forearms, and to the buttocks and thighs. But it never affects uncovered parts. This circumstance, to- gether with the fact of its occurring mainly in those who wash httle and seldom change their linen, seems to indicate that the disease originates in filth. Like other parasitic diseases it is contagious, but its contagious- ness is not well-marked. Treatment.— In the treatment of chloasma perfect cleanliness is neces- sary. The affected parts should be daily washed with soap and water and well scrubbed with a flesh-brush or rough towel ; after which one of the parasiticide appHcations should be well rubbed in. Under these measures- the disease soon becomes apparently cured. Its complete cure, however, demands persistence in treatment long after all visible traces of the disease have disappeared. B. Group of spores x 1000. Fig. 41. MICROSPORON Furfur. ALOPECIA AKEATA. 35^ XXVII. ALOPECIA AEEATA. {A. circiLmscripta. Porrigo or Tinea Decalvans.) Causation and description. — This is an affection mainly of the hairy scalp, but occasionally also involves the eyebrows and eyelashes, the beard and whiskers, the hair of the armpits and pubes, and, it may be, even the general surface of the skin, and is characterised by the tempo- rary or permanent loss of hair in more or less distinctly circumscribed arefe. A well-developed patch of alopecia areata of the scalp is usually un- mistakable. It is a well-defined bald surface of circular or sinuous outline, for the most part clean, smooth, and shining, and free from congestion or scurfiness. The skin indeed appears to be, if anything, thinner than in health, and the orifices whence the hairs should emerge are atrophied and indistinct. The patch may be perfectly bald in its whole extent, or may present here and there groups of such downy hairs as constitute the lanugo ; but not unfrequently a few long hairs still stud its surface at distant intervals ; and often in the neighbourhood of these and of the margin may be seen on close inspection short club-shaped hairs, varying from about a line to 5 or | inch in length. These are most obvious in dark-haired persons, from the fact l?hat each clubbed free extremity still presents the natural dark colour ; but the portion of shaft between it and the scalp becomes more and more attenuated and more and more devoid of colour as it approaches the latter. They can be pulled out more readily than healthy hairs, but still are generally attached with some degree of firmness. Their presence may be taken as indicative of the extension of the disease. When the alopecia has become arrested, downy hairs begin to show themselves view of ^edgt" S'StXo? aiopS over the bald area ; and these may gradually Natural size, (a) Healthy hairs ; (6) assume all the characters of the surrounding ru^:, a^VoSLr t\ " healthy hairs, or become coarse, and white or otherwise modified in colour, or may remain weak and scanty. Some- times new hairs grow up in the centre, while the disease is still spreading eircumferentially. Alopecia areata is for the most part of chronic progress, lasting gene- rally for months, often for years, or even for life. In some cases the patient presents only one or two circular spots, which enlarge up to a certain point and then undergo resolution. In some cases the disease continues to extend indefinitely, partly by the enlargement of old patches, partly by the development of new ones, until the greater part of the scalp or even the whole scalp is involved, and until may be the eyelashes and eyebrows, one after the other, and finally all other collections of hair A A 854 DISEASES OP THE SKIN. disappear. Occasionally the progress of the disease is acute, the hair falling out rapidly and generally, though still perhaps more or less patchily. The final issue of the disease is uncertain. In the great majority of cases recovery takes place after a longer or shorter time ; but there is still a tendency for the disease to recur at irregular intervals, and not necessarily in the part originally affected. In no inconsiderable number of cases, and especially in those in which extensive tracts of sur- face have suffered, complete restoration of the hair never occurs. And, in a few, absolute and permanent general alopecia ensues. The clubbed hairs above referred to present certain peculiarities of microscopic structure. The clubbed end is usually broken mto a brush, and frequently presents in its interior an irregular group of largish cells, which are e\ddently the cells of the axis of the hair, at that part, modified in character. From this point downwards the hair becomes more and more attenuated, until it ends in a very slightly dilated point, which represents the imperfect root. Occasionally, a httle below the clubbed extremity, the dwindlhig shaft is interrupted by a small knot, within which such a group of cells exists as is usually found in the clubbed end itself. Looking to the fact of the occurrence in the originally healthy hair, at a point which seems to separate the normal from the attenuated portion, of a spot in which there has been some sudden modification of nutrition and €;rowth which renders the hair at this part brittle and peculiar in structure ; and to the fact that the portion of the shaft subsequently formed becomes, in consequence of the gradual wasting of the hair-root, more and more attenuated, until it falls out bodily ; it would seem pretty certain that the diseased process, as it affects the hairs, depends on the gradual spreading from some central pomt or points of a wave of mflammatory or other influence which, as it passes over each hair-papilla, momentarily excites it as it were to mihealthy over-production and then leaves it enfeebled and perishmg. This disease is asserted by Bazm and many others to be parasitic, and due to the presence of the microsjjoron Audouini} There can be httle doubt, however, that this ^dew is erroneous. It is believed also by many to be contagious ; but this, again, is doubtless an error. It is certain, however, that it is apt, like psoriasis, to break out periodically in the same individual, and like that also to afiect several members of the same family, and to be transmissible from parent to child. The disease is more common in children than adults, and in females than males. We have seen it m a child ten months old, and it is often met with, still progressing, in persons between forty and fifty. Its presence is neither preceded nor accompanied by any general signs of ill-health ; nor is its progress usually attended with any subjective local symptoms. Occasionally its commencement and spread are marked by tingling or itching, so that the experienced patient not only knows, before the hair > M. Melassez claims to have rediscovered the specific fungus of this disease. He has seen spores of indeterminate character, and in very small numbers, in the horny- layer of the epidermis — none in the rete mucosum, none in the hairs. They are doubtless accidental ; at all events there is absolutely no ground for regarding them as the cause of the disease. — Archiv. cle Physiologic, 1874. ATROPHY. 355 falls out, when a new patch of disease is commencing, hut knows also when an old patch is spreading. Treatment. — The treatment of alopecia areata is very unsatisfactory. Many patients get well who are never subjected to any, and many go on progressively h-om bad to worse m spite of the most sedulous care. There are no obvious indications for constitutional treatment, but tonics and arsenic are often employed empirically. For local medication it is generally thought best to use stimitlants, and especially to blister the affected regions periodically with the acetum cantliaridis or iodine pamt. ^Ye do not beheve that shading the head is of any use, excepting for the purpose of facilitating the apphcation of local remedies. Those who believe in the parasitic nature of the disease would naturally use creasote, sulphurous acid, or other parasiticides. XXVin. ATEOPHY. The skin and organs connected with it, like all dther parts of the body, are liable to tuidergo atrophic changes. Not the least important of these are the whitening of hair, and baldness, and the drjniess, thinness, and scaliness of skm, which are among the characteristic evidences of advancing years. In many diseases, especially such as are of long duration and attended with progressive emaciation and debihty, atrophic phenomena of a hke or closely allied nature often make their appearance. To all these we merely allude. There are two forms of atrophy, however, which may conveniently be briefly considered in this place. A. Glossy skill is the name which was applied by Paget to an atrophic condition of the skui of the fingers coming on after injmy to the nerves supplying them. In this affection, in addition to a constant bm-ning pain which is generally present, the fingers become notably attenuated and tapering, the skui thin, smooth, shinhig, and of a uniform rosy tint or mottled "^ith red blotches, as if fi'om the presence of permanent chil- blains ; the nails get thin and curved, and long from retraction of the skui covering their roots ; and the hair and other appendages dwindle or dis- appear. Moreover, there is a tendency for the affected parts to become relatively cold, and for the jomts to enlarge, stiffen, and even become ankylosed. The affection here described may involve the hand as well as the fingers, and has been met with m the toes and feet. It may be due to disease or injury of the cord, as well as to disease or mjury of nerves. B. Linear atrophy is the name sometimes given to the ' Imete albicantes,' or white hues, which commonly appear in the abdominal walls and upper parts of the thighs of pregnant women, and m the breasts of those who are suckling. Such atrophic hues are also frequently met with in the abdominal waUs of persons who are suffering from ascites or ovarian tumour, or, in fact, any affection causing abdominal distension, and are occasionally observed in hmbs which have been anasarcous. In aU these cases they are obviously due to stretching and interstitial giving way of the skin. A A 2 356 DISEASES OF THE SKIN. They always appear in the parts where the stretchmg has been greatest,, and theh chrection tends to be at right angles to that in which the force producmg them chiefly acts. Now and then similar atrophic Hues appear in groups in patients who are suffering from acute febrile or inflammatory disorders, such as enteric fever and intrathoracic inflammation ; in persons labouring under chronic wasting diseases ; and even in persons who are apparently healthy. They then arise quite independently of any obvious stretching of the skin ; and in some instances, at any rate, seem to be determined by pressure. Under such circumstances, a common seat is the lower part of one or other side of the chest behind, the lorn, the buttock, or the thigh. The atrophic lines are usually irregularly lanceolate in form, various in length and breadth, whiter and softer than the surrounding skin,, slightly depressed, finely wrinkled, and presentmg a scar-like aspect. Occasionally, when for example they are developed without obvious cause on a part of one of the limbs, they are few in number, several inches long, and of proportionate breadth. More frequently, as when they appear in pregnancy, they are smaller, very abundant, and arranged more or less in parallel groups, but tending to run into one another. And not uncommonly their arrangement reminds one of that of the ripples of sand left by the retreating tide ; or they form an irregular network. In tlieir commencement the atrophic Ihies are indicated by rosy redness and delicate desquamation of cuticle, appearances suggestive of the presence of very slight superficial cutaneous inflammation, with tendency to excoriation. At this time, too, there is often considerable itching of the affected parts. The cicatricial character is acquired later. No treatment is called for m linear atrophy. The treatment of glossy skin is mainly that of the nervous disorder on which it depends. Under the continued use of the constant current sometimes a cure, and often great improvement, take place. XXIX. PEUEIGO. Description. — This name is given to a condition of the skin, attended with more or less violent itching, and usually marked by coarseness of texture, and the presence of scratches produced by the action of the finger- nails. It is uncertain whether there is any specific affection to which the name is applicable. Willan obviously included under this term mere pruritus, or itching from various causes, and especially that due to the presence of body-lice. But he also included a papular affection, which he regarded as quite distinct from other varieties of papular diseases. Hebra ^iso describes a similar affection, which he considers to be sui generis, and to which he limits the use of the name. According to the latter authority prurigo is a disease of remarkable intractableness, if not incurable, consisting in the development of flat papules, not differing in colour from the skin, scarcely appreciable by the PEUEIGO. 357 ■eye, but readily detectable by tlie touch, and leading to a general coarseness of texture and more or less pigmental deposit. It may occur upon nearly all parts of tlie body, tliougii rarely attacking all in the same individual ; and it especially affects in an increasing ratio the front and back of the tnuik, and the extensor aspects of the upper arms and thighs, fore- arms and legs. The papules are apt to be irritated into inflammation or torn by scratching, and the eruption to be com.plieated, after a time, with eczema, impetigo, urticaria, and the like. Notwithstanding Hebra's authority, it may still, we think, be a question whether prurigo does not represent a heterogeneous group of ill-developed or ill-defined affections, attended with the common symptom of intense itching, and in which a coarse sub-papular condition of skin is present, in consequence partly of some abnormal nutritive condition of the skin, partly of the influence of constant scratching and other varieties of irritation. According to this view, prurigo may be a legacy left by eczema, impetigo, or erythema ; or it may be present in persons liable to these affections during the periods when they seem to be free from them ; or it may be referrible to phthiriasis or scabies, to jaundice or uraemia, to want of cleanliness, to the irritation produced in delicate skins by the too abundant and too frequent use of soap, or to excessive friction either by the towel or by the clothes. Treatment. — For the treatment of prurigo Hebra especially recom- mends sulphur, in the form of ointment, baths, or fumigation, tar in its various preparations, creasote, and frequent bathing. Besides these remedies lotions may be employed containing opium, prussic acid, acetate of lead, acetate of ammonia, or vinegar, or else black-wash, or mercurial or plumbic ointments. The constitutional treatment must depend on the patient's general symptoms or state of health, or on the nature of the ailment to which the pruritus is referrible. When the itching is due to parasitic affections, parasiticide applications must be employed. XXX. CONCLUDING EEMAEKS. Besides the various affections of the skin which have just been passed in review, there are many others, of more or less interest, which could not be omitted from a work devoted to skin-diseases, yet scarcely call for con- sideration in a manual of medicine. They are either of no practical im- portance, or they are extremely rare, or they fall entirely within the domain of the surgeon, or they are mere symptoms of more important disorders, and considered, so far as is necessary, elsewhere in this volume. We alhide more particularly to such hypertrophic aflections as horns, corns, warts, ntevi, fibromatous and fatty tiuiiours, epithelioma, and other varieties of malignant disease which affect the skin primarily ; to various atrophic conditions of the skm, hair and nails ; to increase or diminution of pigment {ephclis, lentigo, vitiligo, albinism) ; to the eruptions charac- teristic of many specific febrile disorders, and those caused by certain articles of diet or certain drugs ; and to such rare or ill-understood .affections as framhcesia, pellagra, and acrodynia. 358 Chap. III.— DISEASES OF THE RESPIRATORY ORGANS. I. INTEODUCTOEY EEMARKS. A. Anatomical Belations. 1, The organs of resinration comprise the larynx, trachea, bronchial tubes, lungs, and pleurae. Larynx and trachea. — The larynx is situated in the^upper°and fore part of the neck, extending from the hyoid bone above to the lower border of the cricoid cartilage ^ below. The trachea commences at the lower border of the larynx, on a level with the upper orifice of the oesophagus and the fifth cervical ver- ^ tebra,and runs down- wards in the mesial line to the level of the third or fourth dorsal vertebra,where it divides into the two bronchi. The upper half of it is situated in the neck, the lower half in the chest be- hmd the sternum. Behind, it lies in con- tact in its whole length with the oesophagus. In front, it is embraced above, as low down as the fourth, fifth, or sixth rmg, by the thyroid body, and below, just above its bifurcation, is crossed by the transverse arch of the aorta. The roots of the lungs are situated in the posterior mediastinum, on the level of the bodies of the fourth and fifth dorsal vertebra) ; the right bronchus, which is nearly horizontal, being on the level of the fourth vertebra behind and second costal cartilage m front ; the left, which passes down obhquely, reaching as low down as the fifth vertebra behind, and a little below the second costal cartilage m front. The latter passes under the aortic arch, and is therefore in contact, above- with the transverse arch, behind with its descending portion. Fig. 43. DiagTam showing relations of lungs, traclaea and bronchi to the osseous framework and surface of chest. Front ■view, a and 6. 1st and 12th doi-sal vertebra;. INTEODUCTOEY EEMAEKS. 359 Lungs. — The apex of eacli lung rises above the first rib into the root of the neck, and the posterior obtuse margin occupies the groove between the ribs and vertebree as low down as the eleventh rib. The base of the lung varies in position with the varying position of the diaphragm. The vault of the diaphragm rises during expiration on the right side to the level of the fifth rib at the sternum, on the left to the level of the sixth, and of course therefore the / Back Tiew. liver on the right side and the stomach on the left attain these respective elevations. The outer margin o the base, however, owing to the upward convexity of the dia- phragm, reaches to a lower level, and during medium dis- tension of the lungs with air may be traced in nearly a direct line from the junction of the sixth costal cartilage with the sternum out- ^^^•^^- similar diagram to last wards and downwards to the head of the eleventh rib. During deep inspiration the edge may descend conf^iderably between these extreme points. The anterior margin, like the lower one, varies in its position during the respiratory acts. When the lungs are moderately full their anterior borders are separated above by a triangular interval, the base of which corresponds to the sternal notch, the apex to the lower edge of the manubrium. From this point downwards to the interval bet^veen the fourth ribs, they continue parallel and nearly in contact. They then separate again, the edge of the right lung still passing vertically down- wards, while that of the left retreats, forming a notch of which the apex corresponds to the junction of the fifth costal cartilage and rib, or to a corresponding point in the fifth interspace, and within which the heart becomes superficial. After a deep inspiration the anterior edges of the lungs are usually in contact from above down to the commencement of the cardiac notch ; after a deep expiration there may be an interval of an inch or two between them. The extreme apex of the lower lobe of either side is situated behind, and in the adult about three inches below the summit of the lung. Plet(/)'CB. — The cavities contained by the parietal pleurae correspond pretty accurately to the forms of the lungs ; they are, however, only fully occupied by the lungs when these are largely inflated. During ordinary respiration there is a portion of each pleural cavity beyond the lower 360 DISEASES OF THE EESPIEATOEY OKGANS. margin of the lung, and another beyond the anterior margin, in which opposed portions of the parietal pleura are in contact with one another. The pleurte do not line the thoracic parietes quite down to the attach- ment of the diaphragm in front ; and, further, while the anterior margin of the right pleura extends to the mesial line of the sternum from the level of the second rib downwards, that of the left retreats somewhat at about the point at which the notch in the left lung commences. 2. Begions of chest. — It is usual and convenient for clinical purposes to map out the chest into regions. The names of those which are generally recognised sufficiently indicate their respective positions. They are as follows : — in front, the supra- sternal, situated immediately above the sternal notch ; the upper sternal, corresponding to the upper half, the lower sternal to the lower half, of the sternum ; the supra-clavicular, placed just above the inner half of the clavicle ; the clavicular, corre- sponding to the inner half of the same bone ; the infra-clavicular, extendmg from the clavicle downwards to about the level of the third rib ; the mammary, of which the nipple may be taken as the centre, ex- tending from about the third to the sixth rib ; and the infra-mammary, comprising the remainder of the front of the chest ; — at the side, the axillary, bounded by the summit of the axilla above, in front and behind by the axillary folds, and extending half way down the thorax, and the infra- axillary, occupying the lower half of the lateral aspect of the chest ; — at the back, the upper scapular, situated above the spine of the scapula ; the loioer scapular, corresponding to the infraspinous fossa ; the inter- scapular, lying between the vertebral border of the scapula and the spinous processes of the vertebrae ; and, lastly, the infra- scapular, in- cluding all that part of the back of the chest situated below the lower angle of the scapula. We have not assigned exact limits to all of these regions, partly because different writers assign different limits to them, partly because, convenient though they are for ordinary purposes, it seems to us preferable, when there is need of exactitude, to define the position and limits of are* by reference to the ribs and other fixed land- marks, and by measurement. B. Pathology of Voice, Respiration, Cough, and Expectoration. In the investigation of diseases, and more especially those of the respiratory organs, much information may often be obtained by attention to any peculiarities which the voice or respiratory acts may evince, to the presence or absence of cough and to the quality of the cough, and to the character of the expectoration. 1. Voice. — The voice may be feeble, tremulous, or absent, its quality or its pitch may be changed, and its register or compass may be contracted or modified. Mere feebleness of voice is so commonly associated with the presence of diseases, whether in the lungs or elsewhere, which cause enfeeblement of the muscular system generally, that it attracts comparatively little notice. It depends essentially on feebleness or imperfection of the VOICE AND EESPIEATION. 361 •expiratory act, however tliese conditions may be brought about. Hence we meet with it whenever there is much dyspnoea present, especially if at the same time the respirations be hurried and shallow ; and it is a notable characteristic of all cases in which, whether from disease of the spinal cord high up, or from any other cause, the diaphragm or the intercostal muscles or the muscles of expiration are paralysed or weakened. Tremulous or bleating voice arises from want of accurate control over the expiratory muscles or over those of the larynx itself. It is met with chiefly in old age and in persons who are hysterical or nervous. Absence of voice, that is to say, total inability to produce laryngeal intonation, and the capability of evolving only that wheezy sound which forms the basis of all whispered vowels, indicates that the patient is un- able to bring the vocal cords into apposition, and that the rima glottidis remains during his attempts at phonation in that patent condition which it affects during ordinary respiration. This condition is due to a para- lytic state of the adductors of the vocal cords, which may be either of functional or of organic origin. The 2^'i'tch of the voice depends on the action of the larynx alone. There are two widely different diseases in which the voice very frequently becomes markedly high-pitched or squeaky ; these are Asiatic cholera and leprosy. It becomes high-pitched also in those who are under the influence of laughing gas. Trousseau points out that when there is lesion of the superior laryngeal nerves alone, there is, owing to the consequent paralysis of the crico-thyroid muscles, inability to utter the higher notes, and the voice consequently becomes deep-toiied ; and further that in some forms of laryngeal inflammation, attended with hoarseness, the voice is low-toned on first rising, and becomes higher as the day advances. It is obvious that in the last two cases the compass of the voice also must be contracted. Pathological changes in the quality of the voice are largely dependent on conditions external to the larynx. It is thus that it gets altered when the faucial passage is narrowed by the presence of enlarged tonsils, when the soft palate is stiff and sore from inflammation, or paralysed after diphtheria, or when there is cleft palate. Hoarseness or roughness of voice (in other words, loss or impairment of the musical quality of the voice) may depend upon any circumstance which interferes with the regular vibration of one or both of the vocal cords. Thus it may arise from inflammatory or other thickening of the cords, from ulceration, from the presence of warty or other growths, or from the adhesion of mucus or other matters to their surface ; and it not unfrequently arises simply from the fact that while one cord acts perfectly, the other cord is paralysed. Hoarseness passes on the one hand into the normal intonation of the voice, on the other into absolute aphonia. 2. Bespiration. — Ordinary quiet breathing is effected without appreci- able effort, and with scarcely audible sound, at the rate, in the adult, of from sixteen to twenty respirations in the minute : their number havmg to the beats of the pulse a ratio of about one to four or five, and the act 362 DISEASES OF THE EESPIEATOEY OEGANS. of inspiration being probably somewhat longer than that of expiration.. The respiratory acts are liable in health, and still more in disease, to many deviations from the above rules : they may be modified in frequency, depth, and strength, and may be attended with more or less noise, discomfort, and effort. TJie frequency of resjnrcUion is diminished in syncope and collapse and various affections implicatmg the nervous centres, and occasionally also in cases of dyspnoea dependent on the presence of some mechanical obstacle to the entrance and escape of air. It is generally increased in mflamma- tory and febrile disorders, in affections of the lungs, ^Dleurse, and heart, and above all, in some forms of hysteria, in which indeed the acts have been Imown to exceed one hundred in the minute. The de2:)th of the respiratory acts is usually in inverse proportion to their frequency. Hence when they are rapid, they are also, as a rule, shallow and inefficient ; when abnormally slow they are deep and laboured. Under these latter circumstances espe- cially, the relative duration of inspiration and expiration is frequently con- siderably altered ; in some cases, as m certain forms of gastro-intestmal disturbance and in some varieties of cardiac affections, the inspirations are prolonged and sighing ; in others, and more especially in cases of" emphysema, asthma, and mechanical obstruction of the larynx or trachea, the duration of expiration becomes relatively largely mcreased. The respiratory rhythm is affected in another way in a variety of breathing, to which Dr. Stokes has called special attention, which only occurs in a marked form when death is impending, chiefly, he thinks, in cases of enfeebled heart, but also in brain-diseases. It consists of alternate periods, lastuag for a few seconds each, of hurried breathing, and complete arrest of respiratory efforts ; the respirations of each respiratory period begmning feebly and at comparatively distant intervals, increasing rapidly to a maximum in frequency and depth, and then gradually dying away. The term ' Cheyne- Stokes ' breathing is often applied to this phenomenon. The term dysimoea is employed of all cases in which respiration is unusually rapid, and equally of all those in which it is miusually slow, or even of normal rate, but attended with marked exertion. The special muscular efforts which accompany- and indicate dyspnoea are in some cases apparently limited to the dilatation of the nares during each in- spiration ; m some to this act in conj miction with rhythmical openmg of the mouth ; in other cases the muscles of the neck also act more or less powerfully ; and between these conditions and the phenomena of the asthmatic paroxysm, in which breathing is effected with agonising efforts, and every ordinary and extraordinary muscle of respiration is called mto powerful action, there are all gradations. The abnormal sounds which attend dyspnoea are sometimes a sniffing sound produced in the nares,. sometimes a suckmg or sipping sound manufactured with the lips, some- times a panting sound effected in the throat. Further, whenever the rima glottidis is narrowed, and incapable of enlarging to permit the free passage of the breath, or the trachea is dimi- nished in calibre, as it may be from the presence of a diphtheritic mem- COUGH. 363 brane, or tlie pressure of an aneurysmal tumour, both inspiration and expiration acquire what is called a ' stridulous ' character ; they become remarkably harsh and rough, presenting m some cases almost a metallic ring. These peculiarities are always greatly increased when respiration is hurried, or during the inspiration which precedes a cough. Closely related acoustically to stridor is wheezing or whistlmg, which is a common attendant on old bronchitis, and always accompanies the asthmatic paroxysm. 3. Cough is a modification of breathing, which is characterised by a deep-dra"v\ai inspiration, followed by closure of the glottis and a series of short but ^dolent expiratory acts. It is generally excited by some irrita- tion or abnormal accumulation, at the glottis, in the trachea, or in the larger bronchial tubes ; or it is a simple nervous affection. The act of coughmg is generally preceded by tickhng or some other uncomfortable sensation referrible either to the larynx or to some part of the trachea. The cough may be unattended ^dth expectoration or dry, either because there is nothing to be expectorated, or because the offending matter cannot be dislodged ; or it may be accompanied by more or less abundant dischaj-'ge of mucus or other matters. In the first case the cough may be that of the early or dry stage of inflammation, or of hooping- cough, or it may be a nervous disorder. In the second case (that in which the cough is ineffectual) there is probably some mechanical obstacle in the larynx or trachea to the discharge of peccant matter, or clogging of the bronchial tubes mth tenacious or even solid material, or limitation of the mucus to some of the smaller tubes. The third case does not call for special remark. All coughs are from their very nature spasmodic ; but some, fi'om the entire want of control which patients have over them, and from peculiari- ties which they present, are especially deserving of that epithet. The most remarkable of these are the paroxysmal coughs which characterise pertussis, obstruction of the trachea, and spasmodic croup. In pertussis a deep inspiration is followed by a rapid succession of spasmodic expira- tory efforts, contmued until further expiration is mechanically impossible ; then follows a long mspiration, effected through the spasmodically closed glottis, and yielding the characteristic whoop. In spasmodic croup there is a series of coughs, the expirations being remarkably harsh and noisy, the inspirations attended with a whistling sound. In tracheal obstruction, the inspirations are prolonged, stridulous, and wheezing, the expirations also wheezy and often miattended T\'itli marked laryngeal noise, and these are repeated in rapid succession until the patient appears on the eve of suffocation, when probably he is relieved by the discharge of a httle mucus. The noises which attend the acts of coughing have already been partly considered. They may be di'S'ided into those of the inspiratory act and those of expiration. As regards the former, if there be spasmodic closure of the- glottis, there is either a whoop, as in pertussis, or a whistle, as in spasmodic croup : but if the laryngeal orifice be obstructed 364 DISEASES OF THE EESPIEATOEY OKGANS. Iby the presence of a false membrane upon it, or if there be an impedi- ment in the' trachea, the somid of inspiration becomes wheezy or harsh. In the majority of cases the somid of inspiration is merely that of a deep-drawn breath. The somids which attend the expiratory element of the cough are due to the condition of the laryngeal orifice and the force with which the expiratory blast bursts through it. Thus if there be no impediment to the full inflation of the lungs, and the vocal cords be in a normal condition, the expiratory acts will necessarily (if forcible) be more or less noisy and at the same time musical. But the character of the sound will of course be modified according to the degree of tension of the cords, and in some measure in accordance with the degree in which they may have become thickened or have lost elasticity in con- sequence of inflammatory or other change. Many of the most noisy coughs are those which occur in hysterical or nervous patients, in whom the vocal cords are healthy in structure, and in those persons in whom they are affected with only slight catarrh. If, on the other hand, the vocal cords be prevented from vibrating freely, as may happen when the soft parts above the rima are greatly swollen, or the cords themselves and other parts of the larynx are invested with diphtheritic membrane, or laryngeal or tracheal obstruction renders the expiratory blast feeble and insufficient, the cough loses its musical or -sonorous character, and becomes wheezy and voiceless. 4. Expectoration. — The expectoration is often a valuable aid to diag- nosis. Many persons, especially those beyond middle age, spit on rising from bed in the morning a small quantity of viscid or tenacious mucus, studded with black particles. This black matter, which is supposed to be of extraneous origin, is nevertheless contained in cells. Such expec- toration indicates the presence of a little bronchorrhoea, but is hardly to be regarded as a sign of any actual disease. In inflammation of the respiratory passages, the discharge of mucus becomes augmented, some- times enormously. This at first is a watery, slightly viscid, colourless fluid, of saline taste and reaction, containing microscopically shed epithe- lial cells and mucous and granular corpuscles. Later on its viscidity in- creases (sometimes it is very -viscid from the beginning), it becomes difficult to void, and coalesces after expectoration into a coherent mass, which adheres to the vessel into which it is discharged. Such expectoration is sometimes colourless, sometimes greenish or yellowish, and occasionally streaked with blood. At a still later stage the sputa become opaque and yellow or green, less viscid, and acquire either the physical characters of pus or characters between these and those of mucus. This purulent con- version may be general or partial, and in the latter case the sputa not unfrequently present the so-called ' nummulated ' character due to the fact of thick opaque pellets floating in transparent watery mucus. All these varieties of expectoration may arise in the successive stages of acute or chronic bronchitis : the presence of pure mucus alone indicating for the most part acuteness of inflammation ; that of pus, the supervention of a chronic condition or possibly the approach of convalescence. The EXPECTOEATION. 365 ntimmulatecl cliaracter implies that, while the bronchial tubes are partly secreting mucus, they are partly secreting pus, or pus is gaining an en- trance into them from other sources. Nummulated expectoration is frequently met with in cases of dilated tubes, of pulmonary cavities, and of empyematic or other abscesses which communicate with the lung and discharge through it. But it is also met with in simple chronic bron- chitis. In many cases, when abscesses open into the lungs, the expec- toration consists of almost pure pus. The expectoration of ordinary acute pneumonia is cha^racterised by extreme viscidity with more or less transparency, and by the fact that it is uniformly tinged with blood. Its colour presents numerous gradations between yellow or reddish-brown (rusty) and a bright vermilion. As the disease passes into convalescence, the expectoration loses its pecular colour and its viscidity, and gets muco-purulent, like that of bronchitis. In certain cases it becomes either distinctly purulent, or, while still incorporated with blood, watery. The latter form of expectoration is sometimes likened to plum -juice. Blood in streaks occurs in bronchitis, blood uniformly diffused in pneumonia ; but very often unmixed blood is poured into the bronchial tubes, and is discharged thence, either still unmixed or blended only with a small quantity of mucus. The sources of such pulmonary hemor- rhages are the burstmg of aneurysms into the air-passages or lung- tissue ; the laying open of branches of the pulmonary artery or vein during the progress of tubercle ; carcinoma or other destructive morbid processes ; intense hyper^emia of bronchial tubes or of the walls of pul- monary cavities ; and pulmonary apoplexy. In the last group of cases the hemorrhage is generally scanty ; in the others it is often extremely profuse. Copious and sudden hfemoptysis is generally characterised by the arterial character of the expectorated blood, and by its more or less frothy condition ; but when the hemorrhage is small in amount, and expectorated at intervals, it is often in the form of dark-brownish or blackish-red pellets. Casts of the air-jjassages are not unfrequently expectorated. In diph- theria, membranous casts of various parts of the larynx, trachea, or larger bronchial tubes are often thus dis- charged. More rarely, branching casts of systems of the smaller bronchial tubes are spat up. These are sometimes mere coagulated blood, some- times simple pneumonic exudation concreted in the smaller bronchial tubes, sometimes casts of laminated texture apparently identical with diphtheritic membrane. Among the foreign bodies which are occasionally expectorated must be mentioned hydatids, either from the lung itself or from the liver, and earthy concretions — the remnants of dried-up tubercular matter in the Pict. 45. Casts op Air-passages I^- Pl.\.stic Bronchitis. Natiu-al size. 366 DISEASES OF THE EESPIEATOEY OEGANS. lungs or broncliial glands. No doubt tubercular, carcinomatous, and other sucli matters are occasionally brought up, but they can very rarely be recognised as such. The progress, however, of destructive processes in the lungs may often be detected or verified by the discovery on micro- scopic examination of fragments of lung-tissue, A convenient way of finding these is to boil a small quantity of sputum with a strong solution of caustic soda until they form a thin watery fluid, to place this in a conical glass for the purpose of subsidence, and then to examine the sediment microscopically. The matters to be especially looked for are the curved fragments of elastic tissue which bound the orifices of the smaller bronchial tubes, air-passages, and air-cells. The bacillus of tubercle may generally be discovered in the sputum of phthisical patents. Purulent expectoration often has a faint, sickly, or sweetish odour. The only smell, however, of clinical importance is that commonly attri- buted to the presence of gangrene. This is horribly fetid, difficult to describe, but when once smelt impossible to forget. It may be readily detected in the sputum itself ; but it is evolved most intensely with the patient's breath during the act of coughing. The sputa which yield this odour are generally distinctly purulent, occasionally nummulated, and have usually a discoloured or dirty-looking aspect. They may be inter- mixed with blood in a more or less altered condition. C. Investigation by Sight and Touch. The information which may be acquired through the eye by inspection, and through the hand by palpation, as to the condition of those functions of the respiratory system which lie within the scope of such methods of investigation, is obviously very considerable. We will speak of them in relation : first, to the larynx and trachea ; second, to the intrathoracic organs. 1. Larynx and trachea. Laryngoscope. — The apex of the epiglottis may sometimes be seen, and its condition ascertained, by merely looking into the throat when the mouth is widely opened and the tongue depressed. Its condition, and also that of the parts bounding the upper orifice of the larynx, may sometimes, especially in children, be roughly yet sufficiently determined by means of the tip of the forefinger passed back through the mouth into the fauces. The invention of the laryn- goscope, however, and the perfection to which its use has been brought, make it now possible for us to determine the condition of the larynx with the utmost nicety, and to employ local remedial measures with intelli- gence and accuracy. The apparatus usually employed for laryngoscopic examination comprise : first, a lamp yielding a steady, bright flame, provided with some form of reflector or condenser ; second, a circular concave mirror, from 3 to 3| inches in diameter, and with a focal length of 12 or 14 inches, which should be freely movable in all directions upon its support, and should either be fixed to the forehead immediately above the eye by means of an elastic band, or attached to a spectacle frame and adapted to the right eye — in the latter case it should be provided with a THE LAEYNGOSCOPE. 367 central perforation of an oval form ; third, laryngeal mirrors of metal or silvered glass, of circular, oval or quadrilateral form, and varying in diameter from half an inch, for a young child, up to an inch, fixed each at an angle of about 120° to a thin metallic stem or shank, which should itself be fastened into an ivory or wooden handle. The entire length of the combined shank and handle should measure from six to eight inches. In malring an examination the patient should be seated in front of the examiner, with his head inclined a little backwards ; the lamp should be placed at the side of, and somewhat behind, his head ; and the examiner should so arrange himself that his eye, with the mirror adapted, should be at the distance of about a foot in front of the patient's mouth. The mirror should be so adjusted that the light which it reflects may be brought to a focus at about the back of the patient's uvula. He should then be directed to open his mouth widely and to protrude his tongue ; the point of which should be firmly grasped and firmly but gently drawn forwards by the forefinger and thumb of the operator's left hand, en- veloped in a cambric handkerchief or towel. Then, the area of reflected light being steadily kept upon the point previously indicated, the laryngeal mirror (which has been previously warmed either over a lamp or by im- mersion in hot water, in order to prevent the condensation of the patient's breath upon it) is to be carefully passed backward until it reaches the base of the uvula, in which situation it must be held, with its surface facing downwards and forwards, at an angle of about 45° with the hori- zontal plane of the mouth. If the upper orifice of the larynx be not at once seen in the mirror, the direction of the face of the mirror may need a slight alteration, or it may be necessary to pass the mirror a little further upwards and backwards, or otherwise to modify its position. It is important, in order that the examination be satisfactory : first, that both patient and operator be patient and steady ; second, that no needless force be employed to draw the tongue forward, and that it be not injured by undue pressure against the lower teeth ; third, that in introducing the mirror, neither the tongue nor the palate be touched by it, excepting of course only that part of the palate against which it has to rest ; and fourth, that no single introduction be of long duration. It is best, usually, to repeat the operation several times m the course of a sitting. It need scarcely be added that many difficulties present themselves to interfere with the success of laryngeal inspection, some of which render inspection impossible, while others may be overcome with a little patience and delicacy of manipulation. Even if the larynx be healthy, we may in some cases perceive only the epiglottis and the tips of the cornicula laryngis. In more successful observations, however, we may detect not only these bodies but all the other boundaries of the superior orifice of the lar^mx, including the aryteno-epiglottidean folds, the cartilages of Wrisberg, the posterior com- missure, together with the rima glottidis, the true and false vocal cords, and if the rima glottidis be open sometimes the tracheal cartilages, and even the bifurcation of the trachea. All parts of the larynx, except the 368 DISEASES OF THE EESPIEATOEY OEGANS. edge of the epiglottis and tlie true vocal cords, have a reddish hue, like that of the interior of the mouth, gums, or lips, the redness being usually brightest in the false vocal cords, in the cushion of the epiglottis, and. over the cornieula and cartilages of Wrisberg. The vocal cords are pearly-white, the edge of the epiglottis and the tracheal and cricoid cartilages distinctly yellowish. It is always important to observe the movements of the vocal cords, and to examme the larjoix both when the rima is fully open and when it is perfectly closed. The rima is always open dm-ing ordinary quiet respiration ; but, in order to have it as widely open as possible, the patient should be directed to draw a deep breath. In order to effect closm-e, he should be required to utter a vocal sound. The best for this purpose, as requirmg for their pronunciation the greatest expansion of the oral aperture and caM.tj, are the vowel sound which is sometimes termed ' ur vocal,' and is uttered in the words ' cur ' and ' mprh,' and the broad sound of ' a ' represented by 'ah.' The morbid conditions for which we should maualy look are swelling, congestion, ulceration, and exudation, such as may be caused by inflam- mation, diphtheria, s}TohiHs, or other morbid ^Drocesses ; warty or other growths ; paralytic or spasmodic affections of the vocal cords ; and com- pression of the trachea by aneurysmal or other tumom's. As regards the examination of the larynx and trachea from without, the chief points which are ascertamable are : first, the presence of tender- ness ; second, deviation of the trachea from the middle Hne, wliich may be due to tumours either in the neck or within the thorax ; and, third, infiltration and thickening of the soft parts around. Thus, in inflamma- tory affections of the lar}iix, especially in cases where the cartilages are in a state of necrosis, thickening mth indm-ation of the surromiding tissues is often a very remarkable feature ; and still more remarkable is the stony uiduration of parts and the fixation of the larynx which attend some cases of carcmomatous or other mahgnant infiltration. 2. Chest. — The/o7-??i of the chest is often indicative of the presence of disease within. It must not be forgotten, however, that its general form varies widely in different individuals,, sometimes from inheritance, some- times from rickety tendency during early life ; and that want of symmetry is often traceable to the preponderating use of the right hand, or to spinal curvatm'e. But such varieties are quite independent of pulmonary affec- tions, and we must be careful not to confuse them with those attributable to the latter causes. General expansion of the chest is a common characteristic of patients who have suffered for many years ff'om chronic bronchitis or asthma, especially if there be at the same time pulmonary emphysema. Partly in consequence of long-contmued over-exertion of the inspiratory muscles, partly from the difficulty which emphysematous lungs have to get rid of their surplus air, the chest increases in both its antero-posterior and its lateral dimensions, and assumes a rounded or ' barrel-like ' form. If such changes begin in early infancy, it is not unusual to find that, while the INVESTIGATION BY SIGHT AND TOUCH. 369 upper part of the chest becomes generallj- expanded, tlie lower zone (owing to the comparative weakness of the ribs in early life) midergoes more or less contraction. It is seldom that the causes here spoken of operate on one side of the chest only. General enlargement of one side may be caused by accumulation of serum, pus, or air in the pleural cavity. In such cases the intercostal spaces get widened, the intercostal depressions effaced, and sometimes (especially if the effusion be inflammatory) re- placed by actual bulging. Under such circumstances, undulation or fluctuation may occasionally be detected. In cases in which a Imig is wholly or in the greater part of its extent pneumonic, the affected side remains fixed in the position of full inflation. Localised enlargements, or bulgings, may be the result of localised accumulations of air or fluid, or of the presence of aneurysmal, sarcomatous, or other varieties of intra- thoracic tumours. In cases of empyema it is not uncommon for the pus to find its way between the ribs, to form an accumulation between them and the mteguments, and thus to cause a localised swellmg. Contraction of the thoracic walls is exceedingly common ; but it is rarely general and symmetrical, unless it be due to natural conformation, or be the consequence of rickets, or of diseases like hooping cough attended with long-continued impediment to inspiration. It is of chief clinical interest when it is unilateral or limited to definite regions. All 23ulmonary diseases, attended with diminution in the size of the lung, are attended Svith more or less marked contraction corresponding to that diminution. The most remarkable example is furnished by empyema or hydrothorax which has caused complete and permanent collapse of the lung. With the absorption or removal of the fluid the affected side gets reduced in all its dimensions, but especially flattened from before back- wards, and the patient's carriage comes to resemble that of a person suf- fering from lateral curvature of the spine. Atelectasis, apneumatosis, cirrhosis, and the contraction of cavities are all attended with more or less manifest contraction of that area of the chest-waU which corresponds to the portion of lung involved ; but the most frequent, and on the whole the most important, of these locahsed contractions is that so commonly observed beneath one or both clavicles during the progress of phthisis. The movements of the chest, are often very significant. The violent muscular efforts, yet little movement of the ribs, which mark the respira- tory acts of emphysematous patients with barrel- shaped chests are very characteristic. The enthe quiescence or httle comparative movement of the affected side in cases of effusion into the pleura or of pneumonic con- soHdation, and of the apex of the lung in cases of phthisis, is equally matter of uiterest and clinical importance. Whenever grave notes are uttered by the voice a distinct vibratile thrill, the vocal fremitus, may be felt, not only over the larynx and trachea, but over the face and head, and over the whole of the surface of the chest to which lung-tissue is subjacent. The best mode of detecting this thrill in the chest is to place the palm of the liand flat and firmly on the part selected for examination. The degree in which it may be perceptible B B 370 DISEASES OF THE EESPIKATOKY OKGANS. varies greatly in different persons, in dependence partly on the pitcli and strength of the voice, partly on the quantity of muscle or fat present in the parietes of the chest. It is generally best recognised m male adults with spare frames. For obvious reasons it is more perceptible at the upper part of the chest, in fi'ont and between the scapulae, than elsewhere ; and it is either absent from the area of cardiac dulness, or comparatively feeble there. It is said to be a little more marked on the right than on the left side of the chest ; but the difference is at most trivial, and it may be regarded as a general rule that, with the exceptions referred to, it is equal hi degree at all corresponding parts of the two sides of the chest. The presence of disease largely modifies the intensity and distribution of •the vocal fremitus. Whenever there is fluid eifusion into the chest, the thrill becomes greatly enfeebled or absolutely annulled over the sur- face correspondhig to the fluid. Whenever, on the other hand, lung- tissue is consolidated by pneumonia, the vocal fremitus over the affected region is much intensified. It must be added that mere thickening of pleura, or accumulation of solid lymph in its cavity, acts equally with fluid effusion in damping vocal fremitus ; that solid growths, whether m the lung or external to it, have a like effect ; and that m rare cases fi'emitus is diminished even over pneumonic lung. The explanation of the diminution of vocal fremitus in the several cases above enimierated is sufficiently obvious. The intensification which attends most cases of pneumonia is due apparently to the concurrence of two condRxions : the one, consolidation of the vesicular tissue which increases its capability of conducting sound ; the other the permeation of the solid mass by XDer\dous tubes along which the vocal vibrations are carried into its midst. In the act of coughmg an impulse or shock is conveyed to the hand placed upon those parts of the chest which are in direct relation with lung. This shock, like vocal fremitus, is diminished by pleural effusion and increased by pneumonic consolidation. But it is specially mcreased over cavities, pulmonary or pleural, which abut on the surface and are in free communication mth tubes. The explanation is simple. At the moment at which the expiratory shock of a cough is taking place, the glottis is closed, the expiratory muscles are actmg violently, and there is a sudden rise of pressure due to the imprisoned air throughout the bronchial tubes and cavities connected with them ; the percussive effect of which at the pleural surface of any cavity, and consequently on the thoracic parietes over it, must necessarily be in some degree proportionate to the superficial extent of that surface. In support or correction of the judgments formed from the results of visual or manual examination, it is always well to have recourse to actual measurement of the chest, or of portions of it, and of the amount of ex- pansion or movement which they midergo. It is needless to describe in detail how all such measurements are to be effected ; it is sufficient, pro- bably, to name the chief instruments which may be used for the purpose, namely, the measuring-tape and calipers and the cyrtometer. The last name is applied to a metal vdve, or specially devised band, PERCUSSION AND AUSCULTATION. 371 which admits of close adaptation to the surface of the chest, and retains its form after removal, so as to allow of a tracing being made from it. Spirometer. — It is sometimes useful to ascertain what Dr. Hutchinson calls the ' "satal capacity ' of the chest by means of an instrument made on the principle of the gasometer, which he terms the ' spirometer.' . He measures this capacity by the amomit of air which a person who has dis- tended his chest to the utmost is able to discharge by voluntary expiratory effort. This amomit appears to be very constant in relation to stature. Thus, the average -sital capacity of a man five feet seven niches high is about 225 cubic inches, and for each inch of stature above this there is an increase, and for each inch below it a decrease, of about eight cubic inches. It is often difficult to make persons under examination exert a sufficient effort to manifest their true vital capacity ; but if after ha'sdng done so there is any wide departure fi'om the scale above given there is good reason to suspect the existence of some morbid condition, either invohTiig the Imigs, or interfering \di]i the due performance of the respiratory acts. The "s*ital capacity of women is much less than that of men. D. Investigation by Percussion and Auscultation. Of all aids to the recognition of the morbid processes which are going on -nithin the thorax none is so important as the employment oi percussion and auscultation: both, methods of investigation scarcely thought of prior to the commencement of the present century, but which, within the last fifty years, have been largely cultivated and have furnished the most valuable results both to the physiologist and to the physician. 1. By^jerczfssi'o^i is meant the investigation of the condition ofhiternal organs by the sounds which are yielded by sharply strikuig the surfaces over them. There are three pruicipal methods by which this may be effected, namely : 1st, by striking the surface directly either with the fist, the knuckles, or the tips of two or three fingers brought together into the form of a hammer, or by simply filliping with the nail of the forefinger ; 2nd, by the use of the hammer and pleximeter (^the pleximeter is a small thin ivory disc, which, for the purpose of recei^"Ulg the blow of the hammer, has to be laid firmly and flat upon the surface of the part to be percussed ; the hammer, which usually has a comparatively heavy metallic head, is fm'nished at its striking extremity with an india-rubber pad, which alone comes in contact with the pleximeter, and prevents the development of any sound special to the instrument) ; 3rd, by the employment of the fore or middle finger of the left hand as a pleximeter, and the tips of one, two, or three fingers of the right hand as a hammer (in this case the finger of the left hand should be laid firmly and flat, with its palmar sm-face do^Ti- wards, on the surface to be examined, and the tips of the striking fingers of the opposite hand should be brought dovni perpendicularly and sharply upon it). The first of these three methods of percussion has fallen into almost entire disuse, chiefly because of the needless paui which it is apt BB 2 372 DISEASES OP THE EESPIEATOEY OKGANS. to iiiflict ; still it may sometimes be employed with great advantage (and especially the method of filliping with the forefinger), when, as m the chests of young children, and' in the exploration of the abdomen, even slight pressure of the pleximeter is liable to displace air or fluid, the presence or absence of which at some particular pomt it is important to determine. The second method is a valuable one, especially for clinical teaching, because the somids which it evolves are loud and readily dis- tinguishable by a class of students. The -third method is that which is in general use, partly because of its great convenience, and partly because, although the sounds which are evoked by it are comparatively feeble, they are perfectly appreciable. Whenever it is sought to compare by percussion the corresponding parts of opposite sides of the trunk, it is most important that for each pair of examinations the pleximeter, whether the finger or the disc, should be symmetrically placed, and the force and direction of the blows should correspond. Further, it is important as far as possible to prevent any sound due to the instrument itself from inter- fermg with that ehcited from the part percussed. a. Normal percussion 'phenomena. — The sounds yielded to percussion by the healthy chest are of two kinds, resonant and dull. These words are by no means well chosen, but they are sanctioned by long and general usage, and w^ould be difficult to replace. By resonance we mean to imply the presence of more or less musical quality, by dulness the absence of such quahty. i. Besonance. — A resonant sound is yielded by all those parts of the chest-walls which are by their deep aspect in contact with lung, and by that part of the left half of the chest to which the stomach is subjacent. The quality of the "resonant sound which is evolved on percussing the pulmonary regions of the thorax is difficult to describe, but sufficiently characteristic to be easy of recognition when onee it has been heard. It is somewhat deep in tone, short in duration, and vaguely musical. It differs, however, in some degree in quality m different parts of the chest, and considerably in different indi^^iduals. Hence it is important, in judgmg of the significance of percussion-sounds, not to assume the exist- ence of a normal standard-sound with which all others must be com- pared, not to compare the resonance of one person's chest vnth that of another's, nor, indeed, to compare indiscrimmately the resonance of dif- ferent parts of the same indi^•idua^s chest. But we shordd carefully com- pare the sounds yielded by the corresponding points of the two sides of the chest. The chief cause of the resonant quahty of the percussion note is the vibration of the struck walls which is permitted by the fact that an elastic medium (the air) is situated on either side of them. It is ob^dous, however, that the elasticity of the inflated lungs is less than that of the free atmosphere outside, and that hence the vibration of the thoracic walls must be to some extent less perfect than it would be were the air on both sides equally free to move. The somid, we repeat, is mainly due to the vibration of the thoracic walls alone ; but it is difficult (owing to the somowhat irregular form and structure of these waUs, and to the PEECUSSION. 373 interference with their vibration caused, on the one hand, by the solid organs which lie here and there beneath them, and, on the other hand, by the junctions of the chest with the upper extremities) to determine to what extent and in what manner these yibrations are effected. It seems reasonable, however, to assume that so much of each half of the thorax as bounds lung-tissue vibrates bell-like when any part of that half is struck, and that the impure musical sound which is elicited comprises a fundamental note due to the vibration of the whole or a large portion of the side, and harmonic tones due to the vibration of aliquot parts of it. This view is entirely compatible with the fact that percussion notes of somewhat different quality are yielded on striking different parts of the surface, and, if correct, makes it obvious that the sound obtained by the percussion of any spot is by no means necessarily indicative of the condi- tion of the lung-tissue immediately beneath it. It must be added that some, though a very variable quantity of, thoracic resonance is indepen- dent of the presence of air beneath the chest-walls. Thin and elastic bones, even if they be imbedded in solid tissue, vibrate sensibly when percussed. A sound which is not absolutely dull may be obtained by percussing the bones of the skull ; and some degree of resonance may always be elicited over the sternum even when no lung-tissue is beneath it. The ribs, also, especially if the patient be thin, usually yield a somewhat resonant sound. The stomachal resonance may always be recognised (though variable in extent, distinctness, and quality according to the degree of distension of the organ with gas and to the level which it attains within the cavity of the thorax) at the lower part of the left side of the chest, both posteriorly, laterally, and in front, but chiefly in the last two situations. It may readily be distinguished from the normal lung-resonance by its much more distinctly m-usical character, by its purer tone and generally higher pitch. The sound is- often termed tyvipanitic, or drum-like. ii. DU'lness. — Absence of resonance, or dulness, is observable on per- cussing the praBCordial region, and that part of the right side of the chest between which and the liver no lung-tissue intrudes. This sound, again, can be better appreciated by a single experiment than by any description. It may be described as short, somewhat sharp, and unattended with any appreciable ring or tone. The feeble sound elicited by the percussion of the thigh is often referred to as the very type of a so-called ' dull ' sound. It differs, however, materially from that which is yielded by the praecordial region. And, indeed, the quality of dulness, in the clinical sense, presents many varieties, and passes by insensible gradations into that of resonance. Many so-called dull sounds become obviously musical when tested stetho- scopically. b. Ahnormal percussion i^henomena. — Percussion in cases of pulmonary disease is mainly of use in enabling us to ascertain the presence and define the limits of consolidation, pleural effusion, and morbid growths, and of conditions causing extension or modification of resonance. i. Dulness. — Whenever any considerable mass of lung-tissue is ren- 374 DISEASES OF THE EESPIEATOEY OEGANS. derecl solid, either by tubercular infiltration, by inflammatory deposit, by effusion of blood, by carcinomatous growth, or in any other way, all that area of the chest-wall on which it abuts loses its normal resonance and becomes more or less dull. The .presence of fluid in the pleura causes dulness in even a more marked degree up to the level of the effusion. The recognition of the cause of duhiess must depend partly on the situa- tion, extent, and form of the area of dulness, partly on a variety of con- siderations, the collective significance of which will be more conveniently discussed hereafter. It may be mentioned, however, that pneumonic consolidation usually occurs in the lower part of the lung, tubercular m- filtration at the apex, and that pleuritic effusion, unless it be circumscribed by adhesions, or so abundant as entirely to compress the lung, may often be recognised by the changing level of the upper Kmit of dulness in ac- cordance with the different positions which the patient's trunk is made to assume. But although marked duhiess is always present when con- solidation is extensive and continuous, it is often absent, or at all events scarcely appreciable, when either an extensive tract of lung-tissue uni- formly contains more sohd matter or fluid and less air than natural, or miliary or larger nodules of sohd substance, separated from one another by a network of crepitant tissue, are even thickly distributed. Thus congested or oedematous lungs, and lungs in the early stage of inflam- mation, on the one hand, and lungs which are the seat of disseminated tubercles or of lobular pneumonia on the other, are not unfrequently so strikingly resonant as utterly to deceive the too confiding percusser. ii. Besonance. — It is ob'sdous that, whenever there is any extension of the area of duhiess, there must be a corresponding diminution in the area of resonance. On the other hand, the normal arese of thoracic dulness are not very imfrequently reduced or effaced by the extension of resonance. In association with such changes, and sometimes indeed apart from them, the resonance of the resonant area is altered in intensity, quahty, or pitch. To denote different varieties and degrees of resonance many terms have been employed — as, for example, wooden, leather-trunk-hke, tubular, cavernous, tympanitic, high-pitched, and the like. Some of these are ob"saously fanciful, some indicative of a foregone conclusion with regard to the case under examination ; but others do, to some extent, explain themselves, are applicable and convenient. Augmentation of resonance (to which condition the epithet tympanitic is sometimes given) may often be heard over emphysematous lungs, or huigs distended (as they some- times are in cases of acute bronchitis) mth air, but especially over a pleural cavity the seat of pneumothorax. In such cases, however, the augmentation of resonance is for the most part attended with the produc- tion of a purer note, and frequently a note of somewhat higher pitch, than characterises the normal chest-resonance of the patient. But aug- mented resonance with change of quahty and pitch is often heard under very different conditions from those just considered. It is fi-equently observed, for example, that in cases of extensive pulmonary consolidation, or pleural effusion, of one side, the crepitant remnant of Imig-tissue PEKCUSSION. 375 evolves under percussion a much purer note than the corresponding part of the opposite king. The sound is sometimes described as being more resonant than that yielded by the opposite side ; possibly it may be so, but it is at all events more distinctly musical, and always of considerably heightened pitch. Not xmfrequently indeed the sound is almost exactly like that produced by percussing a portion of small intestine, or striking one of the treble keys of the piano. This modified resonance is most frequently observed over the apex of the Imig when the rest of the organ is consolidated or compressed ; but by no means necessarily occurs only hi that region ; and may sometimes be distinctly heard over portions of pneumonic lung which are not yet completely solidified. Various explanations of the phenomena here described have been given. "With respect to the increased resonance which attends pneumothorax, em- physema, and the like, it vnll probably be admitted that it is due to the more ready and perfect vibration of the thoracic walls which the relative increase of air beneath their inner surface permits. This explanation, however, vrill scarcely apply to the higher pitch which the percussion note usually then acquires, and is certainly not applicable to those cases hi which high-pitched resonance occurs over partly consolidated lung, or lung m the neighbourhood of consolidated tissue. Eeverting to the explanation we have already given of the ordinary resonant sound yielded by the thoracic walls (namely, that m its production all those parts of the thoracic walls which are hi contact with the lung under examination vibrate, bell-like, producing a somewhat obscure assemblage of fmidamen- tal and harmonic tones, the general effect of which is deep in some sort of proportion to the extent of surface which ^^brates) ; and knowing that (other thuigs behig equal) the smaller a vibrating area becomes the higher will be the fundamental tone it yields ; and seeing that such a diminution of "vibrating area necessarily takes place when there iS extensive con- sohdation or fluid effusion, and not improbably occurs in the first stage of pneumonia over the affected portion of lung ; it seems reasonable to assmne that mamly in these considerations is to be sought the explanation of the acoustic phenomenon in question. It must not be forgotten, however, that the increase of tension, which in pnemnothorax, and hi a less degree in pleurisy vnth efiiision, the thoracic walls experience, also tends to the production of a higher note. The question ' how far can the percussion note be modified by coiidi- xioiis witlim the chest other than those which have been discussed '? ' still remams for consideration. Can it, for example, be affected by the neigh- bourhood of solid matter separated from the parietes by a layer of crepitant tissue ? Can it be modified by the internal resonance of cavities which abut upon the surface ? The former of these questions ]ias been answered in the affirmative by most Avriters ; who assert that, by re- g'ulating the force of the percussion stroke, the resonance due to the intervening lung and the dulness due to the subjacent solid structure can he distinguished, and that thus the extension of the heart beneath the ihiii edge of the lung, and the ascent of the liver behind the lower margin 376 DISEASES OF THE EESPIEATOEY OEGANS. of the right Iting, can be easily detected. We confess we are not satisfied of the general truth of this assertion. "We may remark, however, as bearing upon it : that the quality and power of a musical tone differ according to the part of a vibrating cord or surface which is struck, and that hence the quahty and power of percussion tones are doubtless modified as we pass from the centre of a resonant area to its margins ; and agam that it is quite possible in the yieldhig chests of young children, if undue pressure be made by the pleximeter, to compress or displace the thin edge of the lung lying between the heart or liver and the parietes, and so to obtam dulness, where normally resonance should be eUcited. But this is the consequence of pressure and not of percussion. As to the latter of these questions, there is no doubt, that if auscultation be practised at the same time as percussion, the resonance due to a sub- jacent large cavity may occasionally be recognised in the form of a superadded musical twang. There is, however, one variety of percussion sound which certamly owes its pecuharity to the conjunction of a sound produced within the chest with that due to the vibration of the thoracic walls, namely, the hruit cle pot feU, or cracked-pot sound — a sound which may be almost exactly simulated by claspuig the hands crosswise and then strikmg the back of one of them sharply against the knee-cap. The ' chink ' which distinguishes it appears to be due to the sudden compres- sion of a portion of lung-tissue and the sharp expulsion of the air which it contamed with an auchble hiss through the bronchial tubes. To pro- duce the sound the percussion stroke must be forcible, and made while the patient is expiring with his mouth open. It is chiefly producible in the front of the chest, either at the apex or in the mammary region. It may indicate the presence of a cavity in the lung, but is more commonly produced in the healthy chests of young children owing to the great yieldingness of their thin thoracic parietes, and m patients suffering from pneumonia or pleurisy in association with the high-pitched resonance so often present. c. Eesistance. — One further indication of importance often furnished by percussion is the presence of unyielduagness or resistance. In the percussion of healthy chests the resilience of the parietes can always be in some degree appreciated ; it is indeed so constant and essential a factor of the process that on that very account it may escape observation. But in cases of solid growths m the cavity of the thorax, and m cases even of pleurisy with much thickening of pleura and much distension, the rigidity of the thoracic walls over some limited area, and their total want of elasticity and of yieldingness, are quite remarkable and unmistakable. 2. By auscultation is meant the process of listening, either by applymg the ear directly to the surface, or by the aid of some conductor, to sounds evolved within the body. The direct application of the ear to the surface is in some respects preferable to any other mode of auscultation. Many sounds are thus heard much more distinctly than they otherwise would be heard ; and some delicate but distinctive sounds are wholly lost in their passage along a conducting rod or tube. But, on the other hand, the AUSCULTATION. 377 naked ear cannot be applied with ease to all parts which it is desirable to auscultate, nor can we by its aid limit our examination ^vdth precision to minute arete. The objections on the score of delicacy and cleanlmess are sufficiently obvious. The instrument which is employed to convey somids produced mthin the body to the ear of the observer is termed the stethoscope. Of this uniumerable forms and varieties have been invented and are in use. As to material, they have been made of bone, ivory, silver, gun-metal, gutta- percha, and different kinds of wood ; as to form, they are always cylin- drical in the whole or greater part of their extent — m the latter case being pro\ided at one end with a circular disc to fit the ear, at the other end mth a conical expansion, the circular base of which is to be applied to the part under examination. Further, they are made of different lengths, sometimes solid throughout, but generally vaih a cylindrical channel running through the stem from the ear -piece downwards to the conical enlargement, where it undergoes a corresponding dilatation. The material, the length, and the general form of the instrument are matters of very ht^le real importance. The great desiderata are that it should be hght and portable, that the ear-piece should be one that readily adapts itseK to the ear of its possessor, and that the conical enlargement at the opposite end should be of medium size, and that (if provided with an opening) its margm should be sufficiently broad and rounded to admit of its adjustment without causing pain. There are certain peculiarities in the acoustic properties of stethoscopes which it is well to be aware of. Solid stethoscopes undoubtedly convey sharp impulsive sounds and musical notes with great intensity ; but they do not transmit the respiratory rustles and other feeble and unmusical sounds with anything like the distinctness with which the hollow stetho- scope conveys them. The difference is very much that existing between a speaking-tube which readily transmits the whispered voice, and a solid rod which, vdih the aid of a somiduig-board, reproduces at a distance the full music of a piano ^\-ith which its opposite extremity is in contact. The hollow stethoscope, however, combines in itself the properties of both, and is therefore the preferable instrument for common use. Again, it is indis- putable that certain sounds are much more distmctly audible with some hollow stethoscopes than others ; and that this fact is, in some instances, due to differences in the length of the instruments. The explanation appears to be that the tubes of stethoscopes consonate, according to their length, "s^dth certaui definite notes and certain of their harmonics. Besides the simple varieties of stethoscope above considered, there are two others which are often of considerable service. These are the hinmtral and the differential stethoscopes. In the former, the stem arismg from the conical end divides into two branches, the points of which respectively fit mto either ear. Both ears are thus equally engaged m listening to the sounds emanating from the area mider examination, which are hence intensified and on the whole more easily appreciated. The other form of stethoscope is also binaural in the sense that there is an ear-piece for each 378 DISEASES OF THE EESPIEATOEY OEGANS. ear, and both ears are engaged ; but the tubes which are prolonged from the ear-pieces remain distinct from one another and termmate each in a conical expansion. The advantage of this arrangement is that by it the auscultator is enabled to hear and determme the synchronism or asyn- chronism of somads which are developed at different spots. In using the stethoscope it is of essential importance that (if it be hoUow) its lower end should rest evenly on the surface to which it is applied, that the ear-piece should be adjusted accurately to the ear, that nothuig whatever should be in contact with the instrument save the ear of the auscultator and the surface under exammation, and that there should be no rustling or friction or other noises in connection with the patient's skin or clothes. It is always best to listen to the naked skin ; and, if covering be necessary, it should be as thin as possible and in one layer only. Further, it is sometimes well to close the opposite ear against extraneous sounds, a. Normal auscultatory phenomena. — The sounds audible through the stethoscope applied over the healthy respiratory organs are those of respiration, articulation, and phonation. In morbid conditions of these parts, the acoustic phenomena attending the several acts referred to be- come variously and often largely modified, and others of a totally different kmd are often superadded. i. Auscultation of the breath. — If we apply the stethoscope to the larynx or trachea during ordhiary respiration, a somewhat harsh blowing somid is heard to accompany both the act of inspiration and that of expiration. The sound is hke that of the loudly-whispered vowel repre- sented by the syllable ' ur,' or like the whispered consonantal somid of the letter w. Each sound lasts as long as the act which produces it, is uniform in character throughout, begins and ends abruptly, and is sepa- rated by an obvious though very short mterval from the sound which follows it. That attenduig inspiration is somewhat sharper and louder than the other, and both may be increased or diminished m intensity by varying the force of the respiratory movements. The sounds are almost certainly developed at the narrowest part of the tube, namely the rima glottidis, by the rustle which its interference causes in the current of air passing through it. The slight but obvious differences m quality and force which distinguish them from one another are hence exphcable ; the sound produced at the rima being carried inwards with the inspiratory current, outwards during expiration. Ordinarily, the sound attending expiration is more audible to oneself and to bystanders than that attending inspiration. The sounds here described, though somewhat modified in character, are in general still audible over the manubrium of the sternum, and between the scapulae, at and above the level of the roots of the lungs. Over the lungs themselves the sounds which attend the respiratory movements are of a very different character from the above. The inspi- ratory sound is difficult to describe ; it has a kind of rustlmg character, and is feebler and of lower pitch than the corresponding tracheal mur- AUSCULTATION. 379 mur ; the expiratory sound is often absent, and wlien present is still feebler and lower in tone than the inspiratory sound. Moreover, the two sounds, instead of presenting uniform mtensity throughout, and being separated by a distinct interval from one another, commence and die away so gradually that they seem hke mere pulses of a continuous murmur. The healthy pulmonary sounds vary a good deal in intensity, and, in some degree, in quality in different indi\dduals ; there are also shght differences between them as heard at different parts of the same chest ; and not unfrequently, especially at the apex, the sound towards the end of a deep inspiration assumes an indistinctly crepitating character. What is the cause of these sounds ? That they are not made in the larger air-passages, and conveyed through the spongy tissue of the lungs to the surface, seems clear from the fact that in those cases where, from contraction of the larynx, trachea, or bronchial tubes (as in laryngitis, pressm-e of an aneurysm, and asthma), a peculiarly intense noise is made in these canals during respiration, the pulmonary murmurs, instead of being correspondingly augmented, are diminished or actually suppressed. The ordinary explanation is doubtless the correct one, namely, that they are produced in the minuter air-passages and air-cells by the passage of air to and fro in them, and by the changes of form — the movements — which these parts midergo. ii. In auscultating the voice it is important to recollect the fact that phonation takes place (the music of the voice is manufactured) at the rima glottidis by the vocal cords ; that articulate sounds are formed only in the cavity of the mouth, by means, chiefly, of the hps, tongue, and palate. If the larynx or trachea be examined stethoscopically durmg the act of speaking aloud or singing, the musical notes which are evolved are conveyed through the instrument to the ear with almost painful force ; similar sounds, dimmished somewhat in intensity, are also audible over the manubrium of the sternum and between the upper parts of the scapula behind. They are still audible, but with much less force, over the whole of those portions of the chest which have lung-tissue sub- jacent to them. The sounds are usually somewhat more intense above than below, in front than behmd, and at the lower part posteriorly some- times present even in health, a somewhat bleating character. The degree in which vocal resonance or hroncliopliony is audible varies in different individuals, chiefly in dependence on the pitch and quahty of the voice. Thus it is, as a rule, more obvious in those who have a deep voice than in those whose voice is high, and in men therefore than in women or children. It is often distinct when vocal fremitus is quite imperceptible, and in some individuals scarcely exists at all. The articulate voice is always best distinguished when the patient speaks in a whisper : words thus uttered are distinctly transmitted through the stethoscope appKed to the windpipe in the neck, or along its course in the thorax, or over the situation of the bronchi ; they may also occasionally be heard over the apices of the lungs of healthy persons, especially children. This pheno- menon is termed i^&ctoriloquy. 380 DISEASES OF THE EESPIEATOEY OEGANS. h. Abnormal auscultatory lolienomena. — The respiratory sounds are often mnch modified in disease. We have adverted to the fact that they are frequently not only greatly diminished, but actually absent, in certain cases of obstructive disease of the larger air-passages ; they are enfeebled also, whenever the respiratory movements are themselves feeble, and are generally much weakened or even annulled where the lung is compressed, consolidated, displaced, or where fluid, air, or solid matter lies between it and the thoracic walls. On the other hand, the respiratory sounds are necessarily intensified whenever the acts which produce them are unusu- ally vigorous. It is due, doubtless, to this cause alone that they may often be heard with preternatural loudness over the healthy lung of a patient whose other lung is pneumonic or compressed by pleural effusion. i. Tubular or bronchial breathing is a modification of respiratory sound frequently heard over liuigs consolidated by pneumonia, compressed by pleuritic effusion, or containing smallish cavities, of whatever origin, imbedded in airless tissue. It almost exactly resembles the breath- sounds- audible over the trachea. The insphatory and expiratory elements begin and end abruptly, are uniform throughout, and separated from one another by a distinct but short interval ; moreover the expiratory sound is some- what deeper and less distinct than that of inspiration. They vary m quality in different cases and imder different circumstances, but are gene- rally higher in pitch than the tracheal sounds are. It is necessary, m order to their full development, that the respiratory acts be moderately forcible, that the air-tubes of the portion of lung under examination be not completely obstructed, and that they do not contain mucus or other matters which are productive of crepitating and other such adventitious sounds. Hence, in pneumonia, tubular breathing may be absent or in- capable of recognition if the bronchia be blocked up with casts ; in pleurisy, if the compression of the lung be so great as to involve the obliteration of the tubes ; in pulmonary excavation, if the vomicae have no free connection with the air-channels ; and in all such affections when the cavities or tubes are loaded with mucus or other fluids. Various explanations have been offered of the production of tubular breathing. By some it has been held that the sounds heard over tlie affected portion of lung are simply those manufactured at the rima glottidis, conducted to the ear through the diseased tissues. Others consider that the tubular sounds are actually produced by the to-and-fro movement of air in the tubes of the diseased tract. While others again, with Skoda at their head, regard them as the laryngeal sounds increased and modified by consonance m the bronchial tubes. An insuperable objection, it seems to us, to the truth of Skoda's explanation is the fact that consonance either increases the intensity of obvious musical tones, or develops an obvious musical tone from unmusical sounds or from vibrations which are musical in rhythm, but of themselves too feeble for the ear distinctly to appre- ciate. But the tubular sounds heard over a pneumonic lung are no more musical than those heard over the trachea. An objection to the second explanation resides in the fact that, in the majority of cases in which AUSCULTATION. 381 tubular breathing is heard, the affected king-tissue neither expands nor contracts during respiration, so that there can be no to-and-fro movement of air in its tubes to cause the sounds which may be heard over it. The first exphmation appears to us to be substantially correct, for the follow- ing reasons : — the sounds of tubular breathing are like those produced at the rima giottidis during respiration ; there is no doubt whatever that these, as well as all other sounds developed at this orifice, are readily conveyed, with little change of character, along the patent bronchial tubes, as along so many small stethoscopes, towards their peripheral distribution ; the intensity of the tubular sound is proportionate, in great measure, to the intensity of the lar^mgeal sound, and indeed a distinctly tubular sound may, even in health, be developed and actually overpower the normal respiratory sounds when patients who are told to breathe deeply breathe noisily through the larynx. . We are by no means prepared to deny that to-and-fi-o sounds, differing httle from those originating in the larpix, may be produced by the to-and-fi-o movement of air in bronchial tubes connected with lung capable of respiration, and that such sounds may contribute in some cases to the collective result which we term tubular breathing. "Whatever explanation be adopted, however, there is no doubt that the homogeneousness of texture which a consolidated or compressed lung presents, allows, far more readily than normal spongy lung-tissue does, of the transmission of sounds which are developed within or conveyed into its substance ; and further, that the total suppression of the healthy respiratory murmur, which characterises all those conditions of lung in which tubular breathing is heard, contributes importantly to its ready recognition. ii. Amplwric, cavernous, or metallic breathing. — These terms are em- ployed to designate the peculiar quality of sound which may sometimes be heard over canities containing air, and usually communicating with the external atmosphere by means of the bronchial tubes or other passages. It consists in a peculiar metallic ring, or musical twang, following upon the respiratory or other sound which calls it forth. A closely similar twang attends the footfall of a person walking between high walls, or over a vault, and may be recognised in perfection if a child's india-rubber ball be placed in contact with the ear, and then sharply tapped or filliped. The addition to any other intrathoracic sound of the musical prolongation here referred to is always indicative of the presence of a ca-vity containing air ; and it may sometimes be heard almost as distinctly in a cavity the size of a walnut as in one corresponding in capacity to the whole of the pleural sac. Its presence does not absolutely prove that there is com- munication between the cavity and the outer air, although in the great majority of cases such a communication does in fact exist ; nor does it prove that the cavity to which it is due is an abnormal cavity, for it may, when detected at the lower part of the left side of the chest, be referrible to the stomach ; nor, again, does it necessarily throw light on the form of the cavity or the structure of the walls, although, for the most part, we have reason to suspect when we hear it that the cavity or some part of it 382 DISEASES OF THE KESPIEATOEY OEGANS. is of a rounded form, and that the walls are somewhat smooth and elastic, or, at all events, of such a character as to allow of reverberation. The cause of this amphoric resonance is obviously the reverberation, or succession of echoes, which occurs between the opposite sides of the cavity when any impulse or sound capable of originatmg it reaches the air in its interior. The chief conditions under which amphoric reson- ance manifests itself in connection with cavities are the following : — First, it attends the respiratory sounds, and more particularly that of inspiration. It is important, however, to observe that the respiratory sounds yielded from a cavity are, apart from the superadded resonance, tubular ; and that if, from any circumstance, the musical twang be ab- sent from them, there is nothing left by which they can be distinguished from ordinary tubular breathing. It is probably never produced in this case unless the cavity communicates with a bronchial tube or by a fistulous opening with the external air ; and although it is probably not essential to its production that there shall be actual movement of air into and out of the cavity, there is no doubt that such movement tends largely to intensify it. Second, it attends both the sounds of vocalisation and those of coughing. Third, it may be evolved over large cavities by per- cussion of the thoracic walls which bound them, and especially if the percussion sound be sharp and short, as it may be made by employing two coins, — one as a pleximeter, the other as a hammer [bruit cVairain). Fourth, it gives a metallic quality to the various rales or rattles which are produced in them or in their vicinity by the passage of air through fluid. It should be noted, however, that short sharp sounds like those of ordinary largish crepitation more readily induce an audible echo than do the duller less intense sounds of respiration and the like ; and that hence crepitation often becomes metallic in small cavities, which give no such quality to respiratory, vocal, or tussive sounds, and sometimes even in the normal cavities of the bronchial tubes. Lastly, in large cavities we not unfrequently get that perfection of amphoric resonance which is termed metallic tinkling ; a sound which is always most characteristically evolved in response to some sharp detonation, such as is produced by the bursting of a largish bubble or by the fall of a drop of fluid from above on to a surface of fluid below. The cavernous echo, although in many cases remarkably distinct and unmistakable, is in some cases so feeble that it fails to be transmitted along the ordinary stethoscope, and can be detected only by aid of the binaural stethoscope or by the ear applied directly to the chest. Further it may be, and often is, effectually concealed by the intervention between the cavity and the thoracic walls of a layer, however thin, of crepitant lung-tissue. And, again, it is important to know that cavities of con- siderable size, especially if there be no communication, or only imperfect communication, between them and bronchial tubes, often yield no sound whatever due to themselves, and merely very feebly conduct tubular or even healthy respiratory sounds due to the lung-tissue in which they are imbedded. AUSCULTATION. 383 There are yet one or two other sounds which may be developed withm cavities, and may hence be included within the meaning of the term cavernous respiration. It is possible, for instance, that a cavity may be of such a size and shape as to be capable of resonating to some par- ticular note ; and that the production of that note by the patient in his larynx may be attended with special resonance within- the cavity. And, agam, it sometimes happens that when a canity communicates, by a flap- like or valvular opening with a bronchial tube, there is no sound audible over the ca%'ity during ordinary respiration or during the earlier period of a forcible inspiration ; but that during the course of the latter the air rushes into the cavity "uath an audible click, hiss, or gurgling sound — a phenomenon which is repeated whenever the patient inspires deeply. iii. Bronchophony , pectoriloquy, and cegophony. — The terms pectori- loquy and bronchophony have been employed with great laxity, even by those who assume to be authorities upon the subject of auscultation. It has been frequently asserted that bronchophony as it becomes more marked passes into pectoriloquy, as though the two conditions were mere grades of the same phenomenon. This, however, is certainly not the fact ; bronchophony never becomes converted into pectoriloquy, although they are often associated ; loud bronchophony, indeed, drowns the pectoriloquy -svdth which it may be associated ; and, in order to be certain of the exist- ence of pectoriloquy, it is always best to eliminate the effects of broncho- phony by making the patient speak in a whisper. As we have already pointed out, bronchophony is the offspring of laryngeal intonation, pecto- riloquy of the articulate somids developed within the cavity of the mouth. Bronchophony, in its pathological sense, means preternatural distinct- ness, or loudness, with little alteration of quality, of the laryngeal musical tones as conveyed to the ear through the tissue of the lung. Its intensity, as well in disease as in health, presents considerable variety. Hence m determining the presence or absence of abnormal bronchophony we must not be content to note that the voice-resonance is louder in one part than another ; but we must observe whether it is relatively loudest over those parts of a Imig in which normally it is comparatively feeble ; and especially we must be careful to compare the resonance of the voice in corresponding parts of the two sides of the chest. Bronchophony is generally developed over consolidated lung-tissue (pneumonic, tuber- cular, or other) and over the sites of vomica. And its development in abnormal situations is clearly due to the same combmation of causes as that to which we have ascribed the phenomena of tubular breathino- ; namely, first, the conduction of the musical vibrations along the patent bronchial tubes, or tubes and cavities, into the very substance of the consolidated tissue ; and, second, the ready transmission of these vibra- tions thence through this tissue to the surface of the chest. Skoda attri- butes bronchophony, as he does tubular sounds, to consonance of the laryngeal sounds^within the bronchial tubes. We are far from denying that the tubes may consonate to musical sounds, or that they do so con- sonate in certain cases. But a tube of a certain definite length can only 384 DISEASES OF THE EESPIEATOEY OEGANS. consonate to a certain definite note, and possibly to some of tlie higlier harmonics of tliat note ; and assuming (wliat seems scarcely possible) that the length of tube capable of consonating is to be measured from the rima glottidis to the terminal part of a bronchial tube at the base of the lung (a length of about twelve inches), the lowest note to which it (being a pipe closed at both ends) could consonate would be one produced by midulations a foot long, or one l}^ig between B and C of the treble clef. There are good reasons for believing that the consonating note would be much higher. Now, if this explanation were true, the deeper tones of the voice, which are actually louder-t in bronchophony, should be comparatively inaudible, and of acute tones one only, or one and some of its harmonics, should be conveyed to the ear. But this is certauily not the case. Pectoriloquy implies the conveyance through the stethoscope placed on the chest of the articulate utterances of the person auscultated, as though he were applying his lips to the instrument and speaking through it into the ear. We have pointed out that this phenomenon is always to be heard most distinctly when the patient whispers, because it is then uninterfered with by the noise of the laryngeal notes. There is another reason why it should then be most audible. Since articulate sounds are produced in the mouth, it is obvious that, in order to reach the bronchial tubes, they must pass the portals of the larynx. But in loud speaking these portals are closed, and must hence materially obstruct the trans- mission of such sounds ; m whispering, on the other hand, they are to a greater or less degree patent, and the obstacle to their transmission is necessarily proportionately diminished. Pectoriloquy and bronchophony are not necessarily concurrent phenomena. Nevertheless, it is certain that pectoriloquy, hke the other, is often detected both over consolidated lung-tissue and over cavities. We believe that it is most frequently and most distmctly audible over cavities which commmiicate freely with bronchial tubes. ^gophony is a modification of bronchophony, and gradually passes into it. It is generaUy compared, as its name implies, to the bleating of a goat, or to the squeaking voice adopted by the exhibitors of ' Punch and Judy.' These comparisons are by no means inapt. The voice trans- mitted along the stethoscope diflers materially in quality from the voice as it emanates from the patient's mouth ; it is, even if musical and fuU- toned as uttered, tremulous, bleating, and high-pitched as it reaches the auscultator's ear. Some degree of this quality of somid may occasionally be recognised, even in health, over the lower part of the chest behind. But it is only heard in perfection in the neighbourhood of the lower angle of the scapula in cases of moderate pleuritic effusion ; and indeed, when well marked, may be regarded as pathognomonic of this condition. It is obvious that the pecuhar bleatmg high-pitched character is due, as Dr. Stone has pointed out, to imperfect transmission of the voice, to the fact that its graver tones are lost or are greatly enfeebled in transmission, while the higher tones and the harmonics of the graver AUSCULTATION. 385 tones are comparatively unaffected. In support of this view may be mentioned the fact that the fegophonic sound, though apparently clearer, is often distmctly feebler than the normal voice-resonance to be heard over the healthy liuig. Somid, as is well known, is readily transmitted through either gases, fluids, or sohds, but it does not so readily pass from one of these media to the others ; and it seems obvious therefore that the sounds produced within or carried into the bronchial tubes should experience some degree of filtration (so to speak) in passiirg from the tubes to the solid lung-tissue, from this to fluid, from this agam to the thoracic parietes, and thence through the stethoscope to the ear. High notes are more penetrating than those of graver tone, and hence would be less likely to suffer in their passage. In association with pectoriloquy, bronchophony, or aegophony there can generally be detected a distmct whiff of tubular quality, either accompamdng or following the articulate or vocal sounds. In broncho- phony and segophony this is perceptible almost exclusively at the end of syllables, and chiefly at the end of those terminating with the explosive consonants h, j), d, t, k, and hard g, and is obviously due to the non- vocal rush of air through the open glottis, which as a rule follows on the utter- ance of these sounds. In whispered pectoriloquy a similar whiff' not only succeeds each syllable, but accompanies it during the whole period of its enunciation. These are merely tubular expiratory phenomena, due to the same cause that determines the ordmary tubular expiratory sound, and have no special significance. It should be added that, mider similar circumstances, a like whiff or blowing sound follows each sonorous expi- ratory shock of cough. iv. Crepitation. Bales. — When mucus, sermn, blood, or other fluids are contained in the air-tubes, the passage of air through them is attended with a variety of sounds to which the above and other names have been given. These are for the most part due to the passage of air in the form of bubbles of various sizes, and to the rupture of these bub- bles at the surface of the fluid through which they pass, or to the sepa- ration of sticky surfaces. The size of the bubbles necessarily has a relation to the size of the tubes or canities in which they occur. Thus, if they be formed in the air-cells or bronchial passages they must be ex- cessively minute ; if in the trachea or larger bronchi they are generally of considerable size. The soimds to which they give rise depend partly upon their size, partly upon then number, partly upon the dimensions of the chainiel or cavity "vsathin which they occur, and partly on the presence or absence of consolidation in the lung-tissue around. Fine creintation (crejntant rale) is produced only in the air-ceUs and bronchial passages, and may be regarded as almost characteristic of the first stage of pneumonia. It is apparently due to the rupture of mnumerable small bubbles, which mdividually are almost inappreciable, but collec- tively constitute a sound which has been aptly likened to that produced by rubbing the hair between the finger and thumb. Crepitation (mucous rale). — In all forms of crepitation, except that just spoken of, the bubbles c c 386 DISEASES OF THE EESPIEATOEY OEGANS. which burst at one thue are comparatively few ; moreover they are indi- vidually distinguishable, and differ to some extent from one another in sound. The collective sonorous result, therefore, is more or less coarse and irregular. In some cases two or three crackles or clicks only can be detected in the course of an inspiration or expiration. In other cases they are so numerous that the whole of inspiration and perhaps the whole of expiration are noisy with them. It Avould be impossible to describe all the minute varieties of crepitation which may be included under the name which we have here selected. It is sufficient to say that they are probably all due to the presence of fluid in medium-sized and large tubes, that the differences which are presented depend partly on the quantity of fluid present, partly on its quality, and partly on the force with which air is driven through it, and that when the larger crepitation approaches that of pneumonia in quality, it is often termed suh-crepita- tion or suh -crepitant mucous rale. Gurgling. — This term fairly well ex- plains itself, but is at the same time difficult to define. It implies partly large crepitation, such as may be heard in the trachea, partly the sounds which result from the mere agitation of fluid, falling, splashing, churn- ing, and the like. It occurs in large tubes and cavities. Metallic crepi- tation.- — This term may be applied to large crepitation in which the bursting of the bubbles is attended with a distinct musical twang or metallic resonance. It is developed either in cavities or in large tubes. We have pointed out that cavernous or metallic respiration is never met ■with in undilated bronchial tubes. The sharp, short sound, however, of a bursting bubble develops an audible resonance under conditions which would fail to affect similarly the prolonged and feeble respiratory murmur. V. BhoncJms. — This word is often used synonymously with rale, and both are often applied to all varieties of unnatural sounds caused by the presence of fluid in the bronchial tubes, or by diminution of their diameter. Eale, however, strictly means rattling or crepitation, which is essentially an unmusical sound ; whereas rhonchus signifies snoring, a sound always to some extent musical, and may conveniently be made to embrace all abnormal musical sounds which are occasioned in the bronchial tubes. Such sounds have sometimes a deep tone, almost exactly like an ordinary snore, or the cooing of a dove ; sometimes, on the other hand, they are high-pitched and of a whistling or hissing character. The deeper notes are usually termed sonorous, the acuter notes sibilant. The former, like the voice itself, may produce distinct fremitus in the thoracic parietes, and both may be distinctly audible, not only to the patient himself but to the bystander. The cause of rhonchus is, not the bursting of bubbles or the passage of air through fluid, but the passage of air through a tube narrowed at some point either by thickening of its parietes or by the adhesion of a plug of tenacious mucus. The almost complete closure of the tube, like the corresponding closure of the glottis in intonation, compels the passage of the air in a series of successive puffs, which soon become rhythmical, and hence a musical note results. The pitch of the musical note depends on various complex conditions, the exact influence AUSCULTATION. 387 of each one of wbicli it would be difficult to estimate, but is determined in a very considerable degree by the size of the bronchial tube within which it is developed. Thus, as a general rule, hissing and whistling sounds or sibilant rhonchi arise in the smaller tubes, and grave tones or sonorous rhonchi are the product of the larger ones. vi. Splashing. — In large cavities containing air and limpid fluid, especially therefore in cases of effusion into the pleura, associated with pneumothorax, a distinct splashing sound may often be caused by the process termed succussion ; in other words, by giving the patient a smart shake. This sound is often audible to the patient himself as well as to other attentive listeners standing by. It may, of course, be more readily recognised by auscultation. vii. Amphoric bubble. — In cases of hydro-pneumothorax may also be very rarely recognised a sound to which the name ' amphoric bubble ' may perhaps be given. Our attention was first directed to it by Dr. T. A. Barker. On applying the stethoscope to the back in the interscapular region while the patient was sitting erect, and then making him gradually bend his trunk forwards, a sound exactly like that which occurs during the decanting of wine was distinctly audible. It was single only, but could be elicited as frequently as the patient was made to bend his body forwards to a certain angle. It was obviously due to the facts : that the partially-collapsed lung hung down from the apex of the pleural cavity so as to form an incomplete septum between its anterior and posterior parts ; that the lower margin of the lung dipped into the pleural fluid, thus rendering the air-chamber behind the lung and that in front of it discon- tinuous ; and that consequently, with change of posture, the level of the fluid tended to rise in one cavity and sink in the other, until the sudden passage of air from the one to the other was permitted under the septum. viii. Friction so2inds are caused by the attrition of opposed pleural surfaces. They never occur in the healthy pleura, and it is essential for their production that the surfaces be roughened by inflammatory or other deposit. Further, as a rule, they have very little intensity, and are scarcely if at all audible beyond the spot at which they are developed. Friction- sounds present many varieties of character. In some cases there is a uniform to-and-fro murmur accompanying inspiration and expiration, and having a close resemblance to the sound produced by rubbing two surfaces of paper together. In some cases the sound differs little if at all from some forms of intra-pulmonary crepitation : there may be a con- tmuous crackling attending one or both respiratory movements, or merely a few isolated clicks or crepitations. In a large number of cases the sounds, whether they be fine or coarse, occur in a seriesof irregular jerks. The jerks, indeed, may exist without the presence of actual friction- sormds, in which circumstances the respirations become (over limited areffi) 'jerky,' or, as they are commonly called, ' wavy.' Friction-sounds have received various names, such as grazing, rubbing, creaking, and the like, which to some extent express their quality. They have also been described as ' superficial ' in character. It need scarcely be remarked, 388 DISEASES OF THE EESPIEATOEY OEGANS. ho"\vever, that this epithet can have no other meaning, as appHed to sounds, than that they are loud or distinct. Its use is altogether objec- tionable, as tending to cause confusion between the facts which we observe and the inferences we deduce from them. Li cases of pleural friction, the rubbing of the opposed surfaces may produce a tremor in the thoracic walls, readily detectible by the hand. It may be observed that loudness or roughness of friction-sound by no means necessarily implies either rough- ness, hardness, or abmidance of lymph. The loudest and coarsest sounds are occasionally produced by the thinnest, softest, and most recent films. E. Detection uf Cavities, Consolidated Lung, and Pleural Ejfusion. Before leading the subjects of auscultation and percussion it may be convenient to recapitulate the phenomena which attend and indicate the presence of cavities, consolidated lung, and pleural effusion, 1. The detection of cavities is often very important ; and in a large number of cases, no doubt, by considering the patient's history, the results of periodical examinations of his chest, and the presence or absence of certam special acoustic phenomena, we may arrive at a fairly correct conclusion. But the acoustic phenomena which by their presence prove the existence of a cavity are, as Skoda asserts, very few indeed. Dulness, hriiit de iMt fele, normal resonance, tympanitic resonance, high-pitched resonance may each be present. Feebleness, with indeterminate character of the respiratory sounds, tubular sounds, gurgling, may also each be present in its turn. There is probably always more or less marked bronchophony and pectoriloquy. Pectoriloquy, indeed, is more distinct, as a rule, over cavities than over merely consolidated lung. The only sounds, however, which positively indicate the presence of a cavity are : first, the musical or metallic ring or resonance which sometimes accom- panies the respiratory sounds, the voice, the movements of fluid in the cavity, and the percussion stroke upon its walls ; second, the splashing- sound caused by succussion ; and, third, the production of the amphoric bubble to which we have adverted. But these sounds may all be absent from canities even of large size. 2. The conditions ivhich collectively indicate consolidation are sense of resistance, impaired or annulled resonance, increase of vocal fremitus, tubular breathing, or correspondhigly modified conditions of rhonchus or crepitation, bronchophony, and pectoriloquy. These conditions are, how- ever, by no means necessarily all X3resent in every case. 3. The indications of 2:)leuml effusion are dulness on percussion, with variation of the limits of dulness and resonance in accordance with variation of posture, tubular breathmg, or more fi-equently extreme feebleness or absence of respiratory sound, impairment or suppression of vocal fremitus, and aegophony. To which may be added, dilatation of the afl'ected side and intercostal spaces, with sometimes obvious fluctua- tion, and displacement of the diaphragm downwards and of the medi- astinum to the opposite side. But, again, many of these phenomena are often absent from otherwise well-marked cases of effusion. LARYNGITIS AND TRACHEITIS. 389 n. LARYNGITIS AND TRACHEITIS. Causation. — Laryngeal and tracheal inflammation is caused mainly by exposure to cold or wet, or both. It is then sometimes the primary affection, but is often a mere extension of ordinary catarrh or of acute bronchitis. It may be due, however, to many other causes : — to the local operation of irritating gases, fluids, or solid particles, among which may be enumerated boihng water, vomited matters, and puriform secretions furnished by the lung itself; to the presence of certam morbid conditions or diseases, such as variola, measles, scarlet fever, diphtheria, erysipelas, syphiHs, and tuberculosis ; to the extension of inflammation from subjacent tissues ; and even, as regards the larynx; to sustained or violent exertion, as occurs ui clergymen and other public speakers, and in those Avho stram themselves in coughing or shouting. It may be determ.med also by local \dolence. There are, further, many conditions which predispose to it ; among the most important of which is the fact of having suffered from a pre^dous attack, and the presence of Bright's disease. Morbid anatomy. — The local changes which attend and indicate laryn- ^tis are those of inflammation of m.ucous membrane generally, with modifications due to peculiarities of arrangement and structure which the larjTigeal tissues present. The mucous membrane and subjacent parts are congested and oedematous ; and the epithehal surface, at first (as in ordinary nasal catarrh) preternaturally dry, soon secretes, though not in large quantities, a glah^y, transparent mucus, which subsequently becomes thick and muco-purulent. In ordinary mild cases the tumefaction and reddening are slight yet pretty uniformly chffused — the vocal cords pro- bably being injected and swollen, and studded with flakes of adherent mucus. In more severe cases the submucous tissue may be largely infil- trated and oedematous ; and hence the affected regions often assume a translucent, almost jelly-Kke, aspect, though still presentmg a congested surface. Such swelling, or oedema, may affect mainly the epiglottis, aryteno-epiglottidean folds, false vocal cords, or some other hmited tract, or may be general. It must be borne m mind, however, that the parts whose tissues ai'e closest in texture suffer least in this respect, and that hence the free edge of the epiglottis and the true cords for the most part escape. In most cases the secretion fi'om the mucous membrane presents simply the ordinary characters of mucus or muco-pus. But in some (even m the absence of diphtheria) an adherent false membrane forms upon the surface. This sometimes follows the attempt to swallow boiling water. Ulceration is an imusual sequel of ordinary inflammation. It occurs most commonly, perhaps, in the course of phthisis and constitutional syphilis, even when no specific lesions are present. Ulceration in phthisis may be the result of simple excoriation. It then begms with round or oval shallow, saucer-like depressions, of an ashy colour and with congested margins. Its most important, if not commonest, 390 DISEASES OF THE EESPIEATOKY OEGANS. seat is the point of the processus vocalis. Ulcers in this situation inchne to extend deeply, to expose more or less of the arytenoid cartilages, and to lead to their partial or total destruction by caries or necrosis. There is a great tendency, indeed, both in phthisis and in syphilis, for ulceration to involve the cartilages (arytenoid, cricoid, and thyroid), and to cause their erosion or necrosial destruction. But in some cases the cartilaginous affection takes its origin in inflammation of the perichondrium. For the most part the necrosed cartilages have midergone more or less complete ossification. The forms of laryngitis last referred to may be regarded as essentially of a chronic nature ; but simple laryngitis also may become chronic. The anatomical characters of this variety differ but little from those of the acute aff'ection. The chief distinctions are that, in the former case, the inflammatory redness is less intense, and the thickened tissues are more opaque and apparently more solid, thus losing their peculiar oedematous character. When laryngitis becomes chronic the follicles of the affected surface often undergo hypertrophy. To such cases the name of glandular laryngitis has been given. The changes which take place in tracheitis are essentially identical with those which characterise laryngitis. The surface, which is at first drier than natural, soon secretes an over- abundance of modified mucus, and occasionally, like that of the larynx, gets covered with an adherent pellicle. The mucous membrane itself, and the subjacent tissues, be- come congested and infiltrated, and not unfrequently, especially in syphilis and phthisis, ulceration takes place. The ulcers are mostly, in the first instance, mere excoriations, which tend gradually to increase in area and thus to coalesce, and in depth so as gradually to expose the cartilages. The latter may thus get eroded or necrosed, and even de- tached and expectorated. Abscesses may form in the walls of the trachea or external to them, and communications may be established between its tube and that of the oesophagus. The healing of ulcers, whether in the larynx or trachea, may produce serious cicatricial contraction. Symiitoms and progress.- — 1. Acute laryngitis is dangerous mainly from the fact that it is liable to cause serious obstruction to the passage of air through the rima giottidis, and hence death from suffocation. The inflammation is for the most part of little intensity, and gives rise to comparatively slight constitutional disturbance. There is usually during the earlier period of the affection elevation of temperature, acceleration and hardness of pulse, flushing of the face, furring of the tongue, thirst, and loss of appetite. But in favourable cases these symptoms soon subside, and in unfavourable cases get replaced by those of asphyxia. The special symptoms of laryngitis are often preceded by those of ordinary catarrh, and especially by those of catarrhal affection of the fauces, which, in many respects, they resemble. The patient complains of drjmess or roughness, soreness, itching, pricking, or aching, or it may be of several or all of these sensations, which he refers to the back of the throat and to the region of the thyroid cartilage. There is generally also some tenderness to touch, and there may be absolute pain when the parts LAEYXGITIS AXD TEACHEITIS. 391 are roughly handled. The sense of soreness is aggravated by the act of swallowing, especially if sohd matters be taken, and there is commonly also a good deal of aching thus caused besides soreness. The dryness and irritability of the throat compel the patient nevertheless to make constant efforts at deglutition, and at clearing the throat, and excite more or less frequent spasmodic attacks of cough. The voice gets altered in qiiahty, and respiration somewhat impeded. Examination with the laryngoscope reveals congestion and thickening of the mucous mem- brane : and if the parts above the vocal cords be much affected they may entirely conceal the rima giottidis and its surroundings fi'om view. Certain of the symptoms here enumerated require to be considered a little more in detail. Some degree of interference with the freedom of resph'ation is probably always experienced, and this, under the influence of excitement or sudden sj)asm, may readily amoimt to manifest dyspnoea ; expiration is a httle prolonged, and tends perhaps to be wheezy. But very often matters become much niore serious ; both inspnation and ex- piration (the former more especially), even when the patient is at rest, get harsh or whistling, noisy and prolonged, and he suffers from continuous difficulty of breathing. In cases of still greater severity all the sj^mptoms of asphyxia become developed ; the patient sits up in bed gasping for breath, which is still harsh, wheezy, or whistling ; with his head thrown back, his mouth open, his nostrils dilated, his respiratory muscles acting with spasmodic force ; anxious, restless, throwing his arms about, or clutchmg at any support which may be near ; with eyes promment and staring, face hvid and ghastly, skin bathed m sweat, and pulse rapid, small, failing, and perhaps irregular. Under these circumstances death may occur suddenly from complete obstruction of the rima giottidis. But more commonly the patient begins to ramble, and presently passes into a condition of insensibility upon which death gradually supervenes. The voice is almost invariably altered in quality ; it becomes hoarse, uncertam, or reduced to a whisper. In the beginning it is hi general merely hoarse ; it is somewhat rougher than natural, and at the same time deeper toned — phenomena which depend either on the adhesion of mucus to the edges of the vocal cords, or on some modification in their thickness, elasticity, or tension. This hoarseness is sometimes apparent only on rising in the morning, and disappears during the day ; it is apt, however, to be brought on again, and to be converted into actual aphonia, by unwonted use of the voice. At a later period of the disease, when the tissues above the vocal cords are highly oedematous, or the cords are much thickened and scarcely movable, complete aphonia is usually present. The cough varies in severity ; sometimes it is incessant, or comes on in tmcontrollable paroxysms. But it is generally attended with so much pain m the larynx that the patient endeavours (probably in vain) to sux^- press it. It is always at first, like the voice, hoarse and loud ; and in many cases, especially in children, and where there is manifest dyspnoea, its mspiratory element is long, loud, and whistling, and the expnatory effort is attended with a remarkably harsh, sonorous, metallic clang. 392 DISEASES OF THE EESPIEATOEY OEGANS. Later on, the cougli, like the voice, becomes ineffective, wheezy, or aphonic. Acute laryngitis is very apt to be attended or followed by bronchitis, or (especially in children) by collapse- and lobular pneumonia — complica- tions which aggravate the patient's symptoms and add materially to his danger. It is sometimes as rapidly fatal as almost any disease with which we are acquainted, but m a large proportion of cases is so mild in its symptoms that but little attention is paid to it ; yet it is always at- tended with risk, and should be carefully treated. The frequency of the occurrence of laryngitis in a mild forin is evidenced by the frequency with which persons, after exposure to cold, suffer from soreness referrible to the larjaix, and hoarseness or loss of voice. This affection generally lasts for three or four days, subsides with increase of laryngeal secretion, and leaves no ill consequences behind. Dr. Cheyne asserts that hoarseness is an micommon phenomenon in the catarrhal affections of yomig children, and that its occurrence should make us dread the supervention of croup. Our own belief, on the other hand, is that hoarseness is not uncommon in children, and that it has no more serious import in them than in adults. The phenomena, how- ever, of slight laryngitis in children under two or three years of age, and even in those who are a little older, are often so remarkable that they are confounded with those of spasmodic croup or laryngismus stridulus. The child, after having suffered from slight catarrhal symptoms, or sometimes in the midst of apparently good health, wakes suddenly during the night in an agony of dyspnoea. He starts up in bed with a look of extreme anxiety and terror, gasps for breath, inspires laboriously with a hissing or whistling sound, and coughs at intervals "v\ith a series of harsh, loud, metallic, expiratory shocks ; his voice is hoarse or reduced to a whisper. After the symptoms have lasted half-an-hour or more, during which time the patient has been enduring all the horrors of impendmg suffocation, they subside, the skm gets moist, and he falls into a comfortable sleep. The next day he probably appears to be pretty well, although there may still be some hoarseness of voice, and the cough may still have a croupy character. It is not micommon for such attacks to occur two or three nights or more in succession. There can be no doubt that they are mamly spasmodic ; and there is some reason to suspect that they are often induced immediately by the entrance of saliva, or even of regurgi- tated food, during sleep, into the larynx. They are seldom fatal. Neither of the above forms of laryngitis, however, differs essentially from the rarer cases in which the symptoms early assume an aggravated character, and in which the patients die, suffocated, after periods varying ffom a few hours to two, three, or four days. 2. Chronic laryngitis. — Under the head of chronic laryngitis may be included : first, simple laryngitis, which has assumed a chronic form ; second, aphonia clericorum ; and third, ulcerative processes, connected especially with pulmonary tuberculosis and syphilis. In the first variety the symptoms differ but little from those of the LAEYNGITIS AND TEACHEITIS. 393 acute affection, excepting in their comparative mildness. They are liable, however, to exacerbations, and rapid oedema of the submucous tissue may at any time ensue. Dr. Mackenzie states that in this form of chronic laryngitis the aryteno-epiglottidean folds are comparatively rarely con- gested and swollen, but that it is chiefly the false vocal cords, capitula Santorini, and epiglottis that suffer. Aphonia clericorum may originate in catarrh, like other forms of laryngitis, or may be the result of simple over-exertion. It soon, however, and mainly in consequence of the persistent use of the voice, becomes a •chronic affection. Its symptoms are like those of ordinary chronic laryn- gitis, but on the whole are more mild. The patient, indeed, often suffers from little except a sense of dryness in the throat, persistent hoarseness, and a tendency to hawk and clear the throat. Laryngoscopically, the appearances are those of chronic laryngitis. It is stated, however, that in this case there is a special tendency to hypertrophy of the laryngeal glands, and that their enlarged orifices may often be distinctly recognised. The laryngeal affection which so commonly attends pulmonary phthisis creeps on insidiously, and is sometimes far advanced before the pulmonary disease has made very manifest progress. It differs from the varieties of chronic laryngitis above considered in its progressive aggravation and its incurability. At the beginning it presents no special symptoms ; but, as the disease goes on, complete aphonia, dyspnoea which may be exceedingly severe, and pain and difficulty in swallowing, become established ; indeed, in many cases swallowing becomes almost impossible, on account of the passage of food through the rima glottidis when the act is attempted. On laryngoscopic examination, the soft parts are seen to be more or less thickened, sometimes congested, sometimes pale, and for the most part opaque ; and Dr. Mackenzie draws attention to the fact that the aryteno- epiglottidean folds usually look like ' two large, solid, pale, pyriform tu- mours, the large ends being against each other in the middle line, and the small ones directed upwards and outwards.' The presence of ulcers may sometimes be recognised. Syphilitic affections of the larynx are not wholly specific. But, whether specific or not, the symptoms to which they give rise are those of progressive chronic laryngitis. In the later stages of constitutional syphilis extensive ulceration of the larynx is not uncommon, and in this case, as well as in so-called ' laryngeal phthisis,' there is a great tendency for caries or necrosis of the various cartilages to take place. Here, however, the epiglottis is most prone to suffer. Such ■complications, no matter what their cause, always largely diminish the ultimate prospect of even partial recovery, and bring in their train special symptoms in addition to those of simple laryngitis. Among these may be mentioned : infiltration and oedema of the tissues of the neck super- ficial to the laryngeal cartilages ; fetid breath and purulent discharge ; the occasional separation of portions of cartilage or bone, which may either be expectorated or cause sudden death by obstructing the laryngeal orifice ; the formation of abscesses or sinuses which may open in various positions ; the perforation of arteries, with profuse and fatal hemorrhage ; 394 DISEASES OF THE EESPIEATOKY OEGANS. and occasionally, as a sequela of the separation of sequestra and cicatri- sation, permanent and serious contraction of the glottis or other parts of the laryngeal canal. 3. The symptoms due to tracheitis are scarcely distinguishable from those of inflammation of the larynx. It may be observed, however, that in inflammation limited to the trachea there is not necessarily any pain in the pharyngeal stage of deglutition, or any aflection of the musical quality of the voice, and that, while the danger of suftocation is less, the benefit to be expected from tracheotomy is also less. Further, some tenderness in the course of the trachea may be expected, some pain in the same situation on coughing, and some tenderness or soreness in the passage of food along the oesophagus. Treatment. — The treatment of laryngitis may be divided into the constitutional or general, and the local, of which the latter is by far the most important. The local treatment to the exterior of the larynx com- prises leeches (which should be applied over the upper part of the sternum), blisters and other counter-irritants (which are also best applied in the same region), and poultices or hot fomentations over the larynx itself. For internal local treatment may be employed : the inhalation of steam, simple, or medicated with volatile aromatic or sedative substances such as turpentine, camphor, benzom, creasote, or conium ; the inhalation of atomised fluids such as solutions of sulphate of zinc or copper, acetate of lead, alum, nitrate of silver, perchloride of iron, or tannin ; the applica- tion, by means of a sponge or brush, of strong solution of nitrate of silver ( 5j ad Ij), tincture of perchloride of iron (5J, 5ij, ad ^j), or any of the other articles just enumerated ; the insufflation of finely-powdered astrm- gents or sedatives ; and scarification of the congested or oedematous tissues. In order that the internal local treatment may be effectual, it is important that (exceptmg in the case of simple inhalation) the remedies should be applied by means of special apparatus under the guidance of the laryngoscope. The application of ice or cold compresses to the exterior of the larynx, and the sucking of ice, are measures which may often be adopted with advantage. As to general treatment, we must be governed mainly by the constitutional condition of the patient and by the character of his attack. In acute cases, ipecacuanha, tartar emetic, and other nauseating remedies have been largely advocated ; opium, as in most inflammatory affections, especially such as are attended with pain or distress, is often of extreme value. Warm baths, and the retention of the patient in an equable, warm, moist atmosphere, are generally of use in the treatment of acute cases ; in the treatment of chronic cases, iron and other tonics, cod-liver oil, change of air, and, if need be, iodide of potassium, or mercurial salts. In the laryngitis which so often attends an ordinary catarrh it is ad- visable to keep the patient in a warm atmosphere, at any rate free from exposure to draughts, to apply hot fomentations or mustard plaisters externally, to order him to gargle his throat frequently with warm milk or with slightly astringent solutions, or to relieve his faucial discomfort by BEONCHITIS. 395 tlie use of gelatinous or oleaginous substances (among which may be included common calves'-foot jelly and black-currant jelly) or to inhale steam. Diaphoresis may be encoiwaged, and expectorant medicines may be administered. Opium is of great value in relieving the patient's dis- comfort. When the case is severe from the beginning, or when it begins to assume a serious aspect, our local treatment must be more active ; leechmg externally, and scarification withm, become then of great im- portance. Sometimes in such cases swabbmg the throat with strong solution of nitrate of silver, perchloride of iron, or alum, is followed by the best results. In the stridulous larpigitis of young children the danger is mainly momentary (so to speak), and due to spasm ; and treatment, therefore, if it is to be efficacious, must be prompt. Generally it is advis- able to x^lace the patient in a hot bath, and to apply a sponge wrung out in hot water over the larynx. It is usually customary to administer an emetic dose of ipecacuanha or sulphate of zinc. It may, however, be questioned whether the inhalation of chloroform is not more likely to be beneficial than the use of an emetic. In the chronic form of laryngitis, local bleeding and scarification are rarely necessary except to relieve exacerbations ; but blisters and other counter-irritants externally, and the systematic emplojonent of medicated applications to the interior of the larynx, are then specially indicated. In the so-called ' aphonia clericorum ' prolonged rest from the use of the voice should especially be enjoined. In all cases, whether they be acute or chronic, specific or non-specific, it must be borne in mind that we may be called upon at any moment to save hfe by the performance of tracheotomy. The need for its perform- ance must generally be determined at the moment. It is difficult to lay down precise rules for the guidance of the judgment of the medical at- tendant in such cases. It is probably sufiicient to say that no one ought to be permitted to die of uncomplicated laryngeal obstruction without having that chance of recovery given him which tracheotomy affords ; that it is unwise to delay the operation until the patient is moribund ; that it is better to perform it needlessly than too late ; and, lastly, that it should not necessarily be discarded even if the patient appears to be just dead. III. BEONCHITIS. Causation. — Inflammation of the bronchial tubes is dependent chiefly on exposure to cold. But it also arises, like laryngitis, fi'om the mhalation of irritant matters ; as a complication or sequela of various febrile dis- orders, such as influenza, hooping-cough, measles, and typhoid fever ; and in connection with various idiopathic aflections, more especially heart and kidney diseases. It may also be developed under the influence of ^duI- monary tuberculosis and carcinoma, and probably, too, in connection with syphilis and gout. Its prevalence depends largely iipon temperature and season, and hence it is chiefly fatal in autumn and winter ; it is favoured 396 DISEASES OF THE EESPIEATOEY OEGANS. by sucli occupations as expose persons to the influence of irritant or other noxious matters, and such as necessitate frequent and sudden exposure to variations of temperature ; it affects persons of all ages and of either sex, but it has a marked preference for such as have had previous attacks, and is especially fatal in early infancy and in old age. Morbid anatomy. — Inflammation of the bronchial tubes, like inflam- mation affecting other mucous membranes, is attended with changes in their epithelial covering and glandular secretions, and in the subjacent tissues. The discharge is, in the first instance, diminished in quantity, but soon becomes more abundant than in health, thin, transparent, and either watery or viscid, and subsequently acquires more or less opacity and thickness, and a yellowish or greenish tint. Sometimes it remains watery, sometimes assumes the characters of pus, and not mifrequently, if the inflammation be intense or the congestion great, presents streaks and spots of blood. Under the microscope the viscid transparent secre- tion presents abundance of shed ciliated epithelial and other cells ; and the acquisition of opacity is connected with the replacement of these by cells of embryonic character, fatty or granule cells, and pus corpuscles. In some rare cases groups of bronchial tubes are found occupied by laminated fibrinous casts, which on separation present a branching or tree-like aspect. The mucous membrane becomes congested, sometimes intensely con- gested, and the seat of minute extravasations of blood ; at the same time it undergoes infiltration and thickening, and may even acquire a granular or villous aspect, and a soft or pulpy consistence. It is important, how- ever, to know that, in a large number of cases, especially chronic cases, the congestion disappears wholly after death, and the mucous membrane seems scarcely changed either in thickness or in texture. The inflammatory process may be limited to the surface of the mucous membrane ; but it often pervades the submucous tissue ; and in some cases involves the whole thickness of the bronchial walls, leading also to infiltration and induration of the connective tissue which surrounds them. In the last case the muscular fibres may either, if merely irritated, be stimulated to unwonted action, or undergo atrophy or degeneration, and lose their contractile properties. In most cases of bronchitis the mucous membrane remains whole ; but occasionally ulceration takes place. This is more common in phthisis than in the uncomplicated disease, and usually commences, as does tracheal or laryngeal ulceration, in simple excoriation. The excoriations, at first small and round or oval, gradually enlarge and coalesce, and at the same time tend to increase in depth. Thus the walls may undergo gradual removal (the cartilages disappearing by caries or necrosis), the surrounding lung-tissue share to a greater or less extent in the destructive processes, and the tubes be converted into irregular channels bounded by diseased lung-tissue. In some cases gangrene occurs. Ulcerative destruction occasionally takes place from without, as when a pulmonary, glandular, or other abscess opens into an BEONCHITIS. 397 adjoining tube. It is thus that abscesses about the roots of the hmgs discharge themselves mto the bronchi, and that calcareous matter from diseased bronchial glands finds its way into these or smaller tubes. Bronchitis is limited, in a large proportion of cases, to the tubes of large and medium size ; but sometimes affects mainly or entirely the minuter tubes. In the latter case, not only is the affection marked by greater intensity of symptoms and aggravated danger to life, but the local pathological changes assume a more serious character ; the thickening of the mucous membrane encroaches more seriously on the channels of the affected tubes, and their secretions tend to accumulate in them and to block them up completely. Hence post mortem we not unfrequently find the smaller tubes distended with pus or mucus, void of air, and quite impermeable. The indirect influence of bronchitis over the structural condition of the bronchial tubes and proper tissues of the lungs is very remarkable. As regards the tubes, we have already pointed out that, by extension of ulcer- ation, they may be converted into irregular channels ; this change may be seen in its greatest perfection in connection with the capillary or terminal tubules. But, independently of ulceration, the tubes, and especially the smaller ones, may undergo considerable dilatation from the combined effects of simple accumulation of contents and inflammatory weakening of their walls. In acute bronchitis, attended with much secretion, the lung-tissue often becomes preternaturally distended with air, and retains the accumu- lated air even after death ; this condition is sometimes incorrectly termed emphysema ; but it not unfrequently proceeds to actual emphysema, in which the vesicular structure is more Or less seriously disorganised. Besides over-distension, the exactly opposite condition of pulmonary collapse is often met with, sometimes alone, sometimes associated with over-distension of other parts ; collapse is intimately related to another frequent complication of bronchitis, and indeed passes by insensible gradations into it ; we mean lobular pneumonia. All the secondary phenomena arising in the progress of bronchitis, which have here been enumerated (namely, dilatation and destruction of tubes, dilatation and destruction of air-cells or emphysema, lobular collapse and lobular pneu- monia), form a more or less important part of chronic bronchitis, and tend both to aggravate its symptoms and to perpetuate them. It will, nevertheless, be convenient to defer their complete discussion. Symptoms and progress. — The symptoms of bronchitis comprise, in varying proportions, those of inflammatory fever, those of defective aeration of blood, and those directly referrible to the condition of the bronchial tubes and lungs ; to which may be added those arising from mechanical impediment to the transmission of blood through these organs. The symptoms of inflammatory fever are always most pronounced at the commencement of acute attacks and of exacerbations of the chronic affection, and often disappear wholly, to be replaced by other conditions, during the progress of the disease. The temperature, excepting in very 398 DISEASES OF THE EESPIEATOEY OEGAXS. severe cases, especially of capillary bronchitis, and in young children, rarely exceeds 100° or 101''. In exceptional cases it may mount to 102°, 103'^, or 104°. With elevation of temperature there may at first be chills or rigors, and dryness of sMn. But perspirations, more or less profuse, are apt to alternate with dryness, or to replace it. The pulse becomes accelerated, the respkations hurried, the tongue furred ; the patient has thirst, loss of appetite, constipation, and scanty turbid urine ; he probably complains of headache and febrile pains in his limbs ; and he is apt to be drowsy, though often wakeful at night. Diminished aeration of the blood tends to the reduction of temperature, to interference with the processes of nutrition, and to enfeeblement of the hearfs action and of the pulse. The temperature of bronchitis may hence be subnormal even in acute attacks. The pulse, moreover, is sometimes full and incompressible, owing either to increase of arterial tension secondary to venous obstruction, or to poisoning of the nervous centres ; and in chronic cases it is often abnormally slow. The face, and especially the Hps and cheeks, assume a pale or livid hue ; profuse perspirations break out ; and there is a tendency to impairment of the mental faculties, to delirium, and coma. The local symptoms are due to the processes going on in the bronchial tubes. They comprise cough, at first dry and irritable, later on freer and attended Vv-ith expectoration ; difiiculty of breathing, with increase in the number of resphations and in the efforts required of the patient ; com- parative prolongation of the acts of exphation ; and the various forms of rhonchus and crepitation, which are caused by thickening of the bronchial mucous membrane, or secretion into the tubes. 1. Acute bronchitis. — The symptoms of bronchitis vary considerably according to its severity and the conditions which cause or comphcate it. In its mildest form it is a comparatively trivial affection. It then usually commences with ordinary catarrhal inflammation of the upxDer part of the respiratory tract, which gradually travels downwards, mvohing first the larynx, and then the bronchial tubes. It is attended with febrile distm*b- ance, irritabihty of the bronchial mucous membrane, tickling or uneasy sensations in the throat, burning, soreness or ravv-ness within the chest, and cough, the paroxysms of which cause considerable aggi'avation of the intrathoracic discomfort. There is frequently, also, tenderness over the manubrium, with tenderness and aching of the muscles of the upper part of the front of the chest. The cough is at first dry, but in a short time becomes loose and attended with the discharge of transparent glairy mucus. With the progress of the case the sputa get opaque and muco- pm'ulent, then gradually cease, and health is restored at the end of a few days, or at most after the lapse of a week or two. In more severe cases, the symptoms are the same in kind, but aggra- vated. The febrile phenomena which usher in the attack are more intense, the cough and pain in the chest are more distressing, and there is more or less obvious dyspncea. There may, indeed, while the mucous membrane is simply swollen, and the cough is yet di-y, be great asphyxial distress and BEOXCHITIS. 399 li\-iclity of surface, and the patient may even at this stage die asphyxiated. More commonly, however, here as in the former case, the mucous sm-face ere long beguis to discharge, and the cough to be attended with expectora- tion, which, except that it is probably much more profuse, and apt to be streaked with blood, passes through the ordinary phases. During this period, also, death may take place from accumulation of fluid in the bronchial tubes and consequent slow asphyxia ; or, without the actual superyention of asphyxia, the patient may gradually pass into a typhoid state, with feeble, quick, irregular pulse, dry cough, copious sweats and delirium ; or he may sink from a combination of these conditions. Oc- casionally death is sudden owing to the sudden obstruction of some of the larger tubes. The most dangerous form of acute bronchitis is that which commonly goes by the name of capillary bronchitis. It is that form in which the inflammation affects mainly, if not exclusively, the minuter bronchial tubes. It is most common in children, yet is not urLfrequent iii persons of more advanced age. The fever which ushers it in is generally pretty intense, the difficulty of breathing and hvidity are considerable ; the cough, however, may be much less troublesome than in other cases, and even during the stage of secretion may, owing to the difficulty of dislodging accumulations in the minuter tubes, remain inefficacious and dry. Further, there is generally comparatively Httle intrathoracic pain even in violent coughing. The tendency in capillary bronchitis is to speedy death from asphyxia and debihty. The auscultatory phenomena of bronchitis comprise mainly sonorous and sibilant rhonchi, and crepitation of various sizes. Musical rhonchi are chiefly heard during the dry stage, crepitation dming the later stages, but even then musical sounds are apt to be present to a greater or less extent. In capillary bronchitis the rhonchus is mostly sibilant, and the crepitation small. The sounds ehcited by percussion differ httle from those of health. If the lung-tissue be much distended with air, as it often is, the percussion sound may be somewhat more resonant than normal ; but obvious dulness is rarely produced, even if there be lobular collapse, unless the collapse be extensive, or pneumonia or other comphcations be present. 2. Chronic bronchitis. — Bronchitis often assumes a chronic form, especially among the labom*ing classes, and in middle or advanced life. It may become chronic, however, at all ages, and in persons of any grade of society. When a patient suffering from acute bronchitis continues to expose himself to the conditions which caused it, the inflammation is likely to be kept up ; and, again, bronchitis is one of those affections which, when once they have been experienced and cured, tend to recur on the shghtest XDrovocation. The ordinary history of a case of chronic bronchitis is to the effect that the patient, after exposure to weather, probably during the winter, has an attack of the disease, from which he recovers durino' the ensuing spring, remaining fauiy well until the approach of the following winter ; that then a fresh attack is contracted, from which again recovery takes place ; that these attacks of winter cough then recur annually. 400 DISEASES OF THE KESPIKATOEY OEGANS. gradually increasing in severity and duration, and being separated from one another by shorter and shorter intervals of comparatively good health ; and that each such successive interval becomes a period of increasing shortness of breath, until it merges in that of the bronchitic condition, which thus becomes continuous, although still probably presenting winter exacerbations. Each bronchitic attack differs but little in its symptoms from an ordinary acute seizure, excepting perhaps that it is rarely attended with such manifest febrile disturbance, and that the expectoration is apt speedily to assume the. muco -purulent condition and to continue of this character, and at the same time to become more or less abundant, until the approach of the long-delayed convalescence. These successive long- continued attacks generally lead gradually but surely to those structural pulmonary changes which have been already enumerated, and to those various remote lesions referrible to long-continued congestion of the systemic venous system which follow equally on this disease and on cardiac affections ; the mucous membrane tends to secrete more abundantly than natural, even when the patient is otherwise ap- parently well ; emphysema, or dilatation of the tubes, or both of these conditions, gradually supervene ; the right side of the heart becomes dilated and hypertrophied ; and systemic venous congestion ensues, in which the liver and kidneys especially share. The symptoms due to these lesions are consequently added one after another to those of simple bron- chitis ; the patient soon begins to suffer from persistent shortness of breath and bronchial accumulation, and sooner or later gets cyanotic, anasarcous, and the subject, maybe, of jaundice, albuminuria, or both. The thorax of a patient who has suffered long from chronic bronchitis gradually assumes, in consequence partly of his persistent powerful in- spiratory efforts, partly of emphysema, a rounded form — the well-known barrel shape so common in this affection. Cases of chronic bronchitis, within certain limits, differ widely from one another in their severity and in the symptoms with which they are attended. In some the bronchial secretion is so scanty, other symptoms being well developed, that the affection has been termed dry bronchitis ; in some the discharge is so profuse that the name hronchorrhcea has been given to the malady ; and, in other cases, even where no gangrenous condition is present, the expectoration is disgustingly fetid — a condition said to be chiefly met with when there is dilatation of the bronchial tubes. The expectoration and the auscultatory, percussive, and tactile phenomena yielded by persons suffering from chronic bronchitis do not differ materi- ally from those presented by patients suffering from the acute disorder, and call, therefore, for no special description. Death, in which, sooner or later, the chronic disease so often terminates, is usually due to asphyxia, asthenia, or a combination of these conditions. The expectoration of laminated casts of the bronchial tubes is an event which may naturally be looked for in cases of diphtheria in which the diphtheritic process has travelled from the larynx into the trachea and thence downwards. And, indeed, since the diphtheritic pellicle may BKONCHITIS. 401 form upon any part of any mucous membrane, there is little doubt that it occasionally forms in the smaller bronchial tubes independently of any such affection of the larynx, trachea, or bronchi, and that equally under these circumstances expectoration of casts may take place. But oc- casionally such casts are spat up from time to time by patients, whom there is no reason to suspect of diphtheria. The causes, pathology, and symptoms of this affection, which has been termed ylastic hroncliitis, are alike obscure. All that is positively known is : that persons, after a longer or shorter period of ill-health, and symptoms something like those of slight chronic bronchitis or lobular pneumonia, expectorate either without warning or after prolonged dyspnoea, and as the result of a suffocative paroxysm of cough, a larger or smaller quantity of this material, often in connection with hemoptysis, which may be profuse, or with muco-purulent discharge ; that this plastic expectoration may then cease or may continue off" and on for an indefinite period ; and that, although some of these patients die ultimately of phthisis, or of the accidents which attend the process of expectoration, the majority appear to make a good and permanent recovery. There is good reason to believe that the portions of lung-tissue to which the obstructed tubes lead are in a state of collapse or lobular pneumonia ; and, indeed, although in most cases there appears to have been perfect pulmonary resonance with more or less rhonchus and crepitation, a few have been recorded in which, as might be expected, there was circumscribed dulness, with total absence of respiratory murmur over the dull area. The co-existence, however, of pulmonary and bronchial lesions does not explain the nature of the rela- tion between them. There is no doubt that, in hemoptysis, blood occasionally coagulates in the bronchial tubes, and that in pneumonia bronchial casts of the same material that fills up the air-cells are now and then produced ; but these seem to be distinct from the casts of plastic bronchitis, which probably originate in situ.. Treatment. — Bronchitis is one of the commonest diseases of temperate climates, one of the most frequent sources of incapacity for useful work and the enjoyment of life, and one of the most fruitful causes of death. Its treatment is therefore a matter of grave importance. It will be convenient to discuss it under different heads. Hygienic treatment. — This comprises the keeping of the patient in an equable and moderate temperature, not below 65° or 66°, and if possible not very largely exceed- ing this, and preferably, therefore, confining him to the house or even to one room ; the maintenance of some degree of moisture of atmosphere ; the use of hot baths, the Turkish bath, or the hot pediluvium ; and the regulation of the diet according to the patient's capabilities and needs. Local treatment. — Under this head may be included : first, treatment applied to the skin, inclusive of counter-irritation by mustard plaisters, blisters, and the like, dry-cupping, and the abstraction of blood by leeches or cupping-glasses ; second, treatment applied to the mucous membrane, such as the inhalation of steam, either simple or medicated with some of those substances which have been enumerated in the treat- D D 402 DISEASES OF THE EESPIEATOEY OEGANS. ment of laryngitis. Medicinal treatment.— The drugs which have heen employed are various. Among expectorant or nauseating medicines, ipecacuanha, squills, and tartar emetic hold a high place ; stimulant drugs, such as the gum resins and balsams, more particularly benzoin, tolu, guaiacum, and ammoniacum, are often valuable ; and as closely related in action to these may be enumerated ammonia, senega, and the stimulant vegetable tonics. Sedatives and narcotics, such as opium, conium, belladonna and hyoscyamus, are of great importance ; and in certain stages and in certain cases so also are sulphuric ether and lobelia. Lastly, tonics and alcoholic stimulants are often, and especially in the later stages of the acute affection and in chronic cases, of extreme value. In ordinary mild bronchitis, little or nothing is needed beyond keeping the patient in a warm room, the inhalation of steam, the application to the chest of a mustard plaister, the use of the hot bath or pediluvium, the exhibition of small quantities of opium and ipecacuanha, and the reHef of thirst and dryness of mouth by warm diluent drinks. In acute cases of greater severity, it may be necessary to abstract blood from the surface of the chest. This can only be needed when there is extreme difficulty and pain in breathing, especially if at the same time there is reason to beheve that the bronchial membrane is congested and swollen, and yielding but Httle secretion. The quantity of blood to be removed must be determined by the age and state of the patient, and by the effect of its removal. It is much better, however, to withdraw an adequate quantity at first than to repeat the operation over and over again. In such cases, too, counter-irritants and inhalation are of great value. As regards medicines, antimony or ipecacuanha in nauseating doses, combined, it may be, with squills, and above all with small doses of opium, and frequently administered, is generally useful. When the bronchial secretion becomes abundant and muco-purulent, these may still be continued, or may be replaced by the more stimulating forms of expectorant medicines. In this stage the combination of drugs recom- mended by Dr. Stokes, namely, ammonia, opium, and senega, is often of much service, as also are the balsams or gum-resins. When the patient suffers much from bronchial accumulation, an occasional emetic dose of ipecacuanha may be resorted to with benefit. Under similar circum- stances, the persistent use of tartar emetic, in pretty large doses, associated with alcohohc stimulants, is frequently of value. In pro- tracted cases, and during convalescence, tonics are called for, and good nutritious diet. Few drugs are more valuable than opium in the treat- ment of bronchitis ;• it relieves pain and distress, diminishes the irritability of the mucous membrane and the need for coughing, and probably also tends to reduce inflammation. At the same time its administration is often fraught with danger. It is generally best to give it in frequent small doses ; and it is well to give it very cautiously or to withhold it entirely when the patient shows signs of imperfect aeration of blood, when his bronchial tubes are overloaded with mucus, or when he tends to ramble. PNEUMONIA. 403 In clironic bronchitis, especially when exacerbations are present, the treatment must in the main be the same as that of the acute affection. On the whole, however, the abstraction of blood, and the use of medicines calculated to depress ihe patient's strength, are not desirable. Counter- irritants, inhalation, stimulant medicines, tonics, and good diet are chiefly indicated. It is in these cases, too, that hygienic treatment is especially likely to be serviceable. The patient who is suffering from a winter cough, increasing year by year in severity, and in whom emphysema and other such lesions are in progress, should dress warmly even in summer, should be careful not to expose himself to draughts or to the evening or early morning air, should give up those pursuits which expose him to the causes of bronchitis, and should pass his winters on the South Coast, or on the shores of the Mediterranean, or in some other warm equable climate, or else confine himself to a room or suite of rooms, well ventilated, but kept at a uniform and comfortably warm temperature. IV. PNEUMONIA. Causation. — Inflammation of the substance of the lungs, like bron- chitis, is due in the large majority of cases to the influence of cold and wet ; and it would seem that it may, under special circumstances, be caused either by brief exposure of portions of the heated surface of the body to a severe chill, or by prolonged exposure of the whole normally warm surface to comparatively slight degrees of cold. It is especially common in temperate climates, and at those seasons (spring more parti- cularly) when the temperature is liable to great variations. It may also be caused by the spread of inflammation (whether originally due to cold or not) from other parts : as from the bronchial tubes, in cases of bron- chitis, hooping-cough, measles, influenza, diphtheria, and the like ; from the pleura in cases of pleuritis ; or, if the pleural cavity be obliterated by adhesions, from the chest-walls or surrounding viscera. And again, it may be developed by the direct action of mechanical and other irritation, such as follows the inhalation of irritant gases, particles of dust or other such substances, solid bodies of larger size, vomited matters, or even water ; or it may spring from the presence of emboli in the branches of the pulmonary artery, or of tubercles or clots in the tissue of the lungs. There are also many pathological conditions (especially the presence of pulmonary congestion or oedema, or of specific poisons or effete matters in the blood) which favour the occurrence of pneumonia. And it is pro- bably due to one or other or all of them that pneumonia is so common in the course of heart-disease, kidney-disease, various infectious fevers, ery- sipelas, rheumatism, and many other inflammatory disorders. It is also apt to occur in persons advanced in syphilis, or worn out whether by disease or over-work. D D 2 404 DISEASES OF THE EESPIEATOEY OEGANS. It must not be forgotten, however, that acute idiopathic pneumonia occurs with considerable frequency amongst those who seem to be in the best of health. This variety of the disease is met with at all ages and in both sexes ; but it is more common in men than women, and far more common among the working classes than others— facts which are ex- plicable by the relatively greater exposure to the causes of pneumonia of those who have to earn their livelihood by the sweat of the brow. A previous attack seems to predispose to subsequent attacks. Morbid anatomy. — It will be convenient, in describing the morbid anatomy of pneumonia, to distinguish, as has generally been done, two forms— namely, lobar and lobular pneumonia, or, as they are termed by German writers, croupous and catarrhal. These names are none of them unobjectionable, and it might be better to replace them by the words diffused and patchy ; the type of the former variety being furnished by the idiopathic affection, that of the latter by the condition which is secondary to diseases of the air-passages. The two varieties, however, pass into one another. A. Lobar pneumonia begins with hyperfemia of the small vessels dis- tributed in the walls of the air-cells and bronchial passages ; swelling and tendency to proliferation of the epithelial cells of these parts ; and exudation of inflammatory lymph (serum, albumen, fibrine), and of the corpuscular elements of the blood. The air-vesicles and passages com- municating with them gradually become filled and finally distended with exuded matter, the air which they contained by degrees gets expelled, and the affected lung-tissue grows solid and heavy. If the parts be now examined microscopically, the dilated blood-vessels will be found to be crowded with their corpuscular contents, and the alveoli full of cells (some merely modified epithelial cells, wdth one, two or more nuclei, some cells undergoing fatty change, in other words granule -cells, and others having the characters of leucocytes or pus-corpuscles) all blended to- gether into a common mass either by an amorphous glutinous cement, or by a delicate fibrillated network. The ordinary process of inflammatory cell-proliferation has taken place, by means of which the epithelial cells have acquired an embryonic character ; and to these, escaped leucocytes have been added. With the progress of the disease the contents of the air-vessels liquefy, and acquire more and more both the naked eye and the microscopic characters of pus. The fatty degeneration which has been referred to may, either before or after the liquefaction of the contents of the air- vesicles, become general throughout the accumulated cells, which may then, if not expectorated, undergo gradual absorption. The conversion of the inflammatory exudation into pus is occasionally fol- lowed by the breaking down of the lung-tissue here and there into ab- scesses ; and occasionally by the occurrence of gangrene. Inflammation of the lung, like inflammation of other parts, rarely if ever takes place without there being more or less abundant serous exudation into the surrounding uninflamed tissues; and, further, pneumonic inflammation tends, like most inflammations, to spread. PNEUMONIA. 405 The progress of pneumonia tlirougli its various phases is quite gradual ; nevertheless, there are at least three stages which severally- present more or less obvious characteristic features. The first of these is the stage of engorgement, the second that of red hepatisation, and the third that of grey hepatisation. In the first stage the lung still contains air, though in diminished quantity ; it is deeply congested, exudes more moisture than natural, is increased in weight, and is more easily lacer- able than healthy lung-tissue. This is the period of congestion and commencing proliferation ; and at this time the condition of the lung is scarcely, if at all, distinguishable from that of simple hypostatic conges- tion. In the second stage the lung is consolidated ; it has lost its air, and its cavities are filled with coherent masses of cells ; it is distended to its full size, and its constituent lobules are distinctly mapped out upon the surface ; on section it appears to be pretty dry and slightly granular (a condition still more noticeable on the surface produced by laceration) ; and it presents a peculiar marbled aspect, which is due to the inter- mixture of nearly colourless inflammatory deposit, patches of congestion, and the irregular slate-coloured or black tracts which commonly stud the lung-tissue of persons who have reached adult age. The general hue of tlie lung is for the most part somewhat pale ; there is probably, however, more decided congestion during life, and even after death the tissue is in some cases almost as deep in hue as we find it in pulmonary apoplexy. Sometimes, indeed, there is actual extravasation of blood. The lung-tissue is easily torn, and readily sinks in water. The third stage differs from the second, mainly in the assumption by the affected lung-tissue of a pretty uniform opaque greyish, yellowish, or greenish tinge, in its largely in- creased friability, and in the ready exudation from the cut surface of thick, turbid, purulent fluid. In some cases the fluid is comparatively scanty ; in some it is so abundant that the lung is like a sponge saturated with pus. We have already mentioned that there is generally, if not always, considerable oedema of the lung-tissue beyond the part actually inflamed. There is also almost invariably a deposit of inflammatory lymph on the sur- face of the inflamed portion of lung, as well as upon the parietal pleura in contact with it, which tends to diffuse itself over the serous membrane, more especially towards its base, but is not generally attended with any large amount of serous effusion. Since pneumonia tends to spread, it naturally follows that different portions of affected lung often present well-marked differences of con- dition, and that we occasionally find all the recognised stages of pneu- monia present at the same time in the same case. Inflammation may involve the lung to very various extents : thus it may be limited to a patch no larger than a walnut, or may include an entire lobe or even a whole lung ; and, further, it may affect both lungs. It is curious how often it is strictly limited by the fissures or fibrous septa which separate lobes, and how often it is accurately mapped out by the margins of lobules. As regards position, it seems to be a well-established fact that the right lung is more frequently affected than the left, and the lower 406 DISEASES OF THE EESPIEATOEY OEGANS. lobe than the upper. In reference to the latter pomt, however, it may- be observed, that if we divide the lung horizontally midway between apex and base, there will be at least some two or three times as much lung-tissue below as there is above the plane of division, and that hence, if all parts of the lung be equally liable to inflame, inflammation of the upper part should be several times less frequent than inflammation of the lower part. The forms of pneumonia which supervene on hypostatic congestion, or come on in the course of renal and cardiac disease, or complicate pulmonary apoplexy and tubercle, differ little anatomically from that which has here been described. B. Lobular pneumonia is especially the pneumonia of young chil- dren ; it is not unfrequent, however, in older persons. In its best-marked form the lung is studded with pneumonic patches, varying in size from about that of a pea to that of a filbert, and involving each one or more pulmonary lobules, circumscribed by the interlobular septa, and separated from one another by a network of still crepitant, and it may be healthy, lung-tissue. The pneumonic patches may be in the condition of engorge- ment simply, in which case their character may possibly fail to be recog- nised ; or they may present the ordinary features of red or grey hepati- sation. Further, by extension of disease, neighbouring patches may coalesce, and thus extensive tracts of Imag-tissue become involved. Lobular and lobar pneumonia here pass into one another. True lobular pnemnonia is always secondary to the blocking up of air-passages, and especially those of capillary size ; and it may be excited immediately either by the gradual extension of the inflammatory process from the tubes to the air- vesicles, or by the entrance into the vesicles during inspiration of inflammatory products of the tubes, which then act as irritants. But, whatever the cause, we find in the inflamed parts not merely overgrown and modified epithehal cells, but also, accordhig to the stage of the disease, granular and embryonic cells in greater or less pro- portion. The connection of lobular pneumonia with obstruction of tubes is further shown by the facts, that lobular collapse is often associated with it, and that then the collapsed and pneumonic conditions may often be seen to pass into one another by gentle gradations. Closely related to lobular pneumonia is the disseminated pneumonia due to obstruction of small branches of the pulmonary artery, either by embolism or thrombosis, or in the course of pyasmia. In these cases, as in the other, the affected patches are usually of small size, and hmited by the margins of lobules. But there is greater variety of result, especially in pyaemia ; in which, while the patches sometimes present simple en- gorgement, or red or grey hepatisation, they not unfrequently are the seat of hemorrhage, or undergo rapid suppuration or gangrene. Lobular pneumonia is generally best marked towards the basal portions of the lungs, and the superficial patches are often the centres of are^e of pleural exudation. In all forms of pneumonia, even in such as are not of bronchitic origin. PNEUMONIA. 407 there is a tendency to tlie development, sooner or later, of bronchitis. But, apart from this, there is a marked disposition, early in the course of pneumonia, to the effusion into the tubes from the inflamed air-cells of a transparent, very viscid fluid, uniformly stained with blood, and con- taining corpuscular elements ; and, in some rare cases, this effusion, like that in the air-cells, whence it is derived, undergoes coagulation in the bronchial tubes, which thus become filled to a greater or less extent with casts consisting of coagulated fibrine and corpuscles. Notwithstanding the frequency with which pneumonia proves fatal, it does not often go beyond the third of the stages which we have described ; sometimes, however, abscesses form, sometimes gangrene takes place, and sometimes the pneumonia lapses into a chronic condition. Pneumonic abscesses are usually of small size and irregular form ; and in some cases, especially when they are developed in connection with lobular pneumonia, the terminal bronchial tubules are primarily affected, their parietes become destroyed, and the abscesses taking their course assume a dendritic character. Gangrene seldom occurs in simple idiopathic pneumonia ; it is chiefly met with in those cases in which the pneumonia is secondary to or complicated with some other affection. It is characterised by the breaking down of the lung-tissue into a fetid dirty greenish-yellow pulp, and by greenish discolouration of the consolidated tissues around. Not unfrequently the latter are oedematous and present a slightly translucent aspect. The gangrenous condition may involve either an extensive tract of lung-tissue or several scattered patches, or even a single small patch. If it be recent at the time of post-mortem examination its margins will be found ill-defined ; if it have existed for some length of time the gangrenous cavity will probably be bounded by a well-defined edge, Of chronic pneumonia we shall speak at length hereafter. Of the associated morbid phenomena of pneumonia there are several that call for mention, if not for detailed description. We have adverted to the co-existence with it of pleurisy and bronchitis ; but, besides these, we often observe an herpetic eruption on, or in the neighbourhood of, the lips ; jaundice without obvious hepatic disease ; intestinal congestion, with sometimes membranous patches on the mucous surface of the large intestine ; and inflammation of the bronchial glands. Further, the con- ditions which give rise to pneumonia occasional!}^ give rise at the same time to inflammation of other organs. Thus accompanying pneumonia we sometimes find inflammation of the brain, kidneys, bowels, or peri- cardium. It is common, after death, for the right side of the heart to be full of fibrinous coagulum which is prolonged into the pulmonary artery, while the left side of the heart is contracted and almost empty. Symptoms and progress. — Idiopathic pneumonia is frequently ushered in with a day or two of feverislmess or undefinable feeling of illness. The mvasion of the disease is generally marked by a sudden and severe rigor, or a succession of rigors, or in children by an attack of convulsions — ]ohenomena which are attended with a rapid and considerable elevation of temperature, and the usual symptoms of inflammatory fever. The 408 DISEASES OF THE EESPIEATOEY OEGANS. specific signs of the pulmonary affection usually declare themselyes immediately or in the course of the next four- and-twenty hours ; yery rarely they are delayed for a still longer period. They consist in rapidity and shallowness of breathing, with dyspnoea ; dorsal decubitus ; cough, soon attended with blood-stained glutinous sputum ; pain probably in the affected side on drawing a deep breath ; and, according to the stage which the pulmonary affection has reached, fine crepitation, or duhiess with tubular breathing, and augmented bronchophony and vocal fremitus. While these local conditions are m progress, the patient's febrile state continues ; his skin is hot and dry or perspiring, his tongue furred, his pulse accelerated ; jaundice is apt to come on, and diarrhoea ; his urine is scanty and perhaps albuminous ; at the same time, probably, he suffers from hebetude, with delirium, which shows itself chiefly at night. The further progress of the case varies according to its severity. In very mild cases, after two or three days of illness, the patient's temperature falls, his other symptoms subside, and convalescence is established. In other favourable cases convalescence may be delayed for a week, ten days, or a fortnight ; and the amendment may then be either sudden or gradual. In cases which end fatally, death may occur at any period of the disease, even durmg apparent convalescence, and is due, as a rule, either to asthenia or to gradual asphyxia, or to a combination of these conditions. Vie will discnssseriativi some of the more important of the phenomena wiiich attend pneumonia. The respirations are usually hurried and shallow, and may vary in rate fi-om the normal up to 60, 60, or even 70 and upwards in the minute ; when very rapid they are usually attended with a sucking sound in the mouth, and expansile movements of the alse nasi ; there is often, but by no mean necessarily, more or less severe dyspnoea, and generally there are signs of breathlessness when the patient attempts to speak. Cough, which is sometimes very troublesome and even paroxysmal, is almost always present. It is at first dry, but is soon attended with the expectoration of transparent and very viscid mucus, tinged with the colouring matter of the blood. This is usually said to have a rusty tint, and indeed often has ; but it varies in colour between a pale saffron and a bright vermilion, and in the latter case may be mistaken, on hasty inspec- tion, for pure blood. After retaining this character for a few days, the expectoration loses its sanguineous tmt and becomes opaque and greenish (acquires in fact a muco-pm'ulent character), and then gradually diminishes in quantity. In some cases, instead of undergoing this, which may be regarded as the normal change, it acquires a deep purpHsh or reddish- brown tint and at the same time a more watery consistence. This form of sputum has been likened to prune-juice, and is generally a sign not only of increased congestion and escape of blood, but of the access of the third stage, and of an unfavourable issue. In some cases, again, the ex- pectoration becomes distinctly purulent, or is attended ^^ith the horrible fetor which usually indicates pulmonary gangrene. The quantity and quality of the expectoration vary remarkably in different cases. In some PNEUMONIA. 409 there is absolutely none from first to last ; in some the patient never coughs up more than one or two rusty- coloured sputa ; in some the expectoration, even if abundant, never presents the characteristic tint. Pneumonic expectoration is characterised by the presence of a super- abundance of common salt, and contains a considerable quantity of mucus and albumen. There is much variety as to the presence and degree of thoracic pain. In some cases there is no pain whatever ; in some there is a mere sense of heat ; in some the patient has severe stitch whenever he coughs or draws a deep breath. This pain is pleuritic in character, and doubtless due to the co-existence of pleurisy. In the first stage of the disease the most characteristic auscultatory phenomenon is minute crepitation, which maybe audible during the whole of inspiration, sometimes during expiration as well, and not unfrequently only at the end of a deep inspiration, such as that which precedes a cough. In association with this there may be no change on percussion, or there may be high-pitched resonance or hriiit cle pot feU. The second stage is marked by the supervention of dulness over the consolidated portion of lung, with increase of vocal fremitus ; cessation of fine crepitation, and the development in its place of well-marked tubular breathing, and the corresponding whiffing character of cough and voice ; bronchophony ; and in some cases pectoriloquy. There may also be sharp metalhc crepitation or rhonchus. In some cases (probably when the bronchial tubes leading to the consolidated portion of lung are completely obstructed) there is almost total absence of respiratory somids and bronchophony over the affected region. In consequence of the co-existence of pleurisy it is common to get friction- sounds mixed up with those due to pneu- monia ; and it is not uncommon even for the pneumonic signs at the lower part of the chest to be suppressed or replaced by the phenomena indicative of pleurisy. At a later stage, when lung-tissue is breaking down, or resolution is taking place, tubular breathing gives way to a kind of coarse crepitation, to which the name of crepitus reclux has been given. This gradually passes into the ordinary bronchitic rales. It may be added that when the pneumonic lung is consolidated, the movements of the thoracic walls in relation with it become impaired, and the resistance on percussion manifestly increased; and. further, that pneumonia may be present, deep-seated in the lung, or limited to its diaphragmatic or inner surface, and thus altogether escape detec- tion by auscultation or percussion. Some degree of dulness on percussion usually persists long after the disappearance of the other local signs of pneumonia. The cardiac pulsations are always increased in frequency during the febrile stage of the disease, but rarely increased proportionately to the respirations. Often indeed their ratio, instead of being about 4 to 1, sinks to 2 or 1^ to 1. In adults the pulse usually ranges from 80 to 120, but it may reach 180 or more ; in children it is generally more rapid, and may rise to 200 and upwards. Extreme rapidity is generally 410 DISEASES OF THE EESPIKATOEY OEGANS. associated with feebleness, and not unfrequently with irregularity, and is hence to be regarded as an unfavourable sign. In the beginning the pulse is often somewhat full and strong, but sometimes full, soft, and dicrotous ; later on it always becomes feeble and dicrotous. During convalescence it may fall below the normal frequency. While pneumonia is in progress the systemic veins are apt to get over-loaded, and the surface may assume a dusky hue. The blood always presents a large excess of fibrinogen. The tongue is coated, and in some cases becomes dry and brown, and sordes accumulate upon the teeth. Thirst is pretty constant ; there is always loss of appetite, and occasionally sickness. The bowels vary ; sometimes they are not particularly affected throughout the disease ; sometimes they are constipated; sometimes, on the other hand, there is diarrhoea, and this may be dysenteric in character. The occurrence of jaundice during the progress of pneumonia is neither uncommon, nor very important. It is said to occur most frequently in those cases in which the right lower lobe is affected. But there is no more necessary connec- tion between right pneumonia and jaundice than between left pneumonia and it. The urine is scanty, dark-coloured, and of high specific gravity, pre- senting a diminished quantity of chloride of sodium and a great excess of urea and uric acid, with a tendency to the deposition of urates. Some- times it contains also a little albumen, with hyaline, granular, or epithe- lial casts, and even blood. During convalescence it gets much more abundant, pale, and of low specific gravity ; and the urea undergoes dimi- nution, while salt increases. The face is flushed in the early period of pneumonia, and may even be somewhat livid ; the skin is generally hot and dry ; but profuse sweats are not uncommon during the progress of the disease, and generally attend its decline. An herpetic eruption about the lips and alse nasi is almost pathognomonic. The patient at first complains of headache and general febrile pains. He is often drowsy, yet, at the same time, restless, especially at night- time. Delirium is apt to come on early, at first being limited to the night, but subsequently becoming more or less constant. In some in- stances, and mainly in persons who have been given to drink, the nervous symptoms soon assume all the characters of delirium tremens. And again, patients, not otherwise obviously affected in mind, occasionally get suddenly and violently maniacal, the paroxysm possibly abating as sud- denly as it arose. In fatal cases delirium is apt to pass into coma. Muscular tremors and subsultus, with loss of control over the bladder and rectum, are frequently observed in severe cases. The temperature rises rapidly from the time of invasion, so that withm a few hours, at most perhaps twelve, it has almost attained its maximum ; this varies from 100° to 106°, or even more. Thenceforward the tem- perature remains high, probably increasing somewhat, with morning remissions and evening exacerbations, until the time of commencing PNEUMONIA. 411 convalescence, when it suddenly or gradually falls. In tlie former case it may sink to the normal or below it in the course of twenty-four hours. Occasionally m fatal cases the temperature rises rapidly before death. The symptoms of uncomplicated idiopathic pneumonia are collectively so characteristic of the disease that it is almost impossible to mistake their significance. The affections, other than those of the respiratory organs, with which it is most liable to be confounded are typhus and enteric fever. No real difficulty, however, can arise unless the specific characteristics of these fevers be in abeyance, and they be at the same time (as they often are) complicated with secondary pneumonia. It is altogether different, however, in respect of the various forms of inter- current or secondary pneumonia, and of the lobular variety of the disease. These creep on, for the most part insidiously, in the course of other grave affections, which have already probably produced serious pulmonary symptoms, such as dyspnoea, cough, expectoration of serous, mucous, or bloody sputa, lividity of surface, and other indications of embarrassed circulation and carbonic acid poisoning ; their onset is not usually marked by rigors or anything equivalent to rigors, nor is their progress usually attended with the high febrile disturbance which characterises the idio- pathic variety ; and, again, they are not often accompanied by labial herpes, or jaundice, and very often there is, excepting towards the close of the disease, an entire absence of delirium. The supervention of these forms of pneumonia may be suspected in patients, suffering from the various diseases which are apt to be complicated by them, when their symptoms, and especially those referrible to the respiratory organs, be- come aggravated ; but they can only be positively determined by careful physical investigation of the condition of the thoracic organs. It must not be forgotten, however, that lobular pneumonia may be present to a considerable extent without producing the characteristic dulness, the tubular breathing, or the other specific signs of the more uniformly diffused variety of the disease. The auscultatory and percussive pheno- mena indeed may differ little if at all from those which attend capillary bronchitis. The breaking down of portions of lung-structure which occasionally attends the later stages of pneumonia does not reveal itself by any special sign, unless the cavities be such as, from their size or position, to give rise to characteristic auscultatory phenomena. Li rare cases such ab- scesses burst into the pleura, or (the lung being adlierent) perforate the thoracic walls, or form sinuses running down behind the peritoneum, and opening ultimately into the colon or some of the hollow viscera of the pelvis. The occurrence of gangrene is usually revealed by the disgusting fetor of the breath, especially during the processes of coughing and expectoration, and in a less degree by the look and smell of the sputa. Here also the cavities due to the destruction of lung-tissue may perhaps admit of detection. The presence of gangrene is generally attended with marked depression of the vital powers, or in other words, collapse. Pneumonia is always a disease of considerable gravity. Still, in its 412 DISEASES OF THE EESPIEATOEY OEGANS. idiopathic form, it comparatively rarely kills, unless the portion of lung involved be extensive, or both lungs be attacked, or except in the case of persons advanced in years, or of those whose constitutions have been injured by long-continued bad habits, over-work, or disease. The secon- dary form of the disease, and especially the lobular variety, on the other hand, are exceedingly fatal, and may be included among the chief immediate causes of death in the various maladies which they compli- cate. Treatfiient.— There are few diseases for which so many opposite plans of treatment have been employed with reputed success as for pneumonia. It is a disease, too, which, more perhaps than any other, has on this very account been appealed to in proof of the change of type of disease. From the time of Laennec to about the middle of the present century almost implicit reliance was placed in the combmed use of blood-letting, anti- mony, and mercury. Since then, especially dating from the time of Dr. Todd, these remedial agents have been to a large extent discarded, and have got replaced by the free exhibition of alcoholic stimulants. Many, indeed, now regard all medicinal treatment as of little or no importance ; and it is quite certain that a large number of even severe cases recover perfectly if left to nature and the nurse. Li the majority of cases of the idiopathic disease it is probably suffi- cient to keep the patient in bed in a comfortable, well-ventilated room, of medium temperatur-e ; to relieve thoracic pains with mustard plaisters and the like ; to assuage febrile thirst by the exhibition of soda-water, orangeade, or lemonade ; to support strength by the frequent administra- tion of milk or gruel, or some equivalent nutritious fluid ; and to relieve, from time to time, by simple measures, diarrhoea or constipation, and other remediable' derangements of the various organs ; and then, as conva- lescence comes on, to give vegetable tonics, and gradually to improve the diet in respect of both quantity and quality. It is doubtless true, how- ever, that in many cases, the above plan of treatment may be judiciously supplemented by other measures. Bleeding from the arm, or the local abstraction of blood from the chest by cupping or leeches, is certainly followed by relief to symptoms when employed early in cases in which there is high fever and much dyspnoea. We believe that bleeding from the arm is more efficacious than the other methods of bleeding, but in any case it is better to remove sufficient blood at a single operation than to be called upon to repeat it. Counter-irritants and detergents are often serviceable at a later period of the disease, or at the beginning of slight cases in which bleeding is not deemed necessary. They relieve pain, and sometimes diminish difficulty of breathing. Dry cupping is of much value. Some physicians think it well to keep the affected side invested in a large poultice or a layer of cotton-wool ; others prefer the application of ice-bags or cold compresses. We do not think that any benefit accrues, from the former plan, but the latter probably has some advantage- Expectorants, such as ipecacuanha in small doses, may possibly aid those cases in which there is frequent and troublesome cough, with difficulty PLEUEISY. 413 of expectoration ; and, under the same circumstances, tlie addition of a small quantity of opium may be serviceable. Wlien the pulse gets very quick and weak, and delirium is established, especially if the patient present the general symptoms of delirium tremens, diffusible stimulants, such as ammonia, and alcoholic drinks, in quantities to be determined by their effects, are indispensable. With the object of reducing temperature, various agents have been recommended ; ,and pos- sibly one or other of them may sometimes be used with advantage ; among these maybe enumerated cold baths, quinine in large doses, salicylic acid, veratria, digitalis, and aconite. The occurrence of suppuration or gan- grene is a special reason for the maintenance of the patient's strength by nutritious food, stimulants, and tonic medicines. Opium is often of great service, but should not be given, or should be given very cautiously, when the patient is suffering from dyspnoea aud insufficient aeration of the blood. The treatment of secondary pneumonia merges in the l^eatment of the disease it complicates. Its supervention, however, is on the whole a plea, not for depletion, but for the use of stimulants and nourishment. V. PLEUEISY. [Pleuritis.) Causation. — Pleurisy is either idiopathic, or the result of local irri- tation. The former class of cases includes pleurisy arising directly from exposure to cold (the form of pleurisy which corresponds to idiopathic pneumonia and bronchitis) and that which takes place in the course of acute rheumatism. Among the latter class may be enumerated, pleurisy due to extension of inflammation from inflammatory and other affections of the lungs, or thoracic parietes ; that due to mechanical injuries, more especially to the rupture into the pleura of pulmonary cavities, or of ab- scesses of the liver or other neighbourmg organs ; as also probably the pleurisy so commonly associated with the progress of pulmonary phthisis and thoracic carcinoma. In addition to the varieties of pleurisy here enumerated must be mentioned those which are developed in the course of small-pox, scarlatina, enteric fever, pyaemia, albuminuria, and heart- disease, and in respect of which these several affections act variously, sometimes as exciting, sometimes, and perhaps more frequently, as pre- disposing causes. Morbid anatomy. — Inflammation of the pleura, like that of all other serous membranes, commences with hyperaamia of the blood-vessels, pro- liferation of the protoplasmic elements of the tissues, more especially the epithelium, and effusion of inflammatory lymph, comprising various but pretty considerable quantities of albumen, fibrine, and corpuscles. The last two for the most part remain adherent to the surface, forming the so-called ' false membrane ; ' the fluid, containing albumen, fibrinogen, and a variable proportion of corpuscles, accumulates within the serous cavity. The inflammatory process combines, therefore, three elements. 414 DISEASES OF THE EESPIEATOEY OKGANS. which may conveniently be considered independently of one another, namely : first, hypertemia and infiltration of the serous and sub-serous tissues ; second, the formation of a false membrane ; and, third, the effusion of serum. The first of these elements is the first in order of development ; but it seldom attains a high degree or forms a prominent item in the collective inflammatory changes. There is always, however, more or less obvious infiltration — its amount having some relation to the intensity of the inflammatory attack ; and this not unfrequently extends into the connec- tive tissue round about, as, for example, along the interlobular septa of the lungs, and into the tissues of the mediastina, diaphragm, and external thoracic parietes. And thus it occasionally happens that the superficial stratum of lung-tissue becomes involved, that the diaphragm and inter- costal muscles suffer, and that inflammation, commencing in one serous cavity, extends to those in its immediate vicinity. The effusion of inflammatory lymph always begins early. At first it constitutes an exceedingly thin, granular, but more or less coherent pellicle, the presence of which renders the serous surface obviously rough to the finger and deprives it of its polish. This gradually extends in area and increases in thickness, usually becoming at the same time more and more yellow and translucent. The thickness which it may attain varies roughly from that of a mere film up to half an inch or even an inch. The character of its surface presents numerous varieties, which depend partly on the tendency of the lymph itself to be deposited in the form of a network, partly on the attrition to which it is exposed during the movements of the opposed surfaces upon one another, and partly on its stickiness. It thus acquires a more or less irregular ribbed, villous, or retiform character. "When the opposed surfaces of an mflamed pleura are separated by fluid effusion it often happens that trabeculse and bands or septa of inflammatory lymph pass irregularly between them. The attached surface of the false membrane is always closer in texture and tougher than its free surface, and becomes with age more and more firmly united to the proper serous membrane, with which indeed it ultimately gets incorporated. It is here, too, that organisation, with the formation of new blood-vessels, commences — a process which, if the case go on favourably, ultimately pervades the entire thickness of the false membrane, and leads to the blending of the opposed layers, their conversion into connective tissue, and the obliteration of more or less of the pleural cavity. The fluid effusion varies greatly in quantity relatively to the other two products of the inflammatory process. It is difficult in many cases to account for this fact, but occasionally it is e'xplicable in some degree on mechanical grounds. In the first instance the fluid is transparent, yellowish or greenish, and probably presents flakes of lymph floating in it. In many cases it retains this character throughout ; but in some it becomes turbid or opaline, and deposits a little milky sediment on standing. Occasionally it acquires the characters of ordinary pus. It may be added that blood is sometimes extravasated, either from rupture of the new-formed vessels of PLEUEISY. 415 the false membrane or from ulcerative destruction of the subjacent lung- tissue ; that gas is occasionally present — an occurrence due either to an external wound or to some communication between the lung or intestine and the pleura ; and, lastly, that the purulent contents occasionally get fetid. The quantity of fluid effused may vary from almost zero up to three or four quarts. In a large number of cases, especially those in which the pleurisy is due to the extension of inflammation from subjacent parts (as for example, when it arises in the course of peritonitis, pericarditis, lobar pneumonia, or the various forms of disseminated pneumonia) the discharge of serum is very scanty, and the lymph forms a thin film, which may be limited- to the area primarily involved, and that opposed to it, or may gradually creap over the whole pleural surface. Moreover, in such cases it is far less liable to spread from below upwards than from above doAvnwards ; but generally even in slight cases with little effusion it is common for the inflammatory products (solid as well as fluid) to subside to the most dependent part of the pleural cavity and to accumulate there. In other cases, and more particularly, perhaps, in the idiopathic form of the disease, in those varieties of it which attend small-pox and other eruptive fevers, or tuberculosis, and in that due to perforation of the pleura by abscess, effusion takes place rapidly and copiously. The effects of the accumulating fluid are the distension of the pleural cavity, the compression of the lung, and the displacement in different degrees of the surrounding- organs. As the fluid rises in the thorax, more and more of the lung, commencing with its lower part, has its air squeezed out of it. Sub- sequently, perhaps, the whole organ suffers, and consequently becomes remarkably reduced in size, and compressed into the neighbourhood of its root and the upper part of the angle between the vertebrae and ribs. There, in fact, it may lie concealed from view by a layer of lymph con- tinuous with that lining the thoracic parietes ; and the unskilled pathologist might at first sight readily assume that the lung had undergone total destruction. If the lung have been the seat of consolidation, or if it have been previously bound to the parietes here and there by old adhesions, or if the distension of the pleura with fluid be incomplete, the compressed lung will probably hang or protrude more or less irregularly into the pleural accumulation. The abundant presence of fluid causes, in addition to compression of the lung, displacement of the heart and mediastinum towards the opposite side (especially observable when the left pleura is affected), depression of the diaphragm, and expansion of the outer parietes of the thorax, with widening and probably bulging of the intercostal spaces. When suppuration {empyema) takes place (a frequent occurrence in the pleurisy of small-pox, scarlet-fever, measles, and pyc^emia, and in that of women who have just undergone childbirth, and from perforation), all the phenomena just described naturally ensue ; but others due to the presence of pus are probably superadded. The abscess sooner or later tends point. Not unfrequently it opens into the lung ; and often it makes its way through the thoracic parietes, forming, in the first instance. 416 DISEASES OF THE EESPIEATOEY OEGANS. a sinus between the ribs, which probably become exposed and carious, then an accumulation between the ribs and integuments, which, gradually enlarging, may, ere an external opening takes place, develop into a large superficial abscess. The route which such a smus may take, and the point at which it may present, are liable to great variety. Thus sometimes the abscess appears at the upper part of the thorax and even above the clavicle ; sometimes it opens in the loin below the level of the twelfth rib. Much more frequently, however, it occupies some intermediate position. In rare cases the empyema perforates the diaphragm, and it may then take the course of a renal or psoas abscess, and finally open in any of the situations in which such abscesses are liable to open. The ultimate consequences of pleurisy are various. In the great majority of cases the fluid accumulation undergoes absorption, the'partially- compressed lung recovers itself, and the effused lymph is slowly converted into a kind of cicatricial connective tissue, which remains permanently. This may ultimately constitute a mere white opacity upon some portion or portions of the pleural membrane ; or, what is far more common, result in the formation of adliesions between the opposed surfaces. The latter may consist in a mere intervening film of connective tissue, or in groups of filaments and bands of various lengths, or in tissue as close, dense, and tough as cartilage or tendon, and which in process of time may become the seat of calcareous deposit. Adliesions may be limited to one or two points only, or may be generally but irregularly distributed, or may involve the whole extent of the pleura, the cavity of which then ceases to exist. When the lung has long been compressed by fluid (whether serum or pus), and rendered entirely airless, especially if at the same time it has been covered with a thick dense layer of false membrane, the absorption or re- moval of the fluid is probably attended with little or no restoration of the lung ; and the space which that organ occupied becomes filled up by the falling in of the surrounding parts. The mediastina and the heart are drawn over towards the affected side ; the corresponding half of the diaphragm rises, carrying with it the stomach or liver, as the case maybe ; the ribs get retracted, and approximated ; the shoulder falls ; the spine bends in the same direction ; and the patient's carriage undergoes a corresponding change. At the same time the adhesions probably remam abundant and thick, and sometimes oedematous. In many cases, on the other hand, when compression has been less complete, or the adliesions are less strong, convalescence, even after an extreme amomit of pleural effusion, is attended with more or less restoration of the affected lung — an event which often requires considerable time for its completion. ' In some such cases when death has ensued before the entire removal of the fluid, the lung is found to be invested in a fenestrated layer of pretty dense false membrane, which by the general pressure it exerts renders the organ irregularly rounded, while the fenestras permit of irregularly distributed lobulated protrusions of crepitant lung-tissue. An empyema may, after the discharge of its contents, be followed by any of the consequences above enumerated ; but, like other deep-seated PLEUEISY. 417 abscesses, its cavity often fails to get wholly obliterated, and a sinus results, tlirougli wliicli it continues to discharge for an indefinite period. This tendency for an empyema to remain open is occasionably traceable to a carious condition of the ribs. On the other hand, circumscribed collections of pus here as elsewhere sometimes dry up into caseous masses. Lastly, inflammation may attack a pleura already partially or wholly obliterated by adhesions. In the latter case the consequences will pro- bably be congestion, infiltration, and thickening of the pre-existing false membrane. In the former case the effused serum or pus will occupy either a more or less definitely circumscribed space or the whole pleural ca\'ity, divided by bands and septa into a series of inter-communicating loculi. Such limited accumulations of fluid are occasionally met with in the interlobar'; fissures, or between the diaphragm and base of the lung, or between the inner aspect of the lung and the mediastina— situations m which they often escape recognition durmg life ; or even at the upper part of the chest. Their usual seat is below. Symptoms and progress.— The symptoms of pleurisy present great variety, both in intensity and in kind — the differences being due mainly to differences in the extent, position, and intensity of the inflammation, in the circumstances under which it is developed, in the diseases with which it is associated, and in the stage at which it has arrived. The specific symptoms nevertheless are simple enough, and in addition to the signs furnished by percussion and auscultation, principally comprise thoracic pain during respiration, dyspncea, and inflammatory fever. The invasion of idiopathic pleurisy is far from uniform in its symptoms. In some cases the patient complains only of a little feverishness, loss of appetite, and general malaise, together with a stitch or pain in one side when he breathes deeply, or coughs, or twists his body or moves the corresponding arm ; and he may continue to follow his ordinary avoca- tion, until, in the course of a week or two, or more, he is restored to health, or until, at the end perhaps of an equally long time, increasing ilhiess and difficulty of breathmg make him consult a medical man, who may possibly then find the implicated side distended with fluid. In other cases the beginning of the disease (even if there be little fever and the attack prove to be a mild one) is attended with such intense pain in breathing and moving, such rapid, shallow, and gasping respiration, and so much appearance of distress, that it is difficult not to believe that the patient is in extreme and immediate danger. In other cases he is suddenly seized with rigors, or (and this may occur even in adults) an epileptiform attack, followed by high febrile symptoms and the characteristic stitch. In other cases, again, after he has complained for a day or two of some degree of feverishness, and pain in the side, the symptoms, both local and febrile, assume sudden intensity. But, hoAvever the disease comes on, whether with rigors or with none, whether slowly and insidiously or by sudden onset, it rarely happens, unless it be suppurative from the beginning or dependent on the presence of some blood-poison, that the temperature rises above 102° ; often, E E 418 DISEASES Oi^' THE EESPIEATOEY OEGANS. indeed, it does not exceed 100° ; and it may be scarcely above the normal. The condition of the pulse and the other general symptoms have some relation Tvdth the temperatm-e. The pulse is generally full and vibratile or dicrotous, and somewhat increased in h-equency, the skin is hot, the tongue furred, the appetite impaired, the thirst increased, the urine scanty and high-coloured, and the bowels confined. There are probably also headache and general febrile pams. From the beginning the patient has a stitch, which is usually referred to the mammary region, and the presence of which renders deep inspiration and all thoracic movements painful, so that the breath becomes hurried, shallow, perhaps hregular, and frequently attended with an expu'atory groan, and the patient avoids all unnecessary movement. There is usually also some tenderness on pressure and percussion of the aifected side. While these symptoms are present and the pleurisy remains in the so-called ' dry stage,' percussion may perhaps reveal some httle dulness at the base of the pleural cavity, and auscultation may detect, here or elsewhere, some variety of hdction-sound. Cough is often absent, and, when present, dry, or attended only with a little frothy expectoration. It is rarely severe, but is sometimes paroxysmal and troublesome, and always painful. As effusion increases, the pleuritic stitch for the most part diminishes, and may at length wholly disappear. ^leanwhile the febrile temperature and general symptoms of illness may remain at the same level, or undergo some diminution. Dyspnoea may or may not increase ; and it is an im- portant fact that the effusion of sufficient fluid to distend the pleural cavity is in some cases attended with Uttle or no obvious dyspnoea so long as the patient remains at rest. On the whole, however, dyspnoea increases with increase of fluid accumulation ; and the patient not only breathes rapidly, but suffers from much distress and anxiety, gets pale or hvid, even to cyanosis, and presents aU the phenomena of slow asphyxia. The presence of fluid in the pleura is indicated : by dulness on percussion up to the level at which the fluid stands — the level, in many cases, distinctly varying, in relation to the different points of the thoracic walls, ^\'ith the patient's movements ; by suppression of vocal fremitus over the dull part ; and generally by absence of respiratory sounds over the same region. Faint tubular sounds, however, or even an indistinct vesicular murmur is occasionally audible. .Fgophony is usually to be heard about the angle of the scapula ; sometimes, also, marked and loud tubular breathmg about the upper margin of the fluid behmd ; friction- sounds above the level of dulness, especially in front ; and high-pitched resonance or the hndt cle pot fele over the uncompressed portion of lung. When the eff'usion fills the pleural canity, and the Imig is wholly compressed, dulness of the side, with absence of vocal fremitus, becomes general, and both aegophony and respiratory somids disappear more or less completely. The last, however, may generally still be heard about the apex, in front and behind, and thence downwards behmd, between the scapula and spme ; and occasionally, indeed, they remain very feebly PLEUEISY. 419 audible over nearly the whole of the affected side. But, in addition to these phenomena, the heart becomes displaced, the diaphragm thrust down, the side distended and almost immovable, with dilated intercostal spaces, over which, by careful manipulation, fluctuation may sometimes be detected. Convalescence may commence at any stage. In a large proportion of cases, the patient begins to recover before there has been any obvious effusion of fluid ; pain in the side gradually ceases, febrile symptoms (if there be any) subside, and friction slowly vanishes. In other cases con- valescence does not commence until after fluid has accumulated, and more or less of the lung has been compressed. Here, again, convalescence is indicated by subsidence of fever and general improvement in the condition of the patient's bodily functions ; his breathmg becomes more natural, and his appetite returns. At the same time the effused fluid is gradually absorbed, the pleural surfaces come again into contact, and consequently paui may return temporarily and friction be re-established. Indeed, fi'iction is often a more marked phenomenon of convalescence than of the early stage of the disease. It may happen that, with the disappearance of the fluid, the lung enlarges, and healthy respiratory sounds are speedily restored ; but, even in favourable cases, it is usually a long time (it may be months) before friction wholly disappears, and even longer before resonance and respiratory sounds return to the basal portion of the affected side of the chest. In less favourable cases, the lung is restored in part only, or remains permanently collapsed. Then all those changes iu the form of the side and arrangement of internal organs, which have been already described, ensue. But even here some improvement may be hoped for in the course of years. The patient, however, usually remains weakly and short of breath. The common cause of death in simple pleurisy is asphyxia due to the pressure of the accumulated fluid ; the patient may die, however, from syncope or asthenia, and in either case death is apt to take place suddenly. The supervention of suppuration (the development of empyema) is often insidious and unattended with either the aggravation of old symptoms or the occurrence of new ones. The simple long persistence of copious effusion affords presumptive evidence of suppuration. Sup- puration is generally indicated also when there has been, from the begin- ning of the attack, much fever, and rapid filling of the side with fluid ; and especially when, in the course of a case hitherto of only moderate severity, rigors occur, and fever, becoming greatly augmented, continues aug- mented. The local mdications of empyema are not necessarily more pronounced than the general symptoms. In addition to those of disten- sion from mere accumulation, we sometimes observe general or partial oedema of the integuments on the affected side, sometimes distinct bulging of the intercostal spaces, sometimes unnatural distinctness of the superficial veins, and sometimes a circumscribed redness and mduration, or a fluctuating swelling superficial to the ribs, due to the escape of B E 2 420 DISEASES OF THE EESPIEATOEY OEGANS. matter from the plem*al cavity through an mtercostal space into the soft tissues beneath the integuments. We have pointed out that an empyema may burrow in ahnost any direction and discharge itself at almost any surface ; the most important practical terminations of this kind, however, are by perforation of the lung and by perforation of the thoracic parietes. In the former case the patient suddenly expectorates a large quantity of pus, and may continue henceforth to discharge pus either continuously in comparatively small quantities, or at irregular intervals profusely. In the case of discharge through, the thoracic parietes, the abscess first points, and then opens either spontaneously or by operation, and as in the former case pus, in more or less abundance, escapes, and probably con- tinues to escape. The sudden expectoration of pus, or the appearance of an abscess in the thoracic walls, is sometimes the first clear indication that there has been a circumscribed empyema. But it must not be for- gotten that a superficial abscess often communicates, by a comparatively long and tortuous passage, with the internal abscess which gave it origin ; and that hence (in the case of circumscribed empyema) it may be impos- sible to trace it back to its source, and make sure of its empyematic origin. Thus an abscess of the lower part of the pleura may be readily and pardonably mistaken for a perinephritic or lumbar abscess. The progress of a discharging empyema is, as has already been pointed out, apt to be very chronic, especially if the orignal cavity were large — the discharge then often becoming fetid ; and, in dependence mainly on the copiousness of the discharge, the patient becomes emaciated, and presents the ordinary spnptoms of hectic fever. In many such cases, fortunately, more or less complete recovery takes place after a time ; this event is, on the whole, more frequent when the empyema opens through the lung than when it discharges externally — a circumstance which seems to depend in some degree on the much greater tendency there is in the latter case than in the former to the decomposition of the purulent contents. In many cases, on the other hand, the patient sinks slowly and at length dies, worn out and exhausted, or he dies with symptoms of septicaemia , or he is carried off by sudden intrapleural hemorrhage, or asphyxia. It often happens that the communication of an empyema with the bronchial tubes, or directly with the external atmosphere, permits of the entrance of air into the pleural sac, and that hence pneumothorax is established. The supervention of this condition may ordinarily be recog- nised by the presence of augmented resonance over the air-containing portion of the cavity, of the splashing sound caused by succussion, of cavernous resonance, and probably of distinct metallic tinkling. In the foregoing account we have discussed the symptoms mainly of simple miilateral idiopathic pleurisy ; it may be added that the symptoms of the compHcated disease are essentially the same, but that they are interwoven with those of the complicating disorder, and are sometimes masked by them; and further that both pleurae are occasionally im- plicated, with corresponding aggravation of symptoms. We may also add that pleuritic patients, during the period of effusion, usually lie on PLEUEISY. 421 or towards tlie affected side ; and also that tliey much more frequently suffer from cough than might perhaps be gathered from the remarks we have made. The cough, however, is no necessary part of the disease, and is often due to the presence of associated pneumonia or bronchitis. Treatment. — The treatment of ordinary cases of pleurisy is not usually a matter for anxiety. In mild cases of so-called ' dry pleurisy ' the appli- cation of a mustard plaister or other comiter-irritant, the binding of the chest with a broad flannel roller or the affected side with strapping to restrain its movements, and the use of opiates m small doses, will pro- bably be sufficient. In severer cases, in which there is manifest fever and increasing effu- sion, it is often beneficial to apply (according to circumstances) from half a dozen to a dozen leeches to the surface of the chest, to follow up their application by poultices or flannels ^\n:ung out in hot water, and then perhaps after a time by counter-irritants. In these cases, even more than in the former, opiates are of value, if only to alleviate pain and distress. Soda-water, or some other febrifuge medicine, may also be employed. If the effusion still increase, and especially if the patient begin to suffer from shortness of breath, the arrest of the effusion and the removal of the fluid which has akeady accumulated become the chief indications for treatment. For these purposes diuretics, diaphoretics, and purgatives have each been strongly advocated, and among drugs, mercury, antimony, digitalis, and iodide of potassium. "We believe that all such agents are practically useless for the purposes here indicated, and that, if we are to trust in drugs at all, they should be those which, by tending to improve the general health of the system, tend mdirectly to promote healthy action at the seat of disease : we mean tonics, especially iron and quinme. Counter-irritants, and more particularly repeated small blisters, some- times seem to aid absorption. The only other means at our disposal for the removal of fluid, and this is in many respects by far the best, is para- centesis. This operation was formerly greatly dreaded and seldom per- formed except in cases of empyema already pointing. It is in great measure due to Trousseau that, during the last thirty years, paracentesis has come to be recognised as a safe and efficacious procedure in cases of excessive accumulation of simple serum. More recently, especially since the introduction of suction instruments, and through the able advocacy of Dr. Bowditch, the use of the operation has been still more widely ex- tended. The objects to be obtained by paracentesis are : first, the removal of pressure from the lung so as to permit of its redistension ; second, the prevention of death from suffocation ; and, third, the removal of purulent fluid. It is also generally believed, and perhaps correctly, that the discharge of a certain portion of fluid fi'om a distended cavity promotes the absorption of the rest. With the first of the above objects the fluid should be let out early, inasmuch as the longer the lung has been compressed and the more firmly it is bound down by adliesions the less likely is restoration to take place. 422 DISEASES OF THE EESPIEATOEY ORGANS. With the second of these objects the pleura should be ptuictured either when the patient suffers from obvioiis difficulty of breathing, or when, even if dyspnoea seems absent, the cavity is greatly distended. The sus- pected presence of pus is always a legitimate ground for operation. In all these casefe a fine trocar and cannula should be employed ; the instru- ment should be plunged into the chest at a suitable point, always in some situation where the indications of fluid accumulation are best marked, but generally, as recommended by Dr. Bowditch, in an intercostal space directly below the angle of the scapula and above the lower limit of the opposite healthy lung ; and the fluid should be removed either by the aspirator, or by a tube guarded by a valvular fold of goldbeater's skui, so as to prevent the admission of air. The entrance of air, however, though an accident to be avoided as mvohToig additional risk, often has no ill effect. It is not generally advisable to attempt the removal of the whole of the fluid at one time. If pus be present it may be taken away by periodical aspirations, or its free discharge may be maintained through a permanent opening. The best method of treatment is, we believe, to treat the case from first to last antisepticaUy, allo\Ning the pus to escape freely through a large cannula or drainage-tube into antiseptic di'essings, which should be renewed daily. In order to permit of a freer opening than can other- wise be obtained, it is sometimes desirable to resect a short length of one of the ribs. If the case assumes a chronic form, and especially if the discharge becomes fetid, it is important to wash out the cavity daily with a weak solution of quinine, nitric acid, chlormated soda, carbolic acid, or some other antiseptic. The operation of paracentesis with a very fine trocar and camiula, if air be excluded, is perfectly harmless. And for this reason, as well as on accomit of the great importance of preventmg permanent coUapse of the hmg, we strongly uphold the practice of the early and, if necessary, repeated removal of pleuritic fluid. Again, it is of little practical im- portance if in attempting paracentesis we womid the lung, kidney, or other neighbouring organs, and hence, although we recommend caution, we advocate early exploratory puncture when there is reason to suspect the presence of circumscribed accumulations of pus. In the treatment of chronic pleinisy, or empyema, and during the whole period of convalescence, the importance of tonics, good diet, and change of air cannot be over-estimated. VI. CIEEHOSIS. {Chronic lyneimonia. Fibroid plithisis.) Definition. — A distinction is not unfrequently made between cirrhosis and chronic inflammation of the lungs. It is difficult, however, to appre- ciate in what the difference consists ; and we prefer, therefore, to regard the two conditions as identical. We mean by these expressions indura- tion of the lung, by the development of nucleated fibroid tissue, either around the bronchial tubes, or in the interlobular septa, or m the walls of CIEEHOSIS. 423 the air-cells, or in all these situations at once, and the consequent gradual effacement of the air-cells. Causation. — There is reason to believe that cirrhosis is an occasional result of ordinary acute pneumonia ; it is far more frequently, however, a sequel of catarrhal or lobular pneumonia, and of chronic pleurisy with effusion. A not uncommon cause is the habitual inhalation of solid parti- cles, such as those of coal-dust, mill-stone g-rit, copper ore, flax-dust, and the like, by those whose occupations expose them to the danger of such inhalations. It is certain that it occasionally ensues on simple chronic bronchitis and on the retrogression of both grey and caseous tubercular deposits. The question how far, in some cases, it is to be regarded as the result of a constitutional taint, has been often raised. There is no doubt that we occasionally meet with a similar condition simultaneously m- Toh^ng several organs — more especially the lungs, hver, and kidneys — a fact which is certainly entitled to some weight on the affirmative side of the question. But, on the other hand, it must be remarked that hepatic cirrhosis is traceable, in the great majority of cases, to the influence of alcoholic irritation of the matrix of the liver, and that pulmonary cir- rhosis (independent of tuberculosis ) is usually limited exclusively to one or other lung — facts which are at least as weighty on the opposite side. Morbid anatomy. — Cirrhosis of the lung consists essentially in the gradual invasion of the solid tissue of the organ by a nucleated fibroid growth. This, on the one hand, surrounds and involves the bronchial tubes (especially the smaller ones) and the vessels which accompany them ; on the other hand, invests the lung itself (which is then usually strongly adherent to the parietes) and separates its lobes from one another ; and from both sides is prolonged into the inter-lobular septa, so as to divide the lung-tissue by bands of fibroid tissue of cUfl'erent degrees of density, thickness, and visibihty, into a series of polygonal islets. With the further progress of the disease, the same khid of thicken- ing takes place irregularly in the walls of the air-cells, so that before long the cut surface presents a coarse retiform arrangement of dense fibroid tissue ; and this, gradually mcreasing, finally renders the whole organ, or portions of it, uniformly dense, hard, and airless. Although in cirrhosis there are usually both induration of the tissues around the bronchial tubes and dense adhesions between the opposed pleural surfaces, it often happens that the most obvious, if not the primary, change is that which pervades the ultimate tissue of the lungs. This is necessarily the most important. Accompanying the mterstitial growth of fibroid tissue, there is usually a more or less abmidant deposit of black pigment in irregular patches. This is natural in the lungs of persons advanced ui age ; but m cirrhosis it is often, if not always, excessive. The pigment is seated in the thickened walls of the air-cells and especially in the comiective tissue which surrounds the bronchial tubes and vessels, and separates lobules from one another. It is always abundant also in the bronchial glands. It may often be found distinctly contained in the comiective-tissue cor- 424 DISEASES OF THE EESPIEATOKY ORGANS. puscles, and taking the course of the lymphatic vessels. There is good reason to believe that it is to a large extent carbonaceous matter of ex- traneous origin, which has been inhaled into the lungs, has been absorbed by the mucous surface of the respiratory tract, and has then got deposited in the tissues and taken up by the lymphatics. The presence of pigment usually gives a peculiar mottled aspect to the sectional surface of the cirrhosed lung ; but, if in great abundance, it renders the tissues uni- formly and intensely black. The ultimate effect of cirrhosis of the lung, like that of the same con- dition in the liver, although it may perhaps under some circumstances, cause temporary enlargement, is to produce gradual contraction and diminution of the organ. The progress of the disease is further always complicated with dilatation and other changes in the bronchial tubes,. and not unfrequently with equivalent affections of the air-cells. The larger tubes are generally dilated, the fibroid and muscular bands which mark their mucous surface with longitudinal and transverse ridges are hy- pertrophied and produce a coarsely reticulated appearance, and the mucous membrane itself is probably congested and thickened. The chief changes, however, occur in connection with the smaller tubes, which in some cases are dilated into bulb-ended channels ; sometimes terminate in round or sub-globular cystiform expansions, from the size of a cherry to that of a small pea ; sometimes open (several of them in common) into cysts or cavities of large size and irregular form ; sometimes are continued into recently-formed and progressing cavities, which, when small, may easily be recognised as originating in the ulcerative destruction of the walls of the smaller tubes and air-passages. The mode of origin of dilated tubes m this and other pathological conditions will be considered hereafter. It will be sufficient to say here, that, in many cases, so-called ' dilated tubes ' are merely tubes in communication with cavities whose walls have under- gone cicatrisation ; that there is (as might be supposed) a strong tendency for the adventitious fibroid growth of cirrhosis to undergo liquefaction under the influence of inflammatory processes commencing at the bronchial surface ; and that the formation not only of vomicae, but probably also of paany dilated tubes, are referrible to such liquefaction. Ordinarily in cirrhosis the air-cells undergo gradual obliteration, their diminishing cavities bemg sometimes filled with disintegrating epithelial and other cells ; but not unfrequently more or less emphysema is developed at the- same time. When cirrhosis is limited to some comparatively small tract of lung, emphysema is common in the tissue which immediately bounds the indurated patch. Occasionally, also, the formation of a dense fibrous reticulum throughout the Imig is associated to a greater or less extent with the breaking down of the thickened walls of dilated air-cells, so that the cut surface of the lung becomes not altogether unlike that of a coarse sponge. We have an impression that the condition last described may ensue on the retrogression of a crop of miliary tubercles. Cirrhotic lungs present great variety of appearance and character ; at the same time it is easy to see that, however much they may differ from CIKKHOSIS. 425 one another in the stage of the disease which they have reached, in the amount of pigment which is present in them, in the condition of their bronchial tubes, and in the tendency to the formation of vomicae, they are all linked together by the community of their origin in simple fibroid overgrowth. The following are some of the varieties of cirrhosis which have been described and named -.—Bed induration — the name given to an early or slight condition of the disease, in which the lung is large, red, and fleshy, and, although denser than natural, and infiltrated to some extent with adventitious growth, is still generally crepitant : Brown induration — the name employed to designate a condition of lung in which the capillaries are dilated and thickened, and in which the colour of the organ has a yellowish-brown tint, and the fluid exuding on pressure is similarly coloured, in consequence of the presence in the tissues of the lung of the colouring matter of the blood in the form of pigment-granules ; brown induration is especially an accompaniment of heart-disease : Grey induration — the name sometimes applied to the condition of the lung in advanced cirrhosis, when the organ is extensively infiltrated with fibroid matter and presents in consequence a general greyish tint and a more or less translucent aspect : Black induration — which is sometimes used as the designation of that form of cirrhosis in which the cirrhotic tissue is largely infiltrated with black pigment, and of which the most striking examples are furnished by the lungs of persons working in .mines or otherwise exposed to the inhalation of soot or other carbonaceous matters. The pulmonary aftections which are so frequently the causes of death amongst those who are engaged in certain avocations, as, for example, among miners, colliers, flax-dressers, millstone-grinders, and the like, and which are commonly known as the phthisis of those who are thus respectively engaged, are mostly, as has already been indicated, of the nature of cirrhosis. They originate in the bronchitis which is caused and maintained by the constant inhalation of solid particles ; of which many get deposited in the solid tissue of the lungs, and remain there permanently. The fibroid infiltration slowly supervenes. It appears from Dr. Greenhow's investigations that the nature of the dust inhaled does not exert any specific influence over the morbid changes which ensue. The nature of the imbedded particles can generally, however, be pretty readily recognised with the aid either of the microscope or of chemical reagents. Symptoms. — The symptoms of cirrhosis of the lungs, apart from those of the numerous conditions which complicate it, and from those of the morbid conditions out of which it may have arisen, scarcely admit of description or recognition. The disease is one the progress of which is exceedingly chronic, and may be prolonged for five, ten, or even fifteen years. It is easy to see, if any large extent of lung-tissue be involved, that the patient must sufl'er from progressive breathlessness ; that, from the obstruction which the indurated and contracted lung-tissue opposes to the pulmonic circulation, hypertrophy and dilatation of the right side of 426 DISEASES OF THE KESPIEATOEY OEGANS. the heart must ensue, to be followed sooner or later by general anasarca ; that there must gradually supervene impah-ment of nutrition, failure of the general powers of the body, weakness and emaciation ; that the joulmonary changes must result in impairment of thoracic movement with retraction of the thoracic parietes, dulness on percussion, and either suppression of the respiratory sounds, tubular breathing, or (if there be secretion into the tubes) the various unnatural sounds which bronchial accumulation is competent to induce. Generally, moreover, there are present (at all events at some stage or other of the affection) more or less bronchitis with secretion, more or less dilatation of the tubes or air-cells, more or less breaking down of tissue with the formation of vomicae, and more or less distinct mflammatory action ; and the symptoms of these conditions must be added in order to have a true picture of the symptomatic phenomena of cirrhosis of the lungs. Briefly, then, it may be stated that a patient with cirrhosis presents the following symptoms variously combined : — He has dyspnoea, especially on exertion, which gradually increases upon him, and is generally aggravated during the winter months, or by the occurrence of ca,tarrh or pulmonary inflammation. Pallor and lividity of surface, with congestion of the nose, fingers, and toes, often supervene sooner or later. Cough is almost always present, and in some cases is very severe ; it may, however, be wholly absent, especially during warm weather. It may or may not be attended with expectoration ; but expectoration is often profuse, especially when the cirrhosis is complicated with dilated tubes or vomicae, and generally muco -purulent or purulent. Under the same circumstances it is liable to be fetid, and in the case of colliers and others, almost black from the presence of pigment-particles. Haemoptysis is not unfrequent. In many cases the sputa are merely streaked with blood as in ordinary chronic bronchitis ; in some cases, however, profuse hemorrhage occurs from time to time. This is due sometimes to perforation of blood-vessels in the course of destructive changes, sometimes to intense hypertemia (probably of inflammatory origin) of the hning membrane of the dilated tubes. The auscultatory and percussive phenomena will be considerably modified according as dilated tubes or cavities are absent or present, and according as these are full or empty of fluid. The pulse may at first present little departure from the normal, but as the disease progresses it becomes rapid and weak, and sometimes irregular ; and at the same time, as has been pointed out, general anasarca may ensue. Elevation of temperature and other febrile symptoms are very variable in their occur- rence. Not unfrequently, at certain periods of the affection, there is a total absence of them. But much more commonly the patient presents the usual symptoms of hectic fever : elevation of temperature, which, how- ever, is liable to fluctuations ; perspirations ; loss of appetite ; sometimes vomiting and diarrhoea ; and gradually mcr easing emaciation and debihty. The local and general symptoms and history of cirrhosis not unfrequently closely resemble those of retraction of the lung after simple pleurisy, or those of chronic bronchitis with emphysema, or those of phthisis. TUBEECLE. 427 Treatment.— Out principal aims in the treatment of cin-liosis slioiild he, by attention to hygiene and diet, to arrest the progress of the morbid process, to prevent the supervention of complications, and to maintain the bodily strength. For these purposes change of scene, removal to a mild but equable and bracmg air in the summer, and to a warm southern climate in the winter, the avoidance of night ah:, exposure to sudden chills, over-fatigue and the like, the use of wholesome and abmidant diet, with a moderate amomit of stimulants, and the exhibition of quhiine, iron, cod-Hver oil, or other tonics, are of ^-ital importance. AYhen the cirrhosis is due to occupation the patient should give it up and follow some more healthy pm-suit. But, m addition, symptoms, as they arise, will necessarily call for treatment : cough and expectoration may demand opiates and expectorants, hemoptysis astrmgents, shortness of breath diffusible stimulants, diarrhcea medicmes which check the ahiiie flux. It is needless, however, to pursue the Hst of possible comphcations and to indicate the various methods by which they may severally be reheved. YII. TUBEECLE. {Laryngeal and imhnonary phtliisis. Tubercular lAeurmj.) Causation. — The etiology of tuberculosis is a subject of the highest ■interest, and at the same time one of extreme difficulty. There are few affections in which the influence of hereditary taint is st) strongly sho-UTi. It is well-estabhshedthat children of tubercular parents are pre-eminently Hable to tubercular affections, and not only so but that, if one parent be tubercular, the children who most resemble that parent in conformation are usually most prone to be affected, and, further, that parents, them- selves seemingly healthy, or at all events free from tubercle, not im- frequently, beget a family of children who die one after the other of pulmonary phthisis. In the case last referred to the tubercular tendency of the children may be due either to the transmission of a taint which is latent as regards the parent, or to the fact that one or other of the parents is scrofulous or syphihtic, or in some other way impaired ui health. But tuberculosis does not occur only among those who inherit a tendency to it. CHmate has certainly some influence in its iDroduction ; for it is much more fi-equent in temperate climates than it is m those which are either very cold or very hot ; and Dr. Buchanan's and Dr. Bowditch's researches seem to prove that m temperate chmates it pre- vails far _^more extensively in low, damp situations than in such as are elevated and dry. There is no doubt that conditions which produce deterioration of the general health tend ultimately to induce tuberculosis ; among which may be enumerated inadequate nourishment, excessive work with insufficient rest, and want of fresh air. Hygienic defects of this kind are especially injurious to the young. Other causes of tubercu- losis are occupations which necessitate the inhalation of solid irritatmg 428 DISEASES OF THE EESPIEATOKY OEGANS. particles (for there is no doubt that tuberculosis, as well as cirrhosis, and not unfrequently both in combination, are thus produced), and the cachexiae which follow or attend upon enteric fever, measles, hooping- cough, syphilis, diabetes mellitus, and various other diseases. No age is free from liability to tuberculosis ; it is extremely common in young children ; but, putting these on one side, the age of greatest liability is from twenty to thirty or thirty-five. The influence of sex is uncertain. Morbid anatomy. — 1. Laryngeal tubercle always manifests itself in the form of minute grey granulations, which may easily be overlooked, but, which, nevertheless, present all the microscopical and other charac- teristics of grey tubercles. They are situated in the substance of the mucous membrane, and tend after a time to form small round shallow ulcers, which by their coalescence constitute sinuous but rarely extensive tracts of ulceration. It is very common in the course of pulmonary phthisis for the larynx to get implicated ; but to what extent this implica- tion, in many cases, is due to actual tuberculosis of the larynx is a matter of considerable doubt. The mucous membrane becomes congested, oede- matous, and thickened, and excoriations appear, which sooner or later extend deeply, exposing the cartilages, and causing their erosion. These deep ulcers are most commonly situated towards the posterior extremities of the vocal cords, and involve the anterior processes of the arytenoid cartilages. All the cartilages, however, are liable to be thus affected. The trachea and bronchi are subject to the same pathological changes as the larynx ; their mucous membrane gets congested and thickened, excoriations manifest themselves with or without the pre-existence of miliary tubercles, and occasionally the cartilaginous rings become ex- posed and eroded, and even detached and expectorated. 2. Pulmonary tubercle. — Those who deny the identity between grey and yellow tubercle will, equally with those who maintain the opposite thesis, admit that the two varieties often co-exist in the same individual ; and, on the other hand, those who believe in their identity will, equally with their opponents, acknowledge that cases of tuberculosis are not un- frequently met with which are apparently characterised by the exclusive presence of one or.other form. It will be convenient therefore, while acknowledging their tendency to pass the one into the other, to describe them independently, as we not unfrequently meet with them in typical cases. Grey tubercles vary in bulk from mere points up to the size of a small pea, but do not usually exceed that of a pin's head ; they are grey, some- what hard, and slightly translucent ; they are sometimes sparsely scat- tered, sometimes closely set, in some cases distributed with tolerable uniformity, in others forming scattered groups or clusters of various sizes. In the last case, those in the central part of a group coalesce, to a greater or less extent, and form tracts individually as large as a marble or walnut. The development of grey tubercles is occasionally limited to one lung ; more frequently it comprises both, and may then involve them equally or unequally. They are in some cases distributed throughout the whole organ, in some limited to certain regions, generally the apex ; and for the TUBEECLE, 429 most part, even when universally distributed, tliey are most numerous and advanced in the upper part of the lung. The growth of miliary tubercles is always, in a greater or less degree, associated with other morbid conditions of the lung ; these are especially congestion and oedema of the pulmonary tissue, consolidation of the intermediate tracts of lung, and bronchial catarrh mainly implicating the minuter tubules. The con- solidation may be of the nature of ordinary pneumonia, with impaction of the air-cells with corpuscular elements ; or of the nature of cirrhosis, with fibroid thickening of the walls of the air-cells and of the other con- nective tissues of the lung. A later change is the breaking-down of the consolidated bits of lung and the formation of vomicas. Such cavities usually commence at the apex, and may be limited to that part. They may vary from the size of a pea up to that of an orange or beyond, and may present every variety of form. They are usually surrounded wdth a greater or less thickness of indurated tissue, and often present abrupt well-defined margins. For the most part, miliary tubercles are developed with great rapidity, and tend to a rapidly fatal issue. Occasionally, however, their progress is arrested, and the patient recovers, but with permanent damage to the tissue of the lung. When this happens in respect of discrete tubercles the organ gets seamed throughout with minute patches of cicatricial tissue, the fibres of which have somethmg of a stellate" arrangement, and within the limits of which the lung-tissue presents, from the presence of concurrent emphysema, a coarsely spongy character ; and occasionally in the centres of the scars minute fibroid knots or concretions may be recognised. When the affection becomes arrested after groups of tubercles have got consolidated by the intervention of inflammatory over-growth, more or less extensive tracts of tissue, probably studded with cretaceous or caseous masses and black pigment, assume a cirrhotic character, and contract, while usually emphysema arises in their immediate neighbour- hood. Further, when cavities have formed, they either shrink and become lined with a definite smooth membrane, continuous with that of the bronchial tubes, or possibly, in rare cases, get obliterated. Yellow tubercles in process of development present an opaque, yellomsh- white, slightly granular character. They are dry and friable, furnishing no juice, but readily yielding, on being scraped or squeezed, a pulpy detritus. They are usually of larger size than grey tubercles, and present for the most part a well-defined outline and more or less irregular form. They evidently comprise groups of air-cells or lobules, and are hence polygonal when cut across ; but, when divided in the direction of the bronchial tubes, are found to involve the minuter branches of these and to be arranged upon them in a lobulated or foliaceous manner. In their early stage a cross-section will probably have the size of a split tare or pea ; they soon, however, partly by indi\ddual growth, partly by coalescence, assume larger dimensions. Occasionally, as the result of such coalescence, large tracts of Imig-tissue, possibly the whole of a lobe, become uniformly infiltrated — a condition to which, in the nomenclature 430 DISEASES OF THE EESPIEATOEY OEGANS. of the College of Pliysicians, the name of ' chronic pneumonic phthisis ' has been given. Yellow, like grey tubercles, usually commence at the apex of a lung, sometimes at the apex of the lower lobe, and gradually spread thence downwards. They are usually, too, more advanced at the apex than else- where. It must not be forgotten, however, that they may originate and attain their most advanced stage in any part of the lung. The tendency of yellow tubercles to undergo liquefaction is far more marked than that of grey tubercles ; so that, although a lung may become very largely involved without breaking do'v\ai, in the great majority of cases softening takes place both early and extensively. In one case of rapid phthisis which came under our notice, destructive softening must have been almost coetaneous with the development of the tubercles, for though both lungs were thickly studded with cheesy masses, there was scarcely one of them which was not almost wholly converted into a flocculent-walled cavity. The lungs, indeed, were lighter than natural, and appeared at the first glance to have large air-containing bullae thickly disseminated throughout their substance. The vomicae of this form of phthisis usually originate in the upper parts of the lungs and there attain their chief development. They commence with the liquefaction of those portions of the masses which immediately bound the bronchial passages and smaller tubules ; so that, in the first instance, though roundish when cut transversely, they possess a dendritic form when the incision takes the course of these channels. A cavity once commenced increases more or less rapidly in size, and ere long, by coalescence with neighbouring cavities, may assume gigantic proportions. It may even occupy the whole of a lobe. Large cavities are usually irregular or anfractuous m form, and often crossed by bands of condensed tissue, comprising vessels (mostly impervious) of considerable size. Cavities in process of formation present ragged parietes ; but when they have ceased (as they often do cease) to enlarge, their surfaces get smooth and even polished, and the tissues round them indurated. Yellow tubercle not unfrequently undergoes retro- gressive changes. These consist in its gradual conversion, first into a mortary, and lastly into a calcareous, inert mass, encapsuled by a dense fibroid envelope. The contraction of cavities, the calcareous conversion of tubercular masses, and the induration of the tissues around, are always attended with diminution in the bulk of the afl'ected portions of lung, and compensatory expansion or dis^Dlacement of the neighbouring healthier tissues. In both forms of tuberculosis it sometimes happens that gangrene takes place ; or that profuse hfemorrhage occurs either from intensely congested surfaces or from perforation occasionally preceded by aneurysmal dilatation of an artery ; or that the tubercular vomica, like any other abscess within the chest, opens into the pleura, or through the outer thoracic walls, or perforates the diaphragm. The aneurysms above referred to are usually about the size of a pea ; biit they may be as large as a filbert or a chestnut. TUBEECLE. 431 3. Pleural tubercle differs in no important respect from tubercle of other serous membranes. It appears abnost invariably in the form of minute greyish spots variously arranged, sometimes occupying the serous membrane itself, sometimes apparently imbedded in the substance of recently-formed false membranes. These bodies may be scattered over the whole surface, or limited to certain spots ; and are generally, even when widely spread, most thickly congregated in certain regions where it may be presumed they originated. They are often specially numerous between the lobes and upon the diaphragm. When very abundant they touch one another, or coalesce so as to form extensive tracts. When this takes place the opposed pleural surfaces are usually adherent, and the tubercular lamina? appear to occupy the substance of the intervening false membrane. As the tubercles increase in size and run together they assume an opaque buff colour and become friable, resembling in look and consistence cheesy masses in the lungs. Pleural tubercle is, in the great majority of cases, associated with tubercle of other organs ; occasionally, however, it is primary in the pleurre, and may even be limited to one. It is commonly associated with tubercle of other serous membranes ; and, as might be supposed, is usually coincident with some amount of similar disease in the lungs. It is nevertheless a fact that it is by no means a frequent complication of pulmonary phthisis, notwithstanding that pleuritic inflammation is an invariable attendant on that affection. Tubercle of the pleura is not necessarily accompanied by inflammation of that membrane ; in most cases, however, sooner or later, and sometimes from the very commencement, inflammation takes place, and the usual phenomena of pleurisy then combine with those of tuberculosis : false membrane is formed, effusion takes place, perhaps suppuration ensues, and indeed any one or all of the various events which have been already fully considered under the head of pleurisy are apt to supervene. It would be out of place here to enter at any length upon the associated morbid anatomy of tubercular afl'ections of the respiratory organs, which, however, plays so important a part in the progress and symptoms of ordi- nary cases of pulmonary phthisis. It will be sufficient to draw attention to the fact, that tubercles are rarely limited to these organs, and that their simultaneous development in other organs may induce consequences of much more urgent gravity than those referrible to the laryngeal, pulmonary, or pleural affection. Among the more important complica- tions of pulmonary phthisis are inflammation of the lungs and pleurte, tubercular meningitis, tubercular peritonitis, and tubercular ulceration of the intestine, to which may be added fatty and lardaceous degenerations of various organs. Symp-tovis and progress. — So much attention has been devoted to the symptomatology of pulmonary phthisis, so much has been written on this subject, and so elaborate are the details with which we have been furnished, that it seems at first sight an almost hopeless task to endeavour to com- press our description of the symptoms of the disease within reasonable limits. When, however, we bear in mind that, in most of the elaborate 432 DISEASES OF THE EESPIEATOEY OKGANS. accounts to which we refer, the symptoms of pulmonary phthisis are made to inchide the symptoms due to tuberculosis of all other organs, those referrible to the many complications which are apt to supervene in the course of phthisis, and besides these the symptoms of the various forms of ill-health which so often precede phthisis, it will be seen that the symptomatology of the pulmonary affection has been overlaid with an abundance of matter which, however important, does not immediately concern us now. The following description will be limited almost ex- clusively to the symptoms which are referrible to the affections of the respiratory organs themselves. In a large number of cases the invasion of pulmonary phthisis is remarkably insidious. A patient who has previously, it may be, enjoyed robust health slowly and without obvious cause becomes weak and thin, probably suffermg at the same time from slight remittent febrile symp- toms ; or, possibly after exposure to the causes of catarrh, he becomes the subject of dry irritating cough which he cannot shake off, and ere long experiences loss of flesh and strength ; or he suffers in the first instance from slight symptoms of laryngeal hiflammation, which slowly increase in severity ; or, without previous warning, he has a sudden and profuse attack of haemoptysis, on the subsidence of which some of the various symptoms above considered supervene ; or a patient, subsequent to an attack of fever or pneumonia, or in the course of some wasting disease, is attacked with cough, and the symptoms of phthisis gradually replace those of the primary malady. The frequent occurrence of gradual deterioration of health, without the presence of any specific symptoms of disease, prior to the obvious development of pulmonary phthisis, has induced many physicians to believe in the existence of a stage of phthisis antecedent to that of tubercular deposition— a belief based on utterly insufficient data. But in whatever way phthisis first manifests itself, the symptoms of the fully-developed disease ere long become established. These consist mainly in cough, attended with muco-purulent expectoration, and occa- sional or frequent haemoptysis ; hectic fever, marked by periodical febrile exacerbations, i^rofuse perspirations, especially at night time, rapid emaciation and loss of strength ; and the local evidences, on percussion and auscultation, of progressive involvement and destruction of lung- tissue. We proceed to discuss the various symptomatic phenomena of phthisis seriatim. In a certain number of cases the symptoms of which the patient first complains are referred to the larynx ; and it may be that throughout the whole course of the affection the laryngeal symptoms continue chiefly distressing to him. These differ scarcely if at all from those of ordinary chronic laryngitis except in their obstinacy and pro- gressive character, and in the gradual supervention of emaciation and loss of strength, and of indications of advancing pulmonary disease. Li a still larger number of cases, and indeed in a very large porportion of the entire number of cases, of phthisis, laryngeal symptoms come on TUBERCLE. 433 sooner or later in the course of the pulmonary disease. These are some- times simply irritative or catarrhal, and subside ; but more frequently they resemble in all respects, inclusive of their causation and progress, those of the earlier laryngeal affection. It is a question which can scarcely be said to be even now clearly decided, whether laryngeal phthisis (as it is termed) ever actually precedes the pulmonary disease. The general belief is that it is always secondary, and there is no doubt that at post-mortem examinations laryngeal phthisis is never found un- associated with tubercles in the lungs. The laryngoscopic characters of laryngeal phthisis have been described under the head of chronic laryngitis. The presence of cough is one of the most constant and striking phenomena of phthisis. It generally begins early, and increases in frequency and severity with the progress of the disease. In the begin- ning it is usually short and hacking, and either dry or attended with scanty glairy expectoration. It is probably then due to slight bronchial irritation only, and the discharge consists of bronchial mucus. With the advance of the disease and the breaking down of the pulmonary tissue, the sputa usually become increased m quantity, often very profuse, and at the same time opaque, yellowish or greenish, and purulent, often nummulated, sometimes fetid. The expectoration is not necessarily distinguishable from that of bronchitis. It is furnished partly by the inflamed bronchial tubes, partly by the tubercular vomica ; and some- times, by careful microscopic examination, pulmonary tissue may be detected in it. The cough has no special characteristics by which it may be distinguished from that of bronchitis, or (if the larynx be affected) from that of laryngitis. It presents, however, considerable differences in different cases ; in some it is scarcely a matter of complaint from first to last ; in some (especially chronic cases) it presents periodical variations, increasing, for example, in the winter or cold weather, subsiding in the summer time ; but in the majority of cases it is a serious and increasing cause of distress. Haemoptysis is one of the commonest incidents of pulmonary phthisis. It occurs at some period or other in the course of the great majority of cases. Sometimes it is the first indication of the disease ; more fre- quently it comes on at a later period. It may be only sufficient to tinge or streak the expectoration, or it may be limited to an occasional succes- sion of sanguinolent sputa, or, again, it may be sudden and profuse — the patient bringing up in a very short time half-a-pint, a pint, or even a larger quantity of blood. It may be so profuse, indeed, at any stage of the disease that the patient ia suddenly carried off either by choking or by syncope. But these sudden and profuse hemorrhages are usually among the earliest symptoms of phthisis. Difficulty of breathing is a common but not necessary phenomenon. It may be severe if the larynx be largely affected, or if there be much accumulation in the bronchial tubes, or effusion into the pleura;. In most cases, however, the patient makes little or no complami on this F F 434 DISEASES OF THE KESPIEATOEY OEGANS. score ; he no doubt readily loses wind on even slight exertion, and liabittially, perhaps, the respirations are augmented m frequency ; but when he is at rest his breathmg does not usually trouble him. The patient often suffers from stitch or burning or other Mnd of pain in the chest. This may occur on one or both sides, often at one apex, but is not limited to any one part. Pain is by no means always present ; some patients never experience it ; others suffer from it occasionally only ; in some cases it is pretty constant and severe. It is iisually augmented by movement of the chest, and especially by deep breathing or coughing. It is mostly due to pleuritic complication. The physical signs of pulmonary phthisis are such as would naturally arise from progressive consolidation and contraction of the lung, the formation of cavities, the accumulation of secretion in them and in the bronchial tubes, and pleuritic inflammation and exudation. In consider- ing the significance of the physical signs we must never forget that, as a rule, tuberculosis commences at one or both apices of the Imigs, that excavation usually first takes place in the same situation, and that the morbid processes tend to travel downwards. Nevertheless, the earliest local mdications of pulmonary tuberculosis, even if the tubercles as usual be most abundant at the apex, are occasionally discovered at the base of the lung, being due either to concurrent pleurisy or to progressive subacute pneumonia. The presence of small discrete tubercles in the lungs, even if they be very numerous and close-set, does not necessarily affect the character of the percussion note or the sound which may be heard on auscultation. We can, therefore, readily understand that pulmonary tuberculosis may- have made considerable progress before givmg distinct local indications of its presence ; and we must not too readily assume, because we hear nothing amiss, that, therefore, the patient is free from tubercle, or that he is in the so-called ' pre-tubercular stage.' Generally, however, even if there be no dulness, there are bronchitic signs (rhonchus, crepitation, and the like), and these are probably most marked over the upper part of one or both lungs ; or pleuritic friction, or jerky respiratory sounds, which have sometimes been attributed to the presence of circumscribed patches of pleuritic inflammation, may be audible in the same situation. When, however, tubercles have coalesced into masses, say from the size of a walnut upwards, and abut upon the surface, thek presence materially affects the quality of the percussion note over the area to which they correspond. There is then duhiess on percussion, the extent and com- pleteness of which are determined by the extent and bulk of the con- solidated tract. Duhiess from tubercular disease is generally indicated by the facts : that it occurs mainly at the apex m front or behmd ; that it is rarely equal in these situations, and still more rarely equal in the corresponding points of both apices ; and that it tends gradually to extend from above downwards, so as to involve more and more of the tissue of the lung. In association with dulness, there are usually increased sense of resistance on percussion, increase of vocal fremitus, diminished move- TUBEKCLE. 435 iiient during respiration, and flattening. The last condition is especially noticeable when it occurs beneath the clavicle. The auscultatory pheno- mena at this stage are mainly those which attend the second stage of pneumonia — tubular breathing, together with (if the tubes contain secre- tion) rhonchus, gurgling, crepitation, or occasional clicking or creaking sounds, bronchophony, and probably also pectoriloquy. It need scarcely be added that, if the consolidated patch be imbedded in the substance of crepitant lung, little or no indication of its presence may reach the ear. The phenomena which attend the presence of vomicae are very various, and by no means always characteristic. The existence of one or several small cavities in the midst of consolidated tissue does not obviously modify the percussion note due to the consolidation. Large cavities, indeed, surrounded by a thick layer of condensed lung-tissue, generally yield almost absolute dulness. In other cases, however, the formation of a cavity in consolidated tissue is attended with the redevelopment of resonance, which may become almost normal, or may be high-pitched, or present the characters of the hruit cle pot feU On auscultation over cavities we may detect (if they contain fluid) large crepitation and gurgling — sounds which may also be heard over the larger bronchial tubes when imbedded in condensed lung-tissue ; or (if they be empty) some modification of tubular breathing. Occasionally (and this may be the case in respect of cavities no larger than a walnut) we may hear distinct cavernous sounds. Metallic tinkling is seldom audible over tubercular cavities. In some cases no sounds whatever are produced within a cavity, and all that one hears are normal or abnormal respiratory somids transmitted from the parts beyond. Both bronchophony and pectoriloquy may usually be recognised ; pectoriloquy, however, is on the whole more marked here than over solid lung, bronchophony perhaps less marked. In delicate patients in whom no obvious consolidation can be recog- nised, the persistent presence, at one or other apex, of harsh and pro- longed expiratory murmur, of a few clicking sounds, of rhonchus, of crepitation, or of jerky respiration, is ground for the gravest suspicion. By some physicians, moreover, a systolic murmur over the pulmonary artery and its main branches, or in the course of the subclavian artery within the chest, is equally regarded as an indication of the presence of tubercular consolidation — the belief being that the murmurs are produced by the pressure of consolidated tissue upon the vessels in question. They are probably haemic. The state and action of the circulatory organs are for the most part such as we meet with in all chronic diseases attended with progressive debility and emaciation. In the earlier stages of phthisis the pulse is usually increased in frequency and hardness ; with the advance of the disease its frequency becomes augmented, but there is diminution of fulness and force. With increasing enfeeblement of the circulation it is not uncommon for some degree of anasarca to supervene, especially if the enfeeblement of the left side of the heart be associated, as it occa- Fr2 436 DISEASES OF THE RESPIEATOKY OEGANS, sionally is, with liypertropliy and dilatation of tlie right side. As a rule, however, the heart undergoes general atrophy. In many cases the anasarca is limited to the lower extremities, and is then often due immediately to thrombosis of the iliac veins. It is doubtless owing to the same enfeeblement of the circulation that various parts, and more especially the nose, ears, fingers, and toes, frequently get congested, livid, and tumid. A clubbed condition of the fingers and toes (although by no means confined to phthisis) is, as is well known, of common occur- rence In the chronic form of the disease. Each ungual phalanx becomes swollen and bulbous, and at the same time more or less congested ; and in consequence of the grape-like form which it assumes, the nail, which occupies the upper half only, becomes bent over the summit, forming a kind of slopmg roof. The symptoms referrible to the stomach and bowels are generally of considerable importance. The tongue may be clean throughout the greater part of the patient's ilhiess ; it is often morbidly red, however, and often furred, and towards the fatal termination is apt to get dry, glazed, and fissured or aphthous. Thirst is usual. The condition of the appetite presents great variety. In some cases it is good, and possibly voracious ; in others it is capricious ; while in others again there is complete anorexia, and probably great irritability of stomach, with gastrodynia, nausea, and sickness. The latter conditions depend in some cases on catarrhal inflammation of the mucous membrane of the stomach, and are often associated with thinning and dilatation of that organ. Phthisical patients are exceedingly hable to suffer from diarrhoea, which is often very ob- stinate and profuse, and often assumes a dysenteric character. Persistent diarrhoea, indeed, may be the most serious of all the morbid conditions from which the patient suffers. It is due, in the great majority of cases, to coincident ulceration of the bowels— a lesion which complicates fuUy one-half of the cases of pulmonary phthisis, and which may outrmi, if it do not precede, the pulmonary disease. Diarrhoea may result, however, like the dyspeptic symptoms, from mere catarrh, or some other form of irritation of the mucous membrane. It is a well-recognised fact that tubercular patients are apt to suffer from fistula in ano. The presence of a fatty liver is seldom indicated by symptoms, but may occasionally be recognised by the mcreased bulk which the organ attains. The nervous system does not usually present any very characteristic morbid phenomena. The patient may be irritable, or, on the other hand, apathetic ; he is sometimes desponding, but much more frequently hopeful, buo}ing himself up even to the last with the prospect of eventual recovery. Hectic fever and gradual emaciation are by far the most important and striking of the general i)henomena of phthisis. They commence in most cases "long before the actual proofs of the growth of tubercles exist, and they continue, as a rule, throughout the whole duration of the disease. It is important, however, to observe that phthisical patients often undergo TUBEKCLE. 437 temporary improvement, that under judicious management tliey often gain flesh and strength, sometimes never lose flesh, and that they not unfi-equently remam free from fever for weeks together — sometimes, indeed, have scarcely any febrile symptoms diiring the whole course of their illness. The hectic of phthisis is almost typical in the distmctness of the daily remissions and exacerbations which attend it. There is usually some elevation of temperature after food, especially after hearty meals, but the maximum occurs mostly in the afternoon or evenuig. Tlie mmimum temperature in the day may be normal, or even below the normal ; the maximum may reach anything from 101° to 101° or even 105°. In most ventricle begms. Be- tween these points it presents a semilunar form — the one limiting line taking a nearly straight course beneath the sternum, the other limiting line being convex, and extending m the third and fourth interspaces half-way from the sternum to the osseous ribs. Of the valves, the pulmonic is the highest and most superficial ; it is situated immediately to the left of the sternum (perhaps a little beneath it) in the second interspace ; the aortic, which is deeper-seated than the pulmonic, and indeed partly overlapped by it, is subjacent to the junction of the left third cartilage with the sternum and to the adjoining half of the sternum ; the tricuspid lies beneath the sternum, its centre midway between the sternal ends of the fourth costal cartilages ; the mitral, which lies deepest of all the valves, is situated behind the pulmonic and aortic, and on a lower level than they, its central point probably corresponding to the left third interspace, a little external to the sternum. A small portion only of the heart is in actual contact with the ante- rior walls of the chest, the remainder bemg separated from them by the thin edges of the lungs. In ordinary tranquil inspiration the lungs almost meet in the mesial line of the sternum from abo\'e down to a point midway between the sternal ends of the fourth costal cartilages. From this point the edge of the right kmg still continues vertically downwards, while that of the left retreats to the jmiction of the left fifth cartilage and rib, where it forms a notch just before its termination in PHYSIOLOGY OF THE HEAET. 479 tlie basal edge. A triangular interval is thus produced, situated wholly to the left of the mesial line of the sternum, bounded on either side by the edges of the lungs, and below by the diaphragm, to which the left lobe of the liver is immediately subjacent. In the outer angle of this space a small portion of the apex of the left ventricle becomes superficial, the rest of the triangle being occupied by the right ventricle. Laterally, the heart is bounded by the lungs, from each of which it is separated by both pleura and pericardium ; behind, it is hmited by the posterior mediastinum, with the roots of the lungs above, and the oeso- phagus and thoracic aorta in its whole extent, separating it from the vertebrae ; below, it hes on the diaphragm, which divides it from the liver, and partly, to the extreme left, from the stomach. Above, it is continued into the large vessels, namely the pulmonary artery, aorta, and vena cava. The ascending aortic arch, covered at first by the pulmonary arterial trunk, and then by the right auricular appendage, passes upwards and to the right beneath the sternum, and extends for about a quarter of an inch beyond the edge of the sternum into the right second and first inter- costa;l spaces. The superior cava extends half an mch farther in the same direction. The transverse arch corresponds as nearly as possible to the lower half of the manubrium. The pulmonary artery passes between the two auricular appendages upwards, backwards, and to the left, and having crossed the commencement of the aorta, lies to the left of that vessel, becoming superficial at the inner part of the left second inter- space, just before it retreats under the aortic arch to divide into its two branches. B. Physiology of the Heart. 1. Action of heart. — The function of the heart is to maintain the cir- culation of the blood in both the systemic and the pulmonary vessels. To effect this it undergoes a series of alternately active and passive move- ments, which are rhythmical and follow one another with greater or less rapidity. To commence with the ventricular contraction : — The ventricles, already distended with the blood transmitted to them from their respective auricles, contract suddenly and actively, propelling their contents into the aorta and pulmonary artery respectively, and causing at the same time the closure of the auriculo -ventricular valves. Whilst this contraction is m progress the auricles, which were contracted at the moment of its commencement, gradually dilate, and by the time the ventricles have got completely empty have attained their full dimensions and are fuU of blood. The contracted ventricles now relax and in their turn expand, the arterial valves close, and the auriculo-ventricular valves open and allow of the flow of blood through the still dilated auricles into the ventricles. Soon the passively dilating ventricles are almost filled, when suddenly the hitherto torpid amides contract, adduig their con- tents to those of the ventricles, which thus become distended. Imme- diately after the contraction of the am'icles, and indeed almost by a con- tinuous peristaltic action, the contraction of the ventricles takes place, and the cycle of events above described recurs. 480 DISEASES OF THE VASCULAE OEGANS. Dr. Paul Cliapnian has shown, that the duration of the ventricular systole diminishes in health progressively with the increase of frequency of the cardiac beats ; that when the beats are 50 in the minute the cardiac systole occupies about one-third of a second, when they reach 130 a minute its duration is about one-fifth of a second. It is important to note, in the first place, that the actions of the two sides of the heart are, as nearly as possible, s}'nchronous ; and in the second that the closure of the auriculo -ventricular valves takes place at the begmning of the cardiac systole, that of the arterial valves at the beginning of the cardiac diastole. It should be observed, too, that the force with which the ventricles act is always exactly equal to the resist- ance which they overcome ; that (other things being equal) contraction of the arterioles calls for increase of cardiac exertion, their dilatation for its diminution ; and that ( again other things being equal) increased quickness of the ventricular systole implies augmented exercise of cardiac force, and conversely. The contraction of the heart is attended with distinct pulsation m the precordial region. The area over which this extends varies some- what with the form of the chest, and considerably with different degrees of thinness or plumpness of the thoracic parietes. Generally it is limited to the apex, where it is always most intense, and covers not more than a square inch of surface. A certain amount of epigastric pulsation, due to the movements of the right ventricle, is compatible with health. « Fig. 48. Cardiographic tracing- op Cardiac Implxse. (P. CHAPMA^^) The space marked a corresponds to the duration of the auricular systole; that marked 6 to the duration of the ventriciilar systole from the exact beginning to the end of contraction ; that marked c to "the fall of the lever ensuing on the cessfition of contraction, the notch helow being due to thf mechanical effect of the fall ; that marked d shows a gradual rise, probably due to the filling of the ventriclf^ previous to the auricular contraction. Dr. Roy has shown that the commencement of the sudden fall at the end of 6 corresponds to the cessation of contraction of the muscular substance of the heart. Ihe base line represents the vibrations of a tuning fork vibrating a hundred times per second. 2. Sounds of heart. — The contraction and the dilatation of the ventricles are each attended with a characteristic soimd, which marks the commencement of the act, and is followed by a short mter^-al of silence. These constitute respectively the first and second sounds of the heart. The first, or systolic, sound varies in character in difterent per- sons ; it is, however, always deeper m tone and longer in duration than the other ; it is also more or less compact, beginning and ending with a certain degree of abruptness. It is audible over the whole of the cardiac region, but is most pronounced over the apex of the left ventricle. The THE PULSE. 481 second, or diastolic sound, is short, perhaps half the length of the first, sharp and sometimes ringmg. It is heard with greatest distinctness at the base of the heart, and more especially in the right second interspace and over the second costal cartilage immediately adjoining the sternum. The loudness of the sounds and the extent of surface over which they are respectively audible are subject to great variety. Many causes have been assigned for the cardiac sounds. There is, however, now no doubt that the second somid is due to the sudden closure of the arterial valves which takes place at the commencement of the ventricular diastole ; and there is little doubt that the first sound is mainly attributable to the generally less sudden closure of the auriculo- ventricular valves which attends the commencement of the ventricular systole. But it is pretty certain that the first sound is reinforced by that due to the contraction of the muscular tissue of the cardiac walls. For the most part, as has been already pointed out, the two sides of the heart act in unison ; and hence the two arterial valves usually concur in the production of the second sound, the two auriculo-ventricular in that of the first ; but, inasmuch as the action of the left side of the heait is far more powerful than that of the right, the. valves of that side take the chief share in causing the cardiac sounds. It is owing to this fact that the second sound is usually loudest towards the base of the heart, to the right of the sternum, where the ascending aortic arch approaches the surface, and that the first is usually most obvious where the left ventricle becomes superficial, namely at the apex. "When the sides do not act in perfect unison, a more or less obvious redupHcation of the cardiac sounds takes place. 3. Pulse. — The intermittent injection of blood from the heart into the arteries produces the phenomenon known as the pulse. The beats of the pulse correspond as a rule in number and rhythm to the contrac- tions of the cardiac ventricles ; and, like them, follow one another, for the most part, with remarkable regularity ; although liable, m difierent persons and under difierent circumstances, to present great variations as to rate and force, and always presenting slight relative increase of rate and force during inspiration, and slight relative decrease during expira- tion. The character of the pulse, although depending mainly upon the action of the heart, is largely modified by the condition of the arteries in which it occurs, and by that of the capillary arteries and capillaries, and of the venous system, beyond. During the whole period of the con- traction of the left ventricle its contents are being propelled into the aorta ; and the force which is thus exerted within the arteries is expended, partly in dxiving the blood already within the vessels onwards, partly in stretching the elastic walls of the arteries. The consequent arterial tension attains its maximum with more or less rapidity, and then diminishes before the systolic action is completed. As soon as, with the cessation of the systole, the propulsion of blood into the aorta ceases, the distended arteries contract upon the blood within them, still propelling it onwards, but with gradually diminishing force, until they have attained I I 482 DISEASES OF THE VASCULAE OEGANS. their former calibre or until their contraction is interrupted by the next cardiac systole. The period here adverted to corresponds to the ventricular diastole. If the pulse presented no other elements than those immediately due to the phonomena just considered Fig. 49. (namely, the systolic distension of the artery on the one hand, and its diastolic collapse on the other) the sphygmographic trace of the pulse would have some such form as that represented in fig. 49. There would be a sudden rise, presenting a rounded summit, the highest point of which would correspond to the moment of highest arterial tension ; and this would be followed by a gradual faU. But for the most part the sphygmographic tracing displays other elements besides these. In the first place the line of ascent is usually prolonged vertically upwards and then suddenly falls, forming a very acute angle, before it merges in the convex summit above indicated ; and in the second place the line of diastolic collapse is for the most part interrupted at its com- mencement by a more or less distinct rise, and frequently after a short interval by a further and less distinctly marked wave, or a diminishing series of waves. The typically complete tracing would thus present not less than four successive waves, of which at least two would correspond to the systole of the heart, and at least two to the diastole. The first of these waves, which is known as the primary or percussion wave, is generally attributed, not to any actual addition to the quantity of blood which the artery presenting it already contains, but to the impulse which is supposed to be transmitted along that blood by the shock of the commencing systole ; and is supposed to precede by a scarcely appreciable interval the secondary or tidal loave which follows it. Dr. Galabin, however, shows that this ex- planation is incorrect, and ' that the percussion and tidal waves form in the artery but one wave, and are only separated by the sphygmograph. Owmg,' he says, ' to the mertia of the long lever it is carried up a little too high. Fig. 50.— «, Primary or percussion wave ; 6, seconciary and wlieu in falling it meets the or tidal wave; c, dicrotic wave; rf, foixrth wave; p, i • i "^ -i • aortic notch ; / cj, duration of cardiac systole ; g h, true arterial Wave it IS again duration of cardiac diastole. j. j j j-t i" 4.1 Tlie dotted line represents the tracing -w Well would tOSSea Up, and tnUS lOmiS tlie be drawn if the instrument followed the movement of +,■/]„ 1 -nrct-ua ' TItq -H-n'vrl r\v +1tq the artery with perfect accuracy. Copied, with slight ''■l'-'-'^-'- WdVe. J. Me iniiU, Ui Uie modification from Dr. Galabin s diagram.-rtow/o'''/'^ f^jcro^ic lUaVC, haS, like the first. Degree of M.D. Cantab. ,1%1Z. _ ' ' . ' been variously explamed. It has been attributed by many to the shock of the sudden closure of the aortic valyes, an opinion in which Dr. Galabin concurs ; and again to the recoil of the hitherto distended arteries. But the cause is probably that which Dr. Sanderson assigns for it. He points out that as the THE PULSE. 483 wave due to the injection of the ventricular contents into the aorta takes a certain time to reach the capillary arteries, and as hence the period of greatest movement in the latter vessels must take place distinctly later than that in the aorta, so the subsidence of this wave . and the period of comparative rest which marks the end of systole and the whole of diastole is likewise delayed in transmission to the peri- pheral vessels ; and that consequently there is a moment at which, while the blood is almost stagnant in the aorta, it is still flowing rapidly through the minuter vessels, and a later moment at which the blood in the capillaries also becomes comparatively quiescent. But this arrest in the capillaries, accompanied as it is by the contraction of the elastic arterial coat upon the diminished contents of the vessels, produces a virtual distension and a sudden increase of pressure throughout the arterial system. The dicrotic wave is the expression of this arterial tension. The fourth wave has probably, as Dr. Galabin considers, the same relation to the dicrotic wave as the tidal to the percussion wave. Let us now briefly consider the significance in the order of their occur- rence of the more important of the several factors of the pulse-tracing which have been enumerated. The initial rise will necessarily be largely determined as to its amplitude by the suddemiess and violence of the cardiac systole ; but will obviously be also influenced more or less con- siderably by the condition of the arteries — flaccidity aiding it, tension on the other hand opposing it. The presence of the tidal wave as a distmct event depends mainly upon the duration of the tension of the arteries due to the ventricular systole. If the tension be of short duration the percussion wave falls rapidly and continuously imtil its fall is arrested by the dicrotic rise ; if it be long-sustained, then the second rise becomes developed, varying in its form according to the condition of the artery. The breadth of the combined summits of these two curves is, therefore, a measure of the duration of the tension here adverted to ; the breadth of their bases, as determined by a horizontal line drawn from the commence- ment of the systolic rise to the end of the systolic fall, is a measure of the duration of the cardiac systole ; and the lowest point of the notch which separates the tidal from the dicrotic wave indicates the moment of closure of the aortic valve. The third rise (the dicrotic wave) may be regardea as a measure of the completeness of the check which the systolic wave experiences in the smaller vessels during the diastolic period, and is indicative, therefore, either of comparative feebleness of the heart's action or of high tension of the venous relatively to that of the arterial system. The duration of the diastolic period is measured by the horizontal line which may be drawn from the aortic notch to the commencement of the next systolic ascent. The character of the pulse varies in health, not only in different individuals, but in the same person at different times and under different circumstances. It may be frequent or tmfreqtient, conditions which may be recognised as well by the finger and the watch as by any more com- plicated machinery. It may be long or short. These terms apply, not to ii2 484 DISEASES OF THE VASCULAE OEGANS. the whole interval between the commencement of one pulsation and that of the pulsation which next follows (for in that case they would be synonymous with ' unfrequent ' and ' frequent ' respectively), but to the duration of the systolic wave. These qualities may be roughly recognised by the finger, but are demonstrated with accuracy only by the sphygmo- graphic tracmg. It should be noted here that when a pulse becomes increased in frequency, this increase is due mainly to curtailment of the diastolic period. It may be large or small. These terms are employed somewhat loosely ; the former should perhaps be used of that state in which a considerable volume of blood is propelled into the arteries at each systole, and the latter of the converse condition. We are apt, however, to term that also a large pulse which occurs in dilated arteries, such as those of elderly persons, aiid that a small pulse in which the arteries are simply contracted. These difierent forms of largeness or smallness are often combined, and are indicated respectively in the sphygmographic trace by relative amplitude of the systolic waves. The pulse may be strong or weak, or in other words hard or soft. The former resists compression by the finger, the latter is easily obliterated by it. The best test, however, of streiigth of pulse is again the sphygmograph, by means of which the amomit of pressure necessary to procure oblitera- tion can be estimated with some degree of accuracy. When there is high arterial tension it is necessary to use considerable pressure in order thoroughly to develop the characteristic tracing. C. Pathology of the Heart. The heart and structures associated with it may, as is the case with all other organs, become the seat of mflammatory or other processes, which will produce all the local and general symptoms commonly belonging to such processes. But the heart is an instrument of extreme delicacy, and is liable, under the influence of these and other conditions, to have its mechanism more or less seriously deranged. Its derangements, which may be structural or functional, or both combined, cause various local and remote or general consequences which are the characteristic symp- toms or sequelae of heart disease. We propose, in addition to making some remarks on the physical examination of the heart and structm-es associated mth it, to consider these derangements and their consequences briefly, apart from the intimate nature of the pathological lesions fi'om which they spring, and apart also from the special symptoms due to the specific nature of these lesions. 1. Physical Examination. a. By inspection we may often determine facts of primary impor- tance m relation to cardiac diseases. In eflusion of fluid into the peri- cardium, when there are intra-thoracic growths mvolving this membrane or its vicinity, or when the heart is much enlarged, especially in the case of children and persons with yielding ribs, the precordial region is often PHYSICAL EXAMINATION OF HEAKT, ETC. 485 manifestly protuberant. Under similar circumstances the intercostal • spaces are sometimes effaced, and the ordinary respiratory movements diminished or annulled. The situation and character of the apex-beat can generally be readily determined by inspection. In hypertrophy and dilatation of the heart or of its left ventricle, it is carried downwards and outwards ; in hypertrophy and dilatation of the right ventricle, it is carried outwards ; and always when from any cause the heart is displaced, the situation of the apex-beat is displaced also. Inspection will also show whether the apex-beat is powerful and heaving, as it is in hypertrophy of the left ventricle, or diffused, as it becomes when the right side mainly is enlarged. Again, under various conditions, pulsation may be observed not only over the apex, but over the surface of the ventricles, and even over the great vessels at the base. Thus, in cases of enlarged heart or of pericardial effusion, or even of displacement of the heart to one or other side, pulsation referrible to the surface of the ventricles may often be observed in addition to the ordinary apex-beat. Surface pulsations are generally alternate with the apex-beats, and due to the ventricular diastole ; and, when visible on the left side of the chest, may be observed to run as a wave from the sternum along the intercostal spaces. Further, when the edges of the lungs are retracted as after deep expiration, and still more when the upper part of either lung has shrunk from old tubercular or inflammatory disease, marked pulsation, due to the large vessels and auricles, may be observed in the second and third intercostal spaces. Visible pul- sation occurs also over aortic aneurysms. The pulsations of the large vessels and of aneurysms are synchronous with the apex-beats. h. Palpation will assist in the determination of many of the phe- nomena which simple inspection also reveals. But by palpation we can recognise with greater accuracy the force and character, and the area, of pulsation ; and we can further recognise the presence of unyieldingness which often attends pericardial exudations and intrathoracic growths, and the existence of oedema, doughiness or fluctuation which may accompany pericarditis, or affections involving the parietes of the prsecordial region. But above all, we can ascertain the existence of the tremors or thrills, which are often present generally over the praecordial area in cases in which the pericardial surface is rough from inflammatory lymph, and pericardial friction is to be heard ; and which often occupy definite arefe in various forms of endocardial lesion. Thrills occur also over aneurysms. c. By permission the area of praecordial dulness may be ascertained. As a general rule this is increased when the heart is enlarged, or the pericardium distended, or in the case of mediastinal growths intruding between the thoracic walls and the pericardium. It is diminished when the heart is unduly small, or when emphysematous or distended lungs extend beyond the proper pulmonary limits. By such means, in fact, the area of cardiac dulness may be much reduced, even when abvmdant peri- cardial effusion or great enlargement of the heart is present. Sense of resistance is probably best appreciated by percussion. d. Auscultation reveals the healthy and the unhealthy sounds referrible 486 DISEASES OF THE VASCULAE OEGANS. to the lieart, the former of which have already been considered, the latter of which will be fully discussed further on. 2. Displacements of the Heart. Simple displacement of the heart is met with under many different circumstances. Occasionally, in company with the other viscera of the chest and abdomen, it is found transposed. Ascites or abdominal tumours may carry its apex upwards and to the left ; aneurysms of the arch, and other tumours of the upper part of the chest and posterior mediastinum, may cause it to descend. Serous or other effusions into either pleura commonly push it over towards the opposite side ; while the contraction of the lung and side which so often attends cirrhosis and the absorption of pleuritic fluid tends to attract it more and more towards the affected side. The displacements which result from the last conditions are generally much more noticeable when they take place towards the right than when they take place towards the left ; and, indeed, when the left pleura is distended it is not uncommon to find the heart beating wholly between the right nipple and right edge of the sternum. In spinal curvature also the position of the heart is often much modified, being then largely determined by the relative sizes of the two halves of the chest, and by the degree and form of the curvature ; sometimes it lies wholly to the right of the sternum, sometimes beneath it. Occasionally, when the patient is markedly pigeon-breasted, the heart occupies the whole of the space which lies between the two nipples. The most remarkable displacements of the heart are those which result fi-om the growth of intra-thoracic tumours. In such cases the apex of the organ has been found beating in the right axilla. In reference to displacements, it may be observed that the base of the heart is closely attached to the structures occupying the posterior mediastinum, while the rest of the organ is free ; and that consequently, although, no doubt, the posterior mediastinum and the base of the heart become displaced to a greater or less extent, it is the apex which chiefly suffers. It may be useful to point out that transposition of the heart and other viscera has, m association with pulmonary symptoms, led to the erroneous diagnosis of pleurisy with effusion on the left side ; and that displacement of the vessels at the base of the heart in conjunction with displacement of the. heart itself, or displacement of the vessels alone in dependence on the contraction of tubercular cavities of the apex of the lung, is apt to suggest the presence of an aneurysmal tumour. 3. Affections of the Pericardium. a. Pericardial effusion. — The effusion of fluid into the pericardial cavity is a common incident in various diseases. In general dropsy, more or less serum is commonly poured out into this, as it is into any other, serous cavity. In ordinary inflammation a transparent or opaline fluid PEEICAEDIAL EFFUSION, ETC. 487 accumulates in its sac ; and in rupture of the heart or of an aneurysm at the origin of the aorta its cavity quickly becomes distended with blood. When fluid is poured out into the pericardimn it gradually distends it, enlarging it in all its dimensions, but chiefly in those situations in which its walls are least resistent. The cavity becomes romided, and at the same time elongated, especially in the upward direction along the as- cending aortic arch and pulmonary artery, and thus acquires a pyriform shape with the narrow extremity above. Moreover, by its distension it displaces the diaphragm downwards and the lungs laterally. At the . same time the heart is necessarily carried with the portion of the parietal pericardium to which it is united backwards, and consequently away fi'om the anterior thoracic walls. The quantity of fluid which accumu- lates is sometimes enormous. Two and even three quarts have been met with. The larger quantities are generally the result of chronic disease, which allows of the gradual distension of the canity to a much greater extent than is possible in. acute cases. The physical signs of pericardial effusion are tolerably distinctive. Distension of the pericardium tends to cause prominence of the prtecor- dial region, with widening and smoothing away of the intercostal spaces, which becomes more pronounced and occupies a larger area as the disten- sion increases, and is always relatively greater in the yielding chests of young children than in the rigid chests of adults. Other facts observable by inspection are deficiency of respiratory movement over the affected region, elevation of the apex beat (if indeed the apex beat remains visible), and diffused pulsation chiefly noticeable in the interspaces. As the en- larging pericardium displaces the lungs more and more, so does the prse- cordial dulness become more and more extensive. In accordance with the form which the cavity itself assumes, the enlarging area of dulness acquires the shape of an elongated triangle, of which the acutest angle is above, the shortest side below. This area may extend up to the clavicle, and be bounded to the left by an oblique line passing from the junction of the left first rib and cartilage downwards and outwards through or beyond the left nipple, and to the right by a hne running for the most part vertically somewhere between the right nipple and the median line of the sternum. The only influence of pericardial effusion on the cardiac somids is to render them feeble and indistinct. The direct effects of pericardial effusion are to embarrass the action of the heart, and hence sooner or later to cause such symptoms as usually arise in the course of valvular disease. Abundant accumulation of fluid, especially if it have taken place rapidly, tends to compress the heart, .and to prevent it from expanding. Death in cardiac rupture is largely due to this mechanical influence. The distended pericardium presses upon neighbouring organs, and may thus cause obstruction to the vems which empty themselves into the heart, and difiiculty in swallowing. It may also ca use collapse of the left lung. h. Pericardial roughness and friction. — When the surfaces of the pericardium are roughened, as they are in pericarditis from the formation 488 DISEASES OF THE VASCULAE OEGANS. of a false membrane, a pericardial nmirmur or friction sound may gene- rally be heard. This varies in character : being sometimes a miiform to-and-fro somid like that produced by rubbing two pieces of paper together, sometimes a more or less uniform crackling, rumbling or creaking, sometimes a series of irregular jogs, which are generally more numerous than the sounds of the heart and seldom synchronous with them, and depend on the fact that the equable movement of the opposed surfaces on one another is interfered with by the obstacle which their roughness or stickiness interposes. Pericardial sounds, especially if of limited extent, are not always distinguishable from endocardial murmurs. They seldom however present much intensity, are probably never musical, and are scarcely perceptible excepting immediately over the spot at which they are developed. They are most common and most persistent over the right ventricle. Pericardial friction is usually rendered louder by the pressure of the hand or stethoscope upon the pr^ecordial region, and during expiration, and is often attended ■ with a marked tactile thrill. It occurs at the beginning of pericarditis when the roughened pericardial surfaces are in contact, disappears for the most part as serum accumu- lates and separates them, and recurs as the fluid becomes reabsorbed during convalescence. c. Pericardial adhesions and prmcordial groivths. — After inflammation, the pericardium generally becomes adherent in a greater or less degree ; and the adhesions vary much in thickness and density. Consequently they not unfrequently cause serious and permanent embarrassment of the heart's action. It is sometimes important therefore to determine if possible whether such adhesions be present. In many cases, no doubt, the clinical history will decide this point for us. But in many we have no such aid to diagnosis. Unfortunately the clinical signs of adherent peri- cardium are few and untrustworthy. Among those which have been re- garded as significant are : persistent extension of precordial dulness and prominence of the praecordial area ; abnormal sense of resistance on percussion ; permanent elevation of the apex beat and displacement to the left ; and recession of the thoracic walls over the apex of the heart, at the time of systole, in place of the normal protrusion. The presence of pericardial growths will have much the same local influence as that of old adhesions, at any rate so far as extension of precordial dulness is concerned. But the symptoms are more rapidly progressive ; the heart is liable to undergo traceable and often consider- able displacement ; and there is always the likelihood of the development of obvious tumours in the thoracic parietes, above the clavicles and elsewhere. 4. Affections of the Muscular Walls and Cavities. a. Atrophy. — The heart, like all other muscles, tends to waste, when the work devolving on it undergoes diminution ; or when the body gene- rally wastes. General atrophy of the organ is observed for the most part in chronic wasting diseases, such as cancer of the cardiac orifice or ATEOPHY AND ENLARGEMENT OF HEAET. 489 pylorus, pulmonary phthisis, tubercular disease of the bowels, and diabetes ; and occasionally in such cases attains an extreme degree. Dr. Church records the case of a middle-aged woman dyuig of cancer of the pylorus in which the heart weighed only S^ oz. General wasting is now and then also observed apparently as a consequence of obliteration of the pericardium by adhesions. Partial atrophy is met with in connection mth valvular lesions, and mainly in the case of mitral disease. In con- sequence of interference with the due supply of blood to the left ventricle, this has less work to do than it should have, and atrophy of its walls tends to ensue. The atrophy is probably in most cases relative ; but oc- casionally, and especially in mitral obstruction, the atrophy is actual and well-marked. The muscular tissue of hearts which are simply atrophied is usually darker and firmer than in health. b. Hypertrophy and dilatation. — Hypertrophy of the heart is doubt- less always the result of overwork of the organ. This overwork may be the consequence of undue resistance to the escape of blood from the heart or from any one of its cavities, of dilatation of its chambers, which diminishes their efficiency as organs for propelling the blood, of nervous palpitation or of excessive muscular exertion, or lastly of pericardial ad- hesions, which, by the embarrassment they cause, compel persistent in- crease of cardiac effort. Hypertrophy of the left ventricle tends to take place in the various forms of Bright's disease, but chiefly in connection with contracted granular kidney. It appears to be due to the impedi- ment which there is in these affections to the passage of blood through the systemic capillary arteries, and is associated with heightened tension which prevails throughout the arterial system. It arises also from disease of the aorta and other large arteries ; and is especially common as a consequence of obstructive or regurgitant aortic valve disease. Hypertrophy of the other chambers results directly from disease of the valves immediately in front of them, or from anything else which im- pedes the escape of blood from them. Thus hypertrophy of the right ventricle may be due either to disease of the pulmonic valves, to obstruc- tive disease in the lungs, especially chronic bronchitis and emphysema, or to affection of the mitral orifice. Hypertrophy consequent on peri- cardial disease, and that arising from long -continued palpitation, are for the most part general. Dr. Allbutt beheves that the hypertrophy due to violent muscular exercise begins on the right side of the heart, and is propagated thence to the left side. Dilatation of the heart probably always in some degree accompanies hypertrophy, and owes its origin to similar causes. But it must be regarded, less as an evidence of strength, than as a result of weakness (of the yieldingness of the heart's walls to the increased internal pressure to which they are subjected), and, although accompanying hypertrophy, as antagonistic to it. It will hence be readily understood that, other things being equal, a heart intrinsically weak will become dilated more than hypertrophied, under the stimulus of over-exertion ; and that under similar circumstances a heart, intrinsically strong, will become hyper- 490 DISEASES OF THE VASCULAK OEGANS. trophied more than dilated. It must be added that dilatation, which is sometimes the primary change m hearts that are simply feeble, not only impairs efficiency, but actually furnishes an incentive to cardiac exertion and overgrowth. The muscular tissue of the heart in cases of hypertrophy is for the most part firm and dense ; and in some cases, indeed (as for example in the hypertrophy which attends chronic renal disease), it is supposed that the hardness and closeness of texture are due in some measure to the disproportionate increase of the connective tissue of the organ. It is im- portant to note, however, that occasionally when dilatation is in advance of hypertro^Dhy, the muscular tissue is softer than natural ; and that sooner or later there is a tendency in most cases for the hypertrophied tissue to degenerate, and for the heart to become weak and inefficient. In chronic Blight's disease the heart (mainly the left ventricle) becomes hypertrophied, often to an extreme degree ; but dilatation is comparatively slight. In obstructive disease at the aortic orifice again, hypertrophy afl'ects mahily or exclusively the left ventricle, but dUatation is more marked than m the former case. In regurgitant aortic disease dilatation of the left ventricle is always much greater in proportion than m either of the foregoing cases ; the walls, however, become very thick, and, ui fact, it is in this variety of heart disease that the heart attains its greatest bulk. It may weigh between forty and fifty ounces. In all the above cases the enlarged heart presents its normal conical form, or at any rate deviates but little from it. If, however, the left ventricle be alone or chiefly enlarged, not only does its left edge extend further than usual to the left, so that more of the ventricle is exposed when we look at the organ in situ, but its apex projects far beyond that of the right ventricle, and the heart becomes elongated. In mitral disease, in chronic pulmonary affection, and in disease at the pulmonic orifice, the right ventricle enlarges, while the left undergoes but little change and possibly even shrinks. The result on the form of the heart is that it becomes globular instead of conical or elongated, and that the right ventricle either takes an equal share with the left in formmg the apex of the heart, or forms the apex exclusively. Hyper- trophy and dilatation of the auricles necessarily cause some modification hi the form and dimensions of the base of the heart ; but their eflects do not call for detailed description. c. Signs and symptoms of atroijhy. — The physical signs of general atrophy of the heart are : diminution of the area of prfecordial dulness, feebleness of the apex-beat and of the pulse, and feebleness of the cardiac sounds. But inasmuch as the atrophy is usually in some sort of pro- portion to concurrent atrophy of the rest of the organism, the dwindled heart still remains sufficiently strong to perform the offices required of it, and as a rule gives rise to no untoward symptoms. The atrophy of the left ventricle, which occurs in mitral disease, is related to the weak- ness and irregularity of pulse which characterise that lesion. d. Signs and symptoms of hypertrophy and dilatation. — The physical AFFECTIONS OF VALVES OF HEART. 491 signs of enlargement of the heart are : increase of the area of praecordial duhiess, displacement of the heart's apex, and heaving powerful impulse. But the phenomena differ very much according to the relative amounts of dilatation and hypertrophy present, and according as the right or left side is chiefly affected. Simple hypertrophy tends to render the cardiac sounds, and more especially the first sound, dull and indistinct. Simple dilatation tends to make the sounds short and sharp. When, however, hj-pertrophy and dilatation are proportionate, and especially when dilatation is in excess of hypertrophy, as it is in regurgitant aortic valve .disease, the somids of the heart become extremely loud. When the cardiac enlarge- ment is general or the left ventricle only is involved, the apex is carried do^Niiwards and outwards, and may even impinge in the seventh or eighth interspace ; the apex-beat, moreover, is heaving and covers a wider area than in health. When the right side is hypertrophied and dilated, the cardiac duhiess is increased in its transverse diameter, the apex of the heart is thrown to the left, but probably retains its normal level, and the beat is diffused. Moreover, there is usually marked epigastric pulsation, and sometimes pulsation to the right of the sternum. In enlargement of the left side of the heart the pulse is fuU, strong, and prolonged. In enlargement of the right side the pulse is unaffected, but there is probably undue fulness and possibly pulsation in the larger systemic veins. Since hypertrophy and dilatation of the heart are to a large extent compensatory, their presence for a time and to a greater or less degree prevents the occurrence of spnptoms which would otherwise become developed. A time, however, comes in most cases when, either the conditions causing hypertrophy and dilatation assert themselves, or the cardiac enlarge- ment itself causes cardiac embarrassment, or degenerative changes occur in the hypertrophied muscle, and symptoms of cardiac disease, like those which attend valvular lesions, manifest themselves. In almost all cases of cardiac hypertrophy and dilatation there is valve disease or some other associated condition which largely influences the physical signs, the pulse, and the general symptoms. 5. Affections of the Valves. Any of the four valves of the heart may be the seat of disease. But those of the right side usually suffer during foetal Ufe, while those of the left side are almost exclusively liable to be attacked after birth. More- over, the auriculo-ventricular valves are more frequently affected than the arterial. a. Causes of valve disease. — The causes of congenital valve disease are sometimes inflammation, sometimes arrested or faulty development. The causes of so-called ' acquired ' valve disease are mainly inflammation and degeneration : the former occurrmg, as a rule, in the earlier periods of life in connection -wuth rheumatism and chorea, the latter coming on for the most part with other degenerative changes as old age approaches. Syphilis, also, is a cause of valve disease in adult hfe. 492 DISEASES OF THE VASCULAE OKGANS. b. Manner of valve disease. — The valvular meclianism may be dis- turbed in two ways. Either tlie orifice may be constricted, and the blood- stream in its normal course through it be impeded ; or the cusps may close imperfectly and so allow of regurgitation. The two defects are often associated. Obstructive aortic or imlmonic valve disease [stenosis] may be due to either of the following conditions : — (i.) There may be more or less adhesion of the several segments to one another. As a congenital defect, it is not uncommon to find two contiguous cusps blended as far as their corpora arantii, the coalesced sides forming a vertical froenum dividing the upper aspect of the compound organ into two halves. More rarely the three cusps are thus blended, forming between them a conical funnel with a small orifice in the apex which looks upwards, (ii.) There may be abundant inflammatory granulations, (iii.) The cusps may be thickened, irregular, and rigid from atheromatous and calcareous changes. Regurgitant aortic or pulmonic valve disease may depend (i.) on con- traction or puckering of the free edges of the valves, in consequence of which they fail to meet ; (ii.) on ulcerative destruction or contraction of the valves at their angles, which allows the intermediate free edges to form pendulous or everted flaps ; and (iii.) on rupture with partial detachment, or on perforation, of the curtains. We do not, of course, refer to the fenestras so commonly observed in the lunulae, which, as is well known, do not in any degree impair the efficiency of the valves. Obstructive mitral or tricuspid disease [stenosis) may be caused in various ways, (i.) The edges of the flaps may cohere. This condition is often congenital, and generally, when the cohesion is extensive, the valve assumes a fumiel-like character, with its apex pomting towards the ventricle, and presenting a narrow button-hole slit. In most cases of this kind the valve is generally thickened, the chordae tendines are short and thick, and their smaller branches which radiate into the valves are apt to be blended with them and with one another, (ii.) There may be general inflammatory thickening, together with inflammatory outgrowth, (iii.) The valves may be rigid and irregular from atheromatous and cal- careous deposition. Begurgitant mitral or tricuspid disease may depend (i.) on mere contraction of the free edges of the cusps ; (ii.) on shortening or rupture of the chordae tendineae ; (iii.) on perforation of the valve ; and (iv.), when there is dilatation of the cavities of the heart, either on associated dila- tation of the auriculo-ventricular orifice, which the cusps are then miable to close, or on want of due proportion between the size of the ventricular cavity and the length of the chordae tendinefe and mtiscuH papillares. The tricuspid valve is especially apt to allow of regurgitation from the last-mentioned cause. c. The effects of valvular disease on the walls and cavities of the heart are important and characteristic. This subject has already been briefly considered, but we propose to discuss it now in fuller detail. Whenever there is obstructive disease at the aortic orifice, the left ventricle under- AFFECTIONS OF VALVES OF HEAKT. 493 goes gradual hypertrophy, attended with more or less dilatation. For a time this enlargement is almost purely compensatory ; the increased force of the cardiac contractions almost exactly counter-balances the effects of the obstacle; the heart beats regularly, the ventricle empties itself at each systole, the mitral valve acts perfectly, and the auricle experiences no difficulty in the transmission of its contents into the ventricle. So far all the morbid changes are confined to the left ventricle. But after a longer or shorter period disproportion arises between the hypertrophy of the ventricle on the one hand, and its dilatation and the impediment to be overcome on the other ; the ventricle fails to act efficiently, probably does not wholly expel its contents at each beat, and the auricle consequently begins to experience some difficulty in getting rid of its contents, and now, m its turn, becomes dilated and hypertrophic. The same sequence of phenomena follows that virtual impediment to the aortic circulation which results from aortic valve incompetence. In this case, however, dila- tation doubtless precedes hypertrophy, and the auricle probably becomes stimulated to over- exertion at a comparatively early period. Whenever disease, whether it be obstructive or regurgitant, exists at the mitral orifice, blood tends to accumulate in the right auricle, while increased force is needed for its propulsion thence ; the cavity, therefore, of the auricle becomes enlarged, and its walls thickened. But inasmuch as no valves exist at the orifices of the pulmonary veins, or in any part of the course of the pulmonary vessels, the augmented pressure of blood which commences within the auricle speedily extends backwards through- out the entire pulmonary system. And hence arise, impediment to the escape of blood from the right ventricle, and its consequent hypertrophy and dilatation. Disease affecting the pulmonic orifice, equally with increased resist- ance to the flow of blood along the pulmonary artery, necessarily causes dilatation and hypertrophy of the right ventricle, which are presently followed by similar affections of the right auricle. Disease at the tricuspid orifice provokes like changes in the right auricle, and in connection therewith accumulation of blood in the systemic veins, to be remotely followed by similar conditions in the systemic capillaries and arteries, and consequent impediment to the escape of blood from the aortic orifice. It will be understood from the foregoing remarks that when disease (actual or virtual) exists at any valvular orifice, first, the chamber behind it becomes hypertrophied and dilated, and subsequently the same con- ditions gradually involve chamber after chamber in the backward direction, until possibly every one thus becomes affected in a greater or less degree ; and, further, that in the extension of these conditions from the left auricle to the right ventricle, or from the right auricle to the left ventricle, the pulmonic or the systemic vascular system, as the case may be, necessarily suffers from undue accumulation and pressure of blood within it. But while the immediate effect of valvular disease is progressive 494 DISEASES OF THE VASCULAE OEGANS. hypertrophy and dilatation of the chamber behind the impHcated valve, the chamber in front (at any rate for a time) either does not enlarge, or enlarges very slightly, or even undergoes atrophy. In simple mitral obstructive disease the left ventricle usually shrinks. The form of the heart, as we have shown, becomes largely modified by the hypertrophic and other changes above discussed. d. Cardiac murmurs. — The chief physical sign of valvular disease is the presence of a murmur or bruit, occurring either during the systole or during the diastole of the ventricles, and due either to some impediment to the onward flow of blood, or to regurgitation. Cardiac murmur either replace the normal sounds of the heart, or are super- added to them. They are necessarily loudest at the points at which they are developed ; but in consequence of the intervention of cardiac structures, which are not implicated, or of the free edges of the lungs, they are not necessarily loudest at those portions of the chest surface which lie nearest to these points. Again they are carried, as might be supposed, by the blood- stream, and are heard louder in the course of that stream than in the opposite direction. Endocardial murmurs present a wide range of character, dependent on differences of intensity, quality and pitch. As to intensity, they may be so soft as to be barely detectable, or so loud as to be distinctly audible by the unaided ear at a short distance from the prgecordial region. As to quality, they may resemble a simple whiff, a whispered vowel, a whispered r, or a prolonged s ; they may be harsh and rough, or grating ; or they may be distinctly musical ; and the musical note may vary in pitch from bass to treble, from a deep hum or buzz to a whistle. They are often compared to familiar sounds, such as blowmg, cooing, sawing, rasping and the like ; and, apart from such special qualities, are usually also distmguishable from the normal heart sounds by their greater prolongation, and by their gradual subsidence or onset. Endocardial murmurs are the result of molecular vibrations pro- duced m the blood as it traverses one or other of the cardiac orifices. Such molecular vibrations are, of course, always present, whether in health or disease ; but they are only rendered sufficiently intense to evolve sound either when the blood is driven with unnatural velocity through one or other of the orifices, or when in its course it meets with some impedi- ment, or encounters some roughness or projection or some pendulous vibratile body, or when (as in regurgitation) opposing streams meet. It is not always possible, nor is it important, to determine the conditions on which the different qualities of murmurs depend. It may, however, be remarked that roughness or hoarseness of sound implies for the most part roughness or irregularity (however produced) at the orifice at which it is developed, and that musical quality may be determined by extreme narrow- ness of orifice, and especially by such conditions of the edges of an orifice as permit them to perform regular vibrations. The roughest and most grating murmurs probably are the consequence of partial detachment of valves or of rupture of chords tendine®, which allows the implicated cusp to flutter loosely in the blood current. The most distinctly musical AFFECTIONS OF VALVES OF HEAET. 495 murmurs are for the most part regurgitant, as might be supposed from the combiQation of narrowness of orifice and of vibratile edges which is then commonly present. There can be no doubt that the quahty of cardiac murmurs is often very distinctly modified by the resonance of blood- containing ventricular cavities ; hi fact, that murmurs not otherwise musical are thus rendered musical, and that musical murmurs have some of their harmonics developed by this means with disproportionate power. It is obvious that such modifications must occur mainly while the ventricles are filling, or are full, and hence specially aflect murmurs developed dming the ventricular diastole. It is probable that the deep tone of so-called ' pre-systolic ' murmurs is in some measure due to this •circumstance; and that the different qualities of the same murmur, as heard in the neighbourhood of the aortic orifice where it is created, and at the apex whither it is conveyed, are similarly explicable. e. Differential diagnosis of cardiac murmurs. — Leavmg these general considerations, we proceed to discuss the differential diagnosis of valvular diseases by the aid of the murmurs which severally attend them. i. Aortic valve disease. — Obstructive disease or stenosis is characterised by the presence of a murmur which commences with the commencement of the heart's systole, and is continued onwards during the systolic silence. It is usually loudest over the right second costal cartilage and second interspace close to the sternum, and over the right half of the sternum in the corresponding situation ; it is carried along the transverse arch, across the manubrium, and is sometimes distmctly audible even in the back along the descending arch and upper part of the thoracic aorta ; and it diminishes in force as it is traced from the base of the heart to the apex. The extent of its difliusion depends largely upon its loudness or pitch ; when feeble it may be heard only over the ascending arch. It is synchronous with the carotid pulse and cardiac impulse. The murmur of aortic regurgitation commences with the second sound of the heart, which in some cases it entirely replaces, and is gene- rally much prolonged, sometimes up to the very commencement of systole. It is usually most distmctly audible in the neighbourhood of the aortic orifice, and is carried thence downwards by the refluent stream, m some cases towards the apex, in some along the sternum, generally dimmishiug in intensity in its passage, and possibly even undergomg some change of quality. Occasionally it is most distinct midway between the left nipple and the edge of the sternum, or even over the lower part of the sternum or at the apex. It is in general rapidly lost along the ascendhig arch. It occurs alternately with the carotid pulsations and cardiac impulses. ii. Pulmonic valve disease. — A systolic murmur produced at the pul- monic orifice is heard loudest over the left edge of the sternum, at about the level of the third costal cartilage. It is heard also over the trunk of the pulmonary artery, namely, at or about the left edge of the sternum, as high as the upper border of the second cartilage. But it is inaudible, or nearly so, to the right of the sternum and along the ascending aortic arch, and fades away as it is traced downwards over the right ventricle. 496 DISEASES OF THE VASCULAE. OEGANS. Organic murmurs at this orifice are rare, excepting as the result of con- genital disease. Begurgitant murmurs from defect of the pulmonic valve are extremely micommon. They are best heard over the diseased valve, and thence downwards towards the right apex. iii. Mitral valve disease. — Of all murmurs the systolic mitral, or that due to regurgitation through the mitral orifice, is the most common. It attends the systole of the heart, and, therefore, like the direct aortic, is synchronous with the carotid pulse. It is usually heard most distinctly, not immediately over the valve, but over that part of the left ventricle which is most superficially placed, namely, the apex. If feeble it may be audible in this position only, but if loud, it is often heard over the whole of the precordial region. In the latter case it generally diminishes in force from the apex to the base ; but occasionally increases again over the aortic orifice or ascending arch. A systolic regurgitant murmur is Fig. 51.— Graphic Eepresextation of Cardiac Murmurs. 1, 2. First and second cardiac sounds respectively, a. Systolic murmur. 6. Diastolic murmur, c, d. Presystolic, or direct, mitral murmurs. carried back with the refluent blood into the left auricle ; and partly on this account, partly because of the situation of the left ventricle to the left and back of the heart, it is generally distinctly audible about the angle of the left scapula, and along the horizontal line passing from this point to the apex of the heart— a fact of great importance in the recogni- tion of this murmur. Direct mitral murmurs occur during the diastolic period, and until of late years were generally overlooked or misinter- preted. They are often absent because, although obstructive disease is not uncommon, the force with which the blood passes from the auricle into the ventricle is generally insufficient to generate a murmur. It is well known, however, to physiologists that during the earlier period of the ventricular diastole the blood is flowing almost passively through the auricle into the ventricle, and that it is only at the last, just before the ventricle itself contracts, that the auricle contracts and propels its blood AFFECTIONS OF VALVES OF HEAKT. 497 with vigour. It is at this moment, therefore, that a murmur is most likely to be developed. It need scarcely be added that, when the auricle has become, as it soon does, dilated and hypertrophied, and the time occvipied in discharging its contents more or less protracted, the murmur is likely to be rendered both more intense and of longer duration. A diastolic mitral murmur, then, is audible during the ventricular diastole, but nearer its end than its beginning ; generally indeed running up to the systolic sound, and apparently blending with it. In some of these cases the rhythm of the heart appears to be altered at the apex : a brief interval exists between the murmur and the first sound, so that there is a tendency, on listening at the apex, to reckon the murmur as the first sound, the true first sound as the second, and, from its in- distinctness in the neighbourhood of the apex, either to disregard the true second sound, or to look upon it as a mere reduplication, or, if there be a systolic murmur, to take the second sound for an accentuated portion of it. From the usually peculiar relation of the diastolic mitral murmur to the ventricular systole, it is often iexraedi 'presystolic. From the fact of its being determined by the auricular systole, Dr. Gairdner names it auricular systolic. This murmur is generally prolonged, somewhat deep- toned and rough like a trilled r, or reminding one of the roar of a wave breaking in the hollow of a rock, and audible over a very liinited area at the apex of the heart, or a little to its injier side or above it. It is seldom to be heard in the back or at the base. A presystolic murmur is apt to be very irregular or unequal m its production ; and, above all murmurs, it is liable to disappear when the circulation is tranquil, and to become distinct when the heart's action is excited. iv. Tricuspid valve disease. — Disease of the tricuspid valve is rare ; it is also rare to have a murmur produced at this orifice. A direct murmur, or one attending the ventricular diastole, is of exceedmgly un- frequent occurrence. Its rhythm corresponds to that of the presystohc mitral, but it is audible over the right ventricle, and according to Dr. Hayden chiefly over the left fifth costal cartilage and the fourth inter- costal space close to the sternum. A regurgitant or systolic murmur is much more common ; but this is more frequently due to over-distension or dilatation of the ventricle or comparative shortness of the musculi papillares, and consequent inadequacy of the valves, than to their struc- tural disease. It is sometimes observed in the displaced hearts of persons suffering from angular curvature of the dorsal vertebra, in whom also the right ventricle is occasionally much hypertrophied. The murmur is o-ene- rally somewhat low-toned, audible most distinctly about the ensiform cartilage, diminishing thence towards both the left apex and the base, and absent at the back of the chest. V. Multiple valve disease. — Of course it is possible that only one valvular defect may be present at any one time ; but it is very common for two or more defects to be associated, aaid consequently for several murmurs to occur simultaneously. Thus there may be a double aortic murmur, causing a to-and-fro sound, and simulating pericardial friction K K 498 DISEASES OF THE VASCULAE OEGANS. for wliicli it is often mistaken ; or there may be a double mitral mm-mur, in which case the presystoHc sound rmis mto the systoKc bruit ; or there may be combinations of aortic and mitral murmurs. Murmurs developed at the right side of the heart also may be associated with murmurs arising on the left side ; and mdeed it is by no means micommon for a mitral murmur to be followed after a time by a regurgitant tricuspid murmur, due to the gradually developed hypertrophy and dilatation of the right ventricle which supervene on mitral disease, and the resulting tricuspid incompetence. In differentiating the murmurs due to different valves, when more than one valve is affected, it is necessary not only to have regard to other signs and symptoms which the patient may present, but to determine accurately the points at which the murmurs are heard with chief intensity, and where they fade away or seem to alter in character. /. Other physical signs may assist in the diagnosis of valvular lesions. As we have already shown when speaking of cardiac hypertrophy and dilatation, the shape and dimensions of the praecardial dulness, and the position and character of the apex-beat, are important aids to us m deter- mining the size and form of the heart, and whether, therefore, we have hypertrophy and dilatation of the left ventricle as are met with in aortic valve disease, or whether we have hypertrophy and dilatation of the right ventricle as occur in mitral, pulmonic, and pulmonary diseases. Tremor or freviitus may accompany all forms of valve disease, but mainly attends such as cause rough or deep -toned murmurs. A^alvular tremors generally occupy a circumscribed area : they are felt over the ascendmg arch and pulmonary artery in obstructive disease of the aortic and pulmonic valves respectively, over the base of the heart and the large vessels in aortic regurgitation, and at the apex in mitral affections. The most common and most pronounced thrill is that felt over the apex of the heart in association with presystolic murmurs. Lastly, it may be pointed out that in mitral valve disease the second sound of the heart becomes accentuated to the left of the sternum, where it is often fomid markedly louder than in the neighbourhood of the right second costal cartilage. This phenomenon appears to be connected with the enlarge- ment which in this case takes place in the right ventricle. (J. The ejfects of valve disease on the general organism. — An account of valvular lesions and of their diagnosis would be singularly inadequate if it were limited to the phenomena presented by the heai't itself. A valvular defect, whether causing obstruction or inadequacy, may be so slight as, although causing a murmur readily detectable by the stetho- scope, to have no appreciable influence either on the heart itself or on the circulation. More commonly the defect is sufficiently serious, first, to cause enlargement of one or more of the chambers of the heart, and next, to embarrass the circulation of blood through the pulmonary or systemic vessels, or both. As a general rule, the parts in fi-ont of an actual or virtual obstruction tend to become anemic, while those behind it tend to become congested. In ohstructive aortic disease the pulse is usually regular, and according AFFECTIONS OF VALVES OF HEAET. 499 to the degree of obstruction tends to be small. Tlie associated hyper- trophy of the heart, however, may for a time at any rate neutralise this latter tendency, and especially cause prolonged elevation of the systolic element of the pulse. This affection often goes on for a long time without causing much, inconvenience. But sooner or later pain and palpitation and breathlessness supervene ; the pulse becomes feeble and irregular, the arteries unfilled, and sjmcopic and epileptiform attacks liable to come on ; or pulmonary and systemic venous engorgement occurs, with various consequences, which will be considered when we come to speak of mitral disease. In regurgitant aortic disease the pulse, as in the last case, is usually regular, but it presents a pecuKar jerky quality, which is due to a com- bmation of sudden ^dolence and fulness of the systolic wave (caused by the hypertrophy and dilatation of the left ventricle) , with an equally sudden collapse at the beginning of the diastolic period, the latter being so sudden and extreme that the dicrotic rise is almost or entirely suppressed. This variety of pulse, which has been likened to the passage of shot under the finger, is variously known as Corrigan's, the ' water-hammer,' or a collaps- ing pulse. It is always specially observable in the vessels of the neck and in the subcla\iaus, whose pulsation is sometimes so visible and so violent as to suggest the presence of aneurysmal dilatation. It generally becomes more ob\dous at the wrist when the forearm is held in the perpendicular position. It may be detected even in the arteria centralis retm®, and in the capillary vessels, when the blood is returnmg to an area whence it has been removed by pressure. The last phenomenon may be evoked by dra'ftT.ng the finger nail across the forehead. In regurgitant aortic disease the patient suffers more from deficiency of blood in the arterial system than in any other form of cardiac lesion. He generally becomes notably pallid, much more hable than in sunple obstructive disease to s}iicopic and epileptiform attacks, and often dies suddenly. He is also apt to suffer from palpitation, breathlessness and angina-like attacks. In this case, as in the last, the effects of venous obstruction may ensue sooner or later. Both forms of mitral disease are characterised by a tendency to feebleness and irregularity of pulse. Indeed, these qualities of pulse are usually developed at a comparatively early stage, and become extreme with the progress of the disease. They are due partly to the incomplete filling of the left ventricle, partly to an irritable state of its walls resulting from its comparative emptiness. In mitral as in aortic valve disease the patient may suffer from tendency to syncope and other consequences of imperfectly filled arteries. He may suffer also from angina. But the special characteristic of mitral disease is its tendency to cause, at a com- paratively early period, congestion first of the pulmonary circulation, and then of the systemic vems, and phenomena dependent on such conges- tions. In connection with the pulmonary stasis arise congestion and oedema of the lungs, effusion of blood into the pulmonary tissue (pul- monary apoplexy), thrombosis of the pulmonary arteries, tendency to in- flammation, and all the symptoms (lividity, dyspnoea, cough, haemoptysis) 500 DISEASES OF THE VASCULAR ORGANS. which flow from such affections. In dependence on the sluggish move- ment and accumulation of blood in the systemic veins are developed : general dilatation of vems and capillaries, with congestion specially observable in the hands and feet and face, and tendency to hemorrhage, mainly perhaps petechial extravasation into the connective tissue of the lower extremities ; anasarca, chiefly of dependent parts ; dropsy of serous ca%'ities ; and thrombosis. Further, the Hver becomes congested and in- durated, and assumes the well-known nutmeg character, and jaundice and other consequences of hepatic disorder ensue ; the kidneys get simi- larly affected, and the urine grows scanty and albuminous ; not unfre- quently the gastro-mtestmal tract undergoes functional disturbance, or becomes the seat of hemorrhagic effusion or organic lesions ; also the central nervous system suffers, and headache, vertigo, and delirium ensue, or drowsiness and coma, or even hemorrhage from laceration of cerebral vessels. There are two or three other occasional consequences of venous ob- struction which claim attention. These are pulsation of the larger veins ; pulsation of the liver ; and bulbous enlargement of the terminal pha- langes of the fingers and toes, (i.) Venous pulsation is observed mainly in the veins at the root of the neck, but it may be visible even in the veins of the extremities. It is due, as a rule, to the fact that, owing to their dilatation, their valves allow of regurgitation, and that at the same time regurgitation takes place during the contraction of the right ventricle through the tricuspid orifice. It is usually, therefore, a proof of incom- petence of the tricuspid valve, and that the right ventricle has undergone hypertrophy and dilatation. The pulsation in marked cases may be not only seen, but felt ; and the sphygmographic tracing displays a double rise, of which the second is far more ample than the first, a circumstance which is due to the fact that the latter is caused by the auricular con- traction, the former by that of the ventricle. It must not be forgotten, however, that pulsation of the veins at the root of the neck may be caused simply by auricular contraction when the veins are full, and that it may be simulated by the rhythmical distension of the veins which takes place during expiration, and by pulsation transmitted from neighbom-ing arteries, (ii.) It was first shown by Friedreich, and has since been con- firmed by other observers,^ that, under similar circumstances to the above, hepatic pulsation not unfi'equently occurs. It seems to be due to regurgi- tation into the vena cava ascendens, and thence mto the hepatic veins. The pulsation (which must be distinguished from ordinary, epigastric pulsation, due to the direct influence of the action of the heart, or of the abdominal aorta) is visible over the whole extent of that portion of the abdominal surface with which the distended liver is in immediate relation, and may in many cases ( especially if the enlargement of the Uver be con- siderable) be felt, on graspmg the hepatic zone with the two hands, to be distinctly expansile. The sphygmographic tracing which may be ' Dr. P'rederick Taylor, Guy'^ Hospital Reports, 1875. INOEGANIC OE HiEMIC MUEMUES. 501 obtained from the pulsating organ presents the same characters as that yielded by the venous pulse, and indicates a like origin, (iii,) In cases of long-continued venous obstruction (and especially, therefore, in heart- disease of congenital origin) the last phalanges of the toes and fingers become livid and swollen or bulbous — a condition which is also observed in phthisis and several other affections. 6. Inorganic or Hcsmic Murmurs in Heart and Miirmurs in Vessels. Murmurs which it is sometimes impossible to distinguish from the murmurs of valve disease are often audible over the prascordial region, and in the neighbourhood of the large vessels at the base of the heart. Some of these are referrible to the heart itself, some to the arteries, some to the veins, some to the pericardium, and some probably to the lungs. a. Not unfrequently, even in healthy persons, when the heart is beat- ing \iolently under the influence of vigorous bodily exercise or strong mental excitement, a loud blowing, sometimes musical, systolic murmur is developed at the aortic orifice and along the aortic arch. This is due simply to the unwonted force with which the blood is propelled from the ventricle through the arterial orifice. h. Cardiac murmurs are of common occurrence in chlorotic girls and other persons who are sufi'ering from anaemia. These are systolic, and usually heard at the base of the heart, either in the aortic or in the pulmonic area, and are generally supposed to be referrible to one or other of the arterial orifices. Those heard in the course of the aorta are doubtless aortic. But those heard in the situation of the pulmonary artery, which are the most common, are held by Dr. Balfour (adopting Naunyn's views v^th respect to the conveyance of mitral regurgitant murmurs into the left auricular appendage) to be due to mitral regurgi- tation. If this were true, however, we ought to be able to hear ordinary regurgitant mitral murmurs best or alone in the same situation. The explanation of these liEemic murmurs developed at the arterial orifices is not very clear. By some they are supposed to be due to mere poorness of blood, by some to incomplete filling of vessels, by some to suddenness and rapidity of escape of blood from the heart. When murmurs are developed towards the apex, they are due to regurgitation through the tricuspid or mitral orifice, which must therefore be incompetent. We have shown that such incompetence may exist physiologically on the right side ; and there is no doubt that it may be developed upon either side in consequence of weakness and dilatation of the ventricles. Hence it becomes possible that systolic mitral or tricuspid murmurs may be due indirectly to ansemia, and may disappear, like the truly hfemic basal murmurs, with improved health. c. A systolic murmur is sometimes audible at the apex of the heart, which has been attributed, and we think correctly, to the sudden expul- sion of air from the portion of lung lying over the apex during its systolic impulse — to a similar mechanism, indeed, to that which causes bruit de pot fele at the upper part of the healthy chest in young children. This 502 DISEASES OF THE VASCULAE OEGANS. murmur is soft or high pitched, is liearcl over a small area only, never in the back, and varies with the respiratory movements, being generally loudest during expiration or inspiration, and often inaudible when the chest is fully expanded, contracted, or at rest. Its diagnosis would be aided by the fact of the absence of all other signs of cardiac disease. Basic cardiac murmurs are occasionally manufactured or modified espe- cially in children by the pressure of the stethoscope. cl. Dr. Sibson has drawn attention to a kind of scratchy murmur, occasionally present about the base of the heart, chiefly over the pulmonic area, which seems to be of little importance, and the cause of which is not clear. It has been attributed to slight roughness of the pericardium, and also to sliglit roughness of the valves, and to anaemia. Certainly in some cases in which it has been heard nothing to account for it has been discovered after death. e. It may be added here, that the longer one's experience becomes, the more one's belief becomes confirmed that murmurs arising during rheuma- tism, and presumably therefore of organic origin, not unfrequently disappear permanently. It may be assumed that a rigid valve never again becomes normally pliable, that a contracted or shrunken valve never reattains its original dimensions and form, and that inflammatory vegetations always leave some trace of their former presence. Still slight thickenings and scanty vegetations, sufficient at the time of their formation to disarrange the action of the valves, may doubtless so far become effaced with the cessation of the inflammation that caused them as to restore the valves to a condition of practical healthiness. /. Arterial murmurs. — Murmurs may arise in arteries from simple undue rapidity of flow of blood along them, as sometimes happens during violent palpitation of the heart from over exercise or strong emotion. Under such circumstances the subject of palpitation often hears the murmurs developed in his own carotids and their branches with painful distinctness. Such murmurs are no doubt more readily producible ni anaemic than in healthy persons. Arterial murmurs also occur when the walls of arteries are rough and irregular from atheroma or other degenera- tive changes, in cases also in which the channel is diminished, whether from adherent clot within, from thickening of the walls, or from pressure from without, and even when it is dilated. It is frequently from one of these latter causes that murmurs attend the presence of aneurysms. Tumours pressing on arteries, or involving them, commonly cause murmurs ; and hence abdominal tumours, and growths in the mediastinum or root of the lung, are occasional causes of murmurs within the abdominal and thoracic cavities respectively. Murmurs referrible to the innominate, or first part of the left subclavian, are occasionally due to the pressure of the lungs during the respiratory movements, and are often developed in the third part of the subclavian, as they may also be in the abdominal aorta and super- ficial arteries, by the pressure of the stethoscope. Lastly, murmurs are often carried by the blood- stream to a considerable distance from their point of development. The murmurs commonly heard over aneurysms of MOTOR AND SENSORY DERANGEMENTS. 503 the aortic arch, are to a large extent merely the murmurs of accompany- ing aortic valve disease. And, as we have already shown, aortic valve murmurs, and more especially systolic murmurs, are often distinctly audible in the whole length of the aorta. Occasionally, especially in arteries at some distance from the heart, as for example in the abdominal aorta, a systolic murmur of local origin is prolonged, with some modifica- tion of character, into the diastolic period, and thus, though wholly inde- pendent of regurgitation, simulates a double aortic valvular murmur. g. Venous nnirmurs (bruit du diable), consisting of a continuous humming or buzzing, whistling or hissing, are not uncommonly audible in the larger veins when they are partially obstructed, and especially in anaemic patients. They may generally be best heard in the neck, particularly on the right side. They are largely determined by the pressure of the stethoscope, are modified by the respiratory acts, and are most readily obtained when the patient is erect. A similar musical sound may sometimes be heard in the chest at the base of the heart, or over the large vessels (mainly on the left side) at the end of inspiration or expiration. It is clearly a venous hum, and referrible either to the innominate or to the pulmonary veins. Venous murmurs have little or no clinical importance. 7. Motor and Sensory Derangements, a. Motor derangements reveal themselves by undue feebleness or force, frequency or infrequency of action, by intermission or irregularity, or by sudden arrest of action from spasm or paralysis. Several of these are only exaggerations of conditions which are compatible with health. Feebleness of the heart's action attends most wasting diseases and the later period of many febrile and other acute affections. It is common also in mitral disease, and in some other morbid conditions of the heart. It is characterised by weakness of apex beat ; diminished intensity of the cardiac sounds, especially the first, which may be absolutely abolished ; feebleness of pulse, which is undulatory, thready, or markedly dicrotous, and may be imperceptible at the wrist, even while maintainmg a distinctly dicrotous character in the larger arteries ; and lastly, a great tendency to variation in the rate of the pulsations under the slightest disturbing influ- ences. Increased force of cardiac action tends to take place whenever any impediment to the flow of blood occurs either at the aortic orifice or in the course of the arteries, in the capillary vessels or in the venous system. It is common therefore in aortic valve disease, in the presence of rigid arteries, and in Bright's disease. It may also occur in inflammatory dis- orders, during muscular exertion, and under the influence of nervous excitement. The indications of this condition are, violence and extension of the cardiac impulse, which is often prolonged and heaving, and may be felt in the back and even shake the entire body ; loudness of the cardiac sounds ; and hardness of pulse. Increased frequency of pulsation occurs under many different conditions ; such as nervous excitement, debility, febrile disease, and so on. The individual pulsations may be weak or 504 DISEASES OF THE VASCULAR ORGANS. strong, and the cliaracters presented by the cardiac movements, its sounds, and the arterial pulse will correspond. Diminished frequency of pulsation is common in convalescence from acute disorders. It is also met with in some cerebral affections and in some cases of cardiac disease. The pulsa- tions of the heart may mount up to 200 or even 260 in the minute, and they may fall to 20 or even 12. The term 'palpitation is commonly used of those conditions in which, under the influence of nervous excitement, the pulsations of the heart, arteries, or both, are painfully evident to the patient himself; the beats are frequent, sudden, and violent, and the pulse Fig. 52. — Pulse-tracings in DfcEAcE. a. SListaiiied pul'ie of arterial tension in contracted granular kidnej-. Pressure 10 oz. h. Sustaineii palse of arterial tension in contracted granular kidne>. Pressure 18 oz. c. Sustained ptilse of arteri.il tension in acute read aniisarca. Pressure 10 oz. (ast. 10). d. Sustained pulse of arterial tension in chronic tubal nephritis. Pressure 8 oz. (set. 9). e. Jerky pulse of aortic regurgitation -nitli aneurysm of aorta. Pressure 4i oz. ■f. Jerky pulsse of aortic regurgitation with mitral regurgitation. often attended Avith marked dicrotism. Irregularity of the cardiac rhythm is occasionally observed in gout and indigestion, but is most frequently associated with various forms of heart-disease, and especially with affec- tions of the mitral valve. It is manifested by inequality of the successive pulsations, as regards both their force and fulness, and the length of the interval which elapses between them. Intermission of action is a form of irregularity which is mostly functional ; it is common in dyspepsia, and is occasionally a constitutional peculiarity of the patient. In intermission the general rhythm of the heart's action is not impaired, but at regular or MOTOR AND SENSORY DERANGEMENTS. 505 irreg'ular intervals a pulsation is dropped, as it were. At tlie wrist it is wholly absent ; on listening to the heart, however, the intermission is represented by an abortive throb, followed by a pulsation of greater inten- sity than those which follow next. Occasionally such abortive strokes may occur alternately with effective ones, and the pulsations at the wrist be half as numerous as the cardiac beats. SuclcUn arrest of the heart's Fig. 53.— Pdlse-tracings in Disease. «. Jerky pulse of aortic refrurgitatioii. Pressure 2^ oz. b. Jerky pulse from case of sudden obstruction of abdominal aorta. Pressure 5 oz. c. Jerky and dicrotous pulse from case of acute double pneumonia (4th day). Piessure 7 oz. d. Dicrotous pulse from case of albuminuria. Pressure 5 oz. e. Dicrotous and undulating pulse from case of enteric fever (26th day). Pressure 71 oz. /. Irregular pulse from case of dilated heart. Pressure 6 oz. action, and consequent death, may be caused by shock, or syncope, and is not uncommon in certain forms of heart-disease. Asynchronism in the action of the ventricles, indicated by reduplica- tion of the sounds of the heart, is not unfrequently observed. Occasionally it occurs in health, but much more commonly it is an accompaniment of 506 DISEASES OF THE VASCULAE OEGANS. disease. Eeduplication of the first sound is chiefly met with in connection with hypertrophy of the heart and high arterial tension, especially there- fore in chronic heart disease ; and reduplication of the second sound is observed mainly in affections of the mitral valve. h. Abnormal sensations are frequently associated with cardiac affec- tions. In palpitation the pulsations of the heart and often of the larger arteries are distinctly felt and complained of by the patient. When inter- mission takes place the sufferer generally experiences a kind of throb, or tumble in the region of the heart, or a choking sensation which may be attended with momentary faintness. A feeling of oppression at the chest, or fulness, or aching, is not micommon. And sometimes the piain may be intense, prolonged, and indeed unbearable, extending over the whole cardiac region, or limited to some definite part of it, and often radiating thence to various parts of the trunk and to the extremities, especially down the arms. 8. Prognosis of Cardiac Derangements. Our remarks under this headuig will have reference almost exclusively to valvular lesions, and the conditions which are associated with them. a. Hypertrophy is in most cases compensatory, and therefore, at any rate for a time, rather a benefit than an injury to the patient ; dangers, however, follow in its train, the more important of which are dilatation of cavities, incompetence of valves, and degenerative changes in the muscular tissue of the heart itself and in the arterial system — all of them indications and sources of failing strength. h. Whenever a diseased heart becomes also enfeebled, the symptoms from which the patient suffers are greatly aggravated. Weakness of the heart, indeed, whenever it occurs apart from and out of proportion to weakness of the general system, is always of grave import. c. In attemptmg to estimate the relative prospects of life of patients suffering from the various forms of valvular lesions, many different matters have to be taken into consideration. Thus, if the affection be due to rheumatic inflammation, we know that the patient has special Hability to a recurrence of his rheumatism, and consequently to aggravation of his cardiac malady ; if the disease be the consequence of senile changes, we know that the valve affection must, in the nature of tilings, be progressive ; and both in these and in other cases there is often something in the con- dition of the valves, only to be guessed at during life, which renders the danger of embolism always imminent. Again, the constant bodily or mental labour to which many sufferers are condemned necessarily influ- ences symptoms unfavourably and hastens death ; further, any conditions of failing health which tend to enfeeble the muscular walls of the heart tend, on this very account, to affect injuriously in a disproportionate degree the due action of the organ, and to expedite the fatal issue ; and last, inflammatory and other affections of the lungs, which embarrass the pulmonary circulation, form especially serious and dangerous aggra- vations of all forms of heart-disease. PEOGNOSIS OF CARDIAC DERANGEMENTS. 507 But, putting aside all these sources of danger, wliicli are more or less accidental, and common to most varieties of heart-disease, the question remains, ' what, cateris paribus, are the relative prospects of life of those suffering from the different valvular lesions?' and (it may be added) ' what are the special dangers to which they are respectively liable ? ' Obstructive disease at a valvular orifice is a much less serious matter than regurgitant disease, inasmuch as the hypertrophy of the muscular walls of the ca^'ity behind becomes for the most part accurately adjusted to the increased work which is thrown upon them. The adjustment is often so accurate in the case of aortic valve obstruction, that persons thus affected live for years unconscious of the presence of disease. Indeed, this is certainly the least serious of all valvular lesions. Obstructive mitral valve disease, again, unless it be extreme, is pretty successfully counteracted by hypertrophy of the left auricle. Compensative hyper- trophy of the auricle, however, can scarcely be so efficacious as that of the ventricle, smce the absence of valves at the entrance of the veins allows the increased blood-pressure to be easily propagated backwards through the pulmonary vessels. It is certain, indeed, that in a large proportion of these cases symptoms of cardiac disease manifest themselves before long ; but, on the other hand, it is also certain that many persons who labour under congenital constriction of the mitral orifice live for many years, and for a large portion of their lives suffer little. No degree of hypertrophy can neutralise the effects of regurgitation. Indeed, it is ques- tionable whether the hypertrophy which always follows on regurgitation is in any degree compensative of that regurgitation ; whether, indeed, it is not to be regarded as the result of an effort to neutralise the virtual weakness which the dilatation, always attending regurgitation, causes. Aortic regurgitant disease is probably the most serious and rapidly fatal of all forms of valvular lesion. Regurgitant disease of the mitral is certainly less serious than the last, and patients often labour under it for many years ; nevertheless it is probably more dangerous than obstructive disease of the same orifice. The order of danger in which Dr. Peacock places the four lesions which have just been considered, and we concur with him in this matter, is as follows : first, aortic regurgitant ; second, mitral regurgitant ; third, mitral obstructive ; and fourth, aortic ob- structive. It need scarcely be remarked, however, that this order is necessarily often departed from ; that regurgitation (although productive of a murmur) may be so slight as to be of comparatively little moment ; that obstruction may be so extreme as to lead to the rapid destruction of life. Diseases of the right side are so rare, and when present so often associated with lesions of the left side, that it is impossible, excepting theoretically, to estimate their relative degrees of danger. We have previously discussed the various consequences of heart-disease ; and from what was then said the causes of death in patients suffermg from valvular lesions may for the most part be determined. Sudden death, which was formerly so largely attributed to heart-disease, is not a com- mon sequela of valvular lesion. It is most common in regurgitant aortic 608 DISEASES OF THE YASCULAK OEGANS. disease, and in that case is due to syncope, or perhaps, as some maintain, to cardiac anpemia from non-filHng of the coronary arteries. 9. Treatment of Cardiac Derangements. a. The treatment of simple, cardiac hypertrophy is a matter of sim- pHcity. We can only remove hypertrophy by removmg or obviating the lesion which has provoked it, by maintaining the circulation in an equable and quiet condition, by the avoidance of mental and bodily excitement or over-exertion, and by careful attention to the healthy maintenance of the functions of the body generally. It is, however, of the highest importance to delay or prevent the supervention of that enfeebled condition of heart in which hypertrophy so commonly and disastrously ends ; and this must be effected by promoting the general health of the patient, for which pur- pose iron and other tonics, change of air, and nourishing diet are often necessary. b. The treatment of cardiac debility differs little, if at all, from that needed in the later stages of valvular, and more especially mitral valvular disease, a subject presently to be considered. c. In treating valvular diseases we must never forget that we are dealing with affections which, in the nature of things, are incurable ; that valvular defects tend, on the whole, to increase ; that their ill effects tend gradually to become augmented by the changes which take place second- arily to them in the walls and dimensions of the cardiac chambers, and are always liable to serious aggravation by the presence of any condition, be it normal or morbid, which embarrasses the circulation. Our primary object must, therefore, be to prevent, or at all events to dela)'', the super- vention of those numerous morbid processes and symptoms which have already been adverted to as the consequences of heart-disease. We cannot repair the injured valve. We cannot, and would not if we could, prevent the compensatory hypertrophy which ensues ; we may, however, by for- bidding excessive muscular exertion, or taking precautions against mental excitement, or other provocatives of increased cardiac action, prevent in many cases that hypertrophy from becoming excessive, and therefore in- jurious. We cannot prevent a certain amount of dilatation from taking place in association with hypertrophy ; but by the same measures by which we counteract the one we tend also to counteract the other ; and further, since dilatation is to a large extent dependent on impairment of muscular strength, we may, by maintaining the general strength, main- tain also to some extent that of the heart itself. Lastly, we may often succeed by careful attention in preventing the recurrence of inflammatory attacks, in arresting pulmonary and other congestions which react deleteriously on the heart, and in maintaining the quality and quantity of the blood in a fairly normal condition. Hence a patient whose heart is diseased should abstain from all forms of violent and sustained exertion, and should never push even what seems to be moderate exercise to the extent of causing shortness of breath, or PEEICAEDITIS, MYOCAKDITIS, AND ENDOCAEDITIS. 509 palpitation, or uneasy feelings of any kind, or even fatigue. His pursuits and surroundings should be such as do not entail mental excitement. He should be protected by proper clothing and other precautionary measures against cold. His bodily health should be maintained by the use of wholesome, nutritious, but not too abundant food, by the cautious employment of stimulants, and by carefully regulating the action of his emunctories. But, notwithstanding the greatest care, a time comes sooner or later, and comes soon to those who are compelled to work hard for their liveli- hood, when the consequences of the cardiac lesion become painfully ap- parent. The patient begms to suffer from palpitation, irregularity of pulse, shortness of breath, dropsy, jaundice, albuminuria, pulmonary apoplexy, angina. But even in these cases it is remarkable how often, under the influence of perfect rest and the other items of treatment which have been enumerated, all unfavourable symptoms subside. Indeed, in the treatment of the symptoms and consequences of valvular disease there is no doubt that absolute rest is of far more value as a remedial agent than anything else that can be named. But in aid of rest other agents may often be beneficially employed. Frequency of pulsation, and especially irregularity, are almost invariably connected with feebleness and irritability of the heart's action. To remedy this condition it seems desirable first to give strength to the heart's contractions, and next to diminish their frequency. For the former of these purposes iron and the vegetable tonics, and possibly nux vomica, are valuable ; for the latter probably no drug, at any rate in mitral valve disease, is superior to digitalis. A combination of digitalis with iron is often of very great value. Belladonna is by many preferred to digitalis in the treatment of lesions of the aortic valve. To relieve the overloaded venous system, to which so many of the resultant phenomena of valvular disease are due, we may employ diaphoretics, diuretics, and purgatives, and besides these in some cases the removal of blood by leeches or cupping, or by venesection. Further, to relieve shortness of breath or engorgement of the Imags, or prascordial uneasiness, ether, ammonia, lobelia, stramonium, squills, ipecacuanha, or other expectorants, opium and counter-irritants, may all of them, under slight modification of circumstances, be of use. II. PEEICAEDITIS, MYOCAEDITIS, AND ENDOCAEDITIS. A. Pericarditis. Causation. — Inflammation of the pericardium is evoked in various ways : by extension from the muscular walls of the heart when these con- tain abscesses ; by extension from the pleura, peritoneum, cellular tissue of the neck, posterior or anterior mediastimim, or any other neighbouring part which is the seat of inflammation ; by local injuries, such as penetrating wounds of the pericardium, or the opening into it of sinuses from hepatic 510 DISEASES OF THE VASCULAE OKGANS. or other abscesses, and by the rupture of aneurysms, hydatid cysts, and the Hke. The most frequent and hnportant cause of pericarditis, how- ever, is exposure to cold and wet, especially if that exposure results in the development of rheumatic fever. Pericardial inflammation occurs not unfrequently in association with, if not in dependence upon, chronic albu- minuria, scarlatina, chorea, pyaemia, and occasionally in connection with tubercular, syphilitic, and carcinomatous or other malignant growths. Morbid anatomy. — Inflammation of the pericardium, like that of all other serous membranes, is characterised in the first instance by dilatation of the blood-vessels and consequent hyperemia, effusion of their fluid con- tents into the substance of the serous membrane, and into the subserous tissue, and tendency to proliferation of the endothelium. At first, little more than simple congestion and oedematous thickening of the membrane is present. But soon inflammatory exudation takes place, consisting partly of fibrine, which as it is secreted coagulates upon the surface, and remains adherent to it or blended with it ; partly of serum, which con- taining dissolved albumen and fibrinogen accumulates in the pericardial cavity, and separates one surface of the membrane from the other ; and partly of inflammatory corpuscles, derived either from the proliferating endothelium or from errant leucocytes of which the majority remain entangled in the coagulating fibrine. The relative quantities of solid and fluid exudation, their characters, and the changes which they undergo, present great varieties. In some cases of pericarditis, which is thence often termed ' dry,' the whole sur- face becomes covered with a greater or less abundance of false membrane, but there is little or no accompanying serous effusion. In most cases, however, a few ounces of fluid are poured out in the course of the affection. And occasionally the accumulation amounts to two or three pints, or more. The solid exudation or false membrane forms in the early stage of its production a thin, slightly coherent lamina, which is scarcely distinguish- able except from the fact that it robs the serous surface of its normal smooth glistening aspect. But it soon increases in quantity by the addi- tion of fresh inflammatory matter to its free surface, and may thus by degrees attain the thickness of paper, cardboard, or of ^ or even ^ inch. As its thickness increases, so also as a rule do the density and closeness of adhesion of its deep surface, and the irregularity of its free aspect. At first the latter is merely faintly granular, but it soon gets villous or tuber- culated, or pitted with irregular and deepish holes. It is difficult to give in a few words a notion of the different appearances which may be pre- sented ; in some cases the surface is honeycombed ; in others it is ribbed like the sand which the waves nave just left ; in others it has the aspect which may be produced by separating two hard smooth surfaces which have been stuck together with a layer of butter ; in others again the exudation has been rolled by the to and fro movements of the heart into fusiform pellets, which remain irregularly attached to one or both surfaces of the pericardium. And further, irregular bands, festoons, or laminae PEKICAEDITIS. 511 of the same material not unfrequently extend betweeii the visceral and parietal layers. The pericardial fluid is sometimes limpid and colourless, almost like water, sometimes opaline, and occasionally distinctly tinged with blood. In many cases, no doubt, inflammation commences at some one spot or circumscribed area of the serous membrane ; and, indeed, in mild cases it not very unfrequently remains thus limited, or at all events does not become general. More frequently the whole of the pericardium is involved. In the great majority of cases of pericardial inflammation, resolution takes place after a longer or shorter period. The fluid which has been eflused undergoes absorption ; the false membrane becomes organised, con- tracts, hardens, and ultimately is converted into an imperfect form of con- nective tissue. In some instances circumscribed inflammatory patches result in the formation of those opaque, white, cicatrix-like thickenings which are so commonly met with on the surface of the right ventricle, and are known as ' milk-patches.' In some such cases the opposed pericardial surfaces become adherent at one or two points, or over a small area. But in by far the larger number of cases, when the inflammation has been general, the absorption of the fluid and the coming together of the inflamed surfaces end in their more or less complete coalescence, and in the oblitera- tion in an equal degree of the pericardial cavity. The characters which the resultmg adhesions display depend largely of course upon the quality and quantity of the false membrane from which they have arisen. Some- times they are thin and delicate, and differ little from ordinary connective tissue. Sometimes they are thick, fibrous, and perhaps oedematous, and then measure maybe ^ or ^ an inch or more in thickness. Sometimes they are almost cartilage-like in density and hardness ; and they may become the seat of calcareous formations, constituting bands or patches of considerable extent. In the course of pericarditis other results besides those which have been enumerated may take place. In some cases the newly-formed blood- vessels of the false membrane become ruptured, and blood is effused into its substance, or (if the opposed surfaces be not yet adherent) into the pericardial cavity. This hemorrhage may be so copious as to cause death. In other cases the inflammation becomes suppurative, and the pericardial cavity is converted into an abscess, which may ultimately con- tain two or three pints or more of pus. Suppurative pericarditis is often very chronic in its progress ; and sooner or later the pus may point and discharge externally in the prfecordial region, or extend in other directions beyond the limits of the pericardium. The inflammatory processes of pericarditis, when the attack is slight, are probably limited to the serous membrane ; but, when the inflamma- tion is intense or assumes a chronic form, it invades the deeper tis- sues, which then get congested and oedematous, and often, if muscular, degenerated and enfeebled. Hence the integuments of the pr^ecordial region become in many cases distinctly oedematous ; and it is perhaps 512 DISEASES OF THE VASCULAK OEGANS. occasionally owing to involvement and consequent enfeeblement of the intercostal muscles that the intercostal spaces are observed to bulge. It is a more important fact that, in a large number of cases, the outer layers of the muscular walls of the heart become to a greater or less depth obviously degenerated, softened, and weakened. Symptoms and progress. — The symptoms of pericarditis are so com- monly associated with those of the malady in the course of which it arises, and with those of endocarditis, which is so often developed in common with it, that it is not altogether easy to disentangle them en- tirely from those belonging to these other conditions. Pericarditis is in many cases so mild a disorder that it is attended with few or no symp- toms of any importance. In other cases it is one of the most perilous maladies with which we have to deal, and its symptoms are correspondingly severe. But, between these extremes, cases of all grades of intensity are met with. In its mildest form, pericarditis often escapes detection, or is recog- nised only by the accidental discovery of pericardial friction ; in most such cases, however, there is .at some time or other sHght prsecordial pain or mieasiness, together with extension of cardiac dulness, and febrile dis- turbance. Most cases of what are termed ' latent ' and ' dry ' pericarditis belong to this group. In describing the symptoms of more aggravated cases of pericarditis, it will be convenient to divide them into local and general, and to discuss these seriatim. The local symptoms are due directly to the condition of the pericardium and its influence on surrounding parts. The patient generally complains of pain and tenderness in the region of the heart. He winces if pressure be made over the prgecordium, and still more if it be made in the epigastric region. The pain varies in character, is aching, cutting, burning, or a mere sense of soreness, and occasionally extends from the heart to the left shoulder and down the left arm. It is usually augmented by movement of the diaphragm, and hence the patient tends to breathe rapidly, shallowly, and with little abdominal motion. When the pain and tenderness are very severe, he usually lies upon his back, and, while moving his limbs with tolerable freedom, keeps his trunk almost entirely still. The roughening of the pericardial surface which takes place at the commencement of the disorder is attended with distinct friction- sound, the characters of which have already been described. This usually commences at the base, or along the right side, occasionally at the apex, but soon becomes general ; and having lasted for an uncertain time (a few hours, a day or two, or longer) slowly or rapidly vanishes. The further progress of the case will alone determine whether this disap- pearance is due to adliesion having taken place, and is therefore permanent, or whether it depends on increase of fluid effusion and consequent sepa- ration of the pericardial surfaces from one another. In the latter case, the friction recurs with the absorption of the fluid, and its final disap- pearance, due to adhesion, is a subsequent event. Pericardial friction- sound is usually rendered more intense and at the same time modified in PEEICAEDITIS. 513 character by tlie application of pressure to the prfecordiiun ; and its intensity is often distinctly influenced by the movements of respiration. It may be added that pleuritic sounds developed along the edges of the praecordial region often have a distinct cardiac rhythm impressed upon them. Other phenomena which may often be observed are : oedema of the integuments over the cardiac region ; a perceptible thrill, arising from the grating of the two rough pericardial surfaces upon one another, to be felt by applymg the open hand to the cardiac area ; and more or less complete masking of the normal heart -somids by those of pericardial friction. It is scarcely necessary to say that all the phenomena (local and general), which have been previously described as belonging to peri- cardial effusion, are commonly added during the progress of the disease to those which have now been detailed, and mdeed that they constitute an essential element m the clinical description of pericarditis. The mfluence of pericarditis on the action of the heart and on the pulse is various. Early in the disease the heart itself may be Httle affected ; more commonly its movements are mcreased in frequency, and the pulse is at the same time harder and fuller than natural. With the increase of effusion the beats of the heart become accelerated, and diminished in strength ; the pulse consequently gets small and feeble, and often irregular. Moreover, its rate is apt to be increased by any sHght excitement or muscular effort. Among the general symptoms referrible to pericarditis are the follow- ing : first, those of inflammatory fever, namely, increase of temj)erature, dryness of tongue, thirst, loss of appetite, and scanty high-coloured urine ; second, shortness of breath, often amomiting to dyspnoea, or orthopnoea, and frequent short, hacking cough ; third, vomitmg, a general aspect of distress, a look of anxiety, with pinched features and a pallid, or some- times congested, countenance, weariness, want of sleep, tossing of the arms, irritability, rambling, and occasionally (especially towards the close of fatal cases) maniacal dehrium, convulsions, or coma. The latter phenomena, however, which are certainly not unfrequently associated "s^dth pericarditis, seem almost always to have been observed in cases where the pericarditis was distinctly rheumatic, and where, therefore, it is possible that they may have been due to some other cause. Tetanic spasms and risus sardonicus also have occasionally been noticed m rheu- matic pericarditis. Further, in cases attended with much effusion, diffi- culty of swallowing fi-om pressure on the oesophagus, congestion of the head and neck from obstruction of the superior cava, and aphonia from compression of the left recurrent laryngeal, have been observed. Eecovery from simple pericarditis is attended T\ith the gradual sub- sidence of the symptoms which belong to the disease. In slight cases convalescence is often rapid and complete. Generally, however, when there has been much pericardial eflusion, and the symptoms have been severe, the amendment is slow ; and permanent ill-health is apt to remain. Pain, tenderness, cough, difficulty of breathing while the patient is at rest, and fever, gradually subside, the patient's appetite improves, and he begins 514 DISEASES OF THE VASCULAR ORGANS. to enjoy refreshing sleep. But the pulse frequently remains for a long while preternaturally quick, or on the other hand becomes slow and in- termittent, and the praecordial prominence and increased duhaess still continue excessive. Moreover, imder these circumstances the patient often remains incapable of taking active exercise on account of the per- sistent ready development of cardiac uneasiness, palpitation, and shortness of breath. These symptoms also may in their turn subside more or less completely. Adhesion of the pericardium can rarely be diagnosed with certamty in the absence of a distinct history of pericarditis. It is often attended, however, with persistence of enlarged area of dulness, and permanent and unalterable elevation and displacement outwards of the apex-beat, together perhaps with palpitation, dyspnoea, and some of the general symptoms of cardiac disease. Other occasional diagnostic indications are, retraction at the apex and of the precordial intercostal spaces during the ventricular systole, and an impulse corresponding to the diastole. Moreover, a peri- cardium which has once been inflamed is apt under the influence of exciting causes again to become inflamed, notwithstanding the complete obliteration of its cavity. Pericardial suppuration generally takes a chronic course. The com- mencement of suppuration may be attended with rigors and elevation of temperature. The former may recur from time to time ; the latter pro- bably continues ; and soon the fever assumes a distinctly hectic type. The local phenomena are not always very well marked ; there will pro- bably be some persistence or increase of pain and tenderness, gradual extension of praecordial dulness, and augmenting distension of the prsecor- dial region, with distinct and increasing oedema of the integuments. Severe pericarditis not unfrequently ends sooner or later in death. If death occur during the height of the disease it may be the result of one or other of the cerebral complications which have been enumerated, or of asphyxia due to pulmonary complication ; but in the majority of cases it is the consequence either of slow asthenia or of an attack of syncope. "When death takes place at a later period, it is not unfrequently dependent on the gradual supervention of the orduiary consequences of heart-disease — namely, pulmonary congestion with pulmonary apoplexy, or systemic venous congestion with anasarca, and affection of the liver, kidneys, and other organs. Suppurative pericarditis is generally fatal. B. Myocarditis. Causation and morbid anatomy. — Inflammation of the muscular tissue of the heart rarely occurs except in connection with peri- or endocarditis. In pericarditis, as we have already pointed out, the muscular walls in con- tact with the inflamed serous membrane are often distinctly implicated ; and there is no doubt that their mner aspect may be similarly involved during the course of an attack of endocarditis. It may even happen that in some situations they become thus affected in their entire thickness. Occasionally no doubt idiopathic inflammation arises, independently of MYOCAKDITIS. ENDOCAEDITIS. 515 inflammation of the serous membranes. It is said then to occur chiefly on the left side and towards the apex. It may however be general. Some- times pytemic abscesses, or abscesses due to embolism, are found studding the muscular substance. These are mostly small. But abscesses of con- siderable bulk have been described. Myocarditis presents the same pathological phenomena as inflamma- tion of muscular tissue elsewhere. The aft'ected parts become injected, there is a tendency to proliferation of the stationary protoplasmic elements, and to the escape of leucocytes and red corpuscles ; and in coimection with these phenomena the muscular fibres rapidly lose their striation, be- come granular and opaque, and break down. Not infrequently indeed this affection of the muscular fibres, together with irregularly distributed mottlmg and softenmg of tissue, is the only obvious indication of myocarditis. The early effects of inflammation are to diminish the cohesion of the affected tissues and to render them less resistant than natural. But sub- sequently, if resolution do not take place, they become contracted and hardened, and assume a cicatricial character. Under either of these conditions, especially if the morbid processes be circumscribed, yieldhig of the affected walls may take place, and the foundation of cardiac aneurysm be laid. When abscesses form they may burst into the peri- cardium, exciting mflammation of that membrane ; or into the cardiac cavities, and thus evoke the phenomena of embolism or pyaemia. In many cases, no doubt, the uiflamed muscle becomes completely restored. Symptoms and ^orogrcss. — It is impossible to assign any specific symptoms to myocarditis. Among those most likely to be present, are : fever ; debility of the heart with feebleness of impulse, of first sovmd, and of pulse ; tendency to famt ; difficulty of breathing, with oppression and uneasiness in the precordial region; and nervous phenomena such as restlessness, giddiness, delirium, convulsions and coma. Death usually occurs suddenly from collapse or syncope. C. Endocarditis. Causation. — The causes of inflammation of the lining membrane of the heart's cavities are to a large extent identical with those which excite pericarditis and myocarditis. Most of the local causes, however, to which pericarditis may be due, can scarcely be operative upon the endocardium. Endocarditis is occasionally the result of the accidental rupture of valves or chord® tendine® ; more commonly it depends on exposure to cold ; but by far its most frequent cause is the presence of rheumatism. It may also be caused by extension from abscesses in the muscular parietes. Again, like pericarditis, it is often developed in connection with chorea and scarlet fever. A chronic form of endocarditis also may occur in re- lation with the syphilitic cachexia, chronic alcoholism, Bright's disease, and other affections mducmg persistent dyscrasia. Morbid anatomy. — In the great majority of cases endocarditis is L L 2 516 DISEASES OF THE VASCULAE OEGANS. limited to tlie left side of tlie heart, aud to the valves or their immediate vicinity. Its presence is indicated by increased vascularity of the affected areas ; infiltration and inflammatory overgrowth of tissue, and consequent increase of thickness ; and development of warty growths or granulations upon the surface. The thickening, which is mostly attended with opacity and softening, varies in degree, and, when it involves the thin curtains of the valves or the delicate chordae tendinea, causes them to become puckered or contracted. The granulations are in the first instance mere points ; but they soon increase m size, sometimes becoming small bead- like bodies, sometimes papillary excrescences, sometimes rounded masses from the size of a tare up to that of a filbert. Frequently neighbouring outgrowths coalesce, forming warty, botryoidal, or cauliflower-like masses, and in some cases pendulous frmge-like but irregular processes, which may attam a length of one or two inches. Duruig the mflammatory process it is not uncommon for ulceration to take place. If this affect the valves it leads to their partial detachment, to their attenuation at points, and the production of valvular aneurysms, or to their perforation ; if it involve the tendinous cords, to their laceration. When inflammation attacks the aortic valve the granulations which characterise it first appear as a fringe along the festooned inner margins of the lunulae, but with the extension of disease they may cover the whole of the under surface of one or more of the cusps and even extend down- wards on to the septum. They often, indeed, at length hang from the free edge of the valve, which then usually is thickened, contracted, and irregular in form. The aortic aspect of the valve is rarely the seat of granulations. When the mitral valve is mflamed, granulations appear on its auricular aspect a little within the free edge, whence they may extend over the greater part of that surface and thence on to the auricular walls. With the development of granulations there is usually thickening and con- traction of the free edge of the valve, and at the same time some contrac- tion of the valve at its base, in virtue of which the orifice becomes diminished in capacity. The chordae tendinefe also are apt to be the seat of granulations, to undergo thickening and shortening, and to become blended to a greater or less extent with the valvular curtains. Granula- tions are rarely met with on the ventricular surface of the valve. Inflammation, when it attacks the valves; on the right side of the heart, produces exactly similar effects to those above described. Inflammation of the endocardium is not always acute, or always hmited to the valves. Iia regurgitant aortic disease the surface of the septum ventriculorum, for half an inch or an inch below the valve, generally presents cicatricial thickening, and occasionally marked con- traction. The thickening is the result of chronic mflammation, probably due to the constantly recurring impact of the refluent blood- stream against the ventricular walls in this situation. Again, we occasionally find, es- pecially in connection with some forms of so-called ' atheroma ' of the arteries, the lining membrane of the left ventricle studded vnth. irregular ENDOCAEDITIS. 517 patches of opaque thickening. These are due to hypertrophy, with degeneration, of the endocardium, and are doubtless also of inflammatory origin. Symptoms and progress. — The symptoms of endocarditis, apart fi-om those of the disease (if any) with which it is associated, and of the lesions to which it gives rise, are neither striking nor serious. The symptoms, indeed, which are usually ascribed to this affection, are mainly made up of those of acute rheumatism and valvular obstruction or incompetence. And it must be admitted that it is by the development of the valvular lesions which are an almost invariable accompaniment of endocarditis, that we mainly assume its presence and trace its progress. It is need- less to say that the discovery of valvular mischief is no proof of the presence or even of the pre-existence of endocarditis. But if, in the progress of any one of those diseases of which endocarditis is a common complication, we detect a cardiac murmur which had not previously existed; and if further observation proves this to be a permanent phenomenon ; or if changes in it mdicative of increasmg mischief take place ; or if additional murmurs become developed, we cannot reasonably doubt that endocarditis is present. The same conclusion may be fairly arrived at when a young person, who is known to have been hitherto healthy, presents vague symptoms of ill-health, and reveals under the stethoscope a newly developed and persistent valvular murmur. It is very important, however, to note that, in forming a judgment with respect to cases of this kind, there are many sources of fallacy to be avoided. We must be careful, that we do not mistake a pericardial rub for an endocardial murmur ; that we do not hastily assume that a murmur which we hear for the first time has not existed from some previous attack of rheumatism, or from birth ; and that we do not take a functional or anaemic murmur for one of organic origin. On the other hand, we must not too readily take it for granted that, for example, in a case of rheumatism in which the heart is known to have been uxjured in some previous attack, the cardiac disease which we recognise is all of old date ; we must not forget that direct murmurs due to granulations occasionally disappear ; and, further, we must always recollect that inflammatory vegetations may be formed on the valves, and more particularly on the auricular aspect of the mitral, which never impair the action of the heart and never give rise to abnormal soimds. The remaining indications of the presence of endocarditis are slight and fallacious. From the position of the mflamed arefe it is scarcely possible that prsecordial tenderness should be present ; and, indeed, it is rarely if ever observed. Uneasiness or pain in the region of the heart may, however, be complained of. From the smalhiess of the extent of the inflamed surface we should scarcely expect much febrile disturbance ; nor, as a rule, is simple endocarditis attended with marked fever. Still there may be elevation of temperature, thirst, scanty urme, and other indications of the febrile condition. Again, here as in pericarditis, we may naturally look for some excitement or other modification of the 018 DISEASES OF THE VASCULAE OEGANS. action of the heart. It generally acts more frequently and more power- fully than natural. The prognosis of endocarditis is very serious. It is rare mdeed for perfect recovery to take place. Moreover, the patient remains, for the most part, liable to fresh attacks of inflammation, and consequent mcrease of valvular lesion. The results of endocarditis are mainly those which have already been considered under the head of valvular disease, and will, of course, vary according to the valve affected, and the degree and kind of its affection, and need not be again discussed. But it must not be forgotten that it is in connection with endocarditis and its local conse- quences, far more than with any other form of disease involving the endocardium, that detachment of solid particles or masses takes place which are conveyed as emboli to the brain, liver, spleen, kidneys, lungs, and other organs ; and that the liability to this detachment has little or no obvious relation with the severity of the cardiac lesion. The subject of embolism will be fully discussed further on. . D. Treatment of Inflammation of the Heart and Pericardium. In most cases of the several forms of cardiac inflammation which have been passed m review, the affection is developed in the course of other diseases, such as rheumatism, Bright's disease, and pyaemia, for which the patient is already under observation. The treatment of these maladies, therefore, forms an essential element m the treatment of the heart-affec- tions which complicate them. It is important, however, to consider whether any, and if so what, additional measures may be adopted in reference to the cardiac lesions. In the treatment of pericarditis the abstraction of blood is generally regarded as a most important remedial measure. Blood may be taken by venesection from the arm ; but it is probably most conveniently, and best, removed from the pr^ecordial region by cupping or leeching. To be effica- cious, blood-letting should be performed early, while the symptoms are yet acute ; and should be, so far as is compatible with the patient's age and condition, free, in order to obviate as much as possible the necessity for its repetition. A dozen or twenty leeches may be applied to the chest of an otherwise healthy adult, and the bleeding subsequently encouraged by fomentations or poultices. In slight cases at an early period, and in severe cases after removal of blood, counter-irritatioii is of considerable value. It relieves pain and uneasiness, and probably promotes the ab- sorption of fluid. A large mustard plaister, or cotton- wool saturated with turpentine or spirits of wine, and covered with some impermeable tissue, may be applied to the prsecordium ; or iodine paint or blistering fluid may be painted over the part ; or simple fomentations, as hot as the patient can bear them, may be persisted in. There is, it may be observed, a practical objection to the use of applications which blister the surface : namely, that they interfere with that frequent examination of the cardiac region which is so important. Of the value of opium in this, as in almost all other inflammatory affections, there can be no doubt. It may gene- INFLAMMATION OF THE HEAET AND PEEICAEDIUM. 519 raUy be safely administered, and in large doses ; excepting, perhaps, wlien the heart shows signs of great enfeeblement, when the circulation is em- barrassed, the respirations rapid and shallow, and the skin dusky. When these latter phenomena supervene, ammonia, ether, alcohol, and other stimulants are indicated. In order to reduce inflammation, and remove the products of inflammation, it was formerly deemed essential to put patients under a course of mercury or iodide of potassium. These remedies, however, are probably mefiicacious except m certain constitutional con- ditions. Again, diuretics and purgatives have been largely advocated for the purpose of removing fluid accumulations from the serous ca^■ities. But there is little proof that they have any appreciable influence in this respect. It may, nevertheless, be useful when febrile temperature is present to employ some of those agents (namely, aconite, veratrum, or quinine) which are known to reduce temperature. But the most efficient means of effecting the removal of dropsical accumulations is to improve the patient's general health. And on this and other grounds it is always important to bring him under the influence of tonic treatment as soon as the condition of the digestive organs allows of its emplojTnent. The above remarks as to treatment relate more immediately to pericar- ditis. But they are to some extent apphcable to endocarditis. It must be borne in mind, however, that local bleeding and local medication of all Mnds are necessarily less efficacious in endocarditis than in the other ; and, further, that as endocarditis is (except in its remote consequences) a far less dangerous and severe affection than pericarditis, a far less active plan of treatment is generally needed. When, m pericarditis, the accumulation of fluid appears to be seriously interfering with the action of the heart, especially if it persist despite all treatment ; or when we have reason to suspect the presence of pericardial suppuration ; the question whether paracentesis should be performed for the removal of the fluid will perforce present itself. The operation is one which has been performed neither frequently nor with much success ; moreover, it is an operation of considerable delicacy and difficulty ; still it can scarcely be doubted that it should be attempted under the above circumstances. The chief danger to be avoided is that of puncturing the heart, the next that of wounding the internal mammary artery. To avoid the former danger it is important first to determine accurately the lateral boundaries of the distended pericardium, and next to satisfy oneself, by the presence or absence of sensible mipulse, over what area (if any) the heart is in contact with the anterior thoracic parietes, and then carefully to make an opening into that part of the pericardium from which the heart seems to be remote. The mammary artery rmis doMm behind the costal cartilages, a Httle outside the sternum. The most ehgible spot for puncture is usually towards the mner extremity of the fourth or fifth inter- costal space close to the sternum. It is probably the safest plan to divide the soft tissues with the scalpel one by one until the parietal layer of the pericardium is reached, and then to puncture carefuUy with a fine trocar and cannula. If sermn escape the entrance of air should be prevented ; if 520 DISEASES OF THE VASCULAE OEGANS. pus, it may be advisable to wasli out tbe cavity, and even to inject a weak solution of clilorinated soda or Condy's fluid. In some cases it may be well to make a preliminary puncture with a fine aspirating needle. III. MOEBID GEOV/THS AND PAEASITES. A. Fatty Groicth. The presence of a small quantity of fat upon the surface of the heart, mamly in the course of the transverse and longitudinal sulci, is extremely common, especially in persons who have attained middle hfe, or who present a general accumulation of fat throughout their connective tissue. This condition is of no importance. But occasionally, in persons of great obesity, fatty growth becomes excessive, and encroaches seriously upon the substance of the heart, not only investing the organ, but invadmg the substance of its walls, separating the muscular fibres from one another, and imparting to the walls m places (more especially in the right ventricle) the softness and general aspect of simple fat. The symptoms referrible to this affection (which is sometimes described as a form of fatty degeneration) are those of cardiac feebleness and incom- petence. B. Tubercle. Tubercle is of infrequent occurrence, and generally takes place in con- nection with widespread distribution of the disease. Miliary tubercles are occasionally found imbedded in the substance of the muscular walls. Their most common seat, however, is the pericardial serous membrane. In this situation they may occur in small scattered groups only, or maybe thickly and pretty generally distributed ; and, especially in the latter case, are often associated with more or less abundant inflammatory exudation. Cheesy tubercle in considerable masses, and generally associated with thick and dense adhesions, is also occasionally observed in the peri- cardium. The symptoms of cardiac and pericardial tuberculosis are generally lost in those of more advanced tubercular disease of other organs. If, however, they be sufficiently pronounced to attract attention, they are indistmguish- able from those of subacute or chronic pericarditis. C. Syphilis. Syphilitic affection of the heart is not uncommon. The condition now generally regarded as such is characterised by the presence of fibroid in- filtration, of greater or less extent, of the cardiac walls ; with imbedded caseous masses, closely resembhng the so-called ' knotty ' tumom's of the liver ; and with more or less indurated thickening and adhesion of the pericardium. True gummata of recent formation have also been observed. Microscopically, the diseased tissues present, as do those of gummata MOEBID GKOWTHS OF THE HEAET. 521 developed iii voluntary muscles, overgrowth of the interstitial connective tissue, with fatty or caseous conversion of certain parts, in which the involved muscular fibres share. The disease may impHcate any part of the heart, but most commonly affects the ventricular walls. Sometimes it forms tumours, which project from the outer aspect of the heart, or encroach upon its cavities ; sometimes it leads to thinning of certain parts, and to aneurysmal dilatation. But fibroid change of the cardiac walls may be due to other causes than syphilis, to chronic mflammation for example, and the specific origin, therefore, of all such cases must not be hastily assumed. The conditions here spoken of may, at any rate in a clinical point of view be combined. They are chronic in their progress ; and are not un- frequently associated with adhesion of the pericardium, lesion of the valves, and hypertrophy, dilatation, or other modifications of the walls or cavities of the heart. The symptoms, therefore, which they induce, although liable to considerable variety of detail, are essentially those of chronic heart- disease, and mainly of those conditions or stages of disease m which the heart is enfeebled and incompetent to carry on the circulation efficiently. Dropsy is of common occurrence, and sudden death not unfrequent. The disease occurs almost exclusively among persons of middle or advanced age. D. Malignant Disease. This affects the pericardium, as it does other serous membranes, only ■ much less frequently. It may occur here in the form of miliary granula- tions, lenticular plates, or nodulated outgrowths. It is almost without exception secondary, and probably never attains sufficient proportions to cause obvious symptoms. Malignant disease of the muscular walls of the heart is also not common, and is probably always of secondary origin. Generally it occurs there in the form of small imbedded tumours, which are of no practical importance. Occasionally, however, it forms masses, as large as a hen's egg or orange, which encroach on the cavities or orifices of the heart, and constitute a serious impediment to the circulation. In some instances, sarcomatous and other growths, originating in the pos- terior mediastinum, involve the heart by continuity : they steal, as it were, along the vessels at the base, and then gradually infiltrate the muscular parietes of the auricles and ventricles, separating the muscular fibres from one another, and causing general increase of thickness. In these cases no tumours may be developed, and microscopic examination may be needed for the detection of the nature of the morbid process which has been going on. Among the varieties of malignant disease which have been found in- volving the heart and pericardium may be mentioned scirrhus, encephaloid, melanotic cancer, epithelioma, lymphadenoma, and sarcoma. Malignant disease of the heart and pericardium has rarely, if ever, been diagnosed during life, and indeed rarely gives evidence of its presence by symptoms referrible to the heart. It is obvious, however, that the symptoms to be looked for are those indicative of cardiac obstruction and 522 ■ DISEASES OF THE VASCULAE OEGANS. weakness, and that the supervention of such symptoms in the progress of mahgnant disease might suggest the possibility of cardiac involvement. E. Parasites. These are seldom met with in connection with the heart. The trichina spiralis has never been found m it. The cysticercus celhdosce has been discovered there, but not as productive of symptoms. Hydatid tumours also have occasionally been observed, varying from the size of an orange downwards, and either imbedded in the substance of the muscular walls, or occupymg the subserous tissue of the visceral pericardium. The symptoms to which hydatids would give rise are those : either of interference with the due performance of the cardiac functions ; of sup- puration, to which such cysts are liable ; of pericarditis, dependent on extension from the inflamed cyst, or on its rupture into the pericardium ; or, lastly, of the discharge of the hydatid contents into the interior of the heart. F. Treatment. It is impossible to lay down rules in regard to the treatment of cases m which the heart is involved in adventitious growths or the seat of para- sites. The symptoms likely to be induced are mamly those of cardiac debility and incompetence ; and the treatment must be adapted to the symptoms which are present. It may be said, however, generally, that diffusible stimulants and tonics are indicated. IV. DEGENEEATIONS. A. Degenerations of the Muscular Walls. Causation and morbid anatomy. — We have already pointed out that, mider the influence of starvation and various wasting diseases, more especially phthisis, the heart becomes remarkably diminished m bulk. But this change is due to atrophy alone, the muscular fibres undergou3.g simple attenuation, without structural change. Of actual degeneration, three varieties are generally described :— namely fatty or yellow degeneration, granular or broivn degeneration, and fibroid degeneration. 1. Fatty degeneration in an advanced condition is mdicated by soft- ness of the affected tissues, opacity, a pecuHar pale buff colour, and, it may be, obvious greasiness. Under the microscope, the muscular fibres are found to have lost, in a greater or less degree, their natural striation, to be studded with minute refractive oily molecules, and to be, as a rule, more friable than m health. Li the early stage it sometimes happens that the oily particles occur only at the poles of the nuclei of the muscular fibres, or arranged in longitudinal strings ; but with the progress of the DEGENEKATIONS OF THE HEAET. 523 disease they get more numerous ; and in extreme cases the fibres lose all their normal characteristics and are converted mto opaque, irregular cylinders of accumulated fatty particles. Fatty degeneration occurs mider various conditions. It is fi-equently the result of inflammation, and when developed in connection with peri- carditis occurs more especially in the layer of muscular fibres immediately subjacent to the visceral pericardium. It is sometimes observed in acute diseases, especially certain fevers, and in poisonmg by phosphorus. We have seen it remarkably developed in a child that died of acute purpura. It is a common condition of advanced life, especially if this be attended mth certain diseases or morbid tendencies, such as heart-disease, chronic bronchitis, Bright's kidney, hepatic disease, arterial degeneration, or gout. It is common also, mamly in old age, as an immediate consequence of ob- structive disease of the coronary arteries or of any other morbid condition impairmg the vitality of certain portions of the organ. When the degeneration occurs in connection with inflamed serous membrane, the affected lamina appears to the naked eye anaemic, and in other respects but little altered. When it is due to general disease or to disease influencmg the heart generally the whole organ may become palhd and softened; but more frequently the tissues are mottled with fattily degenerated spots or patches — a condition which is often peculiarly distinct in the carneae column® and on the inner surface of the ventricles. When the degeneration is secondary to obstructed arteries, it usually occupies a circumscribed region which presents, as a rule, remarkable softness and friabihty. 2. Granular degeneration is generally distributed miiformly through- out the muscular tissue of the heart, which assumes a brownish hue. The muscular fibres are studded with longitudinal strings of brownish particles, the exact chemical constitution of which is not known. The circumstances which determine this form of degeneration seem to be the same as those to which general fatty degeneration is also due. 3. Fibroid degeneration affects portions only of the cardiac walls, and is comparatively common on the right side. The affected tracts are greyish, dense, and hard — changes which are due in different degrees to overgrowth of fibroid tissue and to wastmg of the muscular fibres, and their conversion into, or replacement by, fibroid tissue. The change is probably often undistmguishable from the consequences of syphilis, but is sometimes a sequela of myocarditis. Again, hypertrophy of. the heart, and especially the form of it secondary to Bright's disease, is often made up partly of overgrowth of muscular tissue, partly of overgrowth of the intervenmg connective tissue ; and in some cases the latter element becomes disproportionately abundant, and the heart consequently, in a sense, degenerate and enfeebled. Symptoms. — The symptoms of degenerative affections of the muscular walls of the heart are mainly those of cardiac wealoiess and incompetence ; such especially as dyspnoea, lividity, tendency to syncope, indistinctness of the first somid of the heart and weakness of pulse, which may be 524 DISEASES OF THE VASCULAE ORGANS. quick, slow, irregular or variable. To these must of course be added the other usual consequences of defective or impeded circulation. Enfeeble- ment from degeneration is one of the recognised causes of sudden death ; and it is an important fact that sudden death is liable to occur in those in whom degeneration is not yet far advanced, and who have not yet presented definite symptoms of cardiac disease. Eupture of the heart is not uncommon in those cases in which local softenings from arterial obstruction are present. B. Degenerations of the Valves and Endocardium. Causation and morbid anatomy. — Fibroid, fatty, and calcareous changes, or degenerations, of the endocardium are among the most frequent causes of heart-disease. For the most part they come on with advancing years, and may be regarded (with the corresponding conditions of the arterial system) as some of the chief consequences and indications of senile decay. They are apt, however, to manifest themselves even in early advilt life, especially in those who have lived intemperate or over- laborious lives, or have suffered from syphilis, or are the subjects of chronic Bright's disease. They are also apt to supervene on ordinary endocar- ditis ; and hence it is often difficult (except from the history) to distinguish between degenerative lesions of primary origin and such as are the con- sequences of bygone acute endocardial inflammation. It must be remem- bered, however, that the changes, which are here roughly grouped to- gether as degenerations, probably for the most part take their origin in a form of chronic endocarditis — a subject which will be more fully discussed when we come to speak of endoarteritis and degeneration of arteries. Degenerative changes may manifest themselves at any point of the endocardial surface ; but far more frequently involve the valves than other parts. The lining membrane of the left ventricle is more commonly affected than that of the other cavities ; and the aortic and mitral valves far more commonly than the valves of the right side. In some cases the valves present simply a few opaque, buff-coloured (atheromatous) patches ; in some they manifest general fibroid thickening — a condition which is usually accompanied by contraction, and often by fatty or calcareous deposit ; in some cases they are rendered thick, nodulated, and irregular, from the accumulation of combined fibroid, fatty, and calcareous deposit, and then, if the disease be far advanced, project as rigid processes across the orifices to which they belong, become blended to a greater or less extent with one another at their bases, and reduce the valvular aperture to a mere chink ; in some cases, again, the degenerate tissue undergoes erosion, excavations form, and finally perhaps the valve gets perforated or ruptured. These changes generally are not strictly limited to the valves ; but are apt to be prolonged from the aortic to the aorta or the septum ventriculorum, and from the mitral to the chordas tendinese, which be- come thick, short, and sometimes incorporated with one another. The chordae tendinese, like the valves, occasionally get lacerated. DEGENEKATIONS OF THE HEAET. 525 Symptoms. — It is obvious that the conditions here described may produce all varieties of valvular defects, singly or in combination ; and more especially the same defects that' commonly result from acute endocarditis — namely, obstructive and regurgitant disease of the aortic and mitral orifices. The changes are chronic, and the symptoms which they induce creep on insidiously ; so that it often happens that a patient has had the disease upon him for years before its presence is distmctly revealed. Indeed, the first clear indication of heart-disease is sometimes due to the sudden rupture of a valve, or some other untoward com- plication or event ; and we are often astonished to find post mortem how extreme a degree of contraction of the aortic or mitral orifice has been compatible, not merely with life, but with life passed in comparative ease and comfort. The early symptoms of degenerative disease of the valves are usually vague, comprismg, perhaps, some degree of irregularity of the pulse, more or less shortness of breath, occasional neuralgic pain or uneasiness in the region of the heart, attacks of giddiness or faintness, and not unfre- quently impairment of the digestive functions. But masmuch as the cardiac affection is usually associated with degenerative changes in the arteries and even in other tissues, the symptoms due to these become mingled with those of the heart-disease, and may to some extent aid our diagnosis of the actual condition of the heart. Among such indications may be mentioned the presence of rigid or otherwise diseased arteries, as revealed by the condition of the pulse or by cerebral symptoms, and the existence of the arcus senilis. The symptoms of the declared disease are mainly those of the valvular lesions which have already been fully con- sidered. The chief practical point to be remembered is that, however slow the symptoms may have been in attaining serious development, the morbid processes on which they depend are in the nature of things pro- gressive and tend surely to a fatal issue. C. Degenerations of the Coronary Arteries. The coronary arteries and their branches are liable to all those de- generative changes which affect the lining membrane of the heart and arterial system. Their parietes consequently become thickened with fatty or calcareous deposit, and their channels reduced in size or obliter- ated. The latter conditions involve the imperfect nutrition of the parts to which the affected vessels lead, and induce those localised fatty changes, attended with discoloration of tissue and softening, which have already been adverted to. No specific symptoms c&n be referred directly to disease of the coronary arteries. Angina pectoris has been asserted to occur with special frequency in these cases. But it must be recollected that arterial degeneration is usually present in persons advanced in years, and is then usually asso- ciated with other cardiac degenerations. 526 DISEASES OF THE VASCULAE OEGANS. D. Treatment. Degenerative conditions of the heart, as of other organs, call for all measures — tonic, alimentary, and hygienic — calculated to maintain or improve the general health ; but they also need special precautions and special items of treatment, according to the particular phenomena and dangers which each case presents. These have been sufficiently indi- cated on an earlier page under the head of the treatment of cardiac derangements. V. ANEUEYSM OF THE HEAET. Causation. — In addition to that general dilatation of the heart's cavities which has been previously considered, partial dilatations or aneurysms are occasionally met with. They have been oftener observed in men than in women, and for the most part at an advanced period of life. They are not uncommon, however, during middle age, and occur, indeed, though with extreme infrequency, in children. Localised dilatation obviously depends on comparative feebleness of that portion of the cardiac wall which undergoes dilatation, and its inability to resist successfully the internal pressure to which it is subjected. The cause of weakness is doubtless different in different cases. In some dila- tation seems to arise in ulcerative destruction of the lining membrane, or in laceration and breaking down of more or less of the muscular wall ; but in most it is apparently due to the presence of one of those forma of enfeeblement which have just been passed in review, namely, fatty, fibroid, or some other variety of degenerative change. It is obvious, there- fore, that it may be a consequence of endocarditis and myocarditis, in either their acute or their chronic forms, and of syphilis. Not improbably also it occasionally originates, as do arterial aneurysms, in the effects of violent muscular exertion or of violence inflicted from without. Morbid anatomy. — Cardiac aneurysms now and then occur in the right ventricle and even in the left auricle, more especially at the foramen ovale ; but by far their most common seat is the left ventricle. They are generally said to affect chiefly the apex of this cavity ; but they may originate at any spot within it. In size they range from that of a pea to that of the heart itself. In form they may be : a simple hemispherical expansion of the apex or some other part ; or flask-like, communicating by a comparatively small orifice with the ventricular cavity ; or sacculated, consisting of a series of intercommmiicating chambers imbedded in the substance of the walls, and extendmg over a more or less considerable area. Their parietes vary in thickness, and are sometimes as thin as paper ; and generally (especially if the aneurysm be of large size or old date) consist of dense fibroid material, with little or no trace of muscular tissue. Occasionally they undergo calcification. Cardiac aneurysms sometimes are empty, sometimes contain laminated or other forms of coagulum. As regards their results, they seem occasionally, after having EUPTUEE OF THE HEAET. 527 reached a certain size, to remain stationary, or nearly so ; but they tend ultimately to midergo laceration, and thus to cause communication between the left ventricle and one or other of the auricles, iiae right ven- tricle or the pericardium. In their progress towards the surface they not imfrequently cause pericardial inflammation, and adliesions, which both delay rupture and limit its effects. Among cardiac aneurysms must be included those of the valves and coronary arteries. Valvular aneurysms occur chiefly in the aortic and mitral valves, but occasionally in the tricuspid, as the result of inflamma- tory or degenerative weakening or erosion ; and they constitute bulgings of various sizes, which, in the case of the aortic valve, project into the ventricle, m the case of either of the auriculo -ventricular valves into the auricle and usually sooner or later rupture, and thus allow of free regur- gitation. Aneurysms of the coronary arteries are rare. They are generally developed in the trunks at a short distance from the aorta, and form small tumours in the transverse sulci. Occasionally numerous small aneurysms stud not only the tnmks, but also many of the larger branches. Like cardiac aneurysms, they may open into the pericardium, cardiac cavities, or large vessels at the base of the heart. Symptoms. — Cardiac aneurysms for the most part are never suspected to be present until the occurrence of rupture causes either grave symptoms of cardiac disease, or death from escape of blood into the pericardial cavity. There are no special symptoms by which their presence is indicated. They are of course frequently attended with some of the usual symptoms of chronic heart-disease ; and when large and so situated as to come into relation with the anterior thoracic parietes, the presence of a pulsating tmnour distinct from the heart may occasionally be recognised. VI. EUPTUEE OF THE HEAET. EFFUSION OF BLOOD INTO THE PEEICAEDIUM. Causation. — Perforation of the muscular walls of the heart may be due to accidental or other violence ; with such cases, however, the physician has little or nothing to do. Spontaneous rupture is an afi'ection almost exclusively of advanced age ; it sometimes occurs in the floor of an aneurysm, sometimes in a heart generally weakened by degenerative changes, but more frequently in a circumscribed patch of softening, due to atheromatous disease and obstruction of the artery which supplies it ; and it is generally immediately traceable to some muscular efibrt or mental disturbance. Men are more liable to it than women. Morbid anatomy. — Spontaneous rupture occurs almost without excep- tion in the walls of the left ventricle, and mostly in front. It generally forms in the direction of the muscular fibres an irregular rent, or series of rents, which pass irregularly through the walls, and present considerable 528 DISEASES OF THE VASCULAE OEGANS. diiferences of size, form and position, on the inner and outer surfaces respectively. The lacerated tissue, moreover, is generally infiltrated to a greater or less extent with blood. The consequences of laceration of the heart, though in all cases death ultimately ensues, present a good deal of variety. In some instances (especially in cardiac aneurysm) the actual rupture into the pericardium is preceded by the formation of pericardial adhesions ; in some the rupture occurs primarily into the connective tissue beneath the visceral pericardium ; in both of which cases the effusion of blood is at first circumscribed, and the patient may sink, not suddenly from copious hemorrhage, but slowly with the symptoms of pericarditis. In some instances the rupture occurs directly into the pericardial cavity, and rapid escape of blood takes place into it. The pericardium is then found post mortem to be distended with blood — partly serum, partly a bag of undecolorised coagulum in which the heart is enclosed, and by which it is concealed ; the heart, moreover, isfound empty, flattened, and wrinkled on the surface, as if it had been subjected to considerable pressure. Symptoms and progress. — The symptoms of rupture of the heart are far from uniform. In a large number of cases the patient is attacked with severe pain in the region of the heart, gasps for breath, faints, and dies in the course of a few minutes, or even a few seconds. In some cases he is also attacked with sudden severe cardiac pain, faintness, and dyspnoea, but rallies to some extent ; and then, passing into a condition of extreme collapse, attended with remarkable feebleness of pulse, coldness of extremities, profuse sweats, anxiety and restlessness, sighing respiration or extreme dyspnoea, and great oppression, constriction, or pain at the chest, dies at the end of some hours. In some cases again (and these are they in which adherent pericardium or other circumstances delay or prevent the impletion of the serous cavity with blood) the symptoms which mark the occurrence of laceration subside, and the patient returns apparently to a state of more or less complete health ; upon which, at the end of a few hours, or perhaps a few days, either sudden death occurs from the dis- charge of blood into the pericardium, or pericarditis becomes developed, and sooner or later carries him off. The phenomena which attend the rupture of aortic aneurysms into the pericardial cavity are identical with those which have just been de- scribed. Other ruptures of the heart besides those of its outer muscular walls may take place ; thus, either the septum of the ventricles or that of the auricles may become perforated, the musculi papillares or chordae tendineae may be broken, or the aortic, mitral, or other valves torn from their attach- ments or split. Such lacerations occur spontaneously probably in those cases only in which there has been previous weakening from disease. The aortic valve chiefly suffers in this respect, and the tendinous cords of the mitral. The consequences of these lesions are obvious : in the first two cases, a communication will be established between the auricles or ven- tricles ; and in the others regurgitation of blood from the arteries into the ventricles, or from the ventricles into the auricles will be set up or HYDEO-PEEICAEDIUM. SYNCOPE. 529 augmented. The symptoms here will be mainly those of advanced valve - disease ; and the nature of the accident on which they depend may pos- sibly be diagnosed, partly by the sudden occurrence or aggravation of the patient's symptoms, partly by the circumstances under which this sudden occurrence or aggravation took place, and partly by auscultatory signs. VII. HYDEO-PEEICARDIUM. Dropsy of the pericardium, like hydro-thorax or ascites, is one of the incidents of general dropsy. It may depend also on local causes, such as obstruction of the coronary veins, and the growth of tubercles or cancer. A greater or less degree of it is of common occurrence. The amount of serous fluid present rarely exceeds half a pint, and is often not more than one or two ounces. It is insufficient, indeed, as a rule, to cause obvious symptoms or to be discoverable during life. Hydro-pericardium, however, like other varieties of dropsy of serous cavities, may become excessive, and hence not only embarrass the movements of the heart, but reveal its presence by the physical indications (which have been already discussed) of fluid accumulation in the pericardial cavity. When, however, it be- comes thus extreme, there is generally reason to suspect its association with some degree of pericardial inflammation. Hydro-pericardium rarely, if ever, demands special treatment. Counter- irritation of the precordial region, and the treatment of the condition on which the dropsy depends, are the chief measures to be adopted. It is conceivable that paracentesis might be needed. VIII. SYNCOPE. Causation. — The fetiology and symptoms of syncope have been dis- cussed in an earlier part of this work, to which we refer the reader. "With reference, however, to the heart's share in its production we may make a few additional observations here. The cardiac failure (which always takes place to some extent) is commonly referrible to causes, mental or physical, operating through the nervous system ; the heart becomes more or less completely paralysed, and contracts feebly or not at all upon its contents. In some cases, however, its failure to act depends upon the presence of some mechanical impediment to its action, as when it is compressed by rapid serous effusion into the pericardium, or by the escape of blood into that cavity, or as when sudden obstruction of one of the cardiac orifices by a clot or embolus takes place, or the patient is suffering from obstructive valve-disease. Hearts enfeebled either by dilatation or by fatty or other forms of degeneration, or by abundant or dense pericardial false membranes, are especially liable to failure of action, and are necessarily more liable than others to suffer under the influence of those causes of failure which have been previously enumerated. Treatvient.^—A patient suffering from syncope should be placed m the M M 530 DISEASES OF THE VASCULAE OEGANS. . horizontal position, all ligatures should be removed from the neck and elsewhere, and he should be freely exposed to cool fresh air. Ammonia, or other such stimulants, should be held to the nostrils ; ammonia, ether, or alcohol administered by the mouth ; or, if they cannot be swallowed, these or turpentine should be given in the form of enemata ; cold water should be dashed in the face, either from a jug or by means of a wetted cloth or towel, and sinapisms applied to the epigastrium and to the limbs. If death seems imminent, it is important to promote the action of the lungs and heart by frictions, and it may be necessary to employ artificial respiration, to stimulate the heart by galvanism, or, if the veins be dis- tended, to bleed from the external jugular vein. If syncope be the result of profuse hemorrhage, the question of transfusion naturally arises. Whenever the syncopic condition assumes a chronic form it is important to maintain the bodily temperature and to prevent the patient from making any kind of exertion. Then, too, the gradual improvement of the patient's vital powers by the judicious exhibition of nourishment, and the assuage- ment of vomiting and all other symptoms which tend to impede this improvement, become objects of the highest importance. The value of iron and other tonics in promoting restoration to health, and of opium or chloral hydrate in remedying sleeplessness, excitement, or delirium, need scarcely be insisted upon. IX. PALPITATION. GEAVES'S DISEASE. [Exophthalmic goitre.) A. Palpitation. The phenomena of palpitation, so far as they involve the heart and vessels only, have already been adverted to. They comprise increased frequency of cardiac action, suddenness of impulse, together with, not unfrequently, some irregularity or intermission. The symptoms which attend palpitation are throbbing of the heart and arteries, noises in the ears, muscae, giddiness, faintness, hurried respiration, prsecordial mieasiness and anxiety, flushing of face, coldness of extremities, clamminess of surface, together with which are often associated rushing sounds or murmurs at the- cardiac orifices, in the larger arteries, and even in the larger veins of the neck. The conditions under which palpitation occurs are very numerous. Among them may be mentioned : mental excitement ; excessive bodily exertion ; indigestion ; the influence of certain articles of diet or luxury, more especially strong tea, and tobacco ; anaemia and debility, however produced ; hysteria ; gout ; and, besides these, the presence of actual cardiac disease. In many of the cases here enumerated the palpitation is occasional only, and disappears wholly with the removal of the condition on which it depends. But sometimes it assumes a chronic character. The heart is then apt to get dilated and hypertrophied ; and these very changes tend to maintain or aggravate the conditions out of which they arose. GKAVES'S DISEASE. 531 B. Graves's Disease. Definition. — The most remarkable cases of persistent palpitation are tliose described by Graves and Basedow, in wliich, together with pal- pitation, there is enlargement of the thyroid body, and exophthalmos or protrusion of the eyeballs. Causation. — These associated phenomena are most commonly met with in young women above the age of puberty ; they are seldom observed in girls of younger age, and seldom originate in advanced life. Men are affected much less frequently than women. The patients are, in some cases, angemic or hysterical, but by no means mvariably so. Sometimes the commencement of the disease dates from an attack of fever, or is attributed to mental shock or over-exertion. Occasionally it ensues on organic lesions of the heart. By some it has been contended that the cardiac disturbance precedes and is the cause of the goitre and exoph- thalmos. But against this view is the fact that long-continued palpita- tion is constantly met with in persons who never have any apparent ten- dency to affection of either the orbit or the thyroid body. Others have regarded the goitre as the primary lesion, and have referred the cardiac and other symptoms to its influence, exerted either by pressure on the arteries of the neck or in some less obvious manner. It is sufficient, how- ever, in opposition to this view, to point out that Graves's disease is sometimes present without thyi'oid enlargement, and that palpitation and exophthalmos are not specially common among the citrous inhabitants of goitrous districts. The proximate cause, indeed, of the disease is very obscure. Nevertheless there are many circumstances which render it probable that the collective symptoms are due to some affection of the sympathetic system, which allows of passive dilatation of the vessels of the neck, thyroid body and orbit, and at the same time of excited action of the heart. Many of the symptoms, in fact, closely accord with those producible either by paralysis or by functional disturbance of the sym- pathetic. Moreover, various observers have described, in fatal cases of the disease, morbid conditions of the cervical sympathetic. Morbid anatomy, symptoms and progress. — The symptoms of Graves's disease may come on suddenly or gradually. In the latter case the patient probably first complains of ^^olent and frequently repeated cardiac pal- pitation, together with distressing pulsation of the arteries in the neck. After these phenomena have existed for an mdefinite period, changes are observed in the eyes and thyroid body. The affection of the eyes, if not actually prior m point of time to that of the thyroid body, is generally perceived earher. At first the change is sHght, and evident only to those to whom the patient's healthy aspect is familiar. The eyes are a little more prominent, glistening, and staring than they were. But gradually their prominence becomes more and more pronounced, until they pro- trude so far through the eyelids that these are unable to close in sleep, and even at ordinary times are so widely separated that the corneas are visibly M M 2 532 DISEASES OF THE VASCULAE OEGANS. encircled by the sclerotics. Occasionally even the insertions of the recti muscles can be clearly distinguished. The exophthalmos is generally equal on both sides. Occasionally, however, it begins unilaterally, and, even when both eyes become involved, continues more pronounced on one side. It is curious that inflammation rarely attacks the insufficiently protected eyeballs ; and that sight remains for the most part unaffected, excepting, perhaps, that the patient is troubled with musc», becomes long or short sighted, and suffers from fatigue m using the eyes. The protru- sion of the eyeballs is often variable to some extent, increasing under the mfluence of palpitation, or excitement, and at the menstrual periods ; and it appears to be due either to accumulation of fat, or of fat with increase of connective tissue, in the orbits, or to dilatation of the orbital vessels, or to these conditions combined in various proportions. It is often attended with aching or throbbing in the orbits, and not unfrequently subsides wholly after death. The enlargement of the thyroid body is for the most part very gradual ; and attention is generally first directed to it by the continued presence of pulsation in the lower part of the neck. It then causes merely a slight fulness in the usual situation of the gland, but more especially on the right side, and is subject to variations in degree ; sooner or later, however, a manifest tumour results. This may be symmetrical, or may continue to be a little larger on the right than on the left side, but rarely attains a large size, or produces injurious effects by pressure on neighbouring parts. This form of goitre is more vascular and generally softer than ordinary goitre, and is often attended with a thrill or distinct pulsation, perceptible to the patient as well as to the examiner, and with arterial or venous murmur. It has, indeed, more than once been mistaken for aneurysm. Its size, like the prominence of the eyes, is liable to change. The condition of the palpitating heart varies somewhat. For the most part its action is violent and rapid and apt to be irregular, and its sounds loud and ringing ; its area of dulness is often increased. In most cases it is at first structurally healthy, and so it may continue. Often, however, the persistence of palpitation induces hypertrophy and dilatation. A functional systolic murmur is not unfrequently audible at the base, and murmurs are often audible also in the arteries and veins of the neck. Pulsation of the veins in the neck is sometimes observed. Occasionally, as has been already intimated, the phenomena of Graves's disease super- vene on actual cardiac disease ; and in most cases in which post-mortem examinations have been made, atheromatous change has been detected in the arterial system. The j)henomena above described are not the only ones commonly pre- sented in this affection. It has been especially observed that the patient is liable to be irritable, fretful, peevish, incapable of application, and to suffer from sleeplessness ; that her appetite is capricious, often voracious ; that she suffers from flatulence, and at one time from constipation, at another from diarrhoea ; that there is a disposition to febrile excitement, with elevation of temperature by one or two degrees, and that this condi- GKAVES'S DISEASE. 633 tion may be associated with the presence of Trousseau's ' cerebral macula; ' that there is generally amenorrhoea, and not unfrequently leucorrhcea ; that the complexion is liable after a time to become sallow or dead-leaf like, and the hair to get dry, thin, and scanty. Anfemia and cachexia are also sometimes present. In some cases enlargement of the spleen has been observed ; and in some, enlargement of the mammae. Dr. G. H. Savage ^ has drawn particular attention to the fact, which had previously been observed, that patients with exophthahnos sometimes become insane ; and that their insanity is usually acute mania, and often proves fatal. It should be added that, m the early stage of Graves's disease, palpita- tion, with throbbing of the vessels in the neck, may be present without obvious thyroid-gland or eye affection, and that in some cases the goitre, m some the exophthalmos, never becomes developed. Graves's disease is not usually dangerous to life. Occasionally patients recover entirely ; more commonly there is partial amendment only ; and in a large number of cases the disease is slowly progressive, and at best after a while becomes stationary. When death takes place it is mostly the consequence of some intercurrent affection, more especially of tlie lungs. Occasionally the enlarged thyroid-gland compresses the trachea, and causes stridor and dyspnoea ; and in rare cases, of which we have had one mider our own care, causes death by asphyxia. Treatment. — There is considerable difference of opinion as to the treat- ment of this disease. Some recommend, Trousseau condemns, the use of iodine. Iron is generally strongly advocated ; both Trousseau and Von Grafe, on the other hand, regard it as injurious. Depletory measures, and even the removal of blood, have been lauded. Digitalis in largish and frequent doses is said to be exceedingly valuable in promoting contraction of the dilated and pulsatile vessels, and in thus relieving and curing the disease. On the same principle ergot of rye or lead may be supposed to be indicated. Belladonna again seems to act beneficially. Cold applica- tions to the thyToid body and to the precordial region are said to be very serviceable. If the patient be anaemic, or suffer from amenorrhoea, want of sleep, or any other condition calculated to cause or mamtain ill-health, special treatment will of course be needed. When the enlarged thyroid body causes dangerous symptoms from pressure on important parts, opera- tive measures may be needed. Owing to the vascularity of this form of goitre, its resection is attended with great danger. But when the isthmus is small this may be divided with the same beneficial results that attend its division m ordinary goitre. ' ' Guy's Hospital Reports,' vol. xxvi. 534 DISEASES. OF THE VASCULAE OKGANS. X. CARDIAC NEURALGIA. ANGINA PECTORIS. Causation. — The causes whicli induce cardiac neuralgia are numerous, but for the most part such as affect the circulation either through the ner- vous system or by muscular exertion. Among them are mental excite- ment, such as anger, or any sudden impression of pain or pleasure ; intem- perance in eating or drinking ; active exercise, especially ascending a hill or staircase, and straining at stool ; in some cases even a blast of cold air. The attacks are often brought on by mere walking exercise, and not un- frequently occur during sleep. Cardiac neuralgia is of frequent occurrence in heart-disease and cases of aortic aneurysm, and under these conditions may be met with at any age and in either sex. Pathology, symptoms, and progress. — Neuralgia of the. heart is referred primarily and mainly to the pr^ecordial region, and occurs therefore chiefly to the left of the sternum, but sometimes involves the sternal and right mammary regions as well. It varies in severity ; is aching, burning, or indescribable ; but is generally attended with a sense of constriction, dread of breathing deeply, and anxiety. It may radiate down into the lower part of the abdomen, up into the root of the neck, or backwards to the spine ; but is specially characterised by a tendency to extend to the left shoulder, and thence downwards along the mner side of the upper arm to the elbow. Not unfrequently it spreads to both shoulders, thence to both elbows, and thence again to the wrists and even to the tips of the fingers. Occasionally it involves the lower extremities similarly. The abnormal sensation which extends along the arms and lower limbs is sometimes an aching, sometimes a sense of tightness or constriction, sometimes a ting- ling, and not unfrequently a mere numbness. In comiection with these symptoms, the affected limbs, as also the face, suddenly become pale and cold ; to which conditions venous congestion and clammy sweats are apt presently to succeed. During the height of the attack the patient often becomes giddy and faint, and sometimes falls into a state of insensibility which may be attended with convulsioiis. Attacks of cardiac neuralgia vary in their intensity, duration, and fre- quency of recurrence, and in the conditions under which they occur. They may be so slight as to consist in nothmg more than a momentary pain or uneasiness in the region of the heart, with some extension to one or both shoulders. They may be so severe that the patient suffers, and has the a.ppearance of suffering, indescribable agony, with the overpowering dread of impending death. He suddenly becomes still, fearing even to breathe ; clutches whatever is near him for support ; or, assuming some strange attitude whicli experience has taught him, grovels on all fours, lies upon his chest, or sits astride a chair with his face to the back, and his head bent over it. The attacks may last from a few seconds to many hours. In the latter case, however, their continuance is due to the repetition of ANGINA PECTOEIS. 535 paroxysms which are for the most part of no great intensity. Sometimes a patient has one attack only ; or he has a succession of attacks at inter- vals, and then no more ; sometimes the first is fatal ; more commonly the affection commences comparatively shghtly, with attacks succeedmg one another at long intervals, hut gradually the mtervals heeome shorter, and the attacks more severe, and recur on shghter and slighter provo- cation. When cardiac neuralgia occurs independently of distinct cardiac lesion it has received the name of angina pectoris. This is rarely met with below the age of forty or fifty, and is far more common in men than m women. In the majority of cases, too, it has a marked tendency to recur at gradu- ally shortening intervals and with increasing severity, and sooner or later to prove fatal. Occasionally, however, the disease manifests itself in young persons ; and occasionally also (and more particularly in them) complete recovery takes place eventually. After death fi-om angina pec- toris, various lesions have been detected ; and these (the more important of which are calcification of the coronary vessels, and fatty and other degenerative affections of the muscular tissue of the heart) have been regarded as its cause. In other cases the heart has been found to be per- fectly healthy. But it is obvious that such lesions as are here adverted to can only act, if they act at all, as predisposing causes. What, then, is the proximate cause ? It has been assumed to be spasm or cramp of the muscular tissue of the heart ; and in favour of this view it may be ob- sei-ved how intense is the agony which may be produced by the spasmodic action of the bowels, uterus, or voluntary muscles. The character of the pulse has been described as bemg sometimes weak and scarcely x^erceptible ; at other times, slow, full, and strong. There is reason, however, to believe, both fi-om the pallor and coldness of sm-face which attend the onset of the attack, and fi'om sphygmogTaphic observation, that an essential featm-e of the disease is sudden and extreme contraction of the systemic arteries, which both prevents the fi-ee passage of blood to the capillaries, and, dam- ming it up, as it were, in the heart, excites that organ to unwonted but more or less fruitless efforts. Treatment. — The treatment of cardiac neuralgia, or angina pectoris, must be partly prophylactic, partly directed to the rehef of the spasmodic attacks. It is of the greatest importance that the patient should avoid or obviate all those conditions which are apt to produce the affection ; that he should eschew all mental and bodily exertion or fatigue ; and that indigestion and all other fmactional derangements should be as far as possible prevented by careful attention to diet and appropriate remedial measm-es. For the treatment of the anginal attack various remedies have been suggested. Amongst the most valuable are the diffusible stimulants — ammonia, ether, and brandy — and narcotics, such as opium, and bella- donna. During an attack, diffusible stimulants are probably the most useful. Faradism to the cardiac region has been attended with good results. Dr. Brunton, guided by the fact of the spasmodic contraction of the arteries which attends, if it do not cause, angina, has tried the 636 DISEASES OF THE VASCULAE OEGANS. inhalation of nitrite of amyl (which relaxes the muscular walls of these vessels) during the paroxysm with striking benefit. He applies five or six drops to the nostrils on a rag or piece of blotting paper. This method has since been largely employed, and with marked success. XI. CYANOSIS AND MALFOKMATIONS. A. Cyanosis. Causation. — Lividity or blueness of the skin is a frequent symptom of those diseases or conditions in which the due aeration of the blood is inter- fered with, and especially, therefore, of some forms of lung and heart disease. It may be met with, consequently, in all cases in which impediment exists to the passage of air along the larynx or trachea ; in all cases also in which there is obstructive disease of the bronchial tubes, whether it be bronchitis or any other affection ; and in all cases in which, whether from emphysema or other organic lesions, or from pulmonary congestion or oedema, the free transmission of blood along the pulmonary capillaries, or the free admission of air into the air-cells, is interfered with. It is a striking characteristic of cholera ; in which disease, either from alteration in the blood or from con- traction of the smaller branches of the pulmonary artery, the blood ceases to pass in quantity through the pulmonary capillaries. Lastly, it is fre- quently observed in cases of heart-disease, more especially of the right side, and in cases of congenital malformation. Symptoms and progress. — It is in the last class of cases, indeed, that the condition commonly known as cyanosis is most frequently present — cases in which the blueness first manifests itself at birth, or within a few weeks, a few months, or very rarely a few years after that event. We shall describe it as it presents itself in these cases. The blueness of surface varies in depth, but is always most pronounced in the cheeks, lips, tongue, and extremities of the fingers and toes. Here the natural rosy hue may merely present the slightest possible inclination to purple, or the parts may be purple, blue, or almost black. The general surface is dusky, or hvid, and ghastly. The tint varies from time to time ; it gets intensified under the influence of exertion, mental excitement, exposure to cold, or catarrhal or other like affections of the respiratory organs ; and in some cases it almost entirely subsides during times of comparatively good health, and perfect quiescence. The conjunctivae are mostly congested, cedematous, and glisten- ing ; the lips, and perhaps the nose and eyelids, are tumid ; but the most remarkable degree of tumefaction is always manifested by the terminal phalanges of the fingers and toes, which become strikingly thickened and enlarged, or bulbous. The circulation is feeble, the surface (especially that of the extremities) generally cold, and the patient disinclined, and, mdeed, unable to engage m active exercise. He is liable to paroxysmal attacks of difficulty of breathing, during which his cyanosis increases, and he not unfrequently passes into a state of syncope ; and he is apt to suffer from. MALFOEMATIONS OF THE HEAET. 537 congestive and inflammatory affections of the respiratory organs. He is generally sluggish in body and mind, and his temper is for the most part irritable and fretful. Dr. Peacock says that the internal temperature of cyanotic patients is not below that of healthy persons. Pathology. — It is not unnatural to assume that the cyanosis of mal- formation is due to the admixture of arterial and venous blood, which takes place in the great majority of these cases, through an incomplete ventricular septum, a patent foramen ovale, or a persistent ductus arteri- osus. But cyanosis has been proved to exist in an intense form in cases of malformation where no such admixture was possible, and to be absent from many cases of malformation in which the communication between the venous and arterial sides of the heart was unusually free. We are hence driven to the conclusion that cyanosis must in the main be due to the same causes that determine lividity in other forms of heart-disease, namely, im- peded transmission of blood through the lungs, and consequently insuffi- cient aeration, with over-accumulation of blood in the systemic veins. If this be the true explanation, it may fairly be asked what are the distinctive marks by which typical cyanosis is distinguishable from ordinary cardiac lividity ? And it must be acknowledged that the differences are of degree or detail only, and are probably due to the fact that the veins of young children yield more readily under the continued strain to which they are exposed than do those of adults. Cardiac lividity in adults rarely attains that depth of colour which we often meet with in cyanotic children ; and the bulbous enlargement of the fingers and toes which is so common in the latter case is seldom observed as a consequence of acquired heart- disease. B. Malformations. Causation and morbid anatomy. — The subject of cardiac malformations is one of great interest and extent, and impossible of adequate discussion in a work like the present. Yet it cannot be wholly ignored. We proceed, therefore, to make a few remarks upon it. The auricles form originally a single cavity, and the separation be- tween them is effected by the development of a vertical septum, of which the fossa ovalis represents the last-formed portion. This septum may be wholly absent ; or the fossa ovalis may remain patent as it is at birth ; and between these extremes every degree of defect may be observed. The ventricles also constitute, in the first instance, one cavity, which, in the course of development, becomes divided into two by the growth of a parti- tion from the apex of the organ upwards, the last -formed part therefore being that which lies just below the arterial orifices. This septum also may be wholly or in part absent. In the latter event, the deficiency is almost always found immediately below the valves. The bulbus arteriosus, again, in the first stage of its development, is a single cavity continuous with that of the common ventricle, and becomes like that, by the growth of an independent septum, divided into two portions, of which one becomes the aorta, the other the pulmonary artery. It is possible for this separa- 538 DISEASES OF THE VASCULAE OEGANS. tioii never to be completed ; it is possible that one of the arteries may be imperfectly developed or get impervious ; it is possible also for tliem to be transposed, so that the pulmonary artery becomes continuous with the left ventricle, the aorta with the right. Further, the ductus arteriosus, which is patent up to the time of birth, and allows the aortic blood to be distri- buted freely to the branches of the pulmonary artery, may remain patent. Various valvular defects, for the most part causing obstruction, are also of frequent occurrence. Lastly, many of these malformations may coexist, and indeed the appearance of one defect in the course of development usually necessitates the supervention of others at a later period. Defect of either the ventricular or the auricular septum to a slight extent does not necessarily allow of any material admixture of venous and arterial blood, or involve discomfort or danger to life ; if, however, the communication be free, the aerated and non-aerated blood-streams become more or less considerably commingled, and serious sjTnptoms may result. It is obvious that similar consequences will ensue under various other cir- cumstances ; as, for example, when the tricuspid orifice is contracted or obliterated, and all the blood that enters the right auricle has consequently to pass through the foramen ovale into the left auricle, and thence into the left or it may be common ventricle, pre\'ious to its distribution ; or when, owing to relative displacement of an imperfect septum ventriculorum and of the orifices of the pulmonary artery and aorta, both vessels seem to spring fi'om the right ventricle ; or when, assuming also the septmn of the ventricles to be incomplete, the aorta or the pulmonary artery is con- tracted or impervious, and in one case the pulmonic circulation is effected from the aorta through the medium of the ductus arteriosus, m the other the systemic circulation is maintained through the channel afforded by the trunk of the pulmonary artery and the ductus arteriosus between the heart and the descending arch of the aorta. Symptoms and progress . — In the various forms of malformation which have here been passed in review, there is very often disproportion m point of size between the ventricles, and h}-pertrophy of their muscular parietes ; consequently there is generally during life some extension of prsecordial dulness, some modification of its form, and some increase in the area and force of the cardiac pulsations. Further, there is, in a large number of cases, a loud and rough systolic murmur, audible with greatest distmct- ness over the left third costal cartilage or somewhere between this point and the left nipple, and, according to its degree of intensity, perceptible over a restricted area only, or over the whole prsecordial region and beyond it. The general sjTiiptoms which attend malformations of the heart are [\i certain valves only be affected) those mamly of obstructive disease of those valves ; if however, in addition to vahmlar obstruction, there be other con- genital defects, or if, independently of valvular lesions, these other defects are sufficiently serious to cause symptoms, the patient presents in a more or less aggravated form the phenomena which have been described under the head of cyanosis. AETEEITIS. 539 The prospects of life in cliildren born with malformed heart are very gloomy. The great majority die in the first few weeks after birth. A small proportion of them sm'vive to the period of puberty. Few, however, who are markedly cyanotic attain adult life. The chief causes of death, accordmg to Dr. Peacock, are : cerebral disturbance resulting from defec- tive aeration of the blood and congestion of the brain ; and imperfect ex- pansion, collapse, and engorgement of the Irnigs. C. Treatment. The treatment of cases of malformation should be merely hygienic and prophylactic. Patients should be protected by warm clothing against vicissitudes of temperature, debarred from all active bodily exercise and mental excitement, and sustained by nourishing diet. Their digestive organs and emunctories should be maintained as far as possible in a healthy condition. Section II.— DISEASES OF THE AETEKIES. I. AETEEITIS. A. Periarteritis. Causation and morbid anatomy. — The outer tunic of the arteries, and to some extent the middle and even the internal tmiic, may be regarded as merely modified portions of the general comiective tissue. They are directly contmuous with it, and, as might be supposed, readily share in its diseases. Hence, when a district of the body is in a state of uiflammation, the walls of the arteries which are comprised within it also become m- flamed ; a^nd occasionally, indeed, inflammation may attack these more violently than other parts, and may travel along them far beyond the limits of the primarily affected region. Such inflammation is usually limited to the outer tunic, and involves the others (if at all) comparatively late and to a slight degree. It is characterised by congestion, infiltration, and thickening of the affected parts ; is sometimes attended with the de- velopment of pus m and aromid the outer arterial coat ; and occasionally with ulcerative destruction or necrosis of the middle and imier coats, and consequent perforation. From the very shght extent m which usually the internal coat is impHcated, it but rarely happens that the lining membrane loses its polish, or that thrombosis takes j)lace. The symptoms to which this form of arteritis gives rise are pam and tenderness, hardness and induration, along the affected vessel, and some degree of mflammatory fever. The formation of abscesses, the plugging of the artery, and its perforation would severally produce special symptoms. These, however, are matters which will be more conveniently discussed hereafter. 540 DISEASES OF THE VASCULAE OEGANS. B. Eiicloarteritis. Causation and morbid anatomy. — But, besides that form of inflam- mation which commences from without, we not unfrequently meet with inflammation which originates in the Hning membrane, and tends to remain limited to that membrane, or at least involves the outer coats later and by simple extension only. The causes of primary endoarteritis are somewhat obscure. In some cases it is due to the irritation of a thrombus or impacted embolus ; in some to the effect of long- sustained excessive blood-pressure (as in Bright's disease), or to the continued violence of the impact of the blood-stream on certain points. It may be due to cold. It appears, too, in many cases to depend on cachectic conditions of the system, referrible to long- continued exposure, deficiency of food, mtemperance, syphilis, and the like. Indeed, it may be asserted that syphilitic disease of arteries is, at least in many cases, scarcely if at all distinguishable from endoarteritis. Endoarteritis of the larger vessels is indicated by the development in the substance of the internal coat of translucent wheal-like thickenings which project into the vascular channel. They have rounded or irregular margins, and often coalesce so as to form patches of considerable extent, which then present nodulated surfaces. They may be scattered singly in small numbers or may involve extensive tracts, rendering the surface of the vessels remarkably uneven ; and they are particularly apt to appear at the points of bifurcation of vessels, or at the points of junction of branches with the trunks from which they spring. When the affection is the con- sequence of thrombosis, and when it occurs in minute arteries, it often causes uniform thickening of considerable superficial extent. The thick- ening is due to inflammatory proliferation of the protoplasmic elements of the internal arterial tunic ; and it may be observed that, according to Cornil and Kanvier, the acute form of the disease is distinguishable from the chronic by the fact that in it the proliferation begins at the surface, which is consequently roughened, while in the latter it takes place chiefly in the substance of the tunic. After a while, the muscular coat becomes involved, degenerates and loses its contractile power ; and when the in- flammation implicates the whole thickness of the vessel the waUs become generally thick and translucent. Syphilitic endoarteritis, more especially as it occurs in the cerebral arteries, has been closely studied by Heubner, who shows : that it begins with proliferation of the endothelium ; that gradually a growth forms which encroaches on the channel of the vessel, and consists of stellate and flattened cells ; that the innermost of these are in close contact and arranged as an endothelium, while the outer ones are more loosely aggre- gated, and separated from one another by some amorphous matter, and a greater or less number of leucocytes ; that after a time capillary vessels, continuous with those of the external arterial tunic, are developed in the growth ; and that it ends in cicatricial contraction, and does not, like DEGENEEATION OF AETERIES. 541 ordinary endoarteritis, undergo fatty change. The morbid process is Hmited to certain arteries, and affects them irregularly. Dr. Greenfield ' shows that the disease may attack the external as well as the internal coat, and that it may spread thence to the middle tunic. Symptoms. — Endoarteritis may, as has been hinted, be acute or chronic, but there are no special sjonptoms by which its acuteness or chronicity can be distmguished ; and, mdeed, endoarteritis becomes chiefly important and distinguishable by the consequences, mainly mechanical, to which it leads. These (which will be elsewhere more fully considered) are referrible to irregularity, rigidity, degeneration and weakening of the arterial walls, diminution or occlusion of the chainiel, dilatation or aneu- rysm, ulceration and rupture ; to which may be added the consequences of the deposition of fibrme upon the roughened surface, and of the forma- tion of granulations or pendulous fibrinous polypi. When endoarteritis occurs in superficial arteries, in consequence of thrombosis or embolism, considerable, sometimes extreme, pain and tenderness are experienced in the course of the affected vessel. It follows, therefore, that pam may be a symptom of the endoarteritis of deep-seated vessels. The disease is sometimes slowly progressive. In one case under our care, in which no other signs of ill-health were present, it began in the arteries of the index and middle fingers, and in the course of several months gradually crept upwards until apparently all the arteries of the forearm and the brachial m its whole length were obstructed. Then the progress of the disease became arrested ; collateral circulation was estab- lished; and gangrene which had been slowly taking place remained limited to the tips of the fingers. II. DEGENERATION OF ARTERIES. Causation and morbid anatomy. — Primary fatty degeneration of arteries frequently comes on with the advance of years. It is recognised by the presence of irregular opaque yellowish spots, apparently in the substance of the internal membrane, which may be sparsely scattered or so abundant as to produce a general mottling. But although it com- mences m the internal coat, it soon involves the middle coat as well. Microscopically it is foimd that the cells of the affected regions are the seat of more or less abundant fatty deposit. They gradually become enthely destroyed ; and with the progress of the disease the intervening tissues, including the elastic elements and muscular fibres, disintegrate. But more frequently fatty degeneration constitutes a late stage of endoarteritis. The translucent or cartilage-like nodules become opaque, generally in their interior, owing to the fatty transformation of the cells of which they are in so great a degree composed. And after a while the interior of the growth may break down mto an opaque pulp, containing ' 'Path. Trans.,' vol. xxviii. ]}. 249. 542 DISEASES OF THE VASCULAE OEGANS. abundant fatty molecules, degenerate remnants of tissue and cholesterine. A small abscess-like cavity is the result. Or, as in the primary affection, the fatty degeneration may commence superficially and thence gradually invade the whole of the diseased patch. Whether the degeneration be primary, or secondary to arteritis, there is a tendency after a while for the degenerated structures to break down and be discharged into the vascular channel. When the disintegration begins superficially, the affected surface gets eroded, and an ulcer-like cavity results. When, on the other hand, the softenmg mass is at first separated from the blood- stream by a layer of coherent tissue, perforation after a while takes place, and the escape of the detritus through the orifice results in the formation in the substance of the arterial walls of a flask-like cavity, which maintains a free communication with the arterial channel. But fatty degeneration is not the only degenerative change which occurs. In a large number of cases, more especially chronic cases or those of persons advanced in years, precipitation of calcareous matter accom- panies the fatty process. Calcareous molecules are deposited in the tissues which intervene between the fattily degenerating cells ; and the result may be the formation either of amorphous tuberculated calcareous lumps, or more frequently of thin, transparent plates, which are curved in conformity with the curvature of the vessel, and which, though usually covered in the first instance by a thin membranous lamella, soon get denuded. Further, they tend to separate at the margins, and after a time to be shed wholly or in part, and to leave ulcer-like excavations behind. Calcareous plates may be scattered irregularly and in small numbers, or may be so numerous and large as to render the vessel in which they occur a rigid bone-like cylinder. There is yet another form of calcareous degeneration which is occa- sionally met with in arteries of medium and small size. It is not attended with, or consecu-tive to, fatty degeneration, but is due to calcareous trans- formation of the muscular cells of the middle coat. The capillary arteries occasionally undergo complete conversion into calcareous cylinders. The degenerative processes above described, although for the most part originating in, and implicating mainly, the internal coat, tend sooner or later to involve the middle coat also ; and, even if this present no visible structural change, it becomes after a time more or less impaired as to contractile power and capability of resistance. With certain ex- ceptions which have been specified, degeneration affects the aorta (especially its arch) far more frequently than other vessels. Yet none enjoys immunity. The pulmonary artery, however, is comparatively rarely affected. Symptoms. — The presence of arterial degeneration cannot always be recognised with certainty. It causes rigidity, and therefore loss both of elasticity and of contractile power. If superficial vessels be implicated, their condition may often be readily recognised by the finger ; if the larger and deeper-seated trunks be involved, the loss of their elasticity ANEUEYSM. 543 renders the systolic throb of the pulse prolonged and its cessation sudden ; and, further, this same loss of elasticity, adds to the resistance which the heart has to overcome, and tends to induce hypertrophy of that organ. The more serious and striking consequences of arterial degeneration are the same that have already been adverted to in connection with arteritis, and will be best discussed under subsequent headings. III. ANEUEYSM. [Dilatation of Arteries). Definition. — The terms dilatation and aneurysm are of common use as applied to. diseased arteries. By dilatation we generally mean a uniform or somewhat uneven enlargement of the channel of some considerable length of vessel ; by aneurysm, a comparatively abrupt enlargement of a more or less distinctly circumscribed tract. The term aneurysm is, how- ever, also applied to certain tumours which consist of bundles or convolu- tions of simply dilated arteries. Causation. — Aneurysms, in the more restricted sense of the word, are bulgings caused by the pressure of the blood within vessels on walls which have been weakened either by the effects of accidental or other injury, or by the progress of the degenerative changes which have just been con- sidered. The pressure which the blood within the arteries ordinarily exercises on their walls is amply sufficient to cause bulging and aneurysm at points in which their resisting power is impaired. It need scarcely be added that when that pressure is greatly increased, as it is habitually in Bright 's disease, and intermittently in violent muscular efforts, its effect on diseased arteries is necessarily proportionately augmented ; and indeed, under some such conditions, tracts of even healthy arteries may undergo considerable and permanent dilatation. The influence of violence in the production of aneurysm is very important, whether we regard it as acting through the medium of the blood-pressure, or directly on the vessels by strain. Its importance is shown : by the frequency with which aneurysms occur in those vessels which from their situation are especially exposed to violence ; by the frequency with which they occur in those persons whose avocations demand excessive muscular exertion ; and by the frequency also with which the origin of aneurysms may be distinctly traced back to some unwonted effort or injury. The starting-point of the aneurysm is then some laceration, probably of the middle coat, or, if the artery be already diseased, some injury to the degenerated tissue. But in the great majoritv of cases the aneurysm commences in a region already diseased, and probably independently of any undue pressure : the passive and enfeebled wall slowly yielding before the normal dilating force to which it is sub- jected. The surface left by the erosion of an atheromatous patch or the detachment of a calcareous plate, or the cavity produced by the discharo-e of a quantity of atheromatous detritus through a minute orifice, are all of them frequent sites of commencing aneurysm. But mere atheromatous 544 DISEASES OF THE VASCULAE OEGANS. change alone, apart from actual removal of tissue, especially if the middle coat be involved, will cause sufficient enfeeblement to allow of aneurysmal expansion. Other like causes of aneurysm are : especially in the cerebral arteries, the damage to their parietes effected fr-om within by the impac- tion of emboli ; and, notably in the case of tubercular vomicae, injury to arteries fr^om without by the suppurative or necrotic changes going on in the tissues wherein they are imbedded. Aneurysm is a far more common affection in males than in females, mainly on account of their different avocations ; and it belongs almost exclusively to adult life. It is a disease, indeed, chiefly of advanced years ; still it not unfrequently occurs, both m men and in women, between the ages of 30 and 40, and especially in those who have led debauched or hard lives, and have suffered fr'om the conditions which produce endoarteritis. Morbid anatomy. — Many needless refinements have been made in respect of the classification of aneurysms. We shaU not waste time upon this subject, but will describe them with reference (1) to their form and size ; (2) to the constitution of their walls ; and (3) to the nature of their contents. 1. Aneurysms in some cases are mere globose or fusiform dilatations of some limited lengih of artery in its whole circumference. Much more frequently they are thimble-shaped or flask-like bulgings (then termed sacculated aneurysms), which involve the vessel in a portion only of its periphery. In the latter case the orifices by which they commmiicate with the artery vary greatly in size relatively to the aneurysmal tiunours ; are round or oval, with the long diameter corresponding to the axis of the vessel ; and present tumid margins, which in large aneurysms, involving nearly the whole width of an arteiy, are distinctly developed above and below only. In other cases aneurysms present great irregularity of form. This may be due to the fact, either that several aneurysmal bulgmgs have taken place within a short distance of one another, and have coalesced during their progressive enlargement ; or that the walls of the primary anemysmal sac have yielded unequally ; or that they have ruptured or been destroyed at certain points, and the blood has escaped into fresh cavities by laceration, which form diverticula from the original aneurysm, and remam henceforth portions of it. The configuration of aneurysms is also greatly determined by the nature, arrangement, and resisting power of the structures which surround them and oppose their extension. The size which aneurysms attain depends in some degree on that of the arte- ries fr'om which they spring. Aneurysms of the cerebral arteries are rarely larger than a walnut, whilst those of the aorta may vary from, the size of a pea to that of a cocoa-nut or a child's head. 2, Occasionally the walls of an aneurysm comprise all the arterial tunics in a fairly healthy condition, as may be seen in frisiform or globose aneurysms due to general dilatation of a certain length of artery. In most cases, however, the condition of things is different : — The lining membrane of the artery may be traced, often somewhat thickened and ANEUEYSM. 545 pulpy, over the lips of the aneurysmal orifice, and thence with more or less distinctness over the whole inner surface of the aneurysm. The ex- ternal coat also of the artery may be traced from without over the whole extent of the aneurysmal tumour. And as regards the middle coat, while in small aneurysms this may often be recognised as a more or less attenu- ated layer throughout their whole periphery, in larger ones it is usually incomplete, either stopping short around the orifice, or extending for a short distance into the walls, with traces of it still to be detected here and there throughout the rest of the circumference. Even when an aneurysm commences with perforation of the internal membrane of the artery, an adventitious lining forms before long, and becomes continuous with that of the artery. And indeed it is obvious that in all large aneurysms the lamin®, which correspond to the inner and outer arterial tunics and are continuous with them, are mainly, if not entirely, of new formation. Further, these two coats become, in the course of time, iden- tical in structure, and blend, enclosing within them any remnants there may still be of the middle coat. Not unfrequently also they become the seat of fatty or calcareous change. As an aneurysm extends, surrounding organs and tissues get involved in it, and take a share in the formation of its walls, the proper coats at the same time disappearing to a greater or less extent. 3. An anem-ysmal cavity sometimes remains perfectly fi-ee from clot ; sometimes, on the other hand, becomes m a gi-eater or lesser degree obliterated by its slow deposition. The local conditions which favour co- agulation are roughness of surface and comparative stagnation of blood. Both are usually present in perfection in aneurysms which originate in circumscribed bulging of an artery, and in which the orifice of communi- cation is comparatively small. In these the process begins with the deposition of a thin adherent film upon the surface of the lining mem- brane. To this other fihns are added in slow succession ; and hence the resulting mass of coagulum gradually assumes a laminated or stratified character. This process may, in fortunate cases, go on until the ca-^dty is obliterated, the last-formed lamina? forming a kind of irregular bar or septum across its mouth. But more fi-equently the aneurysm is obliter- ated in part only, the coagulum being often hmited to some diverticulum. When the Hning membrane is fairly miiform and smooth, and the orifice large in relation to the cavity, there is often no attempt whatever at coagulation. And fusiform anemysms, or aneurysms due to general dila- tation, always remain free, or at all events never present more than such patches of clot as may be met with in an undilated aorta, of which the surface is studded with patches of atheroma or calcareous plates. The origin of anemysms m blood-pressure, which the arterial walls are incompetent to resist efi'ectually, has already been considered. Their pro- gressive enlargement is dependent on the contmued operation of the same cause. In accordance with a weU-known hydrostatic law, the force which the blood exerts on a given aneurysmal area is exactly equal to that which it exerts on an equal area of the artei-y in its neighbourhood ; or, in other N N 546 DISEASES OP THE VASCULAR OEGANS. words, the total pressure on the inner surface of an aneurysm is in exact proportion to the superficial extent of that surface, and has no relation whatever either to the size of the orifice or to the form of the aneurysm. Consequently the larger an aneurysm groAvs, the less capable its walls become of successfully o^Dposing the blood-pressure within, unless they undergo some kind of compensative increase of strength. This, however, does not necessarily or even commonly occur. The effects of aneurysms on the organs in their vicinity are in the main those of pressure, and necessarily therefore vary in importance and kind according to the situation in which the aneurysm is developed. When it occurs among easily-displaceable organs it may attain consider- able size without causing any special mischief or uneasiness. In aU cases, however, surrounding parts sooner or later get pressed upon ; if they are rigid they are gradually destroyed ; if yielding they first yield, and only at a comparatively late period are involved in the aneurysmal parietes, and undergo the same fate as that to which the unyielding tissues more readily succumb. Thus bones and cartilages are gradually eroded ; and their eroded surfaces, first exposed in the walls of the aneurysm, presently stand out from tbem into the interior of the ca^dty. Muscular and other soft tissues are first displaced, then flattened and compressed or stretched, and finally incorporated m the advancing wall and lost. Nerves and veins are similarly aifected : pressure on the former causing pam, spasm, or other functional disturbance, and then paralysis or anesthesia ; pressure on veins producing impediment to the circulation, with subsequent congestion and dropsy. Similar effects of pressure may be exerted on the trachea, oesophagus, and intestines, and even on the brain, lungs, liver, and other sohd organs, and in each case with the production of special sjTiiptoms, which we need not stop to discuss. The results of aneurysms, unless a ciu-e be effected by surgical proce- dure, are almost without exception unfavourable. In a small proportion of cases a cure takes place by the spontaneous fiUing up of the cavity with lamuaated clot ; but generally the tumour continues to enlarge, and after a time causes death, by imphcating some important organ, or by perfora- tion and consequent profuse discharge of blood. The latter event may take place into one of the serous cavities, in which case the actual opening is usually caused by laceration ; or at the cutaneous surface or into one of the mucous canals, when perforation is due either to ulcera- tion or to the separation of an eschar. Eupture or perforation may also take place mto the cerebral or spinal cavities, the veins, and even the heart itself. Symptoms and progress. — The symptoms by which an aneurysm may be recognised are : first, those which are due to it as a simple tumour ; and second, those which depend on its relations with other parts. An aneurysm is usually a pulsating tumour. If it be empty of clot its pulsa- tion is expansile like that of the arteries, and if it can be grasped the fingers which enclose it will be sensibly separated at each expansion. If it be full of clot no such expansion occurs ; and should pulsation be then A ANEUKYSM. 647 felt it is merely sucli as may be presented by any other solid tumour lying upon an artery — tlie aneurysm simply follows the movements of the subjacent vessel. It is important to Imow tbat the mere imparted pulsation of a romided tumour may easily be mistaken for expansile pulsation miless the tmnour be grasped at its widest part ; for if it be grasped in some narrower and more superficial zone, the alternate rise and retreat of the skui-covered wedge-hke body between the fingers produce exactly the same periodical and measured separation of them which is so characteristic of true pulsation. The comparative hardness, however, of such a mass, and the probable fact that it may admit of removal from the influence of the subjacent artery, will generally correct any erroneous impression. The pulsation of an aneurysm is sometimes ■\dbratile, especiaUy if it be situated in the neighbourhood of the heart and associated with regurgitant aortic valve disease. It may be vibratile, how^ever, owing to peculiarities of form and the condition of its walls and orifice. Aneurysms are often attended with a murmur. This generally corre- sponds to the cardiac systole, and therefore to the tidal wave of the pulse, and is of a blowing character. It is probably created as a rule in the artery, and due either to contraction of its tube at the point of origin of the aneurysm, or to some irregularity at that part ; but it may be more or less modified, or in some cases developed, by resonance in the aneurys- mal canity. Mm'murs may equally be produced by the pressure of tumours or even of the stethoscope upon healthy arteries. Aneurysms of the aortic arch, Kke other aneurysms, are sometimes attended with a murmur synchronous with the heart's systole, and hke them may be free from murmur. But here a true double murmur is not mifrequent, especially if there be associated regurgitant aortic valve disease. In these aneurysms, again, it is not uncommon to hear the two cardiac sounds, or two somids resembling them, even more distinctly than over the heart itself. They have been supposed to originate within the aneurysm, but are doubtless the normal cardiac sounds carried by the blood- stream, and perhaps mcreased by resonance. The pulse is often distmctly affected in aneurysm. But its aflection is due not so much to the aneurysm itself (though this doubtless has some influence) as to the narrowing of the artery, from pressure or disease, which is so often associated with aneurysm. It is most ob\'ious when the aneurysm involves either the uuiominate artery, the subclavian, the descending aorta, or one of the iliacs. In such cases the pulse in the implicated limb, as compared with that in the healthy hmbs, is dimin- ished in voliune and strength, and appears to be retarded. The systolic rise is slow in attainmg its maximum, and the diastolic fall presents a correspondhig character. The symptoms due to the direct influence of aneurysms on surround- ing organs vary in different cases ; but their general characters may be gathered from the remarks above made. Treatment. — The treatment of internal aneurysms is far from satis- N N 2 548 DISEASES OF THE VASCULAE ORGANS. factory in its results. The chief object at which to aim is the gradual coagulation of blood withm the cavity, and its consequent obliteration. This event occasionally takes place spontaneously in bed-ridden patients or those who are prostrated by lingering diseases — under conditions, therefore, m Avhich the action of the heart and the circulation are un- usually feeble. These facts furnish a clue to the general treatment which should be adopted. The patient should be kept at as perfect rest as it is possible to enforce. He should be exposed to no causes of mental excite- ment, and strictly debarred from all forms of muscular exertion, including that of straining at stool ; if possible, therefore, he should be confined to bed. His diet should be light and nutritious, and not more abundant than is necessary to maintain him in a condition of fair, but not robust, health. Mr. Tufnell, whose treatment appears to have been attended with much success, restricts the patient's food to two ounces of bread and butter, and two ounces of new milk for breakfast and tea ; and two or three ounces each of bread and meat with from two to four oiuices of milk or claret for dinner. It is important, too, that the bowels should be kept moderately free by enemata or mild laxatives, and at all events not be permitted to get constipated ; and that all bodily ailments which arise to complicate the aneurysm should if possible be obviated or cured. Various drugs have been recommended, with the object either of quieting the circulation or of promotmg coagulation. Among those which have been employed with reputed success are acetate of lead, ergot, and digitalis, and of late years especially iodide of potassium in large doses. It may well be doubted, however, whether either of these can have any real influence for good, and whether indeed digitalis is not likely to be injurious. Reduction of the volume of the blood, and of strength, by repeated copious venesections, was formerly largely advocated ; and it is not improbable that, at any rate in some cases, occasional bleeduigs may be really beneficial. To relieve pain or uneasiness opium is invaluable, and as local applications, with the same object, ice, belladonna and other sedatives. The above remarks apply mainly to sacculated aneurysms. In fusiform aneurysms the deposition of laminated coagula is neither to be expected nor desirable ; and meagre diet consequently is not only un- called for but likely to be injurious. A. Thoracic Aneurysms. Morbid anatomy and symptoms. — These occur principally in the different parts of the aortic arch, the descending thoracic aorta, and the roots of the large arteries arising from the arch. They spring most frequently from the ascending arch, and more commonly fi-om the con- vexity than from the concavity of the arch. They usually form pulsating tumours which may be recognised as such if they abut on the surface of the chest, especially if also they be large, but which frequently escape recog- nition in consequence of being small or deep-seated. But whether they be recognised locally *or not, they generally sooner or later induce characteristic phenomena by compressing the surrounding organs, and THOEACIC ANEUEYSMS. 549 iiiterferiug with the due performance of their functions ; and end fatally in one of several fully recognised modes. It is ob'sdous that the situation of the tumom- and the facihty with which it may be recogrdsed, the parts which are specially liable to compression, and the nature of the event, must be largely determined by the part of the aorta whence the aneurysm springs. Aneurysms of that part of the aorta which is embraced by the peri- cardium are almost always of small size ; and therefore liable to be confomided with simple aortic valvular disease, or degenerative arterial changes (with both of which they are commonly associated), or else altogether to escape recognition. They occasionally open into the pul- monary artery, right ventricle or auricle, or superior vena cava ; some- times lead to the production of loculated aneurysmal cavities, extending into the substance of the cardiac walls or along the auriculo -ventricular grooves ; and are apt to rupture at an early period into the pericardial cavity. Aneurysms of the rest of the ascending arch often attain a very large size. In their growth they encroach, as a rule, on the upper part of the right side of the thorax, displacing the lung outwards, and coming in contact by their anterior surface with the anterior thoracic parietes. Sometimes they involve both sides of the chest. They not unfrequently also displace the heart downwards and to the left. According to the amomit of displacement of the lung or luiigs will be the extent of the duhiess on percusssion to which they give rise, and that of their visible pulsation. This may be heaving, vibratile, or purring, and if visible to the eye will probably be seen to correspond distinctly with that of the heart. As the tumom- enlarges it causes bulging of the chest-wall over it ; and soon (erodhig the ribs and their cartilages, the sternum, and perhaps the clavicle, and at the same time involving the muscular tissue) forms a more or less hemispherical pulsating mass. In the interior of the chest it j)resses upon the right lung, which often becomes adherent to it and expanded in some degree over it ; and it is apt to compress the vena cava descendens or the right or left innominate vein, or all of them ■^impeding the passage of blood through them, or rendering them com- pletely impermeable ; and it may even involve the right pneumogastric nerve or the sj^-mpathetic trunk. Aneurysms in this situation are hable to open externally, into the pericardium or right plem-a, or into the lung itself and thence into one of the bronchial tubes, or even into the right bronchus. An aneurysm of the transverse arch, if it spring fi'om its front or con- vexity, expands chiefly upwards and to the left, so that it presses upon and erodes the manubrium of the sternum and the adjoinmg portions of the left upper ribs and cartilages, and clavicle, and forms a tumour which occupies the situation here specified, and tends to rise from behind the sternum into the root of the neck. If it sprmg from the concavity or posterior aspect of the arch, it is often quite latent. If it grow mainly upwards and in front, forming a manifest pulsating tmnour, it may, like 550 DISEASES OF THE VASCULAE OEGANS. aneurysm of the ascending arch, attam a large size and eventually burst externally ; but much more frequently, owuig to the confined limits of this portion of the chest and the many important organs which are con- tained therem, it causes death at a comparatively early period from the effects of pressure on one or other of those organs. Aneurysms of the transverse arch are especially liable to compress the trachea or left bronchus, and may also involve the oesophagus ; and often prove fatal by opening into one or other of these tubes. They may also compress or destroy the left recurrent laryngeal nerve, or the left sympathetic or pneumogastric trunk ; or obstruct the left innominate vein. Further, they may rupture into the pericardium, left pleura or lung. Aneurysms of the descending arch or of the rest of the thoracic aorta are rarely to be detected until they have acquired considerable magnitude. They become superficial by destruction of the ribs and vertebrae in the dorsal region to the left of the spine, and there in some cases form pulsating tumours of enormous size. But before they cause manifest tumour they may sometimes be recognised by the presence of dulness, pulsation, and murmur, and the absence of respiration, over a limited area. An impor- tant hint as to their presence is often furnished by the occurrence of more or less constant gnawing, aching, or burning pain m the situation of certain of the vertebra, and of shooting or aching pains or uneasy sensations in the course of some of the nerves of the brachial plexus or of some of the inter- costal nerves, more particularly on the left side. Aneurysms developed in these portions of the aorta not only tend to cause destruction of the bodies of the vertebra and posterior parts of the corresponding left ribs, and to involve the dorsal spinal nerves and the sympathetic trunk of the same side, but are especially apt to compress the oesophagus and ultimately to open into it, or to rupture into the left pleura. They may indeed rupture into the right pleura. Those arising in the upper part of the chest may also compress the trachea, left bronchus or lung, and eventually open into one or other of them. It may be convenient to pass in review the various pressure-symptoms to which aneurysms of the thoracic aorta give rise, and of which several are often present, when as yet no tumour can be discovered by auscultation, percussion, palpation, or inspection. They are as follows : — 1. Impediment to the arterial circulation. — This may depend either directly on the aneurysm or on the presence of atheromatous or other thick- ening of the vessels springing from the arch. Not unfrequently the artery of one arm alone suffers, and the radial pulse of that arm becomes conipara- tively feeble, or it may be entirely annulled ; sometimes both carotid and subclavian of one side are thus affected ; and occasionally all the arteries springing from the arch are implicated, so that all visible pulsation in them and their branches ceases. When, however, the impediment to the circulation is thus general, it has usually come on gradually, and there have been previous stages in which one or two arteries only have been involved. In consequence of impediment to the carotid circulation, we not micommonly find patients with aneurysm of the arch liable to momentary THOKACIC ANEURYSMS. 551 attacks of vertigo, or loss of consciousness, sometimes attended with epilep- tiform convulsions. 2, Impediment to the venous circulation. — When the vena cava or both innominate veins are obstructed, the veins at the root of the neck form spongy masses immediately above the clavicles, and those of the head, neck, arms, and upper part of the chest undergo great distension. The cutaneous surface gets congested, especially that of the face, the eyeballs injected and prominent, and before long the head, neck, and upper extremities swollen with oedema. The patient suffers also from drowsiness, coma, and other cerebral symptoms, and extreme dyspnoea. When one innominate vein only is obstructed, the venous distension and oedema are limited to one arm and one side of the head, neck, and chest. In this case, if the patient's life be prolonged, it is not unusual for remarkable clubbing of the fingers of the affected limb to supervene. It is an interesting and important fact that even in cases of total oblitera- tion of the descending cava, the resulting congestion and oedema of the head and neck and arms is not mifrequently to some extent averted or remedied by the establishment of vicarious venous routes. Occasionally we have seen the gradual development of a large vein descending from the neck over the clavicle, and entering at the first intercostal space to empty itself mto the cardiac end of the vena cava ; and in one case the return of blood to the heart was effected through a network of veins occupying the right shoulder and neighbouring part of the thoracic parietes, which emptied themselves into a huge tortuous vein that descended vertically beneath the integuments from the axilla to the groin to join the external iliac. 3. Pressure on nerves. — Pressure on the left recurrent laryngeal nerve is soon attended with paralysis of the intrinsic muscles of the larynx which it supplies. The left vocal cord becomes motionless midway between the position of closure and that which it should assume during ordinary calm respiration, and the voice loses its musical character and becomes hoarse or whispering. Pressure on the right recurrent, which may be produced by mnominate or subclavian, and exceptionally even by aortic aneurysm, has a corresponding effect on the right vocal cord. It has often been observed that in intrathoracic aneurysm one of the pupils (as compared with its fellow) is either abnormally dilated or, which is more common, abnormally contracted. Abnormal dilatation has been attributed to pressure upon the sympathetic trunk in the upper part of the chest, causing irritation ; ab- normal contraction to pressure on the same trunk, but sufficient to destroy it or annul its functions. The pneumogastric nerve is at least as liable as the sympathetic to suffer, and to its compression congestion and gangrene of the lungs have been attributed. The effects of pressure on the intercostal nerves and brachial plexus have already been considered. It may be added that pain is apt to shoot up the corresponding side of the neck. It is ob- vious that the phenomena of nervous interference must be looked for chiefly in aneurysms situated to the left of the mesial Ime ; but they occur also m aneurysms of the ascending arch, and of course in those of the larger branches. 552 DISEASES OF THE VASCULAR ORGANS. 4. Pressure on trachea and bronchial tubes. — ^The constantly increasing pressure of an aneurysm on the trachea, if exerted laterally, displaces it to a greater or less extent ; but under any circumstances the pressure sooner or later drives that portion of the surface against which it is exerted inwards, first flattening it, and then causing it to bulge so as to reduce the tracheal channel at this part to a mere semilunar chink. This process is attended with the gradual involvement of the tracheal walls in those of the aneurysm, and their infiltration with inflammatory products, followed by their gradual disintegration and final perforation. While it is going on, the patient sufters from stridor of the breath- sounds ; which becomes especially audible when from excitement, exertion, or the act of cough- ing, the respiratory acts are hurried or deepened, and is attended with more or less dyspnoea. Gradually these symptoms increase, and cough is superadded. The cough is at first occasional and dry, but soon gets paroxysmal, and each paroxysm is relieved by the discharge of a small quantity of mucus. The stridulous respiration, and the stridulous cough in prolonged paroxysms (threatening and sometimes ending in suffocation), are peculiarly suggestive of the presence of an aneurysm or other tumour in the thorax. The suffocative cough is due to the occasional closure by mucus of the narrow tracheal chink and the mechanical difficulty there then is in effecting its dislodgement. Hoarseness or loss of the musical quality of the voice only exists when, associated with the tracheal pressure, there is involvement of the recurrent laryngeal nerve, or some distinct affection of the vocal cords or their muscles. Accumulation of mucus in :he bronchial tubes, lobular pneumonia, congestion of lungs, and pneu- monia, are all of them common sequels of tracheal obstruction. When only one of the bronchi is obstructed, feebleness of respiratory murmur and imperfect expansion may be observed on the affected side of the chest, on which presently supervene rhonchus, crepitation, and other signs of one or other of the lung-affections just enumerated. Further, in this case the aneurysm may also obstruct the pulmonary vessels going to and from the lung, and thus interfere with its nutrition. And from these combined causes may result consolidation of the lung, with breaking down of parts of it, and pleurisy with effusion. 5. Pressure on the oesophagus causes the ordinary phenomena of oeso- phageal stricture. Thoracic aneurysms are often exceedingly difficult of diagnosis, partly because the symptoms to which they give rise are obscure, partly because many affections simulate them in their general and local indications. Among such affections may be included : persistent violent palpitation of the heart, such as is met with in Graves's disease ; and hypertropliy and dilatation of the heart, associated with regurgitant aortic valve disease. In both of these conditions there is often violent pulsation, attended with purring tremor of the arch of the aorta and large vessels, and in both, marked precordial pulsation ; and the cardiac sounds may be propagated over a considerable portion of the right infraclavicular and mammary regions. There may even be, in the latter case especially, some retraction THOEACIC ANEUKYSMS. 553 of tlie anterior edge of tlie right lung and consequent extension of aortic dulness to the right. Other conditions hable to be mistaken for aneurysms (especially if they be associated with palpitation or heart-disease) are me- diastinal tumours, consolidated portions of lung, and abscesses or growths involving the thoracic parietes. In the foregoing account we have referred mainly to typical aortic aneurysms. But aneurysms of the intrathoracic portions of the large arteries which spring from the arch present much the same local and general symptoms as do aneurysms arising from the aorta itself in their immediate neighbom-hood. They are to be distinguished mainly by their position and the special influence which they exert on the circulation through the arteries with which they are connected. So-called dissecting aneurysms are not unfrequent in the aortic arch. They are produced by the sudden laceration of the diseased or merely thinned internal coat of the artery, and the effusion of blood through the rent into the interval between the external and internal coats, and gene- rally into the substance of the middle coat. The extent to which the dis- section may take place, and the event, both vary. In some cases, the dissection is limited to a small well-defined area ; in other cases it cir- cumscribes the vessel, and occupies an incli or two of its length ; and in other cases, again, it involves the whole extent of the aorta. As regards result, dissecting aneurysms occasionally undergo spontaneous cure by the coagulation of the extravasated blood ; sometimes they prove fatal by causing complete obstruction of the aorta, in the thorax or abdomen ; but more frequently they terminate in laceration of the external membrane, and the effusion of blood into some cavity, such as the pericardium, or into the connective tissue of the mediastinum or some other part. Treatment. — In addition to the general plan of treatment which has been laid down for aneurysms, it is sometimes possible, from the fact that aneurysms of the ascending and transverse arch and of the vessels which spring from them come speedily into relation with the anterior walls of the chest, to employ mechanical or other means to cause coagulation within them. The methods which have been had recourse to, but un- fortunately with very imperfect success, are the injection of perchloride of iron or other styptics, the insertion of coils of thin iron wire, horse-hair, or needles, and galvano -puncture. For the last purpose a battery of from ten to thirty cells should be employed, the plates being preferably of small size. The needles connected with the poles should be as large as medium-sized hare-lip pins, and sheathed m vulcanite to ^sathin a short distance of their points. They should be plunged vertically into the tumour, and retained there for twenty or thirty minutes, or until some effect has been produced on its condition. The operation should, if necessary, be repeated at intervals of a few days. Ligature of the sub- clavian and carotid arteries, especially those of the right side in aneurysm of the ascending arch, has occasionally proved beneficial ; it is less use- ful, however, here than in the treatment of aneurysms of the roots of these vessels. 554: DISEASES OF THE VASCULAR ORGANS. B. Abdominal Aneurysms. Morbid anatomy and symptoms. — Aneurysms may be developed in con- nection with any part of the abdominal aorta or of its branches within the abdomen. Those which chiefly concern the physician are connected with the aorta, coeliac axis, superior and inferior mesenteries, renals and com- mon iliacs. The sources of abdominal aneurysms must be determined by their anatomical relations. They may generally, while still of medium size, be recognised as distinct pulsatile tumours, attended with more or less thrill and often with a murmur. It is easy, however, in thin persons, to mistake the pulsation of the abdominal aorta for that of an aneurysm, and especially so to mistake a carcinomatous or other tumour situated upon the aorta. Indeed, it is often impossible to distinguish accurately between an aneurysm and such a solid mass, unless by grasping the tumour we can distmctly satisfy ourselves that it does not expand, or by displacing it from its contiguity with the aorta we annul its pulsations. Abdominal aneurysms generally tend to attain a large size, to cause erosion of the vertebras or other bones with which they come in contact, and to press upon the stomach, duodenum, or other viscera, veins, or nerves. They then cause : pain in the back, which is sometimes very agonising, and often shoots along the branches of the lumbar nerves ; sickness, from pres- sure on the stomach or obstruction of the duodenum ; compression and even obliteration of the inferior cava, or one of the common iliac or renal vems, with dilatation of the veins of the lower extremities, and anasarca ; or similar conditions in one lower limb only, or in a kidney. Abdominal aneurysms occasionally burst into the peritoneal cavity, or into one of the hollow viscera, or even into the spinal canal. More frequently they rup- ture primarily into the retro-peritoneal tissue ; whence blood may be effused round the duodenum, or oesophageal opening of the stomach, or into the substance of the mesentery, mesocolon, or great omentum, and may thus before the supervention of death cause complete obstruction of the cardiac orifice, duodenum, or some other part of the bowel, and sometimes the most intense and long- continued agony of pain. Treatment. — The most important of the special modes of treatment of abdominal aneurysms are : first, that of putting a ligature romid the aorta ; and, second, that of regulated pressure upon the aorta. The latter method may be carried out by the temporary application (say for eight or ten hours), under the influence of chloroform, of a specially adapted tourniquet to the aorta, if possible on the proximal side of the aneurysm. Pressure may be applied, with almost equal efficacy, on the distal side. It must not be forgotten, however, that the application of sufficiently forcible pressure completely to obstruct the aorta is attended with great risk of serious injury to the abdominal viscera; and hence it will generally be best to delay its employment until the effects of perfect rest have been fully tested. Galvano-puncture may sometimes be em- ployed here as in other cases. PHLEBITIS. 555 Section III.— DISEASES OF THE VEINS. I. PHLEBITIS. Gausation and morbid ft7z a to77i^.— Inflammation of a vein is generally- due : either to the formation of a clot within it, in which case the process commences at the inner surface and travels outwards ; or to the involve- ment of the vein in inflammatory processes which are going on round about it, in which case its walls are invaded from without inwards. Phlebitis, indeed, is almost always secondary. Exceptions to this rule are furnished by inflammation of the uterine veins after parturition, and by the comparatively rare thickening of the inner coat of veins which corresponds to the much more frequent thickening of the inner coat of arteries issuing m atheromatous and calcareous degeneration. The presence of clots may be regarded as an essential accompaniment of all forms of phlebitis, with the exception of the chronic form last ad- verted to. Inflammation of veins is characterised by thickening of their walls, comiected with proliferation of the protoplasmic elements of their several laminae. The latter process is generally especially active in the outer coat, which not unfr-equently acquires considerable thickness and blends with the surrounding sunilarly affected connective tissue ; and scattered abscesses are apt to appear here and there in its course. The inner coat tends to become rough, and even to give rise to granulations. The contained clot, whether it be formed primarily or secondarily, soon fills the channel of the vein and adheres more or less firmly to its uuier surface. At the same time it tends to lengthen both above and below — above to the junction of the vein with the next branch or its communica- tion with a trunk vein, below mto the tributary branches. The further changes which such clots undergo will be considered under the head of thrombosis. The symptoms of venous inflammation are, if the vein be within reach of direct observation, pain and tenderness in its course with cylindrical thickening and hardening, and sometimes superficial redness. Abscesses in the course of the vessel, communicating or not with its interior, are not unfr-equent. There is necessarily febrile disturbance. The remote effects of phlebitis are on the whole much more important than the local effects. They embrace : on the one hand, those due to venous obstruction — dilatation of the distal veins, congestion, and ana- sarca ; on the other, those dependent on the discharge of fragments of thrombus, or of inflammatory or other hurtful matters into the circula- ting blood. These will all be best considered hereafter. 556 DISEASES OF THE VASCULAE OEGANS. II. VAKIX. [Dilatation of the Veins.) Causation. — Dilatation of veins is much, more common than that of arteries, but its causes are a good deal more obscure. It occurs, no doubt generally, in obstructive disease of the right side of the heart ; and, when a vein is obstructed, throughout the venous system which is tributary to it, as well as in those collateral veins which take on, or divide between them, the duties of the defaulting vessel. But in a large number of cases veins get dilated and varicose independently of all obstruction, independently of overwork, and independently also of obvious degeneration or weakening of their walls. Morbid anatomy. — "When veins dilate they become at the same time elongated and consequently tortuous. The dilatation usually commences, and is always most marked, immediately above the valves ; and the affected veins assume, therefore, an irregular moniliform aspect. The walls, for the most part, thicken considerably, although presenting occasional attenuations, especially over the convexities of the dilated portions. The thickening is principally due to hypertrophy of the middle coat, the attenuation to its atrophy or disappearance. With the pro- gress of dilatation the valves become inefficient, and often shrivel up ; calcareous plates not unfrequently form in the middle coat ; the con- nective tissue around gets thickened and indurated, and blended with the outer coat of the vem ; phlebolites are often developed in the pouch-like XDrotrusions ; and the last occasionally become perforated either by ex- tension of ulceration from without or by laceration. Dilatation may occur either m veins of medium or large size, or in those which are orduiarily mere capillary tubes. The former occurrence is exemplified by the ordinary varicose veins of the lower extremities, and by varicocele, the latter by the tuft-like groups so common in the lower limbs of pregnant women. Dilatation and varicosity of veins rarely re- quire treatment at the hands of the physician. For him they serve mainly as important aids to diagnosis. Varicose veins in the lower ex- tremities, varicocele, and hemorrhoids are surgical disorders. Dilated or varicose veins of internal organs no doubt occur, and aid in the pro- duction of functional disturbance ; they may even rupture and cause death by hemorrhage. We have witnessed this accident in the case of varicose veins of the oesophagus. But their presence can rarely if ever be recognised during life. The importance of the dilatation of certam groups of superficial veins in enabling us to judge of the seat and character of internal diseases involving the obstruction of deep-seated veins is obvious. THEOMBOSIS AND EMBOLISM. 557 Section IV.— AKTERIAL AND VENOUS OBSTEUCTION. THEOMBOSIS AND EMBOLISM. Definition. — Tliere are few morbid processes of greater interest, and at the same time of greater practical importance to the physician, than those which we are now about to consider. They are the frequent causes of many obscure complaints, as well as of some of the most clearly characterised maladies ; they may involve any organ of the body, and present at least as many different groups of symptoms as there are organs ; and they are intimately related to some of the gravest forms of disease which come under our notice, such as pysemia and puerperal fever. The term thrombosis has been conveniently applied to the coagulation of blood during life in the heart, arteries, or veins, and in- cludes within its meaning nearly all those cases which were formerly re- garded as phlebitic. The term embolism has been introduced to designate those cases in which an artery or vein gets plugged by the impaction in it of a clot or other solid mass conveyed to it from a distance by the blood-stream. The morbid phenomena and symptoms which thrombosis and embolism induce are referrible partly to local inflammation, but principally to arterial or venous obstruction, A. Thrombosis. Causation. — The causes of thrombosis are mainly : stagnation or sluggish movement of the blood ; the contact of the circulating fluid with inflamed or otherwise diseased surfaces ; and special conditions of the blood which render it apt to coagulate. Morbid anatomy. — 1. In the heart, after death, the blood which was contained within its cavities at the moment of death is generally found coagulated, moulded to the form of the cavities, and continuous with cylindrical clots occupying the trunk veins, and often with similar clots extending into the trunk arteries. These clots are sometimes black- currant-jelly-like, sometimes partly decolourised ; and the portions pro- longed into the arteries are usually more or less purely fibrinous, while those seated in the veins are usually soft and black. But not un- frequently the clots contained in the heart's cavities, and more especially those occupying the ventricles, are almost entirely fibrinous, opaque, and bufi^-coloured, close in texture, and even indistinctly laminated. These have for many reasons obviously formed during life, probably during the agony ; but are the consequence of dying and not the cause of death ; and on the whole (except from the fact that their deposition helps, as it were, to confirm the fatal issue) have little clinical importance. Their presence, however, throws light on the development of the peculiar bodies next to be considered. It is not uncommon to find after death in certain cases that rounded buff-coloured masses, varying perhaps from the size of 558 DISEASES OF THE VASCULAE OEGANS. a pea to that of a walnut, are situated either iia tlie apical portions of the ventricles, or in the appendages of the auricles. These, which are some- times termed softening clots, usually occur m groups, are moulded to the surface on which they He, adhere to it, and are continuous with one another by processes which underHe the earner column© ; so that, with careful dissection, they may generally be removed as a continuous whole. They are sometimes smooth, sometimes ribbed, upon the surface, and often variegated in colour. On section they may present a uniform character and consistence ; but are more frequently broken down in their interior mto a thick reddish or yellow pus-like fluid, contaming products of disintegration only — namely, fat-granules, degenerating red and white corpuscles, cholesterine, and sometimes hfematoidine crystals. The bodies are clots, in fact, which have formed in the heart's cavities sufficiently long before death to have undergone the degenerative changes which clots formed elsewhere also undergo. They may be found in any of the heart's cavities ; in one alone, or in two or more at the same time ; but are much more common m the left ventricle than elsewhere. The conditions mider which they are found are various ; but they are especially frequent in cases of advanced heart or renal disease in which the patient has lain for weeks with an extremely feeble circulation, and the balance trembling between life and death. During this period the enfeebled heart probably fails to empty its cavities completely ; the blood remains stagnant or nearly so in those portions of them which are most remote from the direct current ; and coagulation takes place either slowly, or more probably suddenly, on one of those occasions, which are so common in these cases, when the patient falls into a state of apparent death, fi-om which he rallies. Other clots of old formation, which may be found m the heart, are lammated clots such as occur in aneurysms. They may be present in actual aneurysmal dilatations of the ventricles, and have been discovered behind a closely constricted mitral orifice almost entirely occluding the left auricle. 2. In the systemic veins the coagulation of blood during life is common enough. When the venous circulation is simply enfeebled, as in the later stages of heart-disease, and towards the close of phthisis, carcinoma, and other chronic wasting affections, venous thrombosis is of frequent occur- rence. It then takes place more particularly in the trunk vems of the lower extremities, and in those of the pelvis or at its brim. So again when some impediment exists to the passage of blood along a vein, the distal portion of the vessel and in a greater or less degree its tributary branches fill with clot. When veins are involved m inflammation wliich is taking place romid them, this, as has been pointed out, tends soon to pervade the entire thickness of the walls, and then to induce coagulation of the blood within them and their complete obstruction ; and occasionally, indeed, by perforation of a vein or some other process, pus or other in- flammatory products find their way mto its interior or mto the substance of the thrombus. Thrombosis, secondary to mflammation, is common in erysipelas, diffuse cellular inflammation, carbuncle, and the like ; in puer- THKOMBOSIS AND EMBOLISM. 569 peral pelvic cellulitis ; in inflammation involving the cancellous structure of bones, or the walls of the parturient uterus ; and in the venous sinuses of the interior of the skull in connection with disease of the internal ear. The different characters which venous thrombi display depend largely upon their age, and correspond with those presented by cardiac clots. When fresh either they have a uniform consistence and colour, or they present a central black cylinder, enclosed in a fibrinous capsule. They do not necessarily at once fill the vessels in which they are seated, even if they be adherent to them, and hence fresh blood tends to insinuate itself between them and the venous parietes, and presently to coagulate there. The clots which finally occlude vessels thus get more or less distinctly laminated. In their further progress venous thrombi undergo various changes. In some cases they blend with the venous walls, and, becoming converted into connective tissue, cause the obliteration of the vessels ; in some they undergo softening in their interior, and conversion into locu- lated cavities full of fatty detritus and caseous remnants of white corpus- cles ; and occasionally they suppurate and form abscesses. 3. Arterial thrombosis is due in a large number of cases to simple stag- nation of blood. Thus the arteries leading to a district, in which (owing to morbid processes going on in it) the blood has ceased to circulate, get filled secondarily with coagulum. And in precisely the same way, if an artery be ligatured, or obliterated at any point by the pressure of a tumour or tourniquet, the proximal portion of the vessel up to the nearest branch oecomes the seat of thrombosis. Not unfrequently also, when the circu- lation is simply feeble, obliteration of an artery by coagulation of its contents takes place. This occurrence in the smaller branches of the pulmonary artery is a common cause of pulmonary apoplexy. It is occasionally also observed in the arteries of the extremities and even in the aorta itself. Diseases of the inner coat of arteries (atheroma, cal- cification, arteritis, and syphilis) are all of them liable to induce throm- bosis and consequent obliteration. Among arteries especially liable to suffer thus are those of the base of the brain and of the extremities. The varieties of arterial clots and the changes which take place in them are identical with those already described in connection with veins. B. Embolism. Causation and morbid anatomy.- — The sources of emboli are mainly venous thrombi, cardiac vegetations, and disintegrating calcareous, athero- matous, or inflamed surfaces. Additional sources are softening clots in the interior of the heart, and morbid growths or other adventitious bodies. The detached solid mass, whatever its nature, is carried along by the blood-stream until it reaches a vessel which is too small to allow of its further progress. The point at which it becomes finally arrested usually corresponds to the bifurcation of a vessel or to the giving off' of a compara- tively large branch. Here it gets wedged, sometimes blocking up the channel completely, but more frequently forming at first a partial impedi- 560 DISEASES OF THE VASCULAE OEGANS. ment onl3^ In the latter case the constant pressure from behmd tends to drive it farther and farther onwards, in consequence of which, or of the gradual coagulation of blood around it, the vessel becomes at length, as in the former case, completely occluded. Subsequently thrombosis takes place on both sides of the embolus ; the artery and its distal branches get filled with clot which, gradually undergoing changes, blends on the one hand with the arterial parietes, and on the other with the embolus. So that although the embolus may, at first, be readily recognised as an inde- pendent body, it often becomes undistinguishable from the thrombus to which its presence has given rise. Emboli taking their origin in the systemic venous system, or right side of the heart, necessarily become fixed in the pulmonary arteries. Those which originate in the pulmonary vems, left side of the heart, or larger systemic arteries, are conveyed to the periphery of the systemic arterial circulation. And those, lastly, which are yielded by the veins of the chylo- poietic viscera find their resting-place in the branches of the vena portae. Owing to the infrequency of disease of the valves of the right side of the heart, embolism involving the lungs is almost invariably due to the detach- ment of venous clots or fragments of them. In some cases entire systems of thrombi become free, and a complete cast, some inches long, of a venous tree may be carried into the pulmonary artery and impacted in a convoluted form within it. More frequently shorter lengths get successively separated and successively lodged in different branches of that vessel. It is much more common, however, for venous clots to crmnble as it were gradually away ; and for minute fragments to get impacted from time to time in the pulmonic arterioles. It is rare for thrombosis to take place in the pulmonary veins ; and hence embolism is seldom due to this cause. The most common source of embolism of the systemic arteries is undoubtedly the detachment of granula- tions from the diseased aortic or mitral valve ; but another frequent cause is the separation of atheromatous or calcareous particles, or other detritus, either from the valves or inner surface of the heart, or from the large arteries. It is obvious, therefore, that embolism of the systemic arteries must in a very large proportion of cases depend on valvular disease, and is to be regarded as one of the common risks of that affection. Emboli from the various sources just indicated are carried along the aorta and thence into some of the smaller branches of the systemic arteries ; whither is m some degree a matter of accident ; but there are certahi parts, namely, the brain, liver, spleen, and kidneys, and, it may be added, the lower extremities, which are specially prone to suffer. It is probable, however, that their arteries are not so much specially liable to obstruction, as that their ob- struction produces particularly serious and obvious ill-effects. The cerebral arteries chiefly liable to occlusion are the middle cerebral branches of the internal carotids ; and it is curious that the stoppage generally occurs in the middle cerebral of the left side. THROMBOSIS AND EMBOLISM. 561 C. Consequences and Symptoms of Thrombosis and Embolism. Whenever a thrombus forms or an embohis becomes fixed, mflamma- tion of the imphcated vascular walls, if it did not previously exist, speedily ensues ; and hence pam and tenderness soon mark the course of the vessel if it be withm reach of investigation, and febrile disturbance generally arises. Li either case complete obstruction to the passage of blood through the affected vessel takes place very soon if not quite suddenly. It is this fact, indeed, which gives to thrombosis and embolism in common their characteristic features, and wliich renders it difficult, if not impossible, to make any practical distinction between them. In aid, however, of correct- ness of diagnosis it may be pointed out : first, that obstruction of the puhnonary, hepatic and systemic veins by clots can depend on thrombosis only ; second, that obstruction of arteries or of the portal veins may be due either to thrombosis or to embolism ; third, that the pre-existence of systemic venous thrombosis renders it probable that any obstruction oc- currmg m the pulmonary arteries is due to embolism ; and, lastly, that the presence of valvular disease on the left side of the heart, or the fact of previous rheumatism, is presumptive evidence that supervening obstruc- tive disease of any of the smaller systemic arteries is of embolic origin. The results of venous thrombosis are stagnation of blood in the tributary veins with dilatation, soon followed by cedema and compensatory enlarge- ment of the anastomotic veins. These conditions are not secondary to thrombosis only, but attend all cases m which veins from whatever cause are obstructed. The consequences of arterial thrombosis or embohsm, on the other hand, are impairment of nutrition of the region which the artery supphes, and, foUowiug on this, congestion, hemorrhage, inflammation, degeneration, or gangrene, together with special S}-mptoms due to the organ or part whose integrity is compromised. Similar phenomena neces- sarily ensue upon all forms of arterial obstruction, no matter how they are produced. The special effects of thrombosis and embohsm \nR for the most part be best discussed in connection with the other morbid conditions of the several organs in which they occur. There are two or three cases, however, which may be most conveniently considered now. They are phlegmasia alba dolens, thrombosis and embolism of the heart and puhnonary artery, obstruction of the larger arteries of the limbs, and multiple embolism of the smaller systemic arteries. 1. Phlegmasia alba dolens. — -This term is generally applied to the pain- ful and edematous condition of leg which often follows upon parturition. An almost exactly similar condition may. however, occur independently of parturition, and even in males, and is not mafi'equently developed in the course of phthisis and carcinoma. The arms also may be affected in like manner as the lower extremities. Phlegmasia alba dolens is due to throm- bosis of the trunk veins of the limbs, or of the larger veins to which these converge, which become converted into painful rigid cords. When it follows parturition it generally begins h'om a week to a month after that event, and almost always in the left lower limb. And even if the right o o 562 DISEASES OF THE VASCULAE OEGANS. become affected it is usually affected in company with the left, but at a later period. The commencement of this disease is generally sudden, and indi- cated by the concurrence of diffused pain throughout the affected member, and cedema. The pain varies in character and intensity, and is generally at- tended with soreness or tenderness, sometimes with distinct hyperaesthesia, sometimes with loss of sensation ; and not unfrequently the patient is unable, either from pain or from loss of power, to mo.ve the limb or any of its parts. The oedema gradually increases until the member gets large and smooth, and of a pecuhar pale waxy aspect ; it does not generally pit dis- tinctly on pressure, and often presents remarkable elasticity and tension; The superficial veins usually become dilated and unnaturally visible ; and the skin often presents a mottled, retiform character, owing to the rupture, as in pregnancy, of the deeper layers of the cutis. There is not as a rule any manifest change of temperature in the affected limb ; but general febrile disturbance is usually present. If there be no serious complica- tion, the patient probably recovers at the end of three or four weeks. For the most part, however, the veins primarily obstructed remain im- pervious ; and sometimes there is permanence of oedema. Treatment. — Little can be done in the way of special treatment for phlegmasia dolens or other cfidematous conditions arising from obstructed veins. It is generally desirable that the patient be kept at rest, and the affected limb elevated or in the horizontal position. If there be distinct inflammatory mischief in the course of a large vein, a few leeches may be serviceable ; and when oedema and tenderness are present, it is generally of benefit to envelop the limb in wadding or flannel, in order to keep it warm and promote perspiration. Hot fomentations and baths may also be employed. The internal treatment must be determined by the general condition of the patient ; but for the most part tonics are chiefly indicated. 2. Cardiac thrombosis. — It is not easy to specify symptoms by which clots formed in the heart during life may be recognised. It is possible of course that, from their position, they may occasionally interfere with the due action of the valves, and so induce endocardial murmurs ; but it is certain that in the great majority of cases they have no such effect. It may be taken for granted that their presence must in almost all cases be a source of embarrassment to the heart's action, and that they must therefore tend to aggravate the feebleness of circulation out of which they arose, and to increase the severity of the cardiac symptoms which the patient had previously suffered from. It is important, however, to note that when such clots form in the heart, the feebleness of circulation which determines their presence there very commonly also determines their for- mation in arteries and veins ; and that hence the condition of the Imigs and kidneys, comiective tissue, and skin, maybe of some assistance in the formation of a diagnosis. The detachment of such a clot and its entangle- ment in one of the valvular orifices of the heart have been assigned as a cause of sudden death. 3. Embolism and thrombosis of the pulmonary artery. — We do not intend here to discuss the results of that blocking up of the smaller THEOMBOSIS AND EMBOLISM. 563 brandies of tlie artery which is so commonly associated with, and so often the cause of, pulmonary apoplexy, lobular pneumonia, circumscribed abscesses, patches of gangrene, and the like. Our object is to consider those embolic or thrombotic obstructions of the arterial trunk, or of its chief divisions, which are occasionally the cause of sudden death. It is now well established that the chief danger of thrombosis of the larger systemic veins lies in the separation of the whole or a large portion of the clot, and its impaction in the trunk of the pulmonary artery. This accident is apt to occur in cases of phlegmasia dolens, and where, after parturition, the uterine veins have become plugged. The patient, pro- bably in the midst of apparently fair health, is suddenly seized with severe pain in the region of the heart, attended with mtense distress and gaspmg for breath, pallor or lividity of face, and extreme feebleness or ■even suppression of pulse, and dies collapsed. It has been disputed whether death is due to aspliyxia or syncope. It is certain, however, that the sudden obstruction of the pulmonary artery causes shock, or col- lapse, and that the patient sometimes dies of this shock within a few seconds ; and it is further certain that the symptoms of sudden ob- struction are often undistinguishable from those of angina, or rupture of an aneurysm, or of the heart itself, into the pericardial cavity. Indeed, the symptoms of pulmonic obstruction are by no means typical ; and its diagnosis must depend mainly on the association of the symptoms above described with those conditions of the venous circulation which are known to be productive of emboHsm. There are two or three points, however, in relation to this subject which demand a word or two of comment : — First, sudden obstruction of the pulmonary artery by an embolus, even if attended with symptoms of great severity, does not necessarily end in immediate death. The clot may be driven onwards into a branch, the symptoms of impending death subside, and the phenomena due to the obstruction of a branch only pre- sently ensue. Secondly, it is important to bear in mind that many of the recorded cases of sudden death from pulmonary embolism are cases in which the only foundations for this diagnosis were : suddenness of death, possibly from syncope ; and the discovery after death of an ordinary fibrinous clot in the right ventricle, prolonged thence into the pulmonary artery and its branches — a clot originating in the spot in which it was found, and the consequence of dying, not the cause of death. Thirdly, thrombi sometimes form in the larger branches of the puhnonary artery. Occasionally, indeed, the trmik and the greater number of its ramifica- tions are almost entirely occluded by them. It is a fact that these may form without pain, and cause little or no distress, until by some little displacement of them, or by the sudden coagulation of the blood still circulating between them and the walls of the tubes in which they lie, they suddenly bring the pulmonary circulation, and with this life itself, to a stop. 4. Embolism and thrombosis of the larger systemic arteries. — It some- times happens that, from either embolism or thrombosis, one or more of 564 DISEASES OF THE VASCULAE OEGANS. the arteries of the legs, the femorals, the iliacs, or the abdommal aorta itself, becomes obstructed. And the sarae thing may occm- in respect of the arteries of the upper extremities. The immediate result is serious impediment to the circulation through the implicated limb or limbs, characterised by cessation, or at any rate diminution, of pulsation in the vessels beyond, and more or less pallor and coldness. In some cases collateral arteries gradually enlarge, and the general condition of the limb after a time becomes normal. In other cases, the circulation comes generally, or m certain are^e, to a permanent standstill, the affected parts gradually lose their temperature, the surface gets pallid, but mottled with purplish spots, and the tissues assume a doughy consistence, bulla, filled with sanious fluid, soon rise upon the discoloured patches, and dry gan- grene becomes established. Arterial embolism is generally attended with severe pam at the pohit of impaction, and much pain and tenderness are generally present in the course of plugged arteries. Usually, more- over, pain and tenderness are, for a time at least, present in a greater or less deo-ree in the parts which are in process of sphacelation. The causes of sudden aortic obstruction are usually either the estab- lishment of a .dissecting aneurysm, or the displacement of the laminated coao-ula formed in an aneurysmal pouch. In either case the patient is suddenly seized with severe pain, deep seated in the thorax or abdomen, and paraplegia. At the same time, pulsation disappears fi'om the lower extremities, and their temperature falls. Of course under these circum- stances gangrene and a fatal issue are to be anticipated. But in most cases, if the patient sur-sdve sufficiently long, circulation is re-established to some extent, and the gangrene becomes arrested in its progress. Occa- sionally no gangrene whatever ensues, and at any rate temporary con- valescence takes place. The exact seat of aortic obstruction may be determined in some cases, either by the recognition of pulsation down to a particular point, or by the condition of the kidneys or bowels. If the renal arteries be obstructed, the urine is likely to be scanty, and to contain albumen or blood, or to be temporarily suppressed ; if the me- senteric arteries, enteritic or dysenteric symptoms and tympanites may possibly ensue. Treatment. — For the local treatment of gangrene little can be done beyond keeping the parts warm. To this end they may be greased and covered with cotton wool or wadding. For general treatment, it is chiefly important to maintain the patient's strength by the admmistration of food and stimulants, aided by tonics ; and to relieve pain and distress by opiates. 5. Multiple embolism of the smaller systemic arteries. — This is usually the consequence of ulcerative endocarditis, or of the gradual erosion and disintegration of parts of the endocardium (mamly the aortic and mitral valves) which have been the seat of inflammatory thickening and over- growth. It may come on in the course of acute rheumatism as a com- plication, or it may supervene accidentally, so to speak, in persons suffering from chronic heart-disease. THKOMBOSIS AND EMBOLISM, 565 It depends on the constant or repeated discbarge into the blood-stream of minute fragments of detritus, or emboli ; wbicb, distributed tbrougbout tbe system, obstruct the smaller arteries, and mainly those of the kidneys, spleen, and liver — causing infarcts with attendant inflammation, which is apt to spread from the solid organs to the serous membranes. The exact nature of the embolic changes occurring under the above circumstances in different parts of the organism has been described in the article on pyemia, and will be further considered in connection with the diseases of particular organs. There is little doubt that the ulcerative process itself and the general symptoms associated ^dth it are referrible to the influence of septic organisms, which have been detected in the valvular ulcers, and other diseased tissues, and that the disease is closely related to pytemia. The symptoms of ulcerative endocarditis have a close resemblance to those of pyaemia, but on the whole are less intense, and less rapidly termmate in death. The patient generally has rigors, with elevation of temperature, up, it may be, to 105° or more, and perspirations. The febrile symptoms intermit, sometimes several times a day. The respira- tions increase m frequency ; the pulse becomes rapid and feeble or irregular : the tongue gets coated ; cough frequently supervenes with mucous and then sanguinolent expectoration and local uidications of pulmonary congestion or consohdation ; anorexia, thirst, nausea or sick- ness, and oftentimes diarrhoea ensue ; the spleen generally enlarges and sometimes gets distinctly tender ; occasionally jamadice supervenes; the urine fr'equently contains albumen and sometimes blood ; the patient becomes restless, dehrious, or drowsy, and sometimes at length comatose. In addition, inflammation of the joints or serous membranes, and roseo- lous, petechial or pustular rashes are occasionally developed. The col- lective symptoms, nevertheless, are very often vague and misleading, and are liable to be mistaken, not only for those of pyemia, but for those of tuberculosis, enteric fever, or ague. Most frequently, no doubt, the disease chiefly simulates chronic pyaemia ; and, if its source in cardiac disease were overlooked, would be taken for pyaemia. Its resemblance to ague is occasionally very remarkable. Li a case formerly imder our care, which lasted altogether several months, the main symptoms were typical ague- Kke paroxysms, often coming on tT\ace in the twenty-four hours, and separated by uitermissions of complete apyrexia, associated with gradual failm-e of strength, and di'owsiness finally passing into coma. In one case death resulted fr-om plugging of the left middle cerebral artery ; in another fr-om effusion of blood mto the substance of the brain, probably followmg on an embolic aneurysm ; in another fr-om obstruction of both femorals by large emboli. Slight attacks of this affection doubtless occur not unfrequently, are recovered from, and overlooked ; but where it is present in an aggravated form it is probably always fatal sooner or later, often ia the course of two or three weeks ; sometimes, however, not for several months. For treatment little can be done, beyond relieving symptoms, reducing fever, and maintaining the patient's strength. 566 DISEASES OF THE VASCULAE OEGANS. Section V.— DISEASES OF THE DUCTLESS GLANDS BLOOD, ETC. I. DISEASES OF THE THYEOID BODY. To diseases of this organ the term ' goitre ' or ' bronchocele ' is com- monly appHed. It is more convenient, however, to restrict these names to a certain group of hypertrophic affections than to inckide under them every variety of lesion to which the thyroid body is liable. The chief affections which would on these grounds be excluded are inflammation and carcinoma. IdioiMtliic inflammation of the thyroid body is certainly of mafrequent occurrence ; it may, however, follow secondarily upon goitre, or result from operation, or injury inflicted upon the gland. It is probable also that some of the overgrowth of the hypertrophic organ may be due to chronic inflammation. Carcinoma of the thyroid body is extremely rare. Undoubted ex- amples of this affection have however been recorded, in some of which the morbid growths were primary, in others due to extension from neighbouring organs, in others secondary, in the usual sense of that term. It is needless to discuss particularly the symptoms to which these con- ditions give rise, or the special treatment they may require. A. Goitre. [Broncliocele.) Causation. — The circumstances under which goitre arises are various and not very clearly understood. It is far more common in females than in males ; and indeed, as regards women, it has long been known that there is not unfrequently a tendency to temporary enlargement of the thyroid body both during pregnancy and at the catamenial period. It is occasionally observed in the foetus, and is then commonly associated with some peculiarity in the form and situation of the gland. Goitre appears to originate mainly between the ages of eight and puberty ; rarely, if ever, after forty. It occurs in a sporadic form in probably all parts of the globe ; that is, isolated cases, for which no cause can be assigned, are nearly everywhere occasionally met with. It is remarkable, on the other hand, that goitre is endemic in many limited arege scattered nearly all over the world. Such places are, in England, met with in Derbyshire, Hampshire, Nottinghamshire, Sussex, and Yorkshire. Goitrous districts are as a rule of peculiar geological formation : they are mostly valleys ; and usually their soil, or that of the adjoming mountain ranges, is formed largely of lime or magnesian limestone ; and the water of the wells or watercourses which traverse them is largely impregnated mth carbonate or sulphate of lime, with which in a considerable number of cases magnesia is associated. Various reasons have been assigned for the prevalence of goitre in these localities. All evidence, however, seems to point to the drinking water as the efficient GOITEE. 567 agent in its production ; and it is generally held tliat the poisonous ingredient is either sulphate or carbonate of lime, or both, in combination probably with magnesia. The main objection to this view (and it is a serious one) is, that hard waters containing such ingredients in excess occur and are used in non-goitrous localities by persons who never be- come goitrous. And hence it is probable, as is suggested by Virchow, that these salts do not act directly, but that associated with them there is some other principle of a malarious character to which the goitrous tendency is essentially due. It may be added : that endemic goitre is endemic in the strict sense of the term ; that it belongs, as it were, to the locality ; that new-comers are liable to suffer equally with those who have been born and bred in it (allowance being of course made for the relative length of their exposure to the goitrous influence) ; and that, although the children of goitrous parents become in large proportion goitrous in such localities, the tendency is not hereditary, and ceases in them when they are removed from the influence of the poisonous principle. In goitrous districts the disease is not limited to man ; but dogs, mules, and horses are hable to suffer. Morbid anatomy. — Goitre consists in a kind of hypertrophy of th^^ normal constituents of the gland — namely the blood-vessels, connective tissue, and groups of intercommunicating vesicles forming the ultimate lobules which the connective tissue circumscribes. In some cases all of these become increased in equal proportion, and the goitre then differs little if at all, except in bulk, from the healthy organ. More frequently one of these constituents midergoes disproportionate development, and hence the texture of the tumour becomes characteristically modified. Thus, sometimes the connective tissue alone undergoes hypertrophy, and the tumour gets hard and dense ; sometimes the vascular tissue especially becomes preternaturally developed — the veins and arteries, or more fre- quently the veins alone, attaining comparatively enormous dimensions ; sometimes the vesicles are the chief seat of change — becoming dilated and filled with an albummous fluid, or a solid albuminoid or gelatinous substance. Such cysts, partly by simple dilatation, partly by coalescence, may attam the size of a pigeon's or hen's egg, or even a larger bulk. In a case recorded by Mr. Spencer Watson, a cyst of this kind yielded on puncture a pint and a half of blood-coloured fluid. It must be added : that cysts of considerable size may be developed in glands which are in all other respects healthy ; that a goitrous tumour may become, in whole or in part, the seat of inflammation, and that consequently blood may be poured out into the cysts which it contains, or suppuration and ulceration may take place in it ; and that degenerative changes may ensue after a time, the cells within the cysts undergoing fatty disintegration, and the contents of the cysts consequently acquiring a milky character, or the fibroid stroma becoming the seat of earthy deposition — a change often attended with diminution in size and induration of the tumour. A bronchocele varies in consistence according to the natm-e of the pro- cesses which have been afoins: on in it ; so that in some cases it is hard 668 DISEASES OF THE VASCULAR OEGANS. and resisting, in others it is soft and yielding or elastic, and in others, agam, presents in certain situations distinct fluctuation ; and, when the enlargement of its arteries constitutes a special feature of the tumour, there may be pulsation resembling that of aneurysm. A goitre sometimes retauas accurately the form of the healthy gland ; but more frequently it becomes unsymmetrical in the progress of its growth (the right lobe being especially liable to disproportionate development), and then by growing iii certam directions, or throwing out lobules, may press inconveniently or dangerously on important organs in its vicinity. Occasionally small supplemental thyroid bodies may be detected in the neighbourhood of organs thus hypertrophied ; and it is mauily by the development of such masses at the posterior part of the lateral lobes that compression of the oesophagus is sometimes effected. The size of a goitrous tumour varies from that which produces a mere fulness (by some persons regarded as ornamental) m the lower part of the front of the neck, to a mass (usually irregular in form) as large as a cocoa- nut, or in rare cases of such enormous dimensions that it hangs pendulous from the neck, concealmg the chest, the chest and abdomen, or even extenduig to the middle of the thighs. SymjJtoms and progress. — A goitre may generally be readily recognised by its relations with the various structures occupying the lower and anterior part of the neck, and especially by its situation in front of the trachea, and by its following the movements of that tube. Its development is seldom attended with pain, and not usually with uneasiness ; nevertheless various injurious consequences are apt to ensue. In the first place the tumour may prove seriously inconvenient by its mere bulk and weight. In the second place, it may exert pressure on the large veins in its neighbourhood, or on the trunk of the sympathetic nerve, or on the pn-eumogastrie or recurrent laryngeal, or on the brachial plexus. And m the third place it may dis- place and compress the oesophagus or tracliea. Pressure on the oesophagus is induced mainly by enlargement of the posterior parts of the lateral lobes, or of the supplemental bodies occasionally fomid m this situation. Pressure on the trachea is by far the most important of the consequences which goitre entails. In some instances it acts unilaterally, the trachea being displaced towards one side of the neck ; in some mstances this tube is compressed between the two enlarged lateral lobes ; in some the pressure is exerted in the antero-posterior direction, the trachea then becoming more or less flattened against the spine. The effect of pressure in either of these cases is often remarkable : the impHcated portion of tube being sometimes flattened, sometimes made to form a convex bulging, so that consequently the passage becomes on transverse section semilunar or concavo-convex, or (if pressure be exerted equally on opposite sides) arrectihnear or biconcave chink, and sometimes actually obhterated. A slight amount of compres- sion is not unfrequent, the patient hreathing naturally when quiet, but with some degree of stridor and difficulty under exertion or excitement, and yet not with sufficiently pronounced difficulty to excite alarm in himself or others. In all such cases, however, there is danger of the supervention GOITRE. 569 of fatal obstruction. In some tins takes place gradually from the slow encroachment of the tumour ; but ui many it comes on more or less suddenly either from the rapid development of some cyst, or from mflam- matory tumefaction, or from congestion and oedema of the mucous mem- brane of the already compressed trachea. The danger of suffocation de- pends less on the size of the goitre than on its form and situation ; the most serious cases, indeed, are : first, those of sub-sternal goitre, in which the lower portion of the gland, or some process of it, sinks, in the course of its enlargement, behind the sternum, and compresses the trachea there, while there is yet httle ob\dous sign of thyroid gland enlargement ; and second, those of suh-maxillary goitre (a congenital defect described by Virchow), m which the gland is situated at a higher level than natural, and the lateral lobes extend backwards behind the angles of the jaws, and sometimes as far as the mastoid processes. The contraction of the sterno-thyroid muscles may materially aggi-avate the compression of deep-seated organs. To the Hst of dangers just enumerated may be added that due to the rupture of cysts or abscesses either externally or into the trachea or oesophagus. Treatment. — In the treatment of goitre we have to consider : first, the medicinal and other means by which the tumour may be either reduced in size or prevented from increasmg ; and, second, the measures which may be requisite to obviate the efiects of its pressure upon important parts. Whenever a goitrous patient lives in a goitrous district the obvious remedy is his removal to some more salubrious locality ; or, if this be impossible, a careful investigation of the available drinking water of the neighbourhood, and the selection for use of that which is least contaminated with eai-thy salts, or the adoption of measm-es, such as boiling, distillation, or Clark's process, for the precipitation of these mgredients previous to use. Such measm-es, and especially emigration, are often efficacious in the complete removal of goitrous tumours which are of small size, or have been but a short time in existence, and are generally beneficial even m advanced cases. Burnt sponge was formerly largely employed, and with reputed benefit, in the treatment of goitre ; but Dr. Coindet of Geneva, after the discovery of iodine in sea- water and marine productions, was led to suspect that the efficacy of the burnt sponge was due to the iodine which it contained, and to make trial of iodme itself as an anti-goitrous remedy. Since that time iodine and its various preparations have replaced almost all other internal remedial agents, and have enjoyed a smgular reputation as specifics against the disease. The testimony, indeed, in favour of the curative influence of iodine is almost overwhelmmg. On the other hand, it must be remarked : that, altogether apart from the influence of iodine, goitre is liable to con- siderable fluctuations of size, and when small and recent often disappears entirely ; that there is little or no evidence that the drug is efficacious in the treatment of exophthalmic goitre, which is structurally identical with the endemic form of the disease ; that, notwithstanding the supposed cura- tive action of iodine, there is no proof that goitre is now less prevalent or less severe in goitrous localities than it formerly was ; and that, mixed up with the evidence in favour of the specific \drtues of iodine, is e^ddence 570 DISEASES OF THE VASCULAK OEGANS. equally striking iii regard to tlie production of a remarkable concurrence of symptoms known by the name of iodism, which now seems never to attend the use of iodine, however largely it is administered. We must confess that, in our own limited experience of the treatment of goitre, iodine has signally failed. But we need not hmit ourselves to the employment of internal remedies. By many persons coiuiter-irritants applied to the surface of the tumour are strongly advocated. Among such applications may be enu- merated, iodine paint and other iodic preparations, strong mercurial oint- ment, and bhsters or other forms of blistering agents. In some cases (generally, however, when the tumour has been of large size or has given indications of compressing vital organs), operative measures have been resorted to. The tumour has been excised — an operation of no inconsider- able difficulty and danger, owing to the relations of the thyroid body and its enormous vascular supply ; it has been treated by passing a seton through its substance and so exciting and maintaining mflammation or suppuration in it ; and, again, one or more of the arteries supplying it have been tied. Each of these operations has proved more or less successful in certain cases ; but none of them sufficiently successful on the whole to encourage its frequent performance. The recently introduced procedure of removing the isthmus of the enlarged gland, or of excising a wedge- shaped portion of the isthmus involving its whole thickness, promises to be of great value, and, in the cases to which it is apphcable, of little risk. The isthmus itself, even in goitres of large size, often remams small ; and generally, as the result of the operation, the gland slowly shrmks, haply to its normal bulk. Cysts of the thjToid body admit m most cases of ready and successful treatment, either by simple punctui-e mth the dis- charge of their contents, or by puncture and injection of some stimulating fluid, or by the employment of the seton. When goitrous tumours are threatening to obstruct the trachea, we must be alive to the possibility of the supervention at any moment of sudden and fatal asphyxia. What can be done under these circumstances ? Unfortunately very little. If the enlargement be mainly cystic, relief no doubt can be afforded by the puncture of the cyst and the discharge of its contents. If, however, it be solid, as in the main it commonly is, it is difficult to see what other resource than tracheotomy is left us ; and tracheotomy in these cases is both difficult and unsatisfactory ; for it can rarely be performed below the seat of obstruction ; it is a formidable operation if effected through the substance of the enlarged gland ; and if done above the gland, it is necessarily useless miless it be completed by the passage of a sufficiently long tube through and beyond the constricted portion of the trachea. B. Cretinism. Cretins are persons m whom feebleness of intellect or idiocy is com- bined with certain peculiarities of bodily conformation. They are for the most part stunted in growth, with tumid bellies and coarse skins. In a large proportion of cases they are goitrous, though occasionally the goitre CEETINISM. 571 is of the latent or sub-maxillary kind, to which reference has already been made. The head is usually large and misshapen — expanded at the sides and flattened at the top ; the cheek-bones high and prominent ; the nose flattened or sunken at the bridge, broad at the root, and up- turned ; the interval between the eyes increased ; the lips thick ; the mouth wide and open ; and the tongue large. There is generally mus- cular weakness, deficiency of cutaneous sensibility, and impairment or annulment of the sexual functions ; and not unfrequently deaf-mutism is conjoined with the other corporeal defects. The degree of mental impair- ment varies between complete dementia and mere dulness or slowness of intelligence. Cretins are usually quiet and harmless, not given to mis- chief, but liable to occasional outbursts of ungovernable violence. True cretinism appears, according to Virchow's researches, to origi- nate during foetal life in an unnatural tendency which the basilar portion of the occipital bone, and the post- sphenoidal and prfe- sphenoidal bones, have to coalesce with one another by ossification of the discs of cartilage by which they should at that time be separated. The consequences are : that the base of the skull prematurely ceases to elongate, and thus be- comes modified in form ; and that this arrest of development leads, on the one hand, to defective development of the corresponding portion of the brain, and, on the other, to widespread changes in the osseous frame- work of the skull and face. The form of the skull gets modified, partly by the need which its contraction in one direction involves of compensa- tory expansion on the part of those regions whose bones have not yet coalesced, and partly by the opposing tendency which also exists in these cases to precocious union of the bones of the cranial vault along the lines of suture. The peculiar form which the face assmnes is due in some measure to imperfect development of the nasal septum, in some measure to displacement of the cheek-bones and bones of the orbits. Further, in many of these cases the cranial bones acquire remarkable thickness, and the foramina at the base of the skull become much diminished in size. The same tendency which is presented by the cranial bones is presented by those of the extremities, which soon unite with their epiphyses. And, indeed, it is probably due, in part at least, to this cause that these bones remain incompletely developed. According to the above account of the pathology of cretinism, this condition must be regarded as of congenital origin. Children are born cretins ; that is, they are born, either with the peculiar features of cre- tinism already obviously developed, or with that coalescence of the bones at the base of the skull which necessitates the gradual development of cretinism during the period of childhood. Like goitre, cretinism may occur either sporadically or endemically. The causes of sporadic cretinism and those of sporadic goitre are alike obscure. Endemic cretinism, however, and endemic goitre are always associated, and obviously originate in a common cause. Wherever goitre prevails largely there cretinism is also prevalent ; the goitrous tendency, however, occupies a wider area, and goitrous persons always largely out- 572 DISEASES OF THE VASCULAE OEGANS. number their idiotic compatriots. It would seem, indeed, that for the production of cretinism some special intensity of the poison which also causes goitre is requisite. Cretins are not only in large proportion goitrous, but also in large proportion the offspring of goitrous parents. Yet there is no sufficient reason to believe that cretinism, any more than goitre or ague, is hereditary ; for goitrous parents do not beget cretinous children when once they have removed from the regions in which these affections prevail ; and under similar circumstances the children of cretins are themselves free from both goitre and taint of cretinism. It seems clear, indeed, that the morbific matter which, taken into the mother's system, renders her goitrous, acts also on her foetus, causing in it, may be, not only goitre, but also those special developmental changes which ultimately lead to malformation and mental deficiency. In reference to the association in cretinous infants of arrested development of the base of the skull and goitre, it is interesting to bear in mind the fact pointed out by Virchow, of the close proximity in the foetus of the base of the skull to the thyroid body. Assuming the common cause of goitre and cretinism to be, or to have some close relation with, the existence of a superabundance of earthy salts in drinking water, it is natural to specu- late on the influence which these salts may have in causing the too early completion of the process of ossification. We have referred to the great obscurity which inA^olves the causation of both sporadic goitre and sporadic cretinism. There is no evidence that the subjects of sporadic goitre ever beget either goitrous or cretinous children, or that sporadic cretins are ever the offspring of goitrous or im- becile parents. At the same time sporadic cretins seem always to present some abnormal condition of the thyroid body. In some recorded cases such cretins have been distinctly goitrous ; but in a large proportion of them there is an apparent absence of the thyroid body. In Dr. Fagge's' cases, in two previously recorded by Mr. Curling, and in some that have come under our own observation, there were soft elastic lumps occupying the angles between the sterno-mastoids and clavicles, which lumps, in Mr. Curling's cases, were found post mortem to consist of fat only. These facts evidently ally the cases of sporadic cretinism to those of the endemic form of the malady, and suggest the dependence of both on a common cause ; the poison (if it be a poison) being introduced, in the one case constantly and indifferently into the systems of a more or less extensive population, in the other case accidentally, so to speak, into the blood of casual units. Treatment. — The mental condition of cretins, like that of other idiots, admits in many cases of amelioration by proper training ; for which pur- pose a well-ordered asylum with skilled officials is essential. The im- provement, far more the cure, of the structural lesions which underlie cretinism is, however, entirely beyond the resources of our art. The pre- vention of cretinism depends, so far as we know, neither on the prevention of marriage between those who are goitrous or in a condition of semi- • ' Med. Chi. Trans.' vol. liv. MYXCEDEMA. 573 cretinism, nor on prophylactic measures adopted with reference to the young childi-en in whom its presence is obvious or merely suspected ;. but solely on the observance by the parents of those special hygienic measures which are efficacious in the prevention of goitre. II. MYXCEDEMA. Definition and history. — This is a peculiar disease characterised mainly by the general development of a kind of solid oedema, in connection mth a tottering feeble gait, slow and monotonous utterance, slowness of thought and movement, and atrophy of the thyroid body. It was first described by Sir W. Gull • as a ' cretinoid state supervening in adult life in women ; ' and has since been investigated and named by Dr. Ord,^ who extended his inquiries into its morbid anatomy. Sir W. Gull's suggestion as to the nature of the disease has received remarkable confirmation from the observations of Prof. Theodor Ivocher,^ of Berne. He has removed the thyroid body wholly or in part in over 100 cases ; and he finds that, of those patients who survived, all in whom the extirpation had been incomplete remained well, while all (excepting certain recent cases) in whom the gland had been wholly removed presented after a time a very remarkable group of symptoms. These symptoms were more marked according to the length of time which had elapsed since the operation, and were most extreme in those who had been operated on before the growtli of the body had been completed. He was mracquamted with myxoedema ; but his description of the phenomena presented by these cases is the description of myxoedema. His cases seem to prove experimentally the important relations which subsist between the thyroid body and the cretinoid state ; and link together in an unmistakable way, myxoedema, sporadic cretinism, and the true cretinism of Alpine valleys. Causation. — Myxoedema, though it has been met with in men, is a disease mainly of women, and of adult age. No cause for it has yet been discovered. Symptoms and progress. — It begins insidiously, and only after some years attains its full development. At that time the condition of the patient is very remarkable She is probably well-nourished and even fat. There is general oedema, which is more marked in the face and hands than elsewhere ; and the skin is for the most part dry and harsh, and the hair often scanty and weak. The oedematous parts do not pit on pressure. The features are thick, the alee nasi tumid, the lips large and pendulous, and the connective tissue round the eyes swollen, translucent, and colour- less. The skui of these parts and of the rest of the face is dry, but smooth and delicate-looking ; and although the face has generally a pale and waxy aspect, the lips are rosy, and there is a persistent circum- scribed blush upon the cheeks. The hands are large, thick, and clumsy, 1 ' Clinical Society's Transactions,' vol. vii. " ' Med.-Chi. Trans.' for 1877-78. ^ Langenbeck's ' Archiv.' xxis. 2, 1883. 674 DISEASES OF THE VASCULAE OEGANS. and, as Sir W. Gull describes them, ' spade-like ' — an appearance wliicli is due to tlie fact that the fingers are thickened, have lost their natural markings and contour, and are pressed and flattened agauist one another. Her utterance is slow, monotonous, and thick, sometimes squeaky in tone, and is something like that which characterises tonsillitis. She speaks as if her tongue were too large for her mouth, and as if also there were some impediment to the free use of her organs of articulation. The tongue is probably actually larger than natural, and the interior of the cheeks and the soft palate, hke the superficial parts of the body, are oedematous. The muscles generally appear to be well developed ; but there is manifest feebleness, especially in the lower extremities ; she walks with a tottermg uncertain gait, and occasionally her legs give way under her while she is walking, and she falls down. The patient's expression is placid and foolish ; and, just as she is slow and deliberate in her speech and walk, so she is sloY/ and deliberate m all her movements and mental processes. It takes her probably twice as long to get through her work, of whatever kind, whether mental or bodily, as it did when she was in health ; and her interest in what is going on about her is manifestly diminished. Yet notwithstanding this slowness of thought and action, there is in other respects no necessary mental incapacity — she keeps her memory and understandmg, and probably expresses herself as well as ever she did in speech and writing ; and there is no true paralysis of any muscle, no numbness or tmghng ; she retains the sense of touch unimpaired, and has the full use of her eyes, ears, and other organs of sense. Further, there is not necessarily disease of any unportant mternal viscus ; the heart and lungs are healthy, and the urme for the most part normal in quantity and appearance. But the patient usually complains of chilli- ness, the temperature is often subnormal, and the quantity of urea excreted is generally diminished. In Dr. Ord's two fatal cases, which had been long under observation, albuminuria supervened before death, and apparently caused it. Albummuria has been observed also in other cases, more especially as the fatal termination approached ; and one case under our own care was attended with ascites. Although the patient's mental condition is generally clear, occasionally towards the end of the disease loss of memory, somnolence, delusions, and even dementia supervene. She may also become deaf. The disease appears to be incurable. Morbid anatomy. — The chief condition discovered by Dr. Ord after death was general oedema of the connective tissue, mcluding that of the kidneys, liver, and heart. The oedematous tissue of the skin was examined chemically by Drs. Ord and Charles, and fomid to contain mucine in com- paratively large quantities — ordinary oedematous skhi presenting mere traces or several hundred times less. It is from this peculiarity that the name of the disease has been derived. The myxoedematous condition of the kidney closely simulated subacute mterstitial nephritis. The bram was healthy. Later investigations seem to show that the connective tissue of the central nervous organs is affected in the same way as the connective tissue of other parts. The thyroid body undergoes atrophy. Treatment can only be palhative. ADDISON'S DISEASE. 575 III. DISEASES OF THE SUPEA-EENAL CAPSULES. The supra-renal bodies are doubtless liable to most of the organic and other lesions to which other organs are liable ; but there are only two such lesions of them which have any clinical interest — namely, tubercle (Addison's disease) and malignant disease. A. Addison's Disease. [Melasma Addisonii.) Definition. — Tubercular infiltration of the supra-renal bodies, to- gether with the remarkable group of symptoms which seem always to be associated with this lesion, constitutes the malady to which the name of ' Addison's disease ' is now universally applied. When present in its typical completeness it comprises, in association, tubercular destruction of the supra-renal bodies, general pigmentary deposition in the rete mucosum, and a remarkable form of progressive asthenia which sooner or later ends in death. Causation. — Addison's disease occurs much more frequently in males than in females, and is rarely if ever met with under the age of ten or over fifty. Its first symptoms have often been attributed to local injury ; and it is certain that ifc occasionally appears to supervene on caries of the neigh- bouring vertebrae. Morbid anatomy and pathology. — Miliary tubercles appear in the supra-renal bodies, as in other organs, and by their increase in number and size, their coalescence, and the degenerative changes which ensue, lead after a while to their destruction. In fatal cases of this disease, the disorganisation of both glands is usually complete. They may be diminished in size, but are usually enlarged, forming nodulated, rounded, or irregular masses which are adherent to surrounding structures by cicatricial tissue. On section they are found to consist of dense, greyish, translucent, fibroid material, in the substance of which opaque, yellow, cheesy nodules of various sizes are imbedded. In some cases, these have undergone earthy infiltration, in some have softened into tubercular abscesses. There are no lesions of internal organs or tissues which are constantly associated with the supra-renal affection. In a large proportion of cases there is absolutely no trace of any such complication ; in about half the total number (or rather less) miliary tubercles have been met with in the lungs, peritoneum, mesenteric glands, and other parts ; and in a small, but yet significant, proportion of them caries of the vertebra3 has been present. The condition of the skin has a close resemblance to that of a mulatto ; and is variously described as yellowish-brown, dark-brown, greenish-brown, or bronze-like. This dis- colouration, which is more or less general, affects especially those parts of the body which are most exposed, and those which are normally the seat of pigment. Thus, while it tints the face, neck, and hands on the whole more intensely than the chest, belly, and legs, it is usually especially dark in the axillae, areolte of the nipples, umbilical region, 576 DISEASES OF THE VASCULAE OEGANS. external genital organs, and groins. The extensor aspects of the joiiits are generally more deeply tinged than the flexor, and the knuckles, there- fore, and backs of the hands are darker than the palmar surfaces. The discolouration never presents an abrupt margin, but is occasionally spotty, especially on the face and neck ; and is for the most part especially deep upon surfaces which have been blistered or superficially destroyed. Deep cicatrices, on the other hand, tend to remain palhd. Similar brown dis- colourations may generally be observed along the lines of junction of the lips, and spots and patches of the same kind may often be discovered on the mucous surface of the cheeks, gums, and tongue. The fmigiform papillae are occasionally the special seats of pigmentation. The change of colour is due, as is that of common freckles, or of the negro's skin, to the accumulation of molecular pigment in the cells of the rete mucosum. The hair is said occasionally to share m the general pigmentation. The relation between the tubercular disease of the supra-renal cap- sules, the discolouration of the skin, and the remarkable group of symptoms which attend these lesions, is as yet a matter of impenetrable obscurity. It has been suggested that the explanation of the phenomenon lies in the intimate connection which exists between these bodies and the great sjmipathetic in the abdomen. It has also been suggested that the supra-renal bodies, like other ductless glands, exert some important influ- ence over the condition of the blood, and that it is m the abolition of this influence that the source of the special symptoms of the disease is to be sought. But these are, at all events at present, mere barren speculations. It has never been sho-^ii that disease of the abdominal sympathetic mduces symptoms resembling those of supra-renal disease ; nor that the blood or the excretions in Addison's disease present any constant departure from the healthy state. It seems probable, however, that the morbid condition of the supra-renal bodies is directly or indirectly the cause of all the other phenomena of the disease. SynijJtoms mid jprogress. — The chief sjanptomatic phenomenon of Addison's disease is the gradual development of extreme debihty, without commensurate, it may be without appreciable, loss of flesh. The patient observes : that he is less capable than he formerly was of sustained mus- cular exertion and less disposed for it ; that he cannot walk far without suffering from shortness of breath and palpitation ; and that if he persist in his efforts he falls mto a state of prostration, which may continue on him for many hours or for days. Together with these symptoms he suffers from general lassitude and chilliness, and frequent sighuig and yawning ; he probably loses appetite, and has occasional attacks of nausea and vomiting. He perhaps also complains of pains across the loms or sacrum, or m the epigastrium and hypochondriac regions. There may possibly be some giddmess and dimness of ^-ision. The heart's action becomes extremely feeble, its somids perhaps scarcely audible, and the pulse at the wrist small, weak, and sometunes mperceptible. As to rate, it may be normal or quickened, but is often below the average. In the great majority of cases some obvious darkening of the skin goes along ADDISON'S DISEASE. 577 with the above symptoms ; sometimes it precedes them, sometimes follows them, sometimes makes its appearance concurrently with them. It is often first observed by the patient's friends, who probably think that jaundice is coming on, or accuse him of want of cleanliness ; but before long it gets quite obvious to the patient himself as well as to those about him. It is first recognised in the face, neck, and hands ; and generally manifests itself on the upper half of the body earlier than on the lower half. The tint gradually increases in intensity, especially in those situa- tions which usually tend to get darkest ; but the degree which it ulti- mately attains differs greatly in difl'erent cases. In some, though obvious, it is slight up to the close of hfe ; in others the skin acquires the depth of hue of that of a mulatto or negro. In a small proportion of cases no change of colour whatever ever takes place. The conjunctiva in all cases maintain their normal pearly lustre throughout. The phenomena above detailed are associated with many negative features of significant import- ance. The skin remains cool, pliable, and normal in texture ; there is no rise of temperature ; the tongue is clean and moist ; and, beyond nausea and sickness, there are no indications whatever of inflammation or organic disease of the chylo-poietic viscera ; the bowels are regular ; and the urine is scanty but normal in appearance and constitution, excepting that urea is for the most part largely reduced in quantity. With the progress of the case the debility increases. This is not always obvious as the patient lies quiet in bed (to which he is probably before long confined), but especially manifests itself in the supervention of alarmino- prostration after any unwonted effort. The nausea and sickness increase, but are liable to variation, and may even disappear for a while ; they are not unfrequently associated with good appetite. The patient suffers occasionally from headache in addition to his other pains, and complains at times of chilliness — his hands, feet, and nose probably becoming cold and livid from imperfect circulation ; the temperature in the axilla not unfrequently falls a degree or more ; sometimes, on the other hand, it rises one, two, or three degrees ; and, although no actual paralysis may be present, he is a^^t to complain of numbness in his lower extremities and to believe that he has lost the use of them. Towards the close of the disease the breath and skin often yield an offensive cadaveric odour ; the skin occasionally becomes furfuraceous ; the patient grows apathetic, and disincHned to make any unnecessary movement, or even to reply to ques- tions ; and, although now and then becoming delirious, usually remains conscious to the last. Death results from asthenia, and is sometimes brought on by a sudden attack of faintness which may be referrible to some apparently trivial exertion. It has been assumed in the foregoing account that the patient is free from tubercle of other organs or from vertebral caries. The presence of such complications tends to mask the phenomena due to the supra-renal disease. It is important, however, to note that, even in complicated cases, the complications are rarely so extensive or serious as of themselves to cause death, or so engrossing by the phenomena to which they give rise p p 578 DISEASES OF THE VASCULAE OEGANS. as materially to obscure tlie diagnosis of tlie supra-renal lesion. It might, indeed, almost be said tliat the presence of tubercles in the lungs or else- where, or of caries of the spine, should bring with it a thought as to the possible presence of svipra-renal complication. There is unfortunately no reason to doubt that Addison's disease is always ultimately fatal. The duration of the malady is, however, subject to considerable variation. It is probably not possible in any case to ascer- tain the exact date of the commencement of the disease ; there are good reasons, indeed, for believing that the process of supra-renal degeneration is always far advanced before the clinical signs of the affection reveal themselves. Counting, then, from this latter date, the malady is some- times remarkably rapid in its progress — proving fatal in the course of two- or three weeks ; while sometimes it is prolonged for several years. More commonly it terminates fatally within a year. It is important, however, to observe : that the progress of patients with this disease is not always uniformly from bad to worse ; but that they are liable to attacks of nausea and prostration, so severe as to threaten life, alternating with periods of greater or less duration in which they gain flesh, and seem to be fairly comfortable and hopeful ; that many subjects of it doubtless fight against advancing weakness, not admitting themselves to be out of health until possibly one of those sudden failures of the vital power to which they are liable compels them to yield ; and lastly, that such sudden seizures may often be warded off by scrupulous avoidance of mental or bodily exertion, exposure to the influence of cold, and errors of diet, and thus the patient's life be greatly prolonged. The debility induced by supra-renal disease is in this respect very much like that which attends saccharine diabetes. Treatment. — The cure of Addison's disease is beyond our power ; and all, therefore, that we have to do is to endeavour, by counteracting the various secondary phenomena of the disease, to prolong life and render it endurable. It is of the utmost importance to maintain the patient at rest, as regards both mind and body, and to keep him warmly clad and in an apartment of agreeable and moderate temperature. Sickness and irri- tability of the stomach should be relieved by appropriate remedies ; tonics (the nature of which must be determined by the condition of the patient's, digestive organs) should be administered ; and he should be nourished and supported by wholesome and nutritious food, with such a proportion of alcoholic stimulants as may seem to be needed. B. Tumours of the Supra-Benal Capsules. The various forms of malignant disease are all apt to attack the supra- renal bodies secondarily ; and in rare cases these organs are the seat of their primary development. When the disease is secondary, the supra- renal growths rarely attain a large size, and probably nothing occurs during the whole course of the case to direct attention to them. When, however, the disease is primary in them, they may form tumours as large as a cocoa-nut, which from their size and situation may be easily recog- nised during life. It would be difficult, if not impossible, to distinguish DISEASES OF THE SPLEEN. 579 such tumours from renal tumours ; they occupy, m fact, exactly those situations which tumours originating in the upper part of the kidneys would occupy. They form rounded or lobulated immovable masses, springing from the posterior part of the abdomen, and are usually crossed by the ascendmg or descending colon, which they push forwards in their growth. Their development is sometimes attended with frequent par- oxysms of agonising pain, and always with the emaciation, debility, cachexia, and other phenomena which are associated with the progress of visceral malignant disease ; but never, so far as is known, with the specific symptoms of Addison's disease. IV. DISEASES OF THE SPLEEN. A. Congestion. Causation. — Congestion of the spleen is of common occurrence under a large number of circmiistances. It habitually takes place during the progress of digestion. Pathologically it is mainly observed : first, in dependence on lesions involving mechanical impediment to the escape of blood from the spleen, such as obstructive cardiac and pulmonary affec- tions, and especially those diseases of the liver, such as cirrhosis, in which the portal vessels are implicated ; and, second, in connection with nume- rous acute febrile disorders, of which typhus, enteric fever, pyaemia, and malarious affections may be taken as the types. Morbid anatomy. — In congestion the blood accumulates in the small vessels and intervascular blood-passages, and the organ becomes propor- tionately enlarged. The rapidity with which this enlargement takes place and subsides is remarkable. The congested organ may attain five or six times its original bulk, while retaining its normal form ; and usually becomes, in proportion to the amount of blood which it contains, pulpy, lacerable, and even diffluent. When the congestion is frequently repeated, as in ague, or long continued, as in portal obstruction, the enlargement tends not only to increase, but to become permanent. Symptoms and progress. — Simple congestion of the spleen rarely, if ever, reveals itself by symptoms, and equally rarely calls for special medical treatment. It can, however, often be recognised during life (if sought for in those cases in which it is liable to occur) by the presence of a manifest tumour in the splenic region. The normal spleen is situated upon the cardiac extremity of the stomach, its convex surface being in contact with the diaphragm, and no part descending below the ribs. Its lowest point is then in close proximity with the anterior extremity of the eleventh rib, from which point upwards a limited area of dulness, due to its presence, may sometimes be detected on the left side of the thorax The enlarged organ, however, while partly rising into the chest and in- creasing the area of splenic dulness in that situation, mainly spreads farther and farther into the abdominal cavity, taking a course downwards, p p 2 580 DISEASES OF THE VASCULAE OEGANS. forwards, and inwards. In cases of extreme enlargement it may occupy nearly the whole of the left half of the abdomen — extending from the ribs above to the groin below, from the lumbar region behind to beyond the umbilicus, and causing distinct protrusion of the abdominal parietes. A splenic tumour is usually readily movable, sinking and rising with the respiratory movements, and capable of obvious displacement under manual pressure ; its sharp anterior edge can generally be readily felt, and found to present the characteristic splenic notch. If symptoms be present they are mainly a sense of weight or tension in the side and tenderness on pressure. Occasionally rupture of the greatly congested spleen takes place ; in which case death occurs with some rapidity, either from the escape of blood into the peritoneal cavity, or from peritonitis. Treatment. — The treatment of hyperemia consists mainly in the treat- ment of the morbid condition which gives rise to it. B. JSypertrophy . Causation. — True hypertrophy is for the most part the consequence of long-contmued or repeated congestion. It is therefore frequently associ- ated with chrhosis and other chronic affections of the liver, and is a com- mon consequence of repeated attacks of malarious fever. It is, moreover, a usual comphcation of rickets. But some of the most remarkable ex- amples of this affection are furnished by persons who have never suffered fr^om any of the above disorders, and m whom there is no history pointing to the operation of any specific cause. Morbid anatomy. — In true hypertrophy, the organ enlarges without undergomg any obvious change in texture ; there is a general increase of all its elements in pretty nearly equal proportion ; and it acquires a more or less firm fleshy consistence. It is in this condition, and m that asso- ciated mth leucocythsemia, that the spleen attains its greatest volume, sometimes filling the left side of the abdomen, from the ribs above to the pelvis below, and fr'om the lumbar region behind to some inch or two, or more, beyond the umbilicus. It may then measure as much as sixteen inches in length, ten in breadth, and five or six in thickness, and weigh ten, twelve, or even twenty poimds. It retains its normal shape. Syviptoms and progress. — The symptoms due to simple hypertrophy are vague, and difficult to disentangle from those of other lesions with which they are frequently associated. Persons thus affected often suffer fr'om anaemia, discharges of blood (especially fr'om the gastro-intestinal mucous membrane), and abdominal dropsy; but it is uncertam how far these iDhenomena depend on the hepatic lesion which so commonly goes along with splenic enlargement, how far on the splenic disease. But, putting such sjonptoms aside, there is nothing left to indicate the presence of splenic hj^pertrophy beyond the local phenomena to which it gives rise. The chief of these is the manifest existence of a tumour which presents the characters (before described) of enlarged spleen, is tough and unyield- mg in consistence, gives to the patient a sense of weight and fulness, DISEASES OF THE SPLEEN. 581 especially if lie lie upon liis right side, and is unattended with pain or tenderness on pressure. A venous hum, of musical character, may oc- casionally be recognised on the application of the stethoscope over the tumour. The duration of these cases is always uncertain, and often much prolonged. In some instances amelioration or cure takes place mider suitable treatment ; in some the organ remains stationary, and yet with little manifest deterioration of the patient's health ; in many death ensues sooner or later, either from simple anaemia and debility, or from these conditions associated with hemorrhage, dropsy, or some other intercurrent affection. The treatment of hypertrophy must depend largely on the constitutional malady which has given rise to it. If it be a sequel of ague, quinine or arsenic is indicated ; if the patient be suffering from rickets, the remedies suitable for that condition must be employed ; if there be heart, pulmo- nary, or renal disease, our efforts must be regulated accordingly. In many cases no such clue is furnished ; and we must then have recourse to those remedies which the general condition of the patient seems to suggest ; among the more important of which may be enumerated iodine, iodide and bromide of potassium, iron, quinine, and other tonics. The bowels should be kept freely open — if necessary, by the use of mild laxatives. C. Inflammation. Causation. — Liflammation of the spleen, at least in an acute form, is exceedingly rare, excepting m those cases in which it is due to injury, embolism, pyaemia, or the presence of morbid growths or foreign bodies. Morbid anatomy. — Splenic embohsm is most frequently a consequence of valvular disease of the heart. It leads to the formation of wedge-shaped blocks, or masses, which vary in size fi'om a cubic inch or two downwards, are often multiple, and usually abut on the surface of the organ. In the first instance they are mainly hemorrhagic, and distmguishable from the splenic tissue by their darker colour and greater solidity ; but soon the colouring matter gets absorbed, and the masses pass through various stages of reddish-brown, yellowish-brown, and buff colour, until they become almost pure white. Sometimes they soften into a puriform pulp, sometimes undergo suppm-ation, and sometimes (especially if smaU) get absorbed, leaving depressed cicatrices behind, in which earthy particles may remain imbedded. The presence of these infarctions generally gives rise to mflammation in the peritoneal surface over them. Pytemic formations present much the same characters ; but they are usually more numerous and smaller, and their tendency to soften, suppurate, and involve the peritoneum covering them, is much more marked. Splenic abscesses may result from the above and various other causes, and, like other abdominal abscesses, may acquire large dimensions, and are liable to various terminations. They may open externally through the abdominal walls, or rupture mto the peritoneum, or discharge their 582 DISEASES OF THE VASCULAE OEGANS. contents into the stomacli, colon, left lung, or pleura. Adhesive inflam- mation is not uncommon at the surface of the spleen, and occasionally circumscribed suppuration occurs between this organ and some neighbour- ing part, such as the stomach, diaphragm, colon, or abdominal walls. Syviptoms. — In most of the affections now under consideration there is little or nothing special excepting locality to direct attention during life to the spleen as the seat of disease. There may be, and indeed probably always is, manifest increase of size of the organ, together with uneasmess, pain, and tenderness. The pain, when severe, is mainly due to circum- scribed peritonitis, and, from the position and relations of the organ, is liable to augmentation during the respiratory movements. The recognition of an abscess will depend on its attainment of such a size as to form an appreciable fluctuating tumour in the splenic region, and on the pheno- mena which attend and follow the process of pointing and the discharge of its contents. In all these cases, sympathetic vomiting and febrile symptoms will almost certainly manifest themselves, and rigors are not unlikely to supervene. But it is rare for the splenic affection to be so free from complication as to justify us in attributing them to it. Special treatment will only be called for when pain is complained of or when an abscess becomes manifest. In the former case, poultices, fomen- tations, and leeches are the most useful applications ; in the latter the case must be treated as one of hepatic or other internal abscess. D. Tubercle. Tubercles are very common, especially in young children, and in con- nection with tuberculosis of other organs. The spleen thus affected is usually somewhat enlarged and studded more or less thickly with them. They are frequently miliary and grey, in which case they may be readily mistaken for the Malpighian bodies ; usually, however, some of larger size may also be detected which have already undergone caseation, and thus furnish a clue to the nature of the others. Yellow tubercular masses, irre- gular in form, and varying from the size of a horse-bean to that of a tare, are also not unfrequently discovered, in greater or less abundance. Occa- sionally they soften into cavities or form abscesses. Filamentous processes of false membrane, themselves studded with tubercles, are often attached to the surface of tuberculous spleens. Tuberculosis of the spleen can scarcely be recognised during life. If symptoms attend it, they will be such as to suggest either congestion, abscess, hypertrophy, or some other than tubercular lesion. E. Tumours. The various forms of malignant disease affect the spleen with different degrees of frequency and in different modes. First, the peritoneal aspect or the connective tissue about the hiknn may get involved by continuity in the course of malignant disease of the peritoneum, stomach, or glands in the neighbourhood of the stomach ; and then the morbid growth either in- vades the organ from different parts of its surface, or runs into its substance DISEASES OF THE SPLEEN. 583 along the vessels which enter at the hilum. Second, the spleen may have isolated secondary growths developed here and there in its substance. Or, third, it may be the seat of the primary manifestation of the disease. The last alternative is rare. Most of the different forms of malignant disease fail to cause any great enlargement of the spleen, or to indicate their presence by special symp- toms ; and consequently the splenic affection is usually overlooked during life. Still such growths many attain considerable size in that organ, and •convert it into an irregular and more or less mdurated mass, readily re- cognisable during life by palpation, and even (in connection with other phenomena) as a malignant growth of splenic origin. It must not be forgotten, however, that tumours of the great omentum, or other parts of the peritoneum in the neighbourhood of the spleen, are apt to simu- late splenic tumours and to be mistaken for them. These remarks do not apply to lymphadenoma. In this, as in simple hypertrophy, the spleen undergoes a nearly uniform enlargement ; sometimes acquiring gigantic proportions, but still retaining its natural form, and the charac- teristic features by which an enlarged spleen may usually be recognised. The symptoms of splenic malignant disease are not usually of much interest or importance. Those which attend lymphadenoma of the spleen will be most conveniently discussed hereafter in connection with those due to the same affection of the lymphatic glands. F. Cysts and Hydatids. Simple serous cysts are rare in the spleen, and, so far as we know, unimportant. They are occasionally multiple, and associated with the development of numerous similar cysts in the liver and kidneys. In the case of a young man that came imder our observation some years ago, a huge cyst, containing at least a gallon and a half of fluid, had become developed in the course of three or four months in the region usually occupied by an enlarged spleen. It was tapped on two occasions at the interval of a couple of months, and on each yielded a grumous fluid in which only blood-corpuscles could be detected mider the microscope. After the second tapping the patient recovered completely ; and some years later no trace of tumour could be detected in the abdomen. There was no special reason to regard the cyst as hydatid. Hydatids are more common and on the whole far more important. But their course and the symptoms to which they give rise are identical (excepting in one or two obvious particulars) with those of hydatids of the liver or peritoneum, and need not be particularly considered now. G. Atrophy. Atrophy is exceedingly common, and traceable to various causes. In some cases it appears, like cirrhosis of the liver, to be consequent on an interstitial overgrowth of connective tissue ; in some, as also occurs m the liver, to the investment of the organ hi a dense and slowly contracting -fibrous capsule. But, however produced, it is a lesion which, so far as we 584 DISEASES OF THE VASCULAE OEGANS. know, causes little or no inconvenience and no symptoms by wliich it& existence may be diagnosed. H. Lardaceous Degeneration. Morhid anatomy. — Tlie spleen is peiiiaps more frequently the seat of tlie lardaceous change than any other part of the body ; but it is generally thus affected in association with one or more of the several other organs which are liable to the same change, Lardaceous degeneration first affects the minute arterial twigs and the cells external to them with which they are in relation. It is especially apt to commence in the Malpighian bodies and vessels connected with them. The lardaceous spleen under- goes gradual and uniform enlargement, and may attain dimensions nearly as extreme as those reached by the simply hypertrophied organ. Its capsule is usually smooth and glistening ; and on section the organ presents different appearances according to the degree to which the de- generation has advanced. In the earlier stages it exhibits those cha- racters which have gained for it the name of the ' sago ' spleen. It i& thickly studded with greyish translucent rounded masses, which have a close resemblance to boiled sago-grains, and which are separated from one another by a network of still healthy tissue. In the latter stages these rounded bodies have coalesced, and the spleen is involved in its whole extent. In this condition it presents on section a nearly uniform greyish, translucent, glistening aspect, yields little or no fluid on pressure, and takes the impress of the finger like a piece of wax or stifl' dough. It is abnormally heavy, and readily lacerable, breaking however with a some- what vitreous fracture. Symptoms. — Lardaceous spleen is always associated with more or less anaemia or cachexia, and often with dropsy, tendency to hemorrhage, and other symptoms, for the most part indicative of debility.- It is never pos- sible, however, to decide to what extent these various symptoms depend on the splenic disease, which is always secondary to grave chronic lesion of other organs, and generally associated with similar degenerative changes elsewhere ; to what extent they are referrible to these several antecedent or concurrent affections. Treatment. — Lardaceous spleen probably never calls for independent treatment. Our first efforts must be directed to the cure of the lesion out of which the tendency to lardaceous change has arisen ; our next to the improvement of the patient's general health by the exhibition of iron and other tonics, the administration of abundant nutritious food, and attention to those hygienic measures which are generally beneficial in cachectic conditions. V. DISEASES OF THE LYMPHATICS. There are probably no organs or tissues of the body the pathological relations of which are more important than those of the lymphatic vessels and glands ; no organs which are more frequently involved in the course DISEASES OF THE LYMPHATICS. 585 of diseases originating in otlier parts ; none, the proper diseases of which more profoundly affect the general organism. But their affections are, for the most part, so intimately connected with those of other organs, or with so-called ' general ' diseases, that the discussion of the latter necessarily involves that of their lymphatic complications. It is need- less, therefore, notwithstanding its surpassing interest and importance, to enter at any length upon the subject of the diseases of the lymphatic system. A. Inflamynation. Causation. — Inflammation of the lymphatics is, no doubt, sometimes primary, in the sense in which idiopathic pneumonia is primary, and sometimes the consequence of blows or other forms of direct mechanical violence; in the great majority of cases, however, it arises secondarily to some local inflammation, or is the consequence of some irritant acting through the blood. Morbid anatomy. — If the glands be secondarily affected, those only suffer which lie next above the inflamed area, in the line of the lymphatic vessels. In this case irritating matters, probably the products of inflam- mation, are taken up by the lymphatics, and conveyed along them until they get arrested in their progress by the glands. During the passage of these matters the vessels sometimes inflame, and their parietes get thickened and vascular, and the connective tissue around them congested and infiltrated ; and thus their course becomes indicated by red tumid bands. Sometimes, indeed, abscesses form along them. On the other hand, lymphatic vessels frequently convey, without injury to themselves, matters which excite violent inflammation in the glands, and ulterior mis- chief of the gravest character. Inflammation of the lymphatic glands is marked by hyperaBmia,. succulence, softening and swelling, and an exces- sive development of cells resembling those natural to the healthy organs. Suppuration sometimes ensues, and occasionally (especially among lax tissues such as that of the axilla) enormous abscesses result. In some instances the inflammation assvnnes a chronic character, and ends in the induration, contraction, and atrophy of the glands. The nature of the inflammation, and its tendency in respect of result, differ in accordance with the characters of the local inflammation, and of the specific disorder to which it owes its origin. Symptoms and progress. — The symptoms due to lymphatic inflamma- tion are principally swelling, heat, pain and tenderness in the course of the affected vessels and in the affected glands, with visible hyperemia in the situation of such as occupy a superficial position, and febrile symptoms of more or less severity. Indeed the fever is generally severe (apparently out of all proportion to the extent and importance of the inflamed tract), and not unfrequently attended with rigors. Its severity is doubtless due in no small degree to the fact that the inflamed lymphatics are in direct communication with the blood, and are constantly pouring the products of their inflammation into it. 586 DISEASES OF THE VASCULAR OEGANS. • Treatment. — For the general treatment of inflamed glands (supposing them to need any apart from the affection to which their inflammation is secondary) no rules need be laid down beyond such as should guide us in the treatment of tonsilHtis and other such disorders. For local treatment, leeches, fomentations, poultices, and in some cases cold applications, are chiefly important. When the inflammation is chronic, counter-irritants, iodine paint, strong mercurial ointment, and blisters will probably be more efficacious. B, Tubercle. Scrofula. Morbid anatomy. — It is not easy to draw a distinct line between tu- bercle of the lymphatic glands and that enlargement of them which so commonly occurs in so-called ' scrofulous ' children. But however different these affections may appear to be from one another in their early stages, it is certain that in both there is an equal tendency for the affected glands to undergo speedy caseous degeneration, and to be converted into opaque yellowish, friable, fattily- degenerated masses, which, according to their situation and other attendant circum- stances, either soften or suppurate, or become converted into encysted mortary or cretaceous masses. Softening with ulcerative destruction takes place especially in connection with mucous surfaces ; softening with forma- tion of abscesses, in the case of the glands which are superficially placed ; cretaceous changes, in the glands of the mediastinum and mesentery, and others which lie deep in the interior of the body. Symptoms and progress. — The symptoms of tubercular or scrofulous disease of the glands are rarely characteristic except when the affected glands are so situated as to admit of ready examination. They are then as a rule scarcely painful or even tender, and are usually indolent in their progress ; suppuration is long delayed and slow to reach the surface ; and even after the contents have been evacuated the abscess continues to dis- charge for an indefinite time ; and when at length the cavity heals, the scar which remains is ragged and unsightly. The general symptoms are those of debility and constitutional weakness. Treatment. — The constitutional treatment of scrofulous disease of the glands consists in the use of tonics, cod-liver oil, and good nourishing diet, change of air, and generally careful attention to hygienic measures. The local treatment belongs mainly to the surgeon. So long as the glands are neither painful nor suppurating, it is probably best to trust wholly to constitutional treatment ; but when pain or suppuration arises, poultices or fomentations are demanded, and, in the latter case, sooner or later the surgeon's knife. C. Morbid Growths. Morbid anatomy. — Malignant disease, commencing elsewhere, invari- ably soon attacks the lymphatics, and in the first instance those glands which lie nearest to the primary spot of disease, between it and the thoracic duct. These glands indeed generally become rapidly and exten- sively involved, forming large tumours, which sooner or later coalesce MEDIASTINAL TUMOUES. 587 with one auotlier, and implicate in tlie progress of tlieir growth the surrounding tissues. Thus, in malignant disease of the tongue or mouth, the glands at the angle of the jaw first suffer ; when the breast is the source of infection, the axillary glands ; when the lungs, the bronchial glands ; when the stomach or bowels, the mesenteric or retroperitoneal glands ; when the penis, the glands of the groin ; when the testicle, those lying in the lumbar region. In some cases involvement of the lymphatics forms a still more obvious factor of the disease ; and it may be primary. The most remarkable example of this kind is furnished by lymphadenoma, which (as has been before pointed out) affects primarily not only the lymphatic glands but the lymphatic tissues throughout the system, and, though not necessarily limited to these in its ulterior development, com- mits its ravages mainly upon them. Symptoms and lyrogress. — The constitutional symptoms caused by malignant disease of the lymphatics are mainly those of malignant dis- ease generally ; when, however, these organs are implicated, the morbid process has already begun to exert a specific influence over the system, and the so-called ' cancerous cachexia,' if not previously manifest, becomes for the most part rapidly developed. The local symptoms are those of a painful rapidly growing tumour, the direct results of which depend upon its situation. Treatment. — Palliative measures only are as a rule available in malig- nant disease of the lymphatic glands. Accessible glands occasionally admit of removal with temporary benefit. D. Mediastinal Tumours. Morbid anatomy. — Tumours are of common occurrence in the medi- astina, and are often primary in this situation. It is not always easy to •determine in what tissue they have originated. It is certain, however, that they often appear to start from the lymphatic glands in the posterior mediastinum, and from that part of the anterior mediastinum in which are situated the remains of the thymus gland. It is not improbable that they arise also in the substance of the connective tissue. The nature of the disease varies in different cases ; sometimes it is cancer, but probably much more frequently sarcoma or lymphadenoma. Earely it is syphi- litic. The growth, especially in the former cases, gradually increases in bulk, and, even if it did not originate in the lymphatic glands, very soon involves them, and by degrees implicates all the surrounding parts. Thus it may invade all the tissues of the anterior and posterior mediastina, surrounding and involving the fibrous pericardium and the adjoining parts of the parietal pleurse ; or it may mvolve the roots of the lungs, extending along the bronchial, tubes and vessels into the substance of the lungs, or implicating the neighbouring parts of these organs by continuity, and probably constituting large tumours in them ; or it may extend into the cardiac walls, either infiltrating their substance or forming distinct growths. Further, it is apt, sooner or later, to implicate the trachea, bronchi, or oesophagus, the innominate veins or cava, or the recurrent 588 DISEASES OF THE VASCULAE OEGANS. laryngeal nerves ; or to involve tlie lymphatic glands above one or other clavicle ; or to lead to the development of tumom'S in the ribs or soft tissues of the thoracic walls. The dimensions which mediastinal tumours attain are sometimes enormous ; they may become as large as an orange, cocoa-nut, or child's head ; moreover, m their growth they tend to cause much compression and displacement of parts. The heart, for example, may be carried into the left axilla, or even into the right. Symptoms and progress. — The symptoms to which mediastinal tumom'S may give rise are necessarily very various, and depend mainly on their seat and bulk and the particular intrathoracic organs which they implicate. They are almost identical, indeed, with those caused by intrathoracic aneurysms. The early symptoms are vague, but not unfrequently include progressive anemia, debihty, and shortness of breath. The more charac- teristic phenomena slowly supervene — the order of their sequence varying, however, in different cases. Sometimes the veins get obstructed ; those of one-half of the head and neck and face and of the corresponding shoulder, arm, and side of the chest, or those of both sides equally, become dilated, tortuous and full ; and the implicated regions acquire a ghastly, Hvid, or congested aspect, and get more or less puffy or oedematous. This limited congestion and oedema are very striking phenomena ; especially when, as generally happens, the rest of the body is pallid and wasted. Sometimes the respiratory organs suffer, and the patient has difficulty of breathing, with cough, and probably expectoration. The symptoms then are either like those of slowly advanchig bronchitis ; or, owmg to implication of the trachea, or recurrent laryngeal nerve, like those of laryngeal disease, and attended with hoarseness or aphonia, and attacks of suffocative cough ; or, m consequence of the formation of tumours in the lungs or of the super- vention of pneumonia or pleurisy, like those ascribed to these several affections. Sometimes the symptoms are mainly cardiac, and simulate those due to valvular disease. Sometimes the patient has difficulty or paur in swallowing. And often in connection with cardiac, pulmonary, or laryngeal symptoms, or those of venous obstruction, he complains of vertigo, headache, and even of occasional attacks of momentary uncon- sciousness or slight convulsion. It is not uncommon to have blood m the expectoration ; and late in the disease the sputa are apt to be abmidant, muco-purulent, and fetid. The diagnosis of mediastinal tumours is often largely aided by physical examination : by the gradual extension of the area of pr^ecordial duhiess, by the increase of resistance experienced on percussion, by the displace- ment of the heart or huigs, or by the supervention of pulmonary consoli- dation or pleural effusion, and the modification in the auscultatory pheno- mena which these several affections entail. It is further aided by the presence of pencils and knots of dilated capillaries and veins m the thoracic parietes. Important indications are furnished in some cases by the development of tumours in the chest-walls, or above the clavicles ; and in a few by a history of syphilis, or the presence of syphilitic lesions elsewhere in the body. DISEASES OF THE LYMPHATICS. 589 It must not be forgotten that in the course of mediastinal disease secondary tumours are apt to arise in other parts of the organism ; and that these occasionally cause more striking symptoms than the'primary disease, which may then be overlooked. Thus it is not uncommon in these cases for such tumours to develop in the brain, and for the patient to die of the cerebral complication. It is obvious that the symptoms of mediastinal growths are made up mainly of those due to implication of the various important organs which occupy the mediastina or abut upon them ; and in order that the reader may have a clear conception of their variety and importance, and a thorough picture of the disease, we must refer him to the descriptions elsewhere given of the phenomena referrible to lesions of the several -organs here adverted to. Mediastinal tumours are almost always progressive in their course, and sooner or later fatal. If syphilitic, however, improvement and even recovery may ensue. The .causes of death are various. Treatment. — There are no special indications for the treatment of mediastinal tumours, unless there be reason to suspect their origin in syphilis. In this case anti- syphilitic remedies are demanded. As a general rule symptoms must be dealt with as they arise. E. Obstruction and Dilatation of the Lijmphatic Vessels. ■ Morbid anatomy and s?/mj9to7%s.— Obstruction of the thoracic duct may be caused by the pressure of tumours, by disease of its walls, or by a morbid condition of its contents ; but is rare. It might be supposed that it would lead to rapid innutrition, and at the same time to general dila- tation of all the lymphatics, excepting those of the right upper extremity and corresponding side of the head, neck, and thorax. But experience and experiment alike seem to show : that whilst sudden obstruction usually results rather quickly in great over-distension of the lower part of the duct, and especially of the receptaculum chyli, which presently riiptures with extravasation of its contents into the retroperitoneal tissue ; slowly induced obstruction may be compensated for by the enlargement of existing communications between the obstructed left and the still pervious right duct. Obstruction occurring in a group of lymphatic glands in consequence of disease going on in them, or in a group of lymphatic vessels as a result of pressure upon them or of their involvement in disease, always leads in the first instance to stasis and accumulation of lymph Avithin the tributary vessels, which consequently dilate, and subsequently to similar accumulation within the lymphatic spaces and to their dispro- portionately large expansion. The lymph- channels, indeed, and the tissues generally, become surcharged with lymph : a clear or milky yellowish alkaline fluid of a sickly odour, which contains albumen, fibri- nogen, and lymph-corpuscles, and among other occasional constituents sugar and molecular fatty matter, and which, like the plasma of the blood, coagulates on removal from the body. The result is the development of 590 DISEASES OF THE VASCULAK OEGANS. what is often termed solid oedema or leucoplilegmasia of the imj)licated portion of the body ; which becomes swollen and tense, and of a pale waxy aspect, but does not pit on pressure as ia ordinary venous dropsy. And, further, if the condition be of long duration, and especially if it originated in infancy when the organism was undergoing rapid growth, the affected region (not only connective tissue, but muscles, bones, and skin) all become distinctly hypertrophic. Obstruction and dilatation of the lymphatics is the essential feature, or an important factor, of several well-recognised pathological conditions. A particular form of enlarge- ment of tongue, usually congenital, m which the organ tends to grow, to protrude from the mouth, and to interfere by its bulk with the growth of the jaws, has been shown by Virchow to be due to lymphatic obstruction. The tongue is honeycombed with dilated lymph-channels, and the seat of consequent overgrowth of all the tissues of the organ, inclusive of the muscular substance and of the papillary sru'face. The upper extremity has occasionally become, from accidental circumstances, similarly affected. But the most frequent, and, on the whole, the most interesting example of such obstruction and its consequences is afforded by the lower ex- tremity and the adjoining portions of the abdomen and genital organs, in the condition we have already described under the name of elephantiasis lymphangiectodes. The last morbid condition characterised by dilata- tion of the IjTnphatics to which we shall refer is elephantiasis Arabum, a disease which, like the last, is more fully discussed ua another part of this volume. Treatment. — It is ob'^ious that no medicines are competent to reheve the various consequences of obstruction of the lymphatics : recourse can only be had to mechanical or operative measures. In enlargement of the tongue, portions of the organ have been excised with benefit ; as also have bits of the prepuce when that structure has got hj-pertropbied. VI. LEUCOCYTHiEMIA. {LeuJccemia.) Definition. — By the above term is meant a disease characterised by the presence of an excessive number of white corpuscles in the blood, ia asso- ciation ^\-ith enlargement of the spleen, enlargement of the lymphatic glands and lymphatic tissues generally, or affection of the medulla of the bones, or these several conditions combined in different proportions. In the present state of our knowledge it is not possible to define accurately the limits of the affection we are about to describe. For : anatomically, IjTnphadenoma, which we have already described as a form of malignant disease, is scarcely if at all distinguishable fi-om the lesions which occur in typical cases of leucocythfemia ; relative excess of white corpuscles is frequently observed not only ui cases of anaemia however produced, but in affections, which are certainly not leucocythaemic, of the spleen and other regions above specified ; on theoretical grounds there are rea- sons for believing that various disorders of the blood-corpuscle-creating tissues might involve similar modifications in the corpuscular constitution LEUCOCYTHiEMIA. 591 of the blood ; and lastly, cases are undoubtedly met with m which the spleen or lymphatic glands, or both, undergo enlargement like that occurring in true leucocythaemia, in which the symptoms and course of the disease resemble in almost all important respects those of leucocy- thaemia, but in which the anaemia is miattended with excess of leucocytes. Nevertheless typical cases to which the term leucocythaemia is strictly applicable are frequently met with. In these the spleen is with scarcely an exception the main, if not the sole, seat of specific anatomical change ; and it is to this affection that the remarks we are about to make will be chiefly directed. Ccmsation. — The causation of leucocythaemia is very obscure. Dr. Gowers^ has shown that twenty-five per cent, of cases of the disease presented a history of ague or of exposure to malaria. But certainly that origin cannot be suggested for the great majority of them. Depressing mental and physical conditions have also been assigned as causes. The disease occurs at all periods of life, but is by far most frequent between the ages of twenty and fifty. Men are more liable to it than women. Morbid anatomy. — The most remarkable anatomical fact in splenic leucocythaemia is enlargement of the spleen. This organ attains, indeed, a greater size in this disease than probably in any other. It frequently measures from twelve to fourteen inches in length, and has been met with exceeding eighteen inches and weighing over twenty pounds. Usually it is smooth on the surface, though apt to present a little inflammatory exudation, and retains its normal shape. It is for the most part firm and pale, or somewhat mottled on section, and yields less blood on pressure than the healthy organ. On microscopic examination it appears that the enlargement is due mamly to hypertrophy of the splenic pulp, in which there is a large increase both of leucocytes and of fibrous tissue. In about one third of the cases, according to Dr. Gowers, the lymphatic glands generally or partially are enlarged ; and in some of them there is similar enlargement of the aggregations of lymphatic tissue in the bowels and elsewhere. But this glandular affection is almost always a late event m the progress of the disease, and rarely leads to any direct important con- sequences. The enlarged glands are generally soft, rarely attain the size of a walnut, and present simply an overgrowth of the normal constituents. Li a small number of cases the medulla of the bones has been found affected, much as it is in some cases of so-called ' pernicious anaemia.' It is for the most part more fluid than natural, variously coloured, and characterised by disappearance of fat, with accumulation of leucocytes and red corpuscles. The liver is often enlarged and fatty. Inflammatory conditions of the lungs and pleurae, and even of the peritoneum, and ■dropsical effusions into the connective tissue and serous cavities, are not unfrequently observed post mortem. But even more important and interesting than these is the effusion of blood, which is not only met with in a petechial form under the skm, on the surface of the heart and lungs, and in the substance and on the exterior of the brain, but leads ■ ^ ' Transactions of Pathological Society,' vol, xxix. 592 DISEASES OF THE VASCULAE OEGANS. to large and fatal discharges from the mucous surfaces, into the serous cavities and connective tissue, and even into the substance of the brain. The blood, as will presently be shown more particularly, presents a large relative excess of white corpuscles, which after death are not unfi-equently found aggregated in pale clots, or thick creamy masses, in the terminal branches of the pulmonary artery, the cavities of the heart, and the systemic vessels. SymiAoms and progress. — Splenic leucocyth^emia comes on insidiously. In some cases it is the painless enlargement of the abdomen which first attracts attention. In some cases gradually increasing asthenia, pallor, and shortness of breath are complained of for some time before the con- dition of the abdomen is observed. And occasionally all the other phe- nomena are preceded by irregularly recurring slight febrile paroxysms, or by repeated hemorrhages, usually from the nose. But under any circum- stances the patient gradually gets anaemic, loses flesh and strength, "becomes incapable of exertion, short-breathed and liable to palpitation, and the abdomen grows large, solid, and heavy ; and then careful exami- nation reveals the fact that the spleen is enlarged, perhaps enormously, extending not only upwards into the chest, but probably downwards to the groin, and across the mesial line of the abdomen. Painful priapism, independent of sexual desire, coming on frequently and lasting for several hours at a time, or even continuously for several days, is an occasional early incident of the disease. The progress of the case is slow, but as it goes on : the patient's languor and debility gradually increase ; his pulse becomes frequent — up to 90 or 100 ; his breath continues short, especially on exertion or under excitement, and is from time to time deep-drawn or sighing, and often attended with yawning ; his tongue remains fairly clean ; his appetite is variable, but on the whole probably pretty good ; there may be some clamminess of mouth, if not actual thirst ; and diarrhoea is liable to ensue ; the urine is generally fairly abundant, acid, and loaded with urates, and often contains albumen in small quantity, with hyaline or granular casts ; hemorrhages are apt to take place, either into the subcu- taneous or subserous tissues, or from the mucous surfaces, more especially that of the nose ; and occasionally anasarca, mainly of the lower ex- tremities, and accumulations of fluid in the serous ca^dties, supervene. Febrile symptoms are sometimes absent from first to last ; sometimes the patient is liable to paroxysms, coming on at long and irregular inter- vals ; and occasionally he suffers, either during his whole illness or towards its close, from well-marked hectic fever — the temperature rising during the exacerbations to 101°, 102°, or even 103°. With this are neces- sarily associated night-sweats and other characteristic features of hectic. Besides hemorrhages and dropsical effusions, other complications are apt to supervene, especially during the later periods of the disease ; among which may be enumerated splenic peritonitis, pulmonary or pleural in- flammation, and the development of subcutaneous abscesses. Phagedsenic ulceration of the gums, not unlike the ulceration in scurvy, has occasion- ally been noticed ; and occasionally also tenderness of the bones. Liebreich LEUCOCYTH^MIA.— ANiEMIA. 593 first observed, and it is now fully recognised, tliat retinal hemorrhages are of frequent occurrence. These are for the most part small, but are occasionally large, and occur mainly towards the periphery of the retina. They often present a central white spot or area. Sight is not generally materially affected. The spleen does not necessarily enlarge progressively during the whole duration of the patient's ilhaess ; but it ol^en becomes stationary after a while, or even liable to slight variations of bulk. During the coiu'se of the disease, the blood becomes progressively poorer and poorer in red corpuscles, and consequently pale ; but accompanying this change the white corpuscles grow more and more numerous, not only relatively but absolutely, so that at length they may equal in collective bulk the red corpuscles amongst which they lie, or even equal or exceed them in number. The corpuscles are for the most part of the size of the normal leucocytes, but they are often granular from fatty deposit, and .apt like pus-cells to present two or more nuclei under the influence of acetic acid. Fibrine is usually increased. But the specific gravity of the blood is lessened. So far as is known, splenic leucocythtemia is mvariably fatal (usually withm a year or two of its first appearance) either by simple asthenia, or by this in conjunction with the effects of some intercurrent affection, such as loss of blood, diarrhoea, or thoracic inflam- mation. In no inconsiderable number of cases death has resulted from sudden effusion of blood mto the substance of the brain, with apoplectic symptoms. In the cases described as lymphatic leucocythsemia, in which the lym- phatic glands and tissues have been found alone or chiefly affected, the general sjnnptoms have m the main resembled those assigned to splenic leucocythsemia ; but the leucocytes present ua the blood have been of smaller size than those observed m the splenic disease, resembling in this respect the normal lymphatic-gland corpuscles. Treatment. — The successful treatment of leucocythffimia appears to be altogether beyond the resources of our art. We can do little if anything beyond treating symptoms as they arise, and promoting the health of the patient by attention to diet, hygienic management, and the exliibition of tonics. Kemedies which have been specially advocated are iron, quinine, cod-liver oil, arsenic, phosphorus, and iodide of potassium. VII. IDIOPATHIC ANEMIA. {Chlorosis. Pernicious Anamia.) Definition. — Anaemia is the name applied to a condition in which there is diminution of the solid constituents of the blood, and in particular of the red and white corpuscles, attended with pallor of the general surface, and of the mucous membranes, palpitation, feebleness and rapidity of pulse, panting respiration, sighmg and yawning, headache, restlessness, functional disturbance of the organs of sight and hearing, tendency to faint, and general debility. Idiopathic antemia is a form of anaemia coming on independently of any organic lesion or specific dyscrasia. Two varieties Q Q 594 DISEASES OF THE VASCULAK OEGANS. of it are recognised : the one occurring in yoimg women, which is usually amenable to treatment, and is known as ' chlorosis ; ' the other arising under other conditions, almost always fatal, and described by different writers under the names of ' idiopathic ansemia,' ' essential anaemia,' and ' progressive pernicious anemia.' Causation. — Anaemia is a frequent complication or result of many dif- ferent morbid conditions — of the dyscrasiaB, for example, connected with tuberculosis, malignant disease, syphilis, and malarious affections, and of the more or less frequent and copious hemorrhages which take place under various circumstances from one or other of the mucous tracts. Chlorosis is especially an affection of yoimg females, from the period of commencing puberty to about twenty-five. Many causes have been assigned for it, such as deficient and unsuitable diet, unwholesome habi- tations, sedentary habits and want of fresh air, late hours, emotional affections, masturbation, and especially functional uterine or ovarian disturbances. It may readily be admitted that some of these conditions may be predisposing causes of chlorosis ; it is certain that some of them may be consequences of it ; but it is by no means clear that any of them can lay claim to being an excitmg cause. The other form of idiopathic anaemia is chiefly met with in men ; but it occurs also in children and in women of mature age, especially those in whom menstruation is disappearing. Its causes are if possible more obscure than those of chlorosis. Occasionally it seems to be induced by pregnancy. SymiAoms and ijrogress. — Chlorosis generally first reveals itself by gradually increasing paleness of the surface, palpitation, breathlessness on exertion, loss of muscular power, and more or less gastrodynia and impair- ment of the digestive functions, without loss of flesh. To these pheno- mena, however, many others sooner or later are superadded. The pallor usually becomes extreme, the general surface assuming a white or sallow, wax-like appearance ; the face, indeed, may present a greenish tinge, whence the name chlorosis. But the loss of colour takes place in the mucous membranes as well as the skin, and is for the most part strikingly obvious in the palpebral conjunctiva, and in the lips and gums, which become in some cases scarcely distinguishable in tint from^the skin itself. Yet, even in advanced cases, a fallacious bloom may appear in the cheeks under the slightest emotional excitement. Palpitation is a prominent symptom, and painfully apparent to the patient herself ; it is seldom absent, and is always aggravated either by mental excitement or by bodily exercise ; the rapidity with which the heart's contractions succeed one another is sometimes extraordinary, and not unfrequently their rhythm becomes remarkably irregular. The development of abnormal sounds in the heart and blood-vessels, independent of organic lesions, is of common occurrence and highly characteristic ; a soft systolic murmur is to be heard frequently over the situation of the aortic or pulmonic valve, and along the course of the ascenduig arch and innominate artery, occasionally at the apex ; murmurs, coincident with the cardiac systole, may be developed IDIOPATHIC ANEMIA. CHLOEOSIS. . 595 more readily than natural by pressure on the subclavian, carotid, and other large arteries ; and, lastly, continuous murmurs, musical in character, and varying from a feeble hissing to a deep droning [bruit du cliable), may readily be evoked by the pressure of the stethoscope on the veins of the neck, more especially on the right side. The respirations are usually more rapid and shallow than ui health, and occasionally become extraordinarily frequent, particularly under the influence of bodily exertion or emotional disturbance ; and the patient consequently complains of shortness of breath and inabihty to exert herself. There is usually impairment of the digestive functions, with uneasuiess or weight after food, flatulence, loss of appetite, and paui more or less severe and varying m character, in the epigastric region, between the shoulders, in the left hypochondrium or in some neighbouring part. It is apparently in chlorotic girls that per- forating ulcer of the stomach is most common, on which account their dyspeptic symptoms must always be regarded with suspicion and treated with care. The bowels are usually constipated. The urine, for the most part, is abundant, pale, and of low specific gravity. There is not unfre- quently leucorrhoea ; and although the menstrual function in some cases continues to be normally performed, it is usually at fault : the flow is sometimes regular, but scanty ; sometimes profuse or too frequent, or attended with severe pain ; most commonly there is amenorrhoea. Trousseau points out, and probably with truth, that the sexual appetite is diminished rather than (as is often asserted) increased. The muscular system becomes generally enfeebled ; but the subcutaneous fat undergoes little or no diminution (sometimes, indeed, becomes increased), so that the patient, as a rule, presents more or less embonpoint. Some degree of ana- sarca, especially in the lower extremities, occasionally supervenes in the course of the disease. The nervous phenomena which are apt to attend chlorosis are many and various : there are usually listlessness, inability of application to any pursuit or even train of thought, lo^^naess of spirits, and irritability of temper ; usually, also, chlorotic girls complain of neuralgic pains, sometimes in the face and head, sometimes in the intercostal muscles, sometimes in the internal organs or extremities. Again, they are not mifrequently hysterical, have depraved appetites, or suffer from paralysis or convulsions, or even become maniacal. It is rare for the chlorosis of young women to terminate fatally, or even to lead to the development of tuberculosis or any other organic disease, excepting, perhaps, ulcer of the stomach. Under proper treatment the patient generally recovers in the course of a few weeks or a month, but is liable to have relapses. Pernicious anamia is characterised mainly by occurring as a general rule in those who from age or sex are not liable to chlorosis, and by its almost invariably fatal result, usually in from six to twelve months. During life cases of this disease are liable, at any rate for a time, to JDe mistaken for cases of visceral cancer, undetected hemorrhages from the bowels, Addison's disease without melasma, or leucocytha^mia ; with the last two of which especially, and with purpura, ' pernicious anemia ' has manifest qq2 596 DISEASES OF THE VASCULAE OEGANS. and close relations. At first the symptoms are not distinguisliable from those of chlorosis ; but as the disease progresses and approaches its fatal termination, and the patient's vital powers fail, additional symptoms, not observable or unfrequent in chlorosis, manifest themselves ; among which are emaciation, remittent febrile paroxysms, anasarca and dropsical effu- sions into the serous cavities, and extravasations of blood beneath the skin, from the mucous surfaces, and into the retinae and internal organs. Tenderness in the course of the bones has been noticed in some instances, dependent, it is supposed, on changes in the marrow, resembling those occurring in leucocythsemia. Further, not only is the blood pale from deficiency of red corpuscles, but it often presents other departures from health. The corpuscles are for the most part individually lighter coloured than natural ; but not unfrequently associated with these are others which are atrophied, deep-coloured, and maybe nucleated, together with granular masses of protoplasm. A slight icteric tinge occasionally becomes deve- loped. Death usually results from asthenia, and may be hastened by the occurrence of hemorrhages. Effusion of blood into the substance of the brain occasionally carries the patient off. Pathology. — The pathology of idiopathic anamia is not at all under- stood. Trousseau regards chlorosis as a neurosis, looking upon the morbid condition of the blood as secondary to the nervous affection. Some con- sider the reproductive organs, others the chylo-poietic viscera, as being primarily at fault. It is natural to refer the diminution of the corpuscular elements of the blood to some functional disturbance or organic lesion of the lymphatic tissues ; but unfortunately nothing has yet been detected m their condition to justify this view. It is attempted to make a distinction between ordinary forms of anaemia and chlorosis by reference to the com- position of the blood. Ordinary anaemia, it is said, is characterised by the diminution in equal proportion of all the solid constituents of that fluid, whereas in chlorosis it is the corpuscular elements which alone are deficient. It is clear, however, that this distinction can be of little value, for it is well known that when anemia is caused by abstraction of blood, the corpuscles and other organic principles bemg removed in equal pro- portion, the albuminous and other such matters are far more speedily re- stored to that fluid than the corpuscles, and that hence (whatever may have been the patient's condition at first) a time speedily arrives in which the blood presents the assumed typical characters of chlorotic blood. An unnatural thinness and narrowness of the larger arteries has been observed after death from chlorosis, and has had some importance attached to it. Further, fatty degeneration of the muscular walls of the heart, and espe- cially of the carneae columnae and musculi papillares, haply with dilatation of the cavities, and a fatty change in the lining membrane of the arteries, have not vnifr'equently been observed. These phenomena are doubtless the consequences of anemia, and have no causative relation to it. Li the so-called ' pernicious ' form of the disease (in addition to fatty degeneration) hemorrhages and dropsies, and the affection of the marrow of bones already referred to, are occasionally observed. HAEMOPHILIA. 597 Treatment. — It is no doubt important in the treatment of chlorosis to obviate all possible sources of ill-health, and especially to secure for the patient change of scene, good air, moderate exercise, early hours, mnocent amusement, and wholesome diet. But of far greater importance than these is the administration of iron. This metal, indeed, appears to be almost a specific remedy in this disease. Different authorities recommend different preparations ; but they are probably all (if given in equivalent doses) equally efficacious. They are generally best administered in com- bination with some vegetable bitter or stomachic, such as qumine, cin- chona, or calumba ; and in association with occasional purgatives, such as aloes and myrrh pills, to obviate the obstinate constipation which is so often present. The form in which iron should be given must be deter- mmed by the special circumstances of the case. If dyspeptic symptoms are predominant, the tartrate of iron, in combination with an alkali and calumba or quassia, may be most suitable. It may even, under such circumstances, be well to delay the use of iron until some amendment in the condition of the stomach has been obtained by other measures. If menorrhagia be present, the perchloride of iron or the sulphate, in combination with mineral acids, may prove especially serviceable. Zinc is believed by some to have similar virtues to those of iron. In a large number of cases the ferruginous treatment cures not only the chlorosis, but the various com- plications — dyspeptic and uterine — which accompany the chlorosis ; but that is not always the case, and just as it is frequently necessary to deal with the dyspepsia directly, so it may be essential to direct our treatment to the cure of the uterine derangement. In so-called ' pernicious anaemia ' all the usual remedies appear to fail. VIII. HEMOPHILIA. [Hemorrhagic Diathesis.) Definition. — Haemophilia is a congenital defect of constitution, charac- terised by a tendency to uncontrollable hemorrhage even from the slightest wounds or abrasions of surface, and after the most trivial injuries. Causation. — The disease is mainly hereditary, affecting males, how- ever, much more frequently than females. Yet it is curious that the females of ' bleeder ' families, including even those who are not themselves sufferers, are the chief agents in its propagation. Symptoms and progress. — The condition is congenital, and lasts through- out life ; but in some instances seems to undergo some degree of amelior- ation with advancing years. Its presence is discovered accidentally by the occurrence of profuse hemorrhage from some wholly inadequate cause. The prick of a pin, the application of leeches, the extraction of a tooth, breaches of surface of all kinds, are followed by bleeding which lasts for hours, days,^ weeks, until the patient is blanched, and presents all the usual phenomena of acute anaemia, and until, maybe, death ensues. Hemorrhage may of course take place from any surface ; but for obvious reasons it is more frequent from the mucous membranes than from the skin, 598 DISEASES OF THE VASCULAE OEGANS. and at the same time less under control, and consequently more serious. Epistaxis, bleeding from the mouth and throat, haemoptysis, hasmatemesis, and discharges of blood from the bowels and genito- urinary organs are all liable to occur. Further, small subcutaneous hemorrhages are not mi- common, and contusions are apt to be followed by large extravasations of blood into the connective tissue. The neighbourhood of the false ribs, the back, the pophteal sp9;Ces, and inner aspects of the thighs, have been signahsed as the special seats of such hemorrhages. The periods of the first and second dentition are very dangerous to these patients ; and in women the epochs at which menstruation commences and ceases. It is curious that the catamenia are not a source of special danger. Besides anemia, which in a greater or less degree is a necessary consequence of then- malady, bleeders are Kable to a kind of rheumatic affection mainly of the larger joints. The duration of hfe among persons with the hemor- rhagic diathesis is necessarily much below the average, and many die in childhood. According to Grandidier one-half of the total number of bleeders die before the completion of their eighth year, and less than one- eighth survive then twenty-first. Morbid anatomy throws no important hght on the nature of the disease. It is held that in many cases, at any rate, the skui presents marked deHcacy and transparency, the subcutaneous vessels occupy an unusually superficial position, the larger arteries and especially the aorta and xduI- monary artery are narrower than they should be, and the walls of the arteries generally are thin and transparent. Partial fatty degeneration of the Iming membrane of arteries has sometimes been observed. In the blood itself nothing abnormal has been detected. Concerning the treatment of hfemophiha there is very httle to say. Of course it is desirable to prevent bleeders fi-om procreating. And of course also every precaution should be taken against injmies of any kind likely to be followed by bleeding. In the event of hemorrhage, pressure when it is apphcable is the most efficacious mode of treatment ; but local styptics and the usual internal remedies must be had recourse to in the majority of cases. IX. PUEPUEA. Definition. — Extravasations of blood, in the form of points, petechige, vibices, or ecchymoses, are not uncommonly observed beneath the surface of the skin in various diseases, and mider many other conditions, and are then often termed pm*puric. Not unfrequently these subcutaneous extra- vasations (especially if due to constitutional disorders) are associated with similar extravasations into the sohd organs, and beneath the serous and mucous membranes, and with more or less abundant escape of blood from these surfaces. Such extravasations are common in tj^phus, small-pox, measles, scurvy^ obstructive heart affections, and hver disease, and are also met with in scarlet fever, diphtheria, pyemia, and embolism. They further occasionally compHcate certain skin diseases, more especially some forms PUEPUEA. 599 of erythema and urticaria, and may even be induced by mere exposure to atmospheric mfluences. But to none of these affections, however severe they may be, can the term purpura be properly apphed. Purpura, in the strict sense of the term (the morbus maculosus Werlhofii of the Germans), is the name given to a disorder characterised by such hemorrhages as have been above specified, but uncoimected, so far as we know, with any local mischief or general specific disease. Causation. — The causes of purpura or the conditions under which it arises are exceedmgly obscure. It occurs at all ages, but mostly in young children of both sexes. It is frequently observed amongst those who are sickly, underfed, or surrounded by unwholesome sanitary conditions ; but it is also met with amongst the robust and healthy-looking, and those whose hygienic and other chcumstances appear to be unexceptionable. It is certamly not due to insufficiency of vegetable food, nor has it been traced to any special dietetic defaialt. It is apt to recur; and conse- quently it is not uncommon to find a child (and apparently a healthy one) having periodical relapses, at intervals of three, six, or even twelve months. A child of six years old, under our care, died of exhaustion in its eighth attack. SymiHoms and progress. — Purpura is sometimes ushered in with vague premonitory symptoms, such as lassitude, loss of appetite, headache, and achmg in the Hmbs, lasting from one to perhaps three or four weeks. In many cases, on the other hand, the characteristic lesions suddenly mani- fest themselves in the midst of apparently good health. The skin becomes studded with chcular, deep red, almost black spots, varymg h-om about a quarter of an inch in diameter downwards, which are maattended with any abnormal sensation, are not elevated above the level of the sMn, and do not fade on pressure. They are usually most abmidant on the lower part of the trunk and the lower extremities, but are by no means confined to these situations ; and not unfrequently extravasations take place into the eyelids, and beneath the conjunctivae and the mucous surface of the tongue, hps, gums, and other parts withm the cavity of the mouth. These spots go through the ordinary changes of colour which characterise bruises, and, thus fading away, usually disappear completely in the course of a few days. Successive crops of petechia, however, commonly appear from time to time, and thus the disease may be continued for two, three, or four weeks, and sometimes for a still longer period. Larger extrava- sations (vibices and ecchymoses) are usually associated m a greater or less degree with the eruption above described. But these are generally deeper seated, present less abrupt margins, are attended with swelling, and not unfrequently first reveal their existence, as deep-seated bruises do, by the gradual diffusion and coming to the surface of their modified colouring matter. They are not unfrequently the result of mechanical violence. Occasionally there are hemorrhages from the choroidal vessels ; and the hemorrhage may be so abundant as to cause blindness. There is always a tendency in these cases (more pronounced in proportion to their severity) for hemorrhages to take place from the mucous surfaces. 600 DISEASES OF THE VASCULAK OEGANS. Thus, there may be epistaxis, bleedmg from the gums or other parts within the mouth, haBmoptysis, or bleeding from the stomach or bowels, kidneys or other parts of the urinary tract, uterus or vagina. In many cases the hemorrhage is small in quantity and of Httle importance ; but occasionally it is profuse and frequently repeated. When the affection is shght, the patient may seem durmg its con- tinuance to be in good general health ; more frequently, perhaps, he- suffers from a contmuance of such symptoms as may have ushered in the attack ; sometimes the progress of the case is attended with febrile symp- toms of a remittent type ; but when profuse hemorrhages take place, the symptoms due to loss of blood get developed. Not only does the patient then become excessively pallid, but his pulse increases in frequency and gets more or less jerkmg ; he has noises in his ears, dilated pupils, indistinct- ness of vision, with muscae and headache ; he yawns, becomes mieasy and restless, and sometimes falls into delirium, mania, or convulsions. His temperature is sometimes lowered ; sometimes, on the other hand, considerably elevated. Death is usually due to asthenia or syncope ; but is not very unfrequently referrible to sudden and profuse hemorrhage into the substance of the brain. The milder form of purpura is sometimes termed p. simplex ; the more severe p. hcemorrhagica. Morbid anatomy throws little light on this disease. Hemorrhages similar to those beneath the skin are sometimes discovered hi the sub- serous and submucous tissues, and less frequently in the parenchyma of various organs, more especially the lungs, heart, and kidneys. Occa- sionally, as has been above pomted out, large effusions of blood are found in the situations usually imphcated in cerebral hemorrhage. In one case under our care effusion of blood had taken place into one of the ovaries ; and the lymphatic vessels extending from the broad ligament upwards were distended with blood to the thickness of crow's quills. Extreme fatty degeneration of the muscular fibres of the heart has been detected in cases fatal from repeated hemorrhage, after long continuance of the disease. The blood seems to present no constant departure from the normal condition. It is curious, however, that Dr. Parkes has, in two cases which he has examined, detected in this fluid an excess of iron together with a general diminution of the solid constituents. It seems more probable, however, that the primary morbid condition is in the capillary and other small vessels than in the blood, and that the latter escapes into the tissues in consequence of their rupture. Treatment. — The principles of treatment of purpura are as little understood as its pathology. The majority of patients get well in the course of a week or two without treatment. The severer cases are unfor- tunately apt to go on from bad to worse, whatever treatment be adopted. A certain prima facie resemblance which purpura presents to scurvy has induced a common belief that antiscorbutic remedies (fresh vegetables, citric acid, and potash) are indicated here also. Experience, however, does not confirm the truth of this opinion. Among the remedies which have been chiefly recommended are perchloride of iron, acetate of lead,. SCURVY. 601 arsenic, digitalis, turpentine, and gallic and sulphuric acids. If the dis- charge of blood be profuse, one or other of these drugs may be prescribed ; and at the same time the patient should be kept quiet and cool, and should have ice or ice-cold drinks given to him. Hemorrhages taking place from accessible parts may, of course, be treated by local mea- sures. If asthenia be extreme, it may be absolutely necessary to give alcohoHc stimulants. On the whole, tonic treatment is indicated in those persons who have a tendency to purpura and m those who are convalescent from it. X. SCUEVY. {Scorbutus.) Definition.— ScuxY J may be regarded as a peculiar form of anemia arising from deficiency of vegetable diet, and attended with a tendency to the occurrence of hemorrhages, profound impairment of nutrition, and great mental and bodily prostration. Causation. — Scurvy formerly occurred largely among sailors during long voyages. It has often broken out m armies on active service and among populations suffering from famme. It still occurs from time to time under these various conditions ; and is occasionally met with as a sporadic affection among persons who are ill-fed, or whose diet has been, from some cause or other, too exclusively animal. It is needless to go into a history of scurvy, or to discuss the various hypotheses which have been propomided in reference to its causation. It will be sufficient to state that its origin has been clearly traced to insufficiency or total want of fresh vegetables ; but among these must not be included corn or other grammacefe, or peas. It is still uncertain to what constituent or constitu- ents, common to vegetables, their virtue is due. Dr. Garrod beHeves it to reside in the salts of potash ; others maintain that it dwells in the citric and other vegetable acids which they so often contam. There are objec- tions, however, to both of these views ; for the antiscorbutic powers of vegetables do not appear to be proportionate to the potash salts they contain, and potash salts alone are probably inefficacious ; and potatoes, which are powerfully antiscorbutic, are devoid, or nearly so, of vegetable acids. The constant use of salt meat, and long-contmued exposure to privation and other such causes of ill-health, can only be regarded as indirectly favouring the production of scurvy. Symptoms and progress. — The early symptoms of scurvy may be easily mismiderstood when presented by sporadic cases ; but they cannot fail to attract attention when they arise simultaneously or in rapid succession among a number of persons equally exposed to the conditions which are Hable to give origin to the disease. They are : rapidly progressive anaemia, indicated by a dirty-looking, pallid, sallow, or earthy aspect ; growing indisposition for bodily exertion ; pains of a rheumatic character m the back and limbs ; and mental apathy or depression ; while probably the tongue continues clean, though becoming large, flabby, and indented by the teeth, the appetite remains good, and the bowels are constipated. But soon other phenomena arise : petechial spots appear, first on the 602 DISEASES OP THE VASCULAE ORGANS. lower extremities, and then on other parts of the surface ; and to these presently succeed large subcutaneous extravasations, and sooner or later, colourless pufty swellhigs, which seem to be due to deeper seated and more copious hemorrhages, and the natm'e of which gets revealed ere long by the occurrence of bruise-hke staining of the tissues superficial to them. These puffy swellings affect mainly the popliteal spaces, the cor- responding parts of the elbows, the anterior aspect of the lower part of each leg, and the regions behind the angles of the ja;W, mterfering with the movements of these parts, and causing more or less pain and tender- ness. Similar extravasations take place especially into the loose connective tissue in and about the eyehds, leading to considerable puffiness and bruise-hke discolouration of these parts, and to sanguineous accumulation in the occular sub -conjunctival tissue. Concurrently with the appearance of these hemorrhages the gums swell at theix edges, and rapidly increase in bulk until they form lobulated masses, which rise up around the teeth, and sometimes hide them altogether from view. These masses are spongy, deep red or hvid, and insensitive, but apt to bleed ; they readily ulcerate or slough, and impart a fetid odour to the breath. The teeth get loose, and frequently drop out. The same tendency to ulcerate or slough is manifested in a greater or less degree by all parts of the surface of the body, but especially by those which are the seats of the puffy swellings above adverted to, and by those which present the cicatrices of former injuries. The sHghtest scratch, pressure, or blow" is often sufficient to induce these destructive processes. Along vvdth these phenomena the patient's anemia increases ; his face gets puffy ; anasarca takes place hi his lower extremities ; he becomes breathless ; his heart acts rapidly and feebly ; and even though retaining, as he probably does, a good deal of muscular strength, he is hable on the shghtest exertion, even that of rising in bed, to attacks of sudden syncope, which are attended with the utmost danger to hfe. During the later periods of the disease, the appe- tite often fails ; the patient suffers from looseness of bowels, the motions frequently being highly offensive, and contauihig blood ; he has disturb- ance of vision (hemeralopia, nyctalopia), surging in the ears, vertigo, want of sleep, and occasionally dehrium. His intellect, however, remahis for the most part unaffected. In many cases during the progress of the disease thoracic comphcations arise, especially effusion into the pleui'^e, congestion of the lungs with extravasation of blood into their tissue, con- gestion of the bronchial tubes, cough, and sanguinolent expectoration, not unfrequently attended with a marked gangrenous odour. The duration of scurvy is uncertaui, but it may extend over many weeks or even months. Death is usually due to sudden syncope or gradual asthenia, and may at any time be hastened by the occm-rence of hemorrhage, ulceration, thoracic affections, or other complications. Recovery is generally rapid under suitable treatment. But the patient is liable to remain in enfeebled health, and ultimately perhaps to fall a ^dctim to pulmonary phthisis or some other chronic visceral disorder. Morbid anatovnj. — The morbid anatomy of scurvy accords with the SCUEVY.— ALCOHOLISM. 603 symptoms of the disease : there is tendency to rapid decomposition ; ex- travasations of blood in various stages of transformation may be found, not only in the superficial regions already specified, but m the substance of the kmgs, beneath the pleurae, in the walls of the heart, in the sub- pericardial tissue, in the intestinal parietes, and beneath the peritoneal membrane. Sanguinolent serum also may be found in the various serous cavities. Li other respects the condition of the ■sdscera is very variable. The lungs, liver, and spleen may or may not be congested ; the heart may he contracted and empty, or distended with black blood. The brain gene- rally is healthy. The blood contains an excess of fibrine, but presents a diminution in the number of the red corpuscles, and an abnormally low specific gravity. Treatment. — The only effectual treatment of scurvy is the restoration to the dietary of those articles of food to the want of which the disease has been traced — namely, vegetables, and especially those, or those substances extracted from them, which contam citric acid and potash. Among the ordinary articles of diet which are efficacious in this respect must be enumerated potatoes, yams, onions, carrots, turnips, green vegetables of all kinds, inclusive of mustard and cress and scurvy grass ; lemons, oranges, limes, grapes, and apples ; and, among their derivatives, lemon- and lime- juice and sauerkraut. The provision enforced in emigrant ships, and which has been foand effectual in preventing the occurrence of scurvy, is, that each person must have weekly at least eight ounces of preserved potatoes and three ounces of other preserved vegetables (carrots, onions, turnips, celery, or mint), besides pickles, and three ounces of hme-juice. And among the suggestions issued by the Board of Trade to shipowners is the following : — namely, that each man should have at least two ounces of lime- or lemon-juice twice a week, to be increased to an ounce daily if any symptoms of scur-\^ manifest themselves. The importance of ad- ditionally supplying scorbutic patients with good nourishing diet, of takuig precautions against sudden syncope, and of reheving by local apphcations the bleeding ulcerated gums, and ulcers which may exist in other parts, is of com'se obvious. XL CHEONIC ALCOHOLIC POISONING. {Alcoholism.) DELIEIUM TEEMENS. Persons who are in the habit of drinking freely fall after a while into ill-health. They lose appetite, suffer from nausea and sickness, have a furred tongue and offensive breath ; the limbs become tremulous and enfeebled, the face dull and expressionless, the conjmictivae congested and watery ; an eruption of acne rosacea or acne tuberculata not uncommonly appears upon the nose and cheeks ; they cannot sleep, become low-spirited and vacillating, and lose in some degree both memory and readiness or quickness of apprehension. They are apt to become, also, cowardly, cun- ning, and untruthful. Further results of diink are : cirrhosis of the liver, 604 DISEASES OF THE VASCULAE OEGANS. wlaicli may be followed by ascites, jaundice, or hsematemesis ; affections of the nervous centres, including delirium tremens, epilepsy, mania, dementia,, and general paralysis ; and probably also gout and its various consequences- Drinkers (especially, it is said, those who take beer) very often grow ex- ceedingly fat ; on the other hand, they not unfrequently get much ema- ciated. Innumerable material lesions and functional disturbances are, and have been, rightly attributed to the abuse of alcohol ; but there is no doubt that, in a very large proportion of cases, the mistake is made of attributing every ailment from which a drinker suffers to the influence of his drink, forgetful of the fact that habits of intemperance, long continued, expose their subject to many dangers, and to be attacked by many dis- eases, from which he would otherwise probably have escaped. The parts which principally suffer are the alimentary canal, liver, and nervous centres ; but it is to the affections of the last-named organs only that we now propose to direct attention. Nervous Disorders. Delirmm Tremens. Causation. — Of affections of the nervous centres the most frequent, and on that account, if on no other, the most important, is that commonly known by the name of ' delirium tremens.' That delirium tremens, or, as it is sometimes called, ' delirium e potu,' is a direct consequence of the abuse of alcohol is beyond dispute. But different views have been held in respect of the mode in which alcohol influences its production. It was long believed to occur only in persons who, after drinking heavily, were suddenly deprived of their accustomed stimulus. More recent inquiries, however, show that it is more commonly the immediate consequence of excessive drinking, and that it usually comes on m the course of long- continued intemperance or of those occasional outbreaks of intemperance (lasting it may be for a few weeks at a time) to which some persons are liable. It may no doubt supervene at the time when such persons are commencing to abstain ; but not simply in consequence of their abstinence. Symptoms. — The symptoms of delirium tremens creep on gradually. The patient loses appetite, becomes restless and wakeful at night, his sleep being disturbed by frightful dreams ; he grows suspicious, inclined to quarrel, agitated, restless, disposed to busy himself about various matters, and often (as Trousseau observes) to pack up his clothes and prepare for a journey. Generally by the time his disease has become fully established he has had no rest whatever for many nights, and has taken little or no solid food for many days. The symptoms of the declared affection comprise delirium with hallu- cinations, and tremulousness of the muscles, together with various more or less characteristic disturbances of the other corporeal functions. The face is either congested or pale. The pupils usually are dilated, the conjunctivae injected, the skin bathed in sweat. The tongue varies in character, but in most cases is covered with a thick creamy fur. There is thirst, but the appetite is in complete abeyance. Muscular tremors are almost invariably present ; they may be general, or limited mainly ALCOHOLISM. DELIEIUM TEEMENS. 605 to certain parts, such as the head and neck and upper extremities ; and they manifest themselves especially when the patient exercises his muscles, but are not necessarily absent at other times ; the arms tremble when he holds them out, the legs when he stands, the lips when he speaks, and the tongue when it is protruded. But besides the ordmary tremblings, there are often constant fibrillar twitchings of the muscles, which scarcely reveal themselves by causing obvious movement, but may be distinctly felt when the patient's limbs are grasped ; and there are often also (but more especially towards the later stage of the disease) involmatary startings of the limbs. The pulse varies : in most cases it does not, in the begiiming, exceed the normal, and is then probably large, soft, and dicrotous ; at a later period, however, and especially if the disease has taken an unfavourable turn, it increases in rapidity (rising it may be to 120 or 140, or more) and becomes at the same time small and extremely feeble. The temperature usually does not exceed 101°, and often never rises to that height ; but occasionally it runs up more or less rapidly to 105°, or even 108° or 109°. There is no relation between the frequency of the pulse and the elevation of temperature. The mental phenomena are peculiar : — The patient's sleeplessness and tendency to dream are soon attended with hallucinations ; he hears noises ; he sees black spots, or sparks, or figures ; he perceives flavours, or smells smells. His mind begins to wander ; he looks suspicious or frightened ; he searches behind the bed-curtains, under the bed, or in corners, to satisfy himself that there is nothmg there ; he becomes garrulous — talking for the most part of business and of projects which he has in hand, but interruptmg himself from time to time under the influence of some passing dread, suspicion, or angry feeling. At this time he can be readily recalled to himself, and will answer questions rationally and coherently. The incoherence and delirium, however, soon increase upon him. He now probably is incessantly chattering, talking unconnectedly of things absent and things present, but still with a marked tendency, as a rule, to dwell upon matters of business, to give orders to his servants or workpeople, to talk with customers. He suffers, also, from manifest illusions ; he not only has singing and other noises in his ears, but hears voices, and it may be enters mto conversation with them ; he not only sees muscse, but takes them (according to their characters) to be insects, or sparks, or coins, and he may be seen endeavouring either to catch the animals which infest him, or to pick up the silver which is strewed aromid him ; or he fancies that he sees dogs or cats, strange persons or devils, and watches them as they slip behind articles of furniture, or peep at him from obscure corners. In many cases his illusions are wholly of a nature to inspire horror or terror ; policemen are after him for some murder he has committed ; he is haunted by bad spirits ; foul reptiles are crawling about him ; great disasters threaten or have already involved his dearest friends. In some cases they are pleasing or funny : he is surrounded by beautiful scenery, he hears sweet music, he sees dancing girls or acrobats performing the most extraordinary 606 DISEASES OF THE VASCULAE OKGANS. feats. In some cases again he becomes wildly maniacal ; in some sullen, morose, and stupid. He is apt also to mistake those about him for persons who are absent, or to confound them with the grotesque or horrible creations of his mind. His actions are no doubt in relation with the thoughts or fancies which are passing through his brain ; he will often, as above pointed out, be seen busily picking up insects, flowers, or coins which are crawling or falling about him ; or he will sit up and look suspiciously around ; or he will endeavour to rise from his bed and will hunt everywhere for imaginary objects ; or he will strive to avoid some danger or some foe, or will attack his attendant in the belief that he is contemplating or perpetrating some injury against himself or his friends ; or he will perform various grotesque acts, such as climbing up the bed- post, standing on his head, or turning head over heels, or will applaud by shouts or laughter some imaginary performance. But in all cases, even though he has well-marked dominant illusions or frames of mind, there is a remarkable changeableness in his illusions and moods ; he passes mo- mentarily from one thing to another, and is suspicious, cowardly, violent, and merry in rapid succession ; and in all eases, or nearly all, he can be recalled momentarily to himself, and restrained by the voice of authority. Epileptiform attacks occasionally come on in the course of the disease. In most cases, delirium tremens terminates favourably ; and at the end of three or four days, or it may be a week, from the commencement of his malady, the patient falls into a gentle sleep and awakes refreshed and convalescent. But occasionally (and in those persons whose habits insure frequent recurrences, necessarily at length) the attack ends fatally by coma or asthenia. The circumstances which, according to M. Magnan, foretell a fatal issue are elevation of temperature, persistent muscular agitation, and muscular debility or paresis. If the temperature rises to 102° or 103° (even though other symptoms appear favourable) there is ground for alarm ; if, after continuing at this elevation for a day or two, it suddenly rises above 104°, the danger becomes very great and in some degree pro- portionate to the amount of the rise. As regards muscular tremors, it is not so much their intensity as their general prevalence and persistence which should excite alarm. They are especially of ill omen when they continue during sleep, and when to the general muscular vibration is superadded subsultus tendinum. Great rapidity and extreme feebleness of pulse, epileptic convulsions, coma, and the formation of bed-sores point also to a fatal termination. The subject of delirium tremens must not be dismissed without drawing attention to the fact that, in persons who are habitual drinkers, it not unfrequently happens that other illnesses (acute or chronic) which attack them become complicated with some of the symptoms of delirium tremens. Thus it is with serious accidents, pneumonia, and other inflammatory and febrile disorders ; and thus, also, it not uncommonly is with hysteria. Nor must it be forgotten that delirium tremens is apt to be closely simu- lated by various affections, and more especially by meningitis and acute inflammations. ALCOHOLISM. DELIEIUM TEEMENS. 607 Other consequences of drink are epilepsy, insanity in its various forms, general paralysis, and dementia. These, however, are not special to alcoholism, and need not now detain us. Dr. Wilks has drawn attention to a form of incomplete paraplegia (attended sometimes with inco-ordina- tion, sometimes with anaesthesia, and often with pain in the limbs, and mvolving sometimes the legs only, sometimes the legs and arms) due to alcohoUsm, but immediately dependent, he thmks, on chronic spinal meningitis. It appears generally to be curable by abstinence. Pathology and morbid anatomy. — Alcohol taken into the stomach is rapidly absorbed. It is eliminated, but apparently in very minute quantity, by the kidneys, lungs, and skin; yet it disappears" quickly from the sys- tem. Generally, even if large quantities have been imbibed, none can be detected by chemical analysis after the third or fourth day ; but Dr. Dupre believes that ten days may be taken as the period needed for its entire discharge. It is obvious, therefore, that the great bulk must undergo chemical decomposition in the interior of the body. Alcohol may be found post mortem in various organs ; it has been discovered in the liver, but is much more readily detected in the brain, for which it seems to have a special affinity. The conditions of the stomach, intestines, and liver which supervene upon chronic alcoholic poisonmg, are elsewhere described. The post-mortem appearances presented by the central nervous organs are not very strikmg ; in those who have long been given to drink, the brain is often found to be shrunken, the subarachnoid tissue opaque, and its proper fluid in excess ; but in those who die of delirium tremens, there is usually congestion of the cortex and medulla of the brain and of the upper part of the spmal cord. Moreover, there is not unfrequently discovered a deposit of refractive granules, and even of haematoidine crystals m the walls of the small vessels. There is no reason to believe that other tissues or organs suffer m any important degree. Dr. Dickinson has shown that there are no sufficient gromids for referring chronic renal disease to the effects of alcohol. Treatment. — Our remarks under this head will have reference solely to delirium tremens. It is impossible to reconcile the different views enter- tained with respect to the treatment of this disorder. Formerly it was held, and by physicians of high eminence and large practical experience, that the one thing needful was to give the patient sleep. But now Drs. Laycock, Gairdner, Wilks, Anstie, and many others, urge that the disease is one of low mortality, which tends to get well of itself within a limited time, and that not only is opium not needed, but its use is attended with no inconsiderable danger. The patient has been without food, or almost without food, for a considerable length of time ; and they strongly urge that he should be fed with such nourishment as he can be made to take, and that it is by nourishment mainly that he is to be successfully treated. We do not deny that many of these cases do tend to recovery, and that feeding is an essential point in their treatment ; but we cannot help thinking that more power for harm, and less power for good than it deserves, have latterly been attributed to opium. We think, too, that 608 DISEASES OF THE VASCULAE OEGANS. opiates may be given with more benefit and less danger in inflammatory and other lesions of the brain than is generally suspected. A person suffering from delirium tremens should be separated from other patients ; the room in which he is placed should be kept absolutely quiet, and the bright light of day excluded. Everything, indeed, aromid him should tend to quietude and to solicit sleep. He should be constantly watched by a trustworthy and competent attendant. Under these circumstances it is not generally requisite to employ mechanical restraint ; yet some- times it becomes absolutely necessary to tie him down with a sheet or band, or to fasten his hands and feet to the bed with gauntlets. Nutriment should be administered with careful attention in small quantities and frequently. The most appropriate articles of food are milk, arrowroot, beef-tea, broths, and eggs. The bowels should be regulated. Those who consider sleep indispensable would now administer either chloral or some preparation of opium. The chloral is sometimes given with advantage in doses of from ten to twenty grains every half-hour until sleep is induced. Opium or morphia may also be given in comparatively small doses at short intervals. It is better, however, we believe, to administer it from the beginning in large doses, and to repeat it or not according to its effect ; to give, for example, from half a grain to a grain of morphia, or from half a drachm to a drachm of laudanum at once, and to repeat the medicine in smaller doses at intervals of an hour or two, if sleep be not induced. So also with respect to chloral, we believe it better to give a large dose at once, say sixty or eighty grains, and to supplement this with subsequent smaller doses, if needful. If, as is doubtless best, the morphia be given by subcutaneous injection, the dose must be reduced to one-sixth or one- half of a grain. Patients with delirium tremens are difficult to bring under the influence of narcotics. Other remedies which have had, or have, strong advocates, are : digitalis in large doses (half an ounce to an ounce of the tincture) ; cayenne pepper ; and bromide of potassium in doses of from ten to thirty grains. It is sometimes advisable to give the patient some of the alcoholic stimulus to which he has been addicted. When he is convalescent, quinine or other tonics are indicated, and he should, as far as possible, be debarred from drink. The probabihty, however, is that he will, so soon as opportmiity offers, resume his evil habits. XII. CHEONIC LEAD-POISONING. {Plumhism.) COLIC. DEOPPED HAND. Causation. — When lead, in even minute quantities, is habitually introduced into the system, characteristic and serious consequences are pretty certain to ensue sooner or later. In most such cases the poison- ing is very insidious, and not unfrequently its source is only discovered after patient research or by accident. Plumhism was formerly largely prevalent : in Poictou, in consequence of the habitual addition of lead to inferior qualities of wine; in the West Indies, owing to the fact CHEONIC LEAD-POISONING. 609 that leaden worms were used in the stills employed in the manufactm-e of rum ; in Devonshire, as a result of the general employment of lead in the construction of the vessels used in making cider ; and, both m our own coimtry and elsewhere, from the storage of drinkhig- water in leaden cisterns, or its conveyance through leaden pipes. Li all these cases, the fluid acting chemically upon the lead, and rendering it soluble, became in a greater or less degree impregnated Tvith it. It is an important fact that rain and other soft waters act much more readily on lead than hard waters, provided these latter contain sulphate and carbonate of lime, and not too large a proportion of alkahne chlorides or nitrates. At the present day the contamination of drinking-water with lead is comparatively rare ; and the chief source of lead-poisonmg is the employment of this metal in manu- factm-e and trade. To quote the words of Dr. Taylor, ' the carbonate ' (to which salt chronic poisoning is usually attributable) ' finds its way into the system, among white-lead manufacturers, either through the skm or through the lungs, or both together ; it is diffused through the air as a fine dust, and is not only respired, but taken into the mouth and swallowed with the sahva. It has been remarked that ui factories where the powder was gromid m a dry state, not only have the labourers suffered, but horses, dogs, and even rats have died from its effects. Since the practice has arisen of grinding the white-lead in water, cases of cohca pictonum have not been so numerous. They are still, however, not un- frequent among painters, plumbers, pewterers, the manufacturers of some kinds of glazed cards, the bleachers of Brussels lace, and among those engaged in the glazing of pottery, where oxide of lead is employed in the glaze.' ' The workers in metals — plumbers who handle metallic lead — are but little subject to the disease.' Amongst rare but well-ascertained •causes of lead-poisoning are the employment of lead medicinally, its appK- -cation to ulcerated surfaces (Althaus), the use of snuff impregnated with lead (HassaU and Garrod), the employment of cosmetics containing lead, and sleeping in a newly painted room. Some persons present the symp- toms of plumbism who have been exposed in a very slight degree to the poison, who have taken, it may be, only a dose or two of lead medicmally ; while others (pamters, for example) may go on with their work for twenty years or more, and yet escape. Symptoms and progress. — Those who are under the influence of the •chronic operation of lead often suffer in general health ; their com- plexion is said to get sallow and earthy-looking, their skin dry and harsh ; they become thh'sty, lose appetite, and have a sweetish or metallic taste in the mouth. Dr. Garrod pomts out a remarkable connection between gout and plumbism, shown by the circumstance that a large proportion (one-fourth) of his hospital gouty patients had suffered from lead-poison- ing. And, indeed, whether that connection be accidental, or due to the fact that lead-poisoning predisposes to gout, or that constitutions liable to gout are also peculiarly susceptible of the influence of lead, general experience confirms the accuracy of Dr. Garrod's observation. Chronic albuminuria is also not unfrequently associated with lead-poisonino-. A R R 610 DISEASES OF THE VASCULAE OEGANS. curious effect of lead was discovered some years ago by Dr. Burton, which is of great importance from a diagnostic point of view : namely, the for- mation of a blue line along the edges of the gums immediately adjoinmg the teeth. This is situated in the substance of the gum, but appears to be largely determined by the amount of tartar present, and is supposed to be due to the precipitation of the lead, in the form of the sulphide, by the sulphuretted hydrogen emitted by the decomposing matters which are mingled with the tartar. This blue Ime is not, however, an infallible sign of lead-poisoning ; for it occasionally gets developed m the course of a few hours after the use of two or three medicinal doses of lead ; it is generally present in lead-workers who are free from all other symptoms ; it often remains long after all possibility of poisoning has passed away ; it is sometimes absent from cases of undoubted plumbism ; and further, it may be caused by cuprous and other varieties of metalhc impregnation. It is said that a similar blue Kne may be detected at the verge of the anus, and at the margins of ulcers. By far the most important consequences of lead-poisoning, however, "are colic, and certain affections (mamly paralytic) of the nervous system. Of these colic is the more common, and, when the two conditions co- exist or alternate, is usually the earher in making its appearance. A. Lead colic is characterised by the more or less gradual supervention of severe griping pains, attended with obstinate constipation and vomiting. The pains differ in no respect from those which follow upon impermeable intestinal stricture, and apparently are due to the same cause— namely,, the powerful contraction, frequently repeated, of certain lengths of bowel above, in order to overcome some impediment to the passage of their contents into and through the length of bowel immediately following. They are referred mainly, as such pains usually are, to the umbilical region, come on at intervals with extreme severity, and, when the disease is fully established, are associated with inter-paroxysmal uneasiness or pain. The pain is not generally aggravated by pressure, and indeed is often relieved both by that means and by friction. The paroxysms are attended with more or less obvious peristaltic movement of the bowels and borborygmi. Vomiting may arise early from sympathy or late from the direct influence of obstruction. The abdominal walls are usually retracted, and the muscles hard and tense. Cohc rarely proves fatal ; but mio'ht readily become fatal if the cause to which it is referrible should continue in operation. Its duration varies ; it may last for a day or two only, or be continued for a week, or, with remissions, for a still longer period. Moreover, when once there has been an attack there is great liability to recurrence. It is rarely if ever attended with fever or intes- tinal inflammation. B. Nervous disorders. Dropped /mi^c?.— Of nervous disorders, dropped hand, from paralysis of the extensors of the forearm, is by far the most frequent ; but sometimes the paralysis is of much more general distribu- tion. Dropped hand generally comes on consecutively to colic, some- times gradually, sometimes almost siiddenly. In some cases one hand only CHEONIC LEAD-POISONING. 611 is affected, usually the right ; but more frequently both hands are impli- cated, though in unequal degrees. The more obvious symptoms of the affection are loss of power over the extensor muscles of the forearm, in consequence of which the patient is unable to extend the hand upon the arm, or the first phalanges of the fingers upon the metacarpal bones, to adduct or abduct the hand, or to abduct the thumb. The hand con- sequently drops when the arm is held out prone, and both the hand and the first joints of the fingers are flexed in consequence of the predominant action of the flexor muscles. The paralysed muscles waste rapidly, so that a distinct hollow is apt ere long to manifest itself between the bones at the back of the forearm ; they become painful, very tender, and irritable ; and moreover, while retaining their electro-sensibility, they lose more or less completely their faradic contractility, and the tendon reflexes dis- appear. The remaining muscles of the forearm, and even those of the upper arm, are apt to get enfeebled, though not otherwise affected. There is no impairment of cutaneous sensibility. The brachial paralysis is limited, as a rule, to muscles supplied by the musculo-spiral nerve, and mainly to those supplied by its posterior interosseous branch. Those which usually suffer are the following, enu- merated in the order in which (according to Duchenne) they are liable to be attacked :— extensor communis digitorum, extensor indicis, extensor minimi digiti, extensor secundi internodii pollicis, extensor carpi radialis brevior, extensor carpi radialis longior, extensor carpi ulnaris, extensor ossis metacarpi pollicis, and extensor primi internodii pollicis. Oc- casionally the muscles of the ball of the thumb suffer, and much more rarely the interossei. But the supinators, and the muscles of the front of the forearm, although they may get enfeebled, seem never to become distinctly paralysed, to lose their faradic contractility, or to waste. It must be borne in mind, however, that the muscles are not necessarily in- volved in the order above named, and that they do not necessarily all suffer in every case. If the extensor communis be alone affected, the middle and ring fingers only drop, the index and little finger retaining the power of extension, though somewhat enfeebled ; if the extensores indicis and minimi digiti also suffer, all four fingers are implicated ; if the radial and ulnar extensors of the carpus be paralysed, the wrist falls ; if the radial or ulnar alone, then the patient in endeavouring to extend the hand tilts it towards the corresponding side ; if the long muscles of the thumb be implicated, the thumb lies in front of the hand in the position of opposition. The power of supination and that of pronation remain intact ; and, provided the first phalanges be supported in the extended posture, the second and third phalanges may generally be voluntarily •extended, a fact confirming the integrity of the interossei muscles. The non-involvement of the supinator longus is a fact of much practical im- portance ; and is best ascertained by placing the patient's forearm mid- way between pronation and supination, and (while opposing the movement > making him endeavour to bend the arm, when this muscle, which is the flexor of the forearm in this position, starts into high relief. E E 2 612 DISEASES OF THE VASCULAE OEGANS. In some instances the paralysis, loss of faradic contractility, and wasting involve other muscles of the upper extremity besides those of the forearm. Those which are then chiefly Hable to suffer are the deltoid and triceps. In some cases the paralysis is limited to the deltoid. Occasion- ally, again, lead-palsy involves the muscles of the lower extremities, selecting especially the extensors of the foot upon the leg, and of the leg upon the thigh ; or the intercostal muscles ; or the diaphragm. And in some very rare cases, of which Duchenne quotes a striking example, paralysis attacks almost suddenly nearly all the voluntary muscles. The duration of saturnine paralysis is very various ; it may be weeks, months, or years. Moreover, the paralysis, like the colic, is apt to recur. The longer it has been in existence, the less, as a rule, is the prospect of ultimate recovery ; and further, extreme wasting of the muscles, and persistent abeyance of faradic contractility, are also of bad augury. Yet Duchenne draws attention to the interesting fact that in these cases voluntary power may occasionally be recovered, even though the muscles remain irresponsive to faradic excitation. Epileptic attacks sometimes come on in the course of lead-poisoning, and other cerebral phenomena, including stammering, atrophy of the optic disc, either primary or secondary to optic neuritis, amblyox^ia or amaurosis, and coma. Pathology and morbid anatomy. — After lead has been received iato the organism, it is deposited in various parts, and discharged by various emunctories. It has been found post mortem ui the spleen, liver, lungs, kidneys, heart, and intestinal walls, and also in the substance of the brain and in the muscles. It passes off mainly with the urine ; but, according to Dr. Pereira and others, there is some elimination by the skin ; and Dr. Taylor states that it has been found in the milk. It is apt to remain in the tissues for some time, and has been detected in them by M. L. Orfila as long as eight months after its reception has been discontinued. The appearances found after death h'om chronic poisoning are for the most part very indecisive. After death from colic, or in cases in which colic has been present, the bowels (especially the large intestines) are said to be generally contracted and empty, or to present alternate contractions and dilatations, or intussusceptions ; occasionally, also, spots of congestion have been seen in the mucous membrane. These are changes, however, which may be observed in many cases besides those of lead-poisoning. The paralysed muscles, as has been already stated, shrink rapidly and to an extreme degree ; and post mortem are often observed to be remarkably pale, and yellowish. But, on microscopic examination, their tissue is usually found to present a perfectly normal appearance. It is only after paralysis has existed for many years that degenerative changes are added to simple atrophy. The fibres sometimes become fatty. Whether the intestines are affected through the nervous system, or by the presence of lead in their walls, may be a subject of doubt. But, as regards the paralysis of the voluntary muscles, there is no doubt that Duchenne is right in regarding it as a consequence of nervous disorder. For if it were CHKONIC LEAD-POISONING. 613 muscular, not only should we find the muscular fibres degenerated m pro- portion to their loss of power, but we should find faradic contractility surviving as long as any healthy muscle was left. On the other hand, the rapid shrinking of the muscles, without degeneration, and their speedy loss of faradic contractility, obviously point to lesion either of the nerve-trunks or of their nuclei of origin. Treatment. — Whenever a case of lead-poisoning comes under treat- ment, a careful inquiry should be made into the probable source of con- tamination, with the object of removing or counteracting it, or of putting the patient upon his guard. It is obvious that it would be well for patients whose occupations expose them to the danger of continued lead- poisoning to seek some other employment. But this they will rarely consent to ; and, indeed, it is often impossible for them to do it. Apart from the question of the improvement of processes of manufacture in order to minimise the risks of those employed (a subject upon which we do not presume to enter), it may be mentioned : that extreme personal cleanliness is important for all those who are exposed to danger ; and that there are good grounds for believing that the habitual use of lemonade made with sulphuric acid is to a considerable extent protective, by converting the carbonate or other salts of lead in the stomach into the insoluble and inert sulphate. Various methods of treatment have been suggested with the object of removing lead from the system — the more important of them being the employment of baths containing some soluble sulphide, and the internal use of iodide of potassium. Pereira recommends baths medicated with sulphide of potassium, in the proportion of two ounces to fifteen gallons, in the belief that the lead escaping from the surface of the skin would thereby be converted into the insoluble sulphide. This result does in fact happen ; but there is no reason whatever for supposing that the baths promote the escape of lead in any important degree. M. Melsens sug- gested the employment of iodide of potassium, on the ground that the iodide makes, with the insoluble salts of lead deposited in the tissues, a soluble double salt capable of removal by the kidneys. This practice is commonly followed. In the treatment of lead-colic it is best, we believe, to relieve pain and discomfort by opiates and fomentations, and to leave the bowels to act of themselves, as they will usually do at the end of a few days. If it be thought right to remove the contents of the lower bowel, this may be effected by means of copious enemata of warm water or warm gruel. Many, however, prefer the course which Sir Thomas Watson advocates : namely, the exhibition of a full dose of calomel and opium (ten grains of the former with two of the latter), which he says usually soothes the vomiting, restlessness, and pain, and may be followed up successfully by a dose of neutral salts or castor oil. Alum, in doses of a scruple or half a drachm three times a day, has been highly recommended. For the restoration of the paralysed and wasting muscles, galvanism is the only effectual remedy. Faradism is employed by Ducheime, who 614 DISEASES OF THE VASGULAE OEGANS. recommends that a powerful current should be used three times a week for as long a period as may he necessary — it may he as much as two or three months. Each sittmg may last for ten or fifteen minutes. He recommends also, that each muscle should he separately galvanised. The slowly interrupted constant current, similarly employed, is even more efficacious. Xni. CHEONIC MEECUEIAL POISONING. {Mercunalism.) Causation. — Chronic mercurial poisoning may result from the long- contiuued medicinal use of any of the preparations of mercury ; but it is most frequently due to habitual exposure to the vapour or dust of mercury, or its salts, which certain manufactures or trades involve. Those, there- fore, who chiefly suffer are the workmen engaged in quicksilver mines ; water-gilders ; the manufactui'ers of looking-glasses, barometers, and thermometers ; furriers, and those engaged in the packing of furs which have been brushed over with solution of nitrate of mercury. Symptoms and progress. — The sjTaptoms of chronic mercurial poison- ing have reference mainly to the nervous and muscular systems, and are commonly included under the term ' metallic tremor.' The first indica- tions of this condition are : a general tremulousness of the hands and arms, coming on for the most part gTadually ; slight numbness or ting- ling in the hands or feet ; and occasional pains in certam joints, more especially those of the thumbs, elbows, feet, and knees. Tremors are common amongst workpeople exposed to the vapour of mercury, and may continue for years without materially interfering with their capacity for work or their general health. But sooner or later they tend to get aggra- vated ; they not only become more violent, but gradually extend to all parts of the muscular system ; so that they involve at length the hands, arms, and legs, the head and neck, including the muscles of expression, speech, and deglutition, and the trunk with the muscles of respiration. Then the violent trembling of the hands and arms renders the patient more or less mcapable of using them for any pm'pose, especially for dehcate operations — he probably cannot hft a glass of water to his hps, or feed or dress himself ; the agitation of his legs gives to his attempts to walk or stand a peculiar jerkhiess or choreic character, and, indeed, before long he is probably unable to stand or walk -ndthout support ; the con%Tilsive action of the muscles of his head and neck causes constant tremulous movements of these parts, while that of the muscles of expression reveals itseH in grimaces, and that of the hps, tongue, and muscles of mastication causes tremulous, mdistinct, and divided utterance, and difficulty of mas- tication ; the involvement of the resphatory muscles induces difiiculty of breathing. All these convulsive movements are usually in abeyance when the patient is lying down and making no muscular effort ; but they reveal themselves whenever he attempts voluntary movement, and become espe- cially aggravated whenever he is under observation. Further, the patient is hable to occasional, apparently causeless, exacerbations. At a very CHEONIC MEECUKIAL POISONING. 615 advanced period of the disease, tlie convulsions do not wholly cease when the patient is in bed, and occasionally also continue during sleep. More- over, they are now not unfrequently associated with sharp pains in the limbs, and occasional attacks of tonic contraction. It would seem (and the point is an important one) that the muscles of the eyebaUs do not share in the convulsive movements, and that there is an absence of nys- tagmus. There is no real loss of sensation. The symptoms above enumerated are not necessarily associated with any other indications of mercurial poisonmg or signs of iU-health. But in a considerable number of cases the patients either have previously suffered from saHvation and ulceration of the gums, fetid breath, nausea, sickness, colicky pains, disturbance of the bowels, and fever ; or present these phenomena at the time when the nervous symptoms supervene ; or begin to suffer fi'om them during the course of the tremors, even if they have never thus suffered previously. And generally after the tremors have attained a high degree of severity, cachectic symptoms come on ; the patient gets sallow, emaciated, and weak ; he loses appetite ; and there is general failure of his circulatory and other functions. Sometimes, also, cerebral complications are developed, such as vertigo, headache, loss of memory, delirium, epilepsy, paralysis, or coma. Chronic mercurialism is not generally a fatal or even dangerous disease ; mainly for the reason that those who are affected with it are usually •compelled to give up their employment, and thus escape further risk. Under such circumstances restoration to health may often, with proper treatment, be effected in a few weeks or months. In aggravated cases, however, the tremors may continue for years, occasionally presenting a remittent character, dependent apparently on accidental conditions of health. But for such as continue to expose themselves to the vapour •of mercury, the prospect of early death is by no means uncertam — death under such circumstances being caused either by extreme debihty, or by some of the ordinary effects of mercury on the gums and mouth, or intes- tinal canal, or by some cerebral comphcation, or by the supervention of mtercurrent disorders. The affections with which mercurial tremors are most likely to be confounded are disseminated sclerosis, and paralysis agitans. But careful attention to the history and details of symptoms will generally enable an accurate differential diagnosis to be made between them. It may, how- ever, be pointed out, as practical hints, that paralysis agitans does not commonly affect the muscles of the head and neck, but imparts to the patient a tendency to run forwards, and that generally m disseminated sclerosis there is well-marked nystagmus. Morbid anatomy. — No characteristic lesions have been discovered in the internal organs of patients who have died of chronic mercuriahsm. But mercury has been detected chemically in various parts of the body, more especially the brain, liver, and kidneys. Treatment. — The preventive treatment of mercurial poisoning includes the taking of measures to guard against the entry of mercury into the 616 DISEASES OF THE VASCULAE OEGANS. system, either by adopting such modifications of the processes of manu- facture as minimise the diffusion of the poison through the atmosphere, or by compelhng the workers to wear respirators or other protective cover- ings to the face, to wash their hands before eating, and to change their clothes and wash after leaving work. The direct treatment of chronic mercurialism by drugs is of little use. It may on the whole be judicious to act on the bowels, kidneys, and skin, for the purpose of promoting the discharge of the poison. It may even be well to adopt the treatment already suggested for chronic lead-poisoning, namely, the administration of iodide of potassium, with the object of combining the mercury in the system therewith into a soluble double salt. But the essential part of the^ treatment, and that which is alone of real efficacy, is the removal of the patient from the influence of mercury. Tonics may often be given with advantage to the patient's general health ; and galvanism may be applied, with benefit to the enfeebled muscles. 617 Chap. Y.— DISEASES OF THE DIGESTIVE ORGANS. Section I.— DISEASES OF THE MOUTH, FAUCES, AND ADJACENT PAETS. I. CATAEKH. Causation. — The most common, and on the whole perhaps the most important, variety of inflammation affecting the mouth, fauces, and parts in relation with them, is that which results from exposure to cold, and gives rise to the phenomena which collectively constitute what is com- monly known as a ' cold ' or ' catarrh.' Morbid anatomy. — Catarrhal inflammation commences with hyper- aemia, infiltration, and tumefaction of the affected mucous tissue, diminu- tion of the secretions from its surface, and from the glands which open upon it, and consequent abnormal dryness. Before long, however, the inflamed parts begin to pour out a thin, watery, somewhat acrid dis- charge, in considerable abundance ; and at the same time the tumefaction usually undergoes some diminution. Subsequently the secretion gets thick, opaque, and yellowish or greenish, and assumes the characters of muco-pus or pus. This change generally indicates the commencement of the end ; for now, if nothing occurs to interfere with the normal progress of the case, the tumefaction and secretion both gradually subside, and the mucous membrane returns to its healthy state. Catarrhal inflammation does not, as a rule, seize at once on any extensive tract, but rather, like erysipelas, begins in a comparatively small area, whence it spreads. Nor does it, even in the case of any one who is liable to it, always commence in the same spot. Thus it often, perhaps most frequently, begins in the mucous membrane of the nose, whence it spreads by continuity to the fauces, and thence to the larynx and probably to the trachea and bronchial tubes ; or it first manifests itself in the larynx, whence it extends upwards into the nose, and downwards into the chest ; or it first attacks the fauces,, soft palate, or it may be the gums. The regions which are liable to be in- volved in the course of catarrh, and in any one of which probably it may commence (thence extending to the others), are the following : — the nose and sinuses in relation with it, with the lacrymal ducts and conjunctivae ; the fauces and pharynx, together with the Eustachian tubes and tympanic cavities, and the oesophagus ; the oral cavity, including the palate, gums, sockets of the teeth, and tongue ; the periosteum of the facial bones, and branches of the fifth pair ; and lastly, the larynx and subordinate respira- tory passages. Symptoms and progress. — The symptoms of a cold necessarily differ 618 DISEASES OF THE DIGESTIVE OEGANS. .according to tlie regions wliich mainly suffer. The special symptoms, however, are always associated with the ordinary phenomena of febrile disturbance. The latter vary in severity, but are generally mild (some- times scarcely noticeable) and always most severe during the first day or two of the attack. They comprise elevation of temperature, heat and dryness of skin alternating with perspirations which come on mainly at night-time, increased frequency of pulse, thirst, constipation, scanty urine with abundant uratic deposit, muscular pains, and frequently drowsiness. The febrile symptoms are sometimes alarming in the case of young children. The symptoms of catarrh affecting the cavity of the nose are in the first instance dryness, obstruction, and irritability of the nasal passages, associated with frequent paroxysms of sneezing, the performance of res- piration mainly through the open mouth, and inability to pronounce the nasal consonants, m, n, and ng. To these succeeds defluxion of thin watery mucus, which frets the margins of the nostrils and the upper lip. There is probably still great irritability of the mucous surface, with parox- ysmal sneezing ; but with the continuance of the discharge the nasal passages become more pervious, and the symptoms due to obstruction to some extent subside. Finally, the discharge gets thick, and at the same time less abundant, the tumefaction and irritability of the mucous mem- brane diminish, and convalescence ensues. Associated with nasal catarrh there is always loss of smell, especially during the earlier stages ; and, probably owing to implication of the frontal sinuses, there is often severe headache, limited to the situation which the sinuses occupy, and not un- frequently attended with drowsiness. The extension of inflammation to the conjunctivae is shown partly by obstruction of the lacr3anal ducts, in consequence of which the tears are compelled to flow over the face, partly by the supervention of ophthalmia. The indications of catarrhal inflammation of the fauces are : unnatural redness of the soft palate and pillars of the fauces, and, in a greater or less degree, of the contiguous mucous surfaces ; and tumefaction of the same parts, but more particularly perhaps of the lax tissue of the uvula, which is apt to become (Edematous and enlarged in all its dimensions. The first symptoms of which the patient complains are dryness, stiffness, and itching or tingling, commencing at one side, or in some defined area, but soon becoming more or less general throughout the fauces and soft palate, and frequent tendency to swallow in order to relieve the uncomfortable feeling in the throat, and to cough a slight hacking cough. The act of deglutition is more or less painful. With the supervention of the stage of secretion, the efforts to swallow and clear the throat get more effective and freer from pain, the patient becomes comparatively comfortable, and convalescence soon follows. Involvement of the Eustachian tube and ear is indicated, first by itching or shooting pains in the course of the tube and in the ear, then by deafness and the usual signs of aural mflammation. Extension of catarrh along the oesophagus to the stomach is rarely if ever manifested by prominent symptoms. Those usually observable are a sen- CATAEKH. 619 sation of warmth along tlie oesophagus and m the stomach, and shght dyspeptic symptoms, more especially frequent eructations and craving for food. Catarrhal inflammation of the mouth more frequently and seriously- affects those who suffer from bad teeth than those whose teeth are sound, and reveals itself mainly by pam, tenderness, and swelling of the gums, and particularly of the periosteum of the sockets of the teeth. The teeth consequently become loose and tender ; and neuralgic pains, often most severe at night-time, flicker about the gums, and sometimes extend to the periosteum of the jaws, and along the superficial branches of the fifth pair. Catarrhal inflammation of the larynx is elsewhere described under the name of laryngitis, and that of the bronchial tubes under the name of bronchitis. It remains to say that catarrh, in the sense in which the word is em- ployed in the present article, is an affection of very various importance. In the majority of cases it must be regarded as a trivial disorder, which reaches its full development in the course of a day or two, and lasts at the outside not more than a week or ten days. Yet, without attaining any special severity, it may be kept up for an almost indefinite period if the patient continue to expose himself to its exciting cause. Nor can it be regarded as entirely devoid of danger, especially if it involve the larynx or bronchial tubes ; for, although in many cases the laryngeal or bronclaial affection is really slight, it differs only in degree from the severest forms of primary laryngitis or bronchitis, and may readily pass into one or other of them. Further, although the pain and discomfort of catarrh are commonly neither severe nor of long duration, there are exceptions to both of these rules. The chief exceptions are furnished by those cases in which the inflammation spreads to the teeth, periosteum, and branches of the fifth pair, and those in which it attacks the ear — in both of which cases the pain is often intense, and continues maybe, with little inter- mission, for weeks or months. Treatment. — Trivial as a common cold may seem to be, it is yet of such frequent occurrence, and a source of so much discomfort, especially to those who are liable to its attacks, that its treatment cannot be regarded as unimportant. As a general rule patients suffering from cold should confine themselves to a warm and well- ventilated but not draughty room ; and should, if not in bed, be warmly clad. A hot bath (water, vapour, or air) should be taken before going to bed, together with some warm drink, and a little Dover's powder — measures which are serviceable in reheving pain and discomfort, in promoting sleep, and in exciting per- spiration. During the day the occasional inhalation of steam is often useful, as also are frequently repeated small doses of ipecacuanha and opium, either in the form of Dover's powder, or associated with some febrifuge mixture, or with ether or ammonia. Sir T. Watson notices with especial approval the treatment of a commencing catarrh with (in the adult) about twenty minims of laudanum at one dose, or with about half 620 DISEASES OF THE DIGESTIVE OEGANS. that quantity of laudanum combined with seven or eight minims of vinum antimoniale, repeated every third or fourth hour for three or four times ; as also Sir Henry Halford's practice (which accords pretty nearly with the usual domestic routine) of giving at bedtime a beaker of hot wine negus with a tablespoonful of the syrup of poppies. He also observes that there is ' a period in catarrh which has gone on unchecked when you may accelerate its departure by a good dinner and an extra glass or two of wine,'' Counter-irritation is sometimes serviceable ; and, if the fauces or larynx be dry and uncomfortable, the frequent sipping of warm milk, barley-water, gruel, or ' treacle posset,' or the use of black-currant jelly, or such like things, is often a source of considerable comfort. Sucking ice in many cases answers the same purpose. In the latter stages of faucial catarrh, or when the affection has become chronic, astringent applications, in the form either of gargles, or of spray by means of the atomiser, may be useful. Occasionally, but for the most part as the result of repeated catarrhal attacks, the uvula gets elongated, and is believed to irritate the larynx, with which it comes in contact. Under such circum- stances the tip may be readily and safely snipped off with scissors. It is very desirable to obviate, if possible, the liability to catarrh which so many persons labour under. There is no doubt that active exercise in the open air, and all other habits which tend to promote good health, tend also to diminish this liability ; and many a person will in his autumnal holiday expose himself with impunity to conditions which at home would certainly have brought on a severe attack. So far as possible, therefore, exercise and other health- conducive practices should be enjoined. It is not, however, the exposure which attends active exercise that as a rule induces cold, unless, indeed, the patient has midergone great fatigue, and conse- quently fails to keep himself warm ; but it is rather the exposure when one is still, especially when one is still after previous violent exertion and exposed to a cool breeze, to a cool draught of air, or to the coldness induced by wet clothes or the evaporation of sensible sweat. The means of obvi- ating such dangers are too obvious to need enumeration. It is generally held, and we believe mth reason, that a matutinal cold bath followed by friction with a rough towel, and then by walking or other exercise, is a good preventive of colds. The shower-bath has been especially recom- mended for this purpose. It is, nevertheless, a fact that the continued use of the shower-bath will in some persons, so far from obviating the liability to cold, uiduce it, and keep up a permanent catarrhal state. II. THEUSH. [AjMhcB. Causation and morbid anatomy. — Inflammatory affections of the mouth and fauces frequently arise in connection with stomach and bowel disturb- ance — sometimes simultaneously with it, sometimes secondarily to it, and more rarely, perhaps, as the first step in the order of events. Such inflam- mations are sometimes catarrhal in the anatomical sense of the word, and THEUSH. 621 hence not readily distinguisliable in all cases from the effects of ordinary cold. They do not, however, so far as we know, tend, as the latter variety does, to involve the nasal cavity and air-passages, or to extend to the eye, ear, sockets of the teeth, or branches of the fifth pair ; while, on the other hand, they involve the mucous membrane of the mouth much more prominently. Thrush is characterised for the most part by the appearance in greater or less abundance, on the tongue, gums and palate, inside the lips and cheeks, on the soft palate, and pillars of the fauces, and even on the surface of the pharynx, of small, elevated, opaque, whitish spots, which are round or irregular in form, pretty firmly adherent, and not unfrequently appear like attached flakes of curdled milk. These can be easily separated, leavmg more or less distinctly excoriated ares or ulcers behind ; and appear to be due mainly to inflammatory overgrowth of the epitheHum with tendency to its detachment. In some instances thrush presents a different character. It begins with the formation of mmute white rounded elevations, which gradually increase in size until individually they attain perhaps the bulk of a mustard- seed or tare. These are hemispherical in form, adlierent by broad bases, smooth on the surface, and uniformly solid. They are scattered irregularly, •sometimes sparsely, sometimes in great abundance, on the lips, and other parts of the surface of the oral cavity and pharynx. Under the microscope these bodies are found to consist of a cryptogamic plant, called the Oidiuvi albicans, the mycelium of which infiltrates the subjacent epithelium. The ■source of this parasite has not been clearly ascertained, but Hallier regards it as identical with the Oidium lactis. If this be so, the explanation of its occurrence in infants at the breast, and in persons wasted with disease, is not far to seek. The oidium may often be recognised in the form of aphtha first de- scribed. It seems therefore probable, not only that it may be derived ■from milk, but that it attacks the mucous membrane under various circumstances, sometimes directly, sometimes at the seat of excoriations or of inflammatory patches — in other words, that aphthae are sometimes primarily, sometimes secondarily, parasitic. Symptoms and progress. — Aphtha are common in young children, more particularly infants at the breast ; but are frequent also both in Fig. 54. — Oidium albicans, x 500. 622 DISEASES OF THE DIGESTIVE OEGANS. children and in adults in the course of many diseases, especially when they are attended with hectic fever or the typhoid state. In young children thrush is generally preceded by and attended with feverish symptoms (heat of skin, fretfulness, and drowsiness), diarrhoea, or other morbid conditions of the bowels, loss of appetite, vomiting, and unwillingness to take food. Gastro-intestinal disturbance, indeed, is rarely absent ; and it is believed by many that aphthae of the mouth indicate a similar con- dition of the stomach and ahmentary canal. The lips usually are dry, and the tongue, especially at the tip and edges, redder and drier than natural, and with a tendency to get furred on the dorsum and towards the base. The anus and its vicinity in such cases are sometimes red- dened and excoriated, and aphtha have been described as existmg there. Aphthae may subside after a few days, or last continuously or with re- missions for many weeks. Thrush is not in itself dangerous, or necessarily an indication of danger in the affection which it attends. , It must not be forgotten, however, that it frequently accompanies gastro-mtestinal lesions which prove fatal, and that its presence cannot but add something to the danger of an already dangerous disease. When thrush supervenes in the course of diseases affecting adults, although it is not necessarily an indi- cation of impending death, it is yet often a symptom of grave omen. A trivial form of the affection is observed in persons who are liable to dyspepsia. The dyspeptic symptoms, which are probably inflammatory, are attended with stiffness and soreness of the back of the tongue and fauces, and sometimes of the anterior part of the tongue as weU. There may be considerable pain on deglutition ; and acid or stimulating articles of diet, and such as are m hard and angular fragments, cause intolerable smarting. On inspection, in some cases, little or no visible departure from the healthy condition can be observed ; in other cases, however, there is ob^dous redness ; and often the presence of cracks or fissures, or even of small patches of excoriation along the edges of the tongue, and elsewhere at the back of the mouth, may be recognised. Treatment. — In the treatment of thrush and of the forms of inflamma- tion related to it, it is important in the first place to attend to the general health, and especially to the condition of the alimentary canal. In children it is o-enerally best to commence the treatment with a dose of castor oil, or of rhubarb in combination with carbonate of magnesia or grey powder, and then to administer medicines calculated to improve the tone of the stomach and bowels. According to the particular symptoms present may be prescribed lime-water with milk, small doses of rhubarb mth gino-er or some other aromatic, aromatic confection with chalk and opium, or vegetable bitters. Locally, rehef may be given by the appHcation of mel boracis, solution of tannm, sulphate of zinc, or nitrate of silver ; by washino- out the mouth with a solution of chlorate of potash ; by rinsmg it with mucilaginous fluids ; or by the use of lozenges containing gelatine or mucilage. With the object of destroying the parasite present in some forms of aphtliEe, solution of sulphurous acid has been recom- mended. ULCEEATIVE STOMATITIS. NOMA. 623 III. ULCEEATIVE STOMATITIS. Causation and morbid anatomy. — A peculiar affection of the mucous surface of the ca'S'ity of the mouth is sometimes met with, chiefly if not entirely in children helow the age of puberty, which has a close relation, at all events anatomically, to that observed in cattle affected with the foot-and-mouth disease. It is imposible to deny that there is also some resemblance between this affection and both thrush and the early stage of gangrenous ulceration. Yet the appearances are so peculiar, and the whole progress of the affection so like that of a specific disease, that there is good reason to regard it as an affection sui generis. It consists in the formation of excoriated patches, chiefly limited to the surface of the gums, and corresponding parts of the cheeks, but occurring also on the dorsum and sides of the tongue, mainly towards the base, on the palate, and on the general surface of the buccal mucous membrane. The excoriations vary in size and shape, but are mostly irregular and tending to run together ; their surface is raw, red, and weepmg, sometimes bleeding ; and the surface of the mucous membrane between them is thickened and opaque. The tongue (excepting the spots of excoriation) is generally covered with a thick, tough, opaque, whitish fur, and its surface looks not unlike a piece of wash-leather. Symptoms and progress. — The approach of the malady is usually indi- cated by some degree of feverishness and malaise — symptoms, indeed, differing little if at all from those that usher in an ordinary cold. Then, after a day or two, some soreness is experienced in masticating, speaking, and deglutition ; and if the mouth be examined, the morbid phenomena above described will be recognised in an early stage. The progress of the affection is attended with febrile symptoms^heat of skin, flushing of face, listlessness, drowsiness, thirst, loss of appetite, and the like. And these, together with the local phenomena, usually subside in the course of a week or ten days. In some cases the affection of the mouth assumes a more chronic character. We are not aware that it ever leads to serious conse- quences. Treatment. — For local treatment mel boracis, or chlorate of potash in solution, seems to be indicated. Internally, a little chlorate of potash or other febrifuge medicine may be admuiistered. IV. NOMA. {Gangrenous Stomatitis.) GANGKENE OF FAUCES. A. Noma. Causation. — Gangrenous ulceration of the mouth occurs almost ex- clusively in children under twelve years old, and indeed is mainly Hmited to those whose ages lie between one and five. Its cause is not very obvious. There is no doubt, however, that it is especially apt to become developed during convalescence fi-om acute febrile disorders, among which 624 DISEASES OF THE DIGESTIVE OKGANS. measles stands pre-eminent, and in children who have been badly fed or are anemic. Morbid anatomy. — The gangrene may commence at any part of the buccal surface, and in several parts atone time. But it usually originates in the sulci between the gums and cheeks, and chiefly (according to Barthez and Eilliet) in that connected with the lower jaw. It begins variously : sometimes with ulceration or the formation of a superficial slough ; sometimes with congestion, thickening and tension of the sub- stance of the cheek or other soft parts circumscribing the oral cavity. In any case there soon appears on some part of the mucous surface of the mouth an irregular greyish or black sloughy patch surrounded with a rim of intense and somewhat livid congestion. This tends to spread rapidly both in area and in depth — its extension being preceded and accompanied by infiltration, hardening, and congestion of the tissues. The cheek in the affected neighbourhood frequently becomes tense, shining and livid. With the extension of the gangrene, the gums may be eaten away, the alveoli necrosed, and, if the patient live sufficiently long, the teeth and portions of the jaw may exfoliate, and the soft palate, fauces, and tongue, each and all, be more or less extensively destroyed. Very frequently the cheek gets perforated ; and the destructive process may then spread almost indefinitely, involving in turn the mouth, the entire cheek, and it may be the nose, the eye, and other contiguous parts. Symptoms and progress. — The symptoms which attend noma are, at all events in many cases, much less severe than one would expect them to be. It often happens that the gangrene has made some progress in the interior of the mouth before anything has occurred to call special attention to what is going on there ; and, indeed, it is not a rare thing to find patients in whom gangrene has committed the most extensive and fright- ful ravages, and for whom recovery is hopeless, who neither suffer pain nor have suffered it, who maintain a good appetite, and contmue sensible and even cheerful. The special symptoms, in addition to swelling of the cheek and the actual progress of the gangrene (which is obvious enough if looked for), are: more or less profuse salivation, the discharge often being bloody and foul ; extreme fetor of this discharge and of the breath ; and swelling of the neighbouring lymphatic glands. As above indicated, the patient often suffers very little pain or uneasiness, remains sensible, talks, and takes an interest in whatever is going on about him, and re- tains his desire for food and the power of taking it. But notwithstanding this, the pulse rises in frequency and gets small and feeble ; the surface grows pale and cold ; drowsiness or delirium comes on ; diarrhoea perhaps sets in ; and death from asthenia supervenes at the end of a few days. Li a small proportion of cases recovery takes place, with more or less deformity. B. Gangrene of Fauces. Causation. — But gangrene, not specially limited in this case to young children, may commence in the fauces or pharynx. In some cases this is NOMA. INFLAMMATION OF THE GUMS. 625 due to diphtlieria or scarlet fever, or results from the mere intensity of the inflammation in ordinary tonsillitis. But it may also occur independently ■of such special diseases, and, like noma, be traceable to profound impair- ment of the general health. Symptoms and progress. — The symptoms in these several cases differ in some degree according to the nature of the disease to which the gan- grene is due. Eliminating, however, the symptoms referrible to the several specific affections which have been named, gangrene of the fauces would be revealed by tumefaction of the tissues, the apjDearance of sloughs upon the surface, fetid discharge and breath, swelling of the glands be- neath and behmd the jaw, and, in addition to these phenomena, difficulty and pain in deglutition, and probably, before long, difficulty of respiration. The situation of the morbid process necessitates the presence of much more pain and discomfort than are usually associated with noma ; and here, as in the other case, very extensive destruction of tissue may take place, and perforation ensue. The general symptoms are : feebleness of pulse, sometimes with quickening, sometimes with marked diminution of frequency ; pallor ; coldness of surface ; tendency to collapse ; and not unfrequently, before death, copious perspirations, diarrhoea, and impair- ment of consciousness, delirium or coma. C. Treatment. In treating gangrenous affections of the mouth and throat, it is in the first place of paramount importance that the patient's strength should be maintained by the regulated administration of nutritious food and alcohol, and of tonic medicines, or these combined with diffusible stimulants. Opium here, as in all similar cases, may be of great service. For local "treatment, it is necessary to keep the parts cleansed ; to wash them frequently with antiseptic fluids, such as solutions of chlorinated soda, chlorine, hydrochloric acid, permanganate of potash, or chlorate of potash; and to treat the gangrenous tracts themselves freely with eschar otics, of which probably the most valuable are pure hydrochloric or nitric acid, and the actual cautery. V. INFLAMMATION OF THE GUMS IN DENTITION. Cutting the teeth is always attended with discomfort, if not absolute pam. Previous to the actual eruption the implicated gum generally becomes congested, swollen and tense, and often distinctly inflamed. Occasionally suppuration or ulceration takes place. The eruption of the second teeth is seldom attended with symptoms which call for the notice of the physician. The eruption of the first set, however, is a fertile source of infantile ailments. This is especially the case when it occurs early. It is well known to mothers and nurses that infants who are on the eve of cutting their teeth begin to dribble and to bite the finger or any other hard substance which may be introduced into the mouth ; and, looking s s 626 DISEASES OF THE DIGESTIVE OEGANS. upon these s}Tiiptoms as an indication for treatment, they give the bahe an ivory or iadia-rubber ring or a piece of coral to bite. So far the symptoms may be regarded as normal ; but in many cases the congestion of the gum produces feverishness and h-etfiilness, iaterferes- with the infant's rest, and induces sickness and diarrhoea. When these phenomena ensue, each may be treated according to its importance : the vomithig may be allayed by the exhibition of some aromatic, or the addi- tion of a small quantity of hme-water to the milk ; the diarrhoea may be rectified by the administration of a Uttle castor oil or Gregory's powder, followed, if necessary, by a little aromatic confection and chalk ; the rest- lessness may be met by minute doses of opium. Li the great majority of cases, however, the most efficacious and the best treatment is freely to- lance the inflamed gum. In some instances convulsions are referrible to the irritation of the emerging teeth. Under such circumstances, in addition to the appropriate treatment for convulsions, lancmg of the gums must be efficiently per- formed. Many other maladies besides the above are commonly regarded as consequences of dentition, the prmcipal of them being eczema, hchen, and impetigo in various forms, bronchitic affections, and paralysis. It is doubtful, however, whether dentition has any other effect upon them than that of asfgravating them. YI. GLOSSITIS. Causation. — Besides the superficial forms of inflammation m which the tongue shares with the other parts bomiding the oral ca^uty, the organ is Hable to become inflamed throughout its whole substance. This occur- rence, which is rare, may take place under the influence of the mercurial poison, or as a consequence of direct mjury, but now and then arises m- dependently of aU such obvious causes. Synqjtovis and inogress. — Idiopathic glossitis is said to be preceded in some cases by premonitory febrile s}-mptoms. In other cases the inflauunation is certainly, so far as one can judge, primary, although attended probably fi"om the commencement with febrile disturbance, and even with rigors. It sometimes commences in the tongue itself, at other times m neighbouring parts, especially the fauces. The tongue then becomes swoUen, stiff, and pauifiil, and incapable of executing its iDroper functions. The swellmg is usually general, although sometimes Hmited to one-haK, or it may be some lesser portion. In the first case the organ gets enlarged in all its dimensions, sometimes so thick as to render inspection of the back of the mouth out of the question, so -udde as to project on either side between the molar teeth, so long as to protrude beyond the lips, and even exerting serious pressiu'e upon the upper part of the larynx. The pain is usually of a throbbing or burning character, and increased by all attempts at movement, so that mastication, deglu- tition, and articulation are m some cases almost impossible. Saliva GLOSSITIS. QUINSY. 627 accumulates in the mouth, and tlie patient's sufferings consequently become much aggravated. The surface of the tongue may m the first instance be redder than natural, but very soon gets enveloped in a thick white creamy fur. Occasionally suppuration takes place and an abscess forms. The affection usually attains its height in the course of three or four days, and, if free fr'om complication, subsides in the com'se of a week or ten days. Permanent hypertrophy of the tongue has sometimes resulted. The sufferings of a patient with glossitis are usually out of proportion to his danger. Some of them have already been referred to ; but one of the most serious is the sense of impending suffocation which is often present, and which alone may be sufficient to prevent all sleep and forbid even temporary ease. It is quite possible, however, that fr'om extension of oedema or inflammation to the larynx dangerous symptoms, and even death, may ensue. The disease, therefore, is one which needs close and careful watching. Treatment. — The patient should have his mouth cleansed, by gargluig (if he can effect it) or otherwise, with solution of chlorate of potash or other detergent lotions ; his strength should be sustained with liquid nourishment, which, if it cannot be swallowed, should be administered by the nose or rectum. Fomentations may be appHed to the throat ex- ternally, and even leeches may be deemed advisable. It may also be necessary (and the practice is very efficacious) either to apply leeches to the tongue itself, or to make longitudinal incisions into it. If an abscess form, it should, of course, be opened. For general treatment, febrifuges may be given ; and opium is of paramount value. It requires, however, to be given with much caution. If suffocation threaten, tracheotomy may need to be performed. VII. QUINSY. {Tonsillitis.) A. Acute Tonsillitis. Causation. — The surface of the tonsil becomes inflamed whenever spreading or general inflammation involves the mucous membrane of the mouth and fauces. Hence, m catarrh, aphtha, and the like, the tonsils are necessarily imphcated. Again, there are several affections in which inflammatory involvement of the substance of the tonsils forms an important and characteristic feature. We especially refer to scarlet fever and diphtheria. Deep-seated or parenchymatous inflamma- tion of the tonsils, however, like ordinary catarrh, is a fr'equent con- sequence of exposure to cold or wet ; the two conditions, indeed, are not unapt to concur. Nevertheless it is a fact that many persons who are subject to catarrh, with all its usual associations, never suffer by any chance fr'om tonsillitis ; and it is equally a fact that tonsillitis often occurs independently of the special symptoms of catarrh. The symptoms and course of tonsillitis, moreover, are very characteristic, and the affection, therefore, calls for independent consideration. TonsiUitis is s s 2 628 DISEASES OF THE DIGESTIVE OEGANS. mostly a disease of childhood, but when once it has developed it is apt to recur, and thus to be perpetuated into the period of adult life. Morbid anatomy. — Simple or non-specific inflammation of the tonsils is characterised by inflammatory swelling of the tonsils themselves and of the soft tissues in their immediate neighbourhood, especially the pillars of the fauces, the soft palate and uvula, the base of the tongue, and the pharynx. The tonsil (for one is generally first and often solely affected) becomes increased in size, deeply congested, and infiltrated with inflam- matory exudation and growth. The crypts upon its free surface produce superabundant epithelium, which accumulates in their orifices, forming opaque, yellowish, creamy pellets. The lymphatic nodules of the interior undergo inflammatory overgrowth, and often soften, suppurate and run together, and ultimately form an abscess. The soft palate and pillars of the fauces become of a vivid red hue, swollen, tense and shining, and more or less displaced ; and thus, if the swelling of the tonsil and sur- rounding parts be extreme, we find the soft palate on the affected side pushed downwards, forwards, and inwards, the anterior faucial pillar correspondingly displaced, and both together forming a smooth, tense, vividly red swelling with the convexity facing forwards. The swelling and displacement indeed of the surrounding parts are sometimes so great that the enlarged tonsil itself is almost concealed. When both tonsils are involved, their affection is sometimes concurrent, more frequently in sequence. Often indeed the one is getting well when its fellow first shows signs of disease. When the tonsils are both very large, they may meet one another in the mesial line, becoming flattened and sometimes ulcer- ated from mutual pressure, and between them almost completely closing the faucial canal. The uvula, which is usually swollen, tense, and con- gested, often clings to one of them ; and it may be so much elongated as to hang into the upper part of the larynx. Further, the tongue gets covered with a thick creamy fur, and the glands at the angle of the jaw, and sometimes the salivary glands, share in the inflammation, and become hard and large. Symptoms and ])r ogress. — The invasion of tonsillitis is almost always marked by the occurrence of severe febrile symptoms, associated with sore- ness, itching or tingling, dryness and aching in the region of the fauces. The febrile symptoms increase in severity with the increase of the local affection, and with the cessation of the latter gradually, or, it may be, suddenly subside. At the beginnmg the patient experiences alternate flushes of heat and chills, and even distinct rigors ; his temperature rises, and often reaches an elevation of at least 102° ; not unfrequently, indeed, by the time the disease has attained its maximum, it mounts to 104° or even 105° and vipwards ; his pulse increases in frequency, rising to 100 or 120, and is at the same time more or less full and firm ; his skin is hot and pungent, but with a marked tendency to remittent sweats ; he com- plains of headache, pains in the back and limbs, thirst and anorexia ; his bowels are confined, his urine dark-coloured and scanty. The appearances which the tonsils and interior of the mouth present may be gathered fi-om QUINSY. 629 the description wliich has been given of these parts. It remains to say that the patient has severe pains at the back of the throat and base of the tongue whenever he moves his jaws, or speaks, and especially when- ever he opens his mouth widely or attempts to swallow. The pain then not unfrequently shoots along the Eustachian tubes to the ears. He has a constant desire to swallow in order to relieve his mieasiness, but the pain and difficulty of swallowing are so great that he permits the secretions to accumulate in his mouth ; and, in attempting to swallow, fluids not unfrequently pass up into the nose. The quality of the voice is nasal and characteristic. There is often deafness, and always more or less fulness and tenderness behind the angles of the jaw. The swollen tonsils indeed may be felt in these situations. If one tonsil only be inflamed, or both be simultaneously affected, the malady will probably attain its height in three or four days, and end in convalescence at the end of a week or ten days. Occasionally its course is yet more rapid, and the patient is well, or nearly so, in three or four days. But when one tonsil is affected after the other, the course of the disease is necessarily protracted. If an abscess form, as is usually the case when the attack is severe, the severity of the symptoms progressively increases up to the moment at which the abscess breaks. Then the tonsil suddenly shrinks within moderate dimensions, and the patient is probably at once restored to comparatively good health. The matter which escapes is fetid and thick, and usually swallowed. The symptoms of tonsillitis are severe out of all proportion to the seriousness and danger of the affection. Any other termination than that of recovery within a brief period is very rare. The interference with swallowing, which seems so serious, never prevents the taking of food for more than a very limited period. Occasionally, however, death results from suffocation, due either to the sudden bursting of a large abscess and the entrance of its contents into the larynx, or to the mechanical impediment which the inflamed and swollen parts interpose to respiration. Treatment. — Tonsillitis is one of that large number of diseases which take their own course. It may, nevertheless, be relieved by appropriate measures. The patient should be submitted to the same plan of general treatment that has already been recommended as suitable for catarrh. Nor need there be much difference in respect of local treatment. Hot fomentations, or flannel, or cotton wool may be applied to the exterior of the throat ; and the patient be persuaded to gargle his fauces frequently with warm milk, or to allow the steam of boiling water to play upon them, or to suck black currant jelly and such like substances. Sucking- lumps of ice, however, and the application of ice-cold compresses to the neck often give far greater relief than warmth. Astringent and stimulating gargles are often recommended, as is also the application of nitrate of silver. Such treatment, however, is more suitable to the period of con- valescence, at which time also tonics and good food may be specially needed. Opium judiciously administered generally gives great relief. Salicylate of soda in large and frequent doses has been strongly recom- mended. When the swelling of the tonsil is extreme and the congestion €30 DISEASES OF THE DIGESTIVE OEGANS. intense, and the patient at the same time is suffering severely, relief may sometimes be afforded by scarifying or pmicturing the tonsil. The value of such treatment, however, is chiefly seen when suppuration has taken place. Care should be exercised in puncturing the tonsil not to wound the large vessels which run along its outer aspect. The point of the lan- cet should be directed backwards, with an inclination mwards. But even if no large vessel be injured, dangerous hemorrhage occasionally ensues. B. Chronic Tonsillitis. Symjjtoms and progress. — As a consequence, sometimes of frequently repeated attacks of acute tonsilHtis, sometimes of chronic inflammation, the tonsils undergo gradual hypertrophy, and form indolent tumours, which more or less seriously diminish the size of the faucial passage, and occa- sionally come into actual contact with one another. The presence of such tumours may be scarcely apparent to the patient himself ; but in many cases, especially if large, they give a peculiar quality to the voice, which is indescribable, but impossible not to recognise when once it has been pointed out ; and not unfrequently there is associated wii^i them chronic thicken- ing of the mucous membrane of the pharynx and Eustachian tubes, together with deafness. Further, such patients are generally Hable to frequent exacerbations of the affection. Treatment. — Tonic medicines, iron and quinine and the like, good diet, fi-'esh air, and healthful exercise are of essential value in the treatment of chronic tonsillitis. It is commonly held that the application of strong solutions of nitrate of silver or of the solid caustic, or other such agents, is serviceable in promoting the disappearance of these bodies. Such apphcations are no doubt frequently beneficial m allaying inflammation affecting their surface. But the only effectual way of deahng with them is to remove them by the knife. VIII. EETKO-PHAEYNGEAL ABSCESS. Causation. — Eetro-pharyngeal abscess is usually due to caries of the cervical vertebras, and is sometimes one of its earliest indications ; it may be connected also with suppuration in and about the tympanum and Eustachian tube, even when the bone is not involved. We have met with it in a case of aortic aneurysm. Symptoms and progress. — A retro-pharyngeal abscess is situated, as its name indicates, between the posterior wall of the pharynx and the anterior aspect of the vertebrae, and forms a convex protrusion of greater or less extent and prominence at the back of the pharynx. It may be so high or so low as to escape detection by the usual method of observation ; but in most cases it forms a visible bulging at the back of the throat. It is sometimes symmetrical, sometimes more or less one-sided, soft and yielding to the touch, and not necessarily presenting superficial congestion. It is liable to undergo perforation from time to time, to allow of the OZiENA. 631 temporary escape of matter, and consequently to vary in bulk. Its presence is sometimes productive of pain and difficulty in swallowing, and has been known to impede respiration, and even to cause death by such impediment ; but not unfi'equently it is, for a time at least, simply a source of discomfort to the patient, in consequence of the pus which it exudes, the foul taste which it gives, and the fetor which it imparts to the breath. The progress of the abscess depends mainly on that of the •disease which produces it. The treatment, apart from the use of tonics, which is generally clearly mdicated, is essentially surgical. IX. OZ^NA. Causation. — This term is applied to all those cases which are attended with fetid discharge from the nose. The causes of oz^na are in some cases mere chronicity of uaflammation of the mucous surface, in some ulcerative destruction or gangrene, and m a large proportion of cases ■caries or necrosis of the nasal bones. These several morbid conditions are for the most part connected, either with scrofula, with syphilis, with lupus, or with polypoid or malignant growths occurring in the nasal -cavities. Symptoms.— The discharge which escapes from the nostrils varies con- siderably both in character and in quantity. Sometimes it differs little in appearance from ordinary mucus, often it is thick and purulent, some- times it contains blood, sometimes it is thin and ichorous. It frequently also tends to concrete in the cavities of the nostrils into thick crusts. The accumulation of mihealthy discharges in the antrum and other sinuses comaected with the nose often leads to their decomposition, and to fetor ; and the escape of such discharges is apt to take place at irre- gular mtervals. The nature of the stench which is emitted varies greatly both in quality and in intensity. In some cases it is horribly disgusting. Ozfena is generally attended with more or less complete loss of smell. The source of fetor may, even in the absence of discharge, be readily . ascertained by making the patient respire alternately through the mouth and nose, and ascertaining under which of these conditions it is chiefly developed. Treatment. — For this purpose the determination of the cause is of fundamental importance. If it be syphilitic, antisyphilitic remedies must be given ; if connected with enfeebled constitution, tonics and good diet must be enjoined. Under any circumstances the nose should be kept kjlean ; it should be frequently washed out, by means of a syringe or the nasal douche, with a weak alkaline solution, or a weak solution of quinine, Condy's fluid, chlormated soda, chlorate of potash, or carbolic acid ; and either stronger solutions of the same agents should be occasionally employed as injections, or appropriate powders should be frequently blown in or sniffed up. For the latter purpose Trousseau reccommends 632 DISEASES OF THE DIGESTIVE OEGANS. bismuth diluted with an equal part of some inert powder, or whit& precipitate mixed with about forty times its weight of finely powdered sugar. X. MOEBID GEOWTHS. A. Tubercle. — Miliary tubercles are described by Virchow as occasion- ally affecting the mucous surface of the tongue, palate, and nose, and there producing shallow sinuous ulcers, such as characterise the tuber- cular process in other mucous membranes. Tuberculosis of the tongue for the most part affects the posterior part of the organ, and is generally associated with similar disease about the fauces. Tubercular ulcers affectmg these situations are much like the tubercular ulcers of other mucous membranes. They are at first shallow, circular, ashy pits, which run together, and form intractable, slowly spreading ulcers, various in size, smuous in outline, with irregular thickened congested margins, and depressed shreddy greyish surface. B. SiJiMlis. — Syphilis in its secondary and tertiary stages is very ajot to affect the tract of mucous membane now mider consideration. 1. Erythematous patches, for the most part symmetrical, may appear on the pharynx or palate, inside the lips, or elsewhere m the mouth, during the prevalence of the secondary cutaneous eruption. 2. Mucous tubercles may develop durmg the same period, principally on the lips, dorsum and edges of the tongue, tonsils, and palate, and in the pharynx ; and shallow ulcers, secondary to these tubercles, or of independent origm, are not unfrequent in the same situations. 3. At a later period of the disease deep ulcers appear, most commonly in the soft palate, tonsils, fauces, and pharynx, frequently spreading in a serpiginous manner, and gradually involving a wide extent of surface or penetrating deeply, and in either case leading to serious destruction of tissue. 4. Lastly, gummatous tumours are not uncommonly developed in the soft palate and pharynx, but more especially in the substance of the tongue. For a further account of these affections, and their treatment, we must refer to the article upon syphilis. C. Malignant tummirs. — Tumours of various kinds originate in, or involve, the mucous membrane of the mouth and fauces, or the organs which are contained -wdthin the mouth. But it scarcely falls mthin the province of the physician either to investigate or to treat them. Malignant affections of these parts alone have any medical interest. They are not uncommon. In persons advanced in years, epithelioma of the lips (more especially of the lower lip) is apt to occur ; in those who have attained or passed middle life a similar affection of the tongue is not micommon ; and not unfrequently, imder the same circumstance of age, malignant disease (mostly epithelioma but sometimes carcinoma, sometimes sarcoma) be- comes developed in some part of the fauces or pharynx. Again, maHg- nant tumours (commonly some soft variety of carcinoma or sarcoma). DISEASES OF THE (ESOPHAGUS. 633 occasionally form in comiection witli the mucous membrane of the nose, for the most part in young children or persons advanced in life. Further, sarcomatous and carcinomatous tumours, originating either in periosteum or in bone, form outgrowths from the bones of the upper and lower jaws, from those bounding the nasal cavity, and from the cervical vertebrae. Malignant tumours of the mucous membrane are nearly always primary ; they are often slow and insidious in their progress, and apt at first to be mistaken for some trivial affection ; they are especially liable when they have made some progress to be confounded with syphilitic affections. That they are not syphilitic is, however, soon revealed by the total inoperativeness upon them of antisyphilitic treatment, and by their further progress. They gradually and surely invade the smTOunding tex- tures, gradually ulcerate and slough (causing more and more extensive destruction, and yielding a foul discharge), and always before long involve the neighbouring lymphatic glands. These then form gradually enlarg- ing tumours, which presently undergo precisely the same changes as the primary tumour. The diagnosis of these cases, which is often very un- certain in the beginning, rests mainly upon microscopic examination, and on careful observation of their gradual and characteristic progress. Their treatment is purely surgical. Section II.— DISEASES OF THE (ESOPHAGUS. I. INTEODUCTOEY EEMAEKS. Anatomical relations. — The oesophagus commences at the cricoid car- tilage, opposite the lower border of the fifth cervical vertebra, and runs down along the spine, a little to the left side, as far as the ninth dorsal vertebra, opposite which it penetrates the diaphragm, and opens into the stomach. In the neck it has the trachea in front of it, with the recurrent laryngeal nerves between them, and on either side the common carotid artery. In the chest it is covered in front by the lower part of the trachea and then crossed by the left bronchus, after which it comes into contact with the pericardium. On either side of it is the pleura. The transverse and descending arch of the aorta cross the front and left side of the oeso- phagus on the level of the second and third dorsal vertebrae ; and the thoracic portion of that vessel lies to its left and behind it throughout the rest of its course, excepting just as it perforates the diaphragm, when the aorta slips altogether behind it. II. INFLAMMATION OF THE (ESOPHAGUS. Caiisation and morbid anatomy. — The oesophagus is liable to share in all those inflammatory conditions which affect the pharynx and larynx. We have pointed out that the inflammation of a simple ' cold ' may travel downwards along this tube ; and when inflammation of special intensity 634 DISEASES OF THE DIGESTIVE OEGANS. involves the organs in relation with it, the oesophageal inflammation may be equally intense. Occasionally, indeed, under such circumstances thickening of its walls, with purulent infiltration of them and of the surrounding connective tissue, may extend from the pharynx to the cardiac orifice of the stomach. Further, the specific eruptions of some of the infectious fevers may involve the oesophagus, the diphtheritic false membrane may pervade its whole extent, and aphthous patches may form here and there upon it. Inflammation is sometimes also the result of swallowing boiling water or corrosive substances, such as the mineral acids, caustic alkalies, and other chemical agents. Symptoms. — In nearly all the above cases the oesophageal inflamma- tion is associated with similar but probably more severe inflammation, either of the larynx, pharynx, and fauces above, or of the stomach below ; and the graver symptoms of these other affections tend to mask the presence of the oesophageal complication. The special indications of in- flammation of the oesophagus are : heat and pain in the course of that tube ; aggravation of pain in the same situation during the act of swallow- ing, and in severe cases inability to swallow ; and tenderness on pressure applied to the neck in the situation of the oesophagus. The absence, however, of such symptoms does not disprove the presence of either general slight inflammation, or limited tracts of inflammation. III. CHKONIC AND OBSTEUCTIVE DISEASES OF THE (ESOPHAGUS. A. Ulceration. Causation and morbid anatomy. — The most frequent causes of ulcera- tion are mechanical violence, and the operation of destructive reagents, to which may be added perforation of the oesophagus from without. Small ulcers and mere excoriations doubtless get well, as a rule, with- out leaving any permanent ill effects behind ; but when ulcers are exten- sive and deep, even though they be free from any malignant taint, they are liable sooner or later to induce serious results. Of these the most important is cicatrisation, with consequent contraction of the calibre of the tube, and the supervention of a stricture which tends to become more and more tight. Other results are the formation of a sinus between the oesophagus and trachea, or left bronchus, and the perforation of an artery. B. Morbid Growths. Morbid anatomy. — The oesophagus is occasionally the seat of syphilitic disease with ulceration, which by cicatrisation may cause more or less serious contraction and obstruction. Of all adventitious formations, how- ever, the most common and. the gravest are of a malignant character. These are chiefly met with after the age of 40 or 45, and in the great majority of cases are of primary origin. The most frequent variety of ma- lignant disease probably is epithelioma ; but encephaloid and scirrhous DISEASES OF THE (ESOPHAGUS. 635- •cancers are not nnfrequent ; and colloid cancer also has been observed. The seat of the disease varies. In some cases it occupies the upper extre- mity of the tube, probably then involving also the contiguous pharjTax and larynx ; in some cases it is found at the lower extremity, when it is often associated with similar disease of the neighbouring cardiac extremity of the stomach ; but m the greater number of cases it occurs in some inter- mediate region, and very frequently in that part of the tube which is m relation with the trachea and bronchi. The affection, when primary, usually commences at some spot in the thickness of the mucous and sub- mucous tissues, whence it spreads, superficially, so that before long it probably occupies three or four niches of the length of the oesophagus and its whole circumference ; and in depth, so that sooner or later it implicates the whole thiclaiess of the walls, and probably invades also the trachea or other neighbouring tissues and organs. The fi'ee aspect of the growth is at first somewhat nodulated ; but the nodules running together soon form flattish elevations, in connection with which, before long, ulceration, sloughmg, and the formation of fungous outgrowths take place. The thickened walls and nodulated outgrowths reduce the calibre of the oesophagus, and sometimes render it almost impervious. The subsequent ulcerative destruction occasionally leads to its imperfect restoration. When the disease is of the colloid variety, the close-set vesicles of the growth open on the mucous surface, and abundant, clear, glairy fluid escapes. In the progress of malignant disease various accidents are apt to arise. Sometimes the trachea or left bronchus gets perforated, and a communi- cation between it and the oesophagus established ; sometimes the oesopha- gus opens into the posterior mediastinum, or externally, or communicates by ulceration with one of the oesophageal or intercostal arteries, or the left subclavian. And, besides the mere spread by contiguity, oesophageal mahgnant gro'svths, like those of other parts, soon cause secondary disease in the neighbouring lymphatic glands, and, if the patient sur\T.ve sufficiently long, disease of remote organs. The involvement of lymphatic glands, especially if they be those of the neck, is very often valuable as an aid to diagnosis. Further, it not very unfrequently happens that the recurrent lar}Tigeal nerve, especially that of the left side, is implicated, and paralysis of the corresponding vocal cord induced. C. Afections implicating the (Esophagus from zoithout. Causation and morbid anatoimj. — The oesophagus is apt to be pressed upon or otherwise affected by tumours and other morbid conditions origi- nating externally to it ; and the patient's sufl'erings in many such cases •are mamly, if not entirely, due to interference with the functions of this canal. Thus it may be compressed by an overgrown thyroid body eneh-clhig the trachea and acting upon it laterally ; by a carotid or in- nominate aneurysm, or an aneurysm of the descending arch or thoracic :aorta ; by enlargements of the bronchial glands and other mediastinal .growths ; by tumours sprmgmg fi-om the vertebrae ; by abscesses ; and ■even by a distended pericardium or dilated auricles. 636 DISEASES OF THE DIGESTIVE OEGANS. Again, aneurysms and abscesses not tinfrequently open into tlie oeso- phagus with a sudden and copious escape of blood or pus. Occasionally they open simultaneously into the oesophagus and trachea, or one of the bronchi, causing more or less free communication between these tubes. And further, rupture of an aneurysm of the lower part of the thoracic aorta occasionally causes an accumulation of coagulum around the cardiac end of the oesophagus with complete obstruction of its passage. D. Dilatation. Causation and morbid anatomy. — Whenever a stricture of the oeso- phagus has existed for any length of time, a tendency shows itself for the part of the tube below to contract and even to undergo atrophy, and for the part of the tube above to become dilated, and at the same hypertro- phied in respect of its muscular parietes. The same results indeed follow here that follow in the case of the bladder when there is stricture of the urethra. The dilatation and hypertrophy are in the majority of cases not strikingly apparent ; sometimes, however, they are considerable, and espe- cially when stricture is situated low down, is non-malignant, and has been in existence for many years. Under such circumstances the oesopha- gus becomes dilated either in its whole length, or in a part of its length only, forming an elongated pouch, which may have a circumference of five or six inches. Such dilatations are sometimes discovered in cases where their development cannot be traced to the existence of any mechanical impediment. It seems obvious, however, that they must even here be due, partly to distension by accumulated contents, and partly to powerful and sustained efforts of the muscular tunic to drive these contents onwards ; and that hence there must have been in the first instance some weakness or sluggishness of the tube, some virtual impediment, permitting of such accumulation. E. Spasm and Paralysis. Spasmodic stricture of the oesophagus generally occurs in nervous persons, and especially in hysterical women. It may appear, however, without obvious cause in persons of quite different nervous organisation ; and not mifrequently supervenes in the course of organic oesophageal disease, causing temporary aggravation of the patient's symptoms. Paralytic conditions of the oesophagus are rare. They may be hyste- rical, or dependent on profound affection of the central nervous organs. Occasionally they are a result of inflammation of the tube. F. Syviptoms. Dysphagia. A common symptom of nearly all the above lesions is dysphagia, or difficulty or pain in swallov/ing. It is this symptom, indeed, which generally first attracts attention to the oesophagus as the seat of disease ; and it is only by the subsequent history of the case, by the supervention or non- supervention of other phenomena (oftentimes mere hints), that we are enabled to ascertain the exact nature of the disease which is present. DISEASES OF THE (ESOPHAGUS. 637 Dysphagia is a symptom of many other morbid conditions besides these ; and especially of affections of the mouth, fauces, larynx, and pharynx. But under these circumstances, it is for the most part merely a subordinate symptom of diseases otherwise well characterised. It is very different, however, when the impediment to swallowmg exists in the course of the oesophagus ; it is then not merely a symptom, but it is the symptom by which alone, in many cases, the presence of disease is indicated. The sym|)toms of organic obstruction are usually of slow development ; the patient perhaps first experiences an occasional hitch in the passage of food to the stomach — a hitch which is chiefly obvious when sohds are being swallowed. This is variable, partly because the bulk and character of the swallowed bolus differ from time to time, and partly h-om the occasional superaddition of spasmodic contraction. Further, it is pro- bably always referred to a definite point, and is not mifrequently asso- ciated with soreness or pain there. For some time probably these symptoms have little attention paid to them ; but gradually they increase in severity and constancy, and attend the swallowing of both liquids and sohds ; further, the food before long begins to accumulate above the seat of obstruction, and hence to be regurgitated after a longer or shorter period of time with a kind of gulp — -an effort which often has little or no resemblance to ordinary vomiting. The period at which regurgitation takes place after deglutition depends partly on the seat of obstruction, partly on the degree of irritability of the oesophagus, and partly upon its condition as to dilatation. Generally when the obstruction is high up, the regm'gitation is immediate ; when, however, it is low down, as at the cardiac extremity, the return of food is usually delayed for a few seconds or mmutes, and in some cases for half an hour, an hour, or more. The food indeed may be retamed so long as to undergo early putrefactive changes, but the vomit contains neither the acid secretions of the stomach, nor bile. As the disease progresses, the patient has to restrict his diet to slops, and ere long finds that he can take even such food as this only in the smallest quantities, and with difficulty and distress. He then rapidly emaciates, his abdomen becomes hollow, and, if no fatal comphcation ensue, he dies after a longer or shorter period of suffering from simple starvation. Such deaths are usually exceedingly distressing, because the patient, as a rule, retains his mental powers unimpaired to the last, and craves for nom-ishment which camiot be administered to him. These are the general symptoms of oesophageal obstruction ending fatally. But the progress of the case is usually largely modified by the nature of the disease on which it depends. If the case be one of simple stricture from a cicatrix, its course is generally much protracted. And although such cases are often ulti- mately fatal, instances are on record in which patients have lived, though with more or less discomfort, to a good old age, and have then died of some other ailment. It is in them especially that dilatation of the tube above the stricture with compensatory hypertrophy takes place — condi- 638 DISEASES OF THE DIGESTIVE OEGANS. tions whicli, confined within certain limits, tend to neutralise the effects of the stricture. If the case he one of malignant disease, this fact is often for a while incapable of determination. The points which especially indicate it are : the comparative rapidity with which the case goes on from bad to worse ; the advanced age of the patient ; the appearance of indurated glands in the neck ; the supervention of hoarseness or impurity of voice from impli- - cation of the recurrent laryngeal nerve ; and the discharge from the oesophagus, in company with regurgitated food, of offensive, puriform, or sanious matter or detritus. Further, the sudden discharge of blood in large quantity, or the establishment of a communication between the oesopha- gus and air-passages, strongly indicates, though it does not prove absolutely, the presence of a malignant ulcer. Copious hemorrhage is occasionally one of the earliest phenomena. The symptoms due to the pressure of external growths differ but little from those arising from actual disease of the oesophageal walls ; indeed, the latter usually after a time become distinctly implicated. To aid our diagnosis we must carefully explore the neck and thorax, m order to ascertain whether there be an enlarged thyroid body, a mediastinal growth, an aneurysm, or any other form of tumour. But although in many such cases we may be enabled to form a correct diagnosis, in many all our efforts will necessarily be fruitless. We have stated that organic obstruction is usually of slow develop- ment ; nevertheless it occasionally arises with sudden completeness. In the case, for example, of obstruction from the compression exerted by a circle of effused blood around the cardiac orifice, the symptoms occur quite suddenly, and the patient dies probably of starvation at the end of ten days or a fortnight. An important point in reference to oesophageal obstruction is to ascer- tain its exact seat. It is important, partly in connection with the treat- ment to be adopted, partly as an element in determining the exact nature of the obstruction. Its site may be pretty correctly determined in many cases by the sensations of the patient. It is often indicated to some extent by the phenomena already considered which follow the ingestion of a few mouthfuls of milk or other food. It is, however, on the passage of the bougie, and the determination of the exact point at which its progress gets arrested, that our main reliance must be placed. Another occasionally useful method is that of auscultating the oesophagus. If the stethoscope be applied to the back in the course of this tube, and the person examined be made to swallow a mouthful of fluid, its momentary passage in the form of a compact mass is distinctly audible. If, however, an impediment exist, especially if the impediment be considerable, there will be some obvious delay in the passage of the mass at its seat ; and, moreover, the mass, instead of passing in a compact form, will probably trickle through in driblets, and its passage be attended with comparatively prolonged gurgling. It is not sufficient, however, to determine on one occasion the existence of gurgling at a particular spot. We must ascer- DISEASES OF THE (ESOPHAGUS. 639 tain, by repeated observation, whether that locaHsed gurgHng is perma- nent or not. Dilatation alone of the oesophagus is an impediment to the act of deglutition. The presence of dilatation, even if there be muscular hyper- trophy, necessarily renders the oesophagus a less efficient instrument for the propulsion of its contents. These, instead of being driven readily and rapidly onwards, accumulate in the flaccid bag, and thence find their way fitfully into the stomach. One of the most interestmg phenomena con- nected with dilatation is the tendency which there often is for the accu- mulated contents of the tube to be regurgitated by an effort, more or less voluntary, into the mouth, as m the act of rumination. Spasmodic stricture is apt to come and go more or less suddenly, and, if it be long continued, to present intermissions or variations of severity. It is attended with many of the symptoms of organic stricture, for which it may easily be mistaken, and may even, if neglected, lead to death by starvation. The diagnosis rests partly on the patient's history and general state of health, partly on the variableness of the oesophageal obstruction, and partly on the evidence furnished by the unopposed pas- sage of the bougie. It may affect any part of the oesophagus. In one case under our care a man of 50 had spasmodic stricture of the upper part of the tube, which for a week prevented him from swallowing the least portion of fluid or solid food. The act of deglutition was performed, but followed immediately by the spasmodic ejection of whatever he had attempted to swallow. He was permanently cured by a single introduction of the bougie. In another case an hysterical girl had obstruction of the lower part of the oesophagus. For many weeks little, if any, food entered the stomach ; but it was retained in the oesophagus for a variable time^ and then regm'gitated without the ordinary phenomena of vomitmg. In this case also a cure was effected by the use of the bougie. The symptoms due to paralysis of the gullet are also mamly those of obstruction. The food fails to be transmitted onwards to the stomach, and at the same time tends to accumulate in the tube, to distend it, and sconer^or later to be regurgitated. The bougie passes without impediments G. Treatment. (Esophageal obstruction is, in a very large proportion of cases, difficult and unsatisfactory of treatment. If it be functional only, the passage of a bougie will sometimes at once restore the capability of swallowing. The permanent cure, however, of such cases is often to be obtamed only by curing the nervous conditions on which the obstruction depends. If, on the other hand, the obstruction be organic, the tendency of the disease is to render the occlusion of the tube more and more complete, and actual cure is probably out of the question. We have no drugs which promote the absorption of cicatricial bands, or of carcinomatous or other tumours.. We can, however, in some cases, by surgical means, check the progress of contraction, and even cause dilatation of a part already strictured. We have pointed out the importance, for diagnostic purposes, of passing 640 DISEASES OF THE DIGESTIVE OEGANS. an oesophageal bougie. The careful passage of a bougie through a stric- ture, and the repetition of the operation at intervals with instruments of gradually increasing size, wiU not only aid us in diagnosis, but in some cases reheve the stricture materially, and maintain that rehef. The passing of a bougie, however, through an obstructed oesophagus is an operation of much delicacy, and attended with no mconsiderable danger, especially if the impediment consist of a tract of soft ulcerating cancerous material, or be due to the pressure of a thoracic aneurysm. The bougie may in fact, under such circumstances, readily form a false passage into either the trachea, the mediastinum, or the cavity of an aneurysm, and so induce speedily fatal symptoms. So great is this danger, that many practitioners regard this mode of treatment as almost entirely inadmis- sible ; and indeed it must, we think, be conceded that it is quite inadmis- sible m cases of compression of the oesophagus by an aneurysm, and in ■cases of malignant disease hi which ulceration or sloughing has taken place. But there camiot, we think, be a doubt of the benefit which may accrue from the regulated use of the bougie, m skilful hands, in cases of simple stricture. The dilator suggested by Dr. M. Mackenzie is well suited for such cases. The passage of the bougie has occasionally rup- tured an abscess to which obstruction was due, and in this way cured the patient. When the ingestion of food is largely interfered with, and the patient shows manifest signs of starvation, the question as to whether he may be supphed with food by any other route than the oesophagus arises. The use of nutritive enemata is one of the methods which suggest them- selves, and is often useful in prolonging hfe. Another method is that of laying open the stomach itself through the anterior abdominal wall, and feeding the patient through the artificial opening. This operation has occasionally been performed, and although the cases have not been very successful, the feasibihty of the operation has been clearly demonstrated. When the stricture is simply spasmodic, it may, as we have already shown, generally be treated successfully by the employment of the bougie. In those cases in which the dysphagia is due to paralysis or simple dilata- tion of the oesophagus, the patient may, of course, be fed and life main- tamed by the constant use of the stomach-pump. Section III.— DISEASES OF THE STOMACH, INTESTINES, AND PEKITONEUM. I. INTEODUCTOEY EEMAEKS. A. Anatomical Belatlons. The surface of the abdomen is artificially divided into regions which are convenient in determining the relations of the organs situated within. This di^dsion is usually effected by drawing two horizontal Hues : one above, from the lowest point to which the ribs descend on the one side to the corresponding point on the other side ; one below, between the an- terior superior spines of the iliac bones ; and then intersecting them by EXAMINATION OF THE ABDOMEN. 641 two vertical lines drawn, one on either side, from the cartilage of the eighth rib above to the centre of Poupart's ligament below. Nine un- 'Cqual spaces are thus mapped out ; of which the three occupying the median aspect of the abdomen are, from above downwards, the epicjastrium or scrobiculus cordis, the uinbilical region, and the hypocjastrium ; and the three on either side are, in the same order, the hypochondrium, the Ittmbar region, and the iliac region. The hypochondriac and iliac regions are small and triangular ; the lumbar extend round to the spine, occu- pying on either side the whole interval between the ribs and the crest of the iHum, and are, therefore, of considerable extent. The epigastric region is occupied mainly by the stomach, inclusive of its pyloric extremity, portions of the right and left lobes of the liver ap- pearing above on either side of the ensiform cartilage ; more deeply seated lie the hepatic vessels, pancreas, coeliac axis, and semihmar ganglia. The umbilical and hypogastric regions are occupied almost exclusively by the ■convolutions of the small mtestine ; along the upper part passes the transverse colon, and into the lower part ascend the distended bladder and the gravid uterus. Deep in these regions lie the third portion of the duodenum above, and the mesentery with its vessels and glands below. The aorta divides opposite the navel. The rigid hypochondriac region contains the lower edge of the right lobe of the liver with the gall-bladder, and the hepatic flexure of the colon ; more deeply the first and second portions of the duodenum ; and more deeply still the upper part of the right kidney and the supra- renal capsule. The left hypochondrium is occupied by the lower portion of the spleen, the cardiac extremity of the stomach, the splenic flexure of the colon, and more deeply by the upper part of the left kidney and the supra-renal body. Each lumbar region is occupied by the convolutions of the small intestine, laterally by the ascenduig or descending colon, and further back by the lower half of one of the kidneys. In the right iliac region is placed the cfecum, in the left the sigmoid flexure. B. Exavmiation of the Abdomen. The direct examination of the abdomen in all cases of disease of the contained viscera, and in aU affections attended with symptoms referrible to these organs, should never be neglected. And in conducting such examinations, and forming our opinions from them, we must always recollect, not only the normal positions of the parts within, but the facts that even in health many organs are liable to considerable changes of bulk and position, and that in disease such changes are often in the highest degree misleading. Apart from rectal, vaginal, and urethral ex- aminations, which we shall not now enter upon, the methods of investi- gation include mspection, palpation, percussion, and auscultation. 1. Inspection. — Much may often be learnt by simple mspection. The Jorm of the abdomen in many diseases is no doubt entirely normal ; but it is often importantly and characteristically modified. In cases of extreme emaciation, especially from starvation, the surface becomes flattened or even concave ; and a somewhat similar retraction of the parietes is frequently T T 642 DISEASES OF THE DIGESTIVE OEGANS. observed in cerebral disease, particularly among children. On tlie other hand, the abdomen is often more prominent than natural. This condi- tion may be due to fat in the parietes, or to anasarca ; in which case the general symmetry of the belly is maintained, but the umbilicus is usually deeply sunk. It may depend on distension of the stomach and bowels ; when not unfrequently the abdominal walls (especially if they be thin) are moulded in some degree to the alternate depressions and elevations of the subjacent organs. When distension is the consequence of ascitic accumu- lation, the belly (owing to the influence of gravitation) has a tendency, as the patient lies on his back, to expand laterally and to bulge in the flanks — a tendency, however, which often disappears when the accumulation be- comes very large, and may be masked by coincident tympanites or rigidity of the parietes. Enlargement due to hypertrophy of solid organs, to tumours, or to abscesses, is rarely symmetrical. The movements of the abdominal walls are often significant. In pericarditis and pleurisy, and especially in paralytic affections of the diaphragm, and peritonitis, with other inflammatory affections of the abdominal organs, the diaphragm is inactive, and the surface of the belly remains quiescent during respira- tion. In cases of distension of the stomach or bowels, especially if it be due to any mechanical impediment to their action, the peristaltic move- ments of the dilated organs may often be distinctly seen and traced. It need scarcely be added that the movements of the foetus in the gravid uterus are distinctly visible. The condition of the parietes, again, may be of service to us. We may note the presence or absence of eruptions, or of dilated veins which generally accompany ascites, tumours, and obstructive disease of the portal vein, vena cava, or iliac veins. We may also observe whether they present circumscribed redness, brawniness, or swelling, such as indicates the pointing of an abscess or the extension of inflammation from beneath, or whether there be any cutaneous or subcutaneous tumour, or an umbilical or any other hernia. Further, it may be remarked, not only that abdominal walls which have been the seat of much dropsical effusion or fatty accumulation fall into wrinkles when the fluid or fat disappears, but also that when once the abdomen has been largely dis- tended (whether by pregnancy, ascites, or any other condition) they are liable to present those atrophic lines which habitually follow childbirth. 2. Palpation. — By manual or tactile examination we distinguish the different degrees of hardness, softness, resistance, and elasticity of the abdominal walls and subjacent parts, and can thus often determine the size, shape, quality, and relations of tumours. Moreover, we may recog- nise the fluctuation due to the presence of fluid, the pulsation of arteries and aneurysms, the thrill or crepitation resulting from inflammatory de- posit, and the peristaltic movements of the stomach and bowels. When the parietes are flaccid, especially if they be at the same time thin, we may sometimes by careful manipulation map out the form of the kidneys and other deep-seated solid organs. Indeed, under such circum- stances the kidneys have been mistaken for tumours, and the abdominal arteries (especially those which lie on the promontory of the sacrum) for EXAMINATION OF THE ABDOMEN. 643 an aneurysm. When the walls are rigid (as in fact they are only too apt to be in those cases where examination is most needed) it is often ex- ceedingly difficult to determine the condition of parts within. Moreover, portions of the rigid recti muscles are then very liable to be mistaken for tumours. In this case the patient should be made to lie on his back with elevated shoulders and knees, and heels pressed into the bed ; and then the physician with warm hand or hands should press quietlj^ but firmly on the abdomen, making the patient from time to time draw a deep breath. By such means, and taking constant advantage of each momentary relaxation, he may often in a short time overcome the muscular rigidity, and learn all that is necessary with regard to the subjacent organs. If these measures fail, the patient must be examined under the influence of anaesthetics. The source of a tumour is in great measure distmguishable by its site and relations to the abdominal organs. We need not particularise the different localities in which we should expect to discover tumours of the liver, spleen, kidneys, or other viscera. We may, however, point out the im- portance and mode of determining whether a tumour be in the abdominal walls or adherent to them, or spring from the back of the cavity, or be connected with some of the movable parts within. A tumour of the walls necessa.rily rises and sinks with the walls during respiration. A tumour connected with the liver, spleen, stomach, bowels, or omentum ascends and descends with the movements of the diaphragm, and, if unattached to the abdominal walls in front, can be distinctly felt to glide under them. This locomotion, dependent on the diaphragm, is of course most obvious in the case of tumours restmg against the diaphragm or near it. Tumours springing from the kidneys or back of the abdomen are usually fixed, or, if movable at all, generally slightly in the transverse direction. Many growths connected with the stomach, bowels, ovaries, and peritoneum are freely movable, either under the hand of the examiner or with change of position. The form, size, and consistence of tumours, and the presence or absence of fluctuation in them, are points of importance. The presence of fluid in the peritoneal cavity is generally attended with the sense of fluctuation. This is best obtained by pressing the left hand firmly and flat upon the abdomen, and then giving a sharp tap or fillip with the fingers of the opposite hand. It is most marked when the fluid is abundant, and the walls thin and tense. The sense of fluctuation comprises two elements : the one an instantaneous impulse conveyed through the fluid and not generally very perceptible ; the other a wave which travels over its surface and involves the abdominal parietes. The latter is what is usually meant by the term ; but it must be remarked that it (or something very like it) is occasionally observed m flaccid abdomens free from dropsy, and that it may be arrested or annulled by pressure made on the abdomen between the finger which percusses and the hand which receives the impression. In connection with the presence of ascites it may be observed that a layer of fluid, varying say from half to one inch in thickness, often intervenes between the upper surface of an T T 2 644 DISEASES OF THE DIGESTIVE OEGANS. enlarged liver and the anterior abdominal walls ; and that the presence of the liver may then often be readily detected by pressing the finger per- pendicularly with suddenness and force, and thus displacing the fluid and coming into sudden contact with the surface of the solid organ. 3. Percussion. — On percussing the abdomen we obtain as a general rule resonance or dulness, according as we operate over the stomach and bowels or over solid organs. Abdominal resonance is higher pitched and more musical than that elicited over the lungs. It is also much more variable in health, owing to the varying distension of the different parts of the alimentary canal. The percussion note is of course higher ac- cording as the tube percussed is narrower ; hence deeper notes are usually obtained over the stomach than over the colon, and over the colon than over the small intestine. But in morbid states (which need not here be specified) the stomach may contract so as to yield a note like that of the healthy ileum, or the ileum or colon may become so much dilated as to furnish a note like that usually belonging to the stomach. Although percussion for the most part gives a dull sound over solid organs, it is an important fact that distinct resonance may often be elicited over the thin edge of the liver, due to the liver and abdominal parietes vibrating to- gether over the subjacent stomach. Occasionally also such resonance may be elicited over the spleen. The determination of the exact dis- tribution of resonance and dulness is often very important in reference to the diagnosis of abdominal tumours — the course, for example, which the ascending, descending, or transverse colon may take in relation to a tumour, often deciding for us whether it arises in the kidney, liver, retro- peritoneal glands, or some other part. It is necessary, therefore, to bear in mind that a line of bowel lying superficially to a solid mass may be readily overlooked if care be not taken in the examination ; for if, as in ordinary percussion, the finger of the left hand be pressed upon the part to be percussed, the bowel may be readily flattened under its influence, and dulness result. In all such cases, and indeed generally in abdominal percussion, when we are anxious to make a minute and critical examina- tion of the condition of parts lying immediately under the walls, it is best to percuss by simply filliping the surface with the nail of the right forefinger. Of the peculiar prolonged thrill often observed on percussion over a hydatid tumour we shall speak hereafter. 4. Auscultation. — Of course gurgling and musical sounds of all sorts may be heard with the stethoscope over the stomach and alimentary canal, but little or nothing is to be learnt from them. Besides these, arterial murmurs due to the presence of aneurysms, or to the pressure of tumours, or of the stethoscope, venous murmurs in connection with the gravid uterus, abdominal tumours, or dilated veins, the beats of the foetal heart, and fric- tion sounds in connection with hepatic or splenic peritonitis, may be met with under different circumstances. GASTKITIS. 645 II. GASTEITIS. Causation. — Acute gastritis in its severest form is exceedingly rare, unless it be the result of the direct application of irritant or corrosive substances to the mucous surface of the stomach. Its milder varieties, on the other hand, are very common at all ages and in both sexes, and from their mildness not unfrequently escape notice. The causes of gastritis are various ; and include the ingestion of irritant or corrosive substances, the use of food which is ill-masticated, too abundant, or unwholesome (there- fore, excess in eating and the abuse of alcohol), exposure to cold, and other atmospheric influences. Among predisposing causes must be enumerated constitutional debility, tuberculosis, various acute febrile complaints, heart, lung, and renal disease, and cirrhosis of the liver. Morbid anatoviy. — Slight inflammation, though obvious enough when seen, as in the case of Alexis St. Martin, during life, often leaves little trace of its existence after death. It is indicated by patchy congestion ; enlargement of the epithelial cells, with a cloudy condition of their proto- plasm, and the appearance of fat granules within them ; similar changes in the cells of the mucous glands ; and hypertrophy of the lymphatic tissue. These conditions involve some degree of thickening and softening of the mucous membrane, and are attended with the formation of a greater or less abundance of ropy alkaline mucus, and diminished secretion of the true gastric juice. But these are not the only changes. Frequently, small extravasations of blood take place here and there into the substance of the mucous membrane, and small quantities of blood may even escape into the cavity of the stomach ; and sometimes erosions, shallow ulcers, or super- ficial sloughs are developed. Some of the latter appear to be connected with previous hemorrhagic infiltration, if not dependent on it. When in- flammation is due to the action of corrosive substances, the morbid ap- pearances are determined largely by their several peculiarities of chemical action. There is usually, however, intense congestion, with more or less extensive destruction of the mucous membrane. Inflammation involving the whole thickness of the gastric walls is rare as an idiopathic affection. In these cases they are swollen in their entire thickness, sometimes in- filtrated with simple inflammatory exudation, or pus, sometimes presenting scattered abscesses. The morbid anatomy of chronic inflammation differs little from that of the acute affection. There is generally, however, less congestion and more degeneration. The mucous membrane is usually thicker than normal, pale, and comparatively tough. It may present extravasations of blood, and excoriations or ulcers. But more frequently it is studded here and there with black or slate -coloured spots, which are the pigmental remains of old extravasations or congestions ; and with opaque white patches, which are due to fatty degeneration of the epithelial contents of groups of gland tubes, and even of the corpuscles of the connective tissue between them, and are often associated with atrophy and shrivelling of the glands, and a tendency to the formation of cysts. 646 DISEASES OF THE DIGESTIVE OEGAXS. Syviptoms and ijrogress. — 1. In severe idiopathic gastritis, as also in gastritis due to irritant poisoning, the symptoms are of an exceedingly violent character. The patient suffers from intense burning and shooting pain in the epigastrium and lower part of the chest in front, and between the shoulders, attended vrith rigidity and retraction of the abdominal muscles ; extreme tenderness on pressure in the epigastric region ; aggrava- tion of pain on drawing a deep breath, with consequent shallow respfration ; nausea, retching, and vomiting, not only after everything that is taken into the stomach, but even when the organ is empty ; total loss of appe- tite ; intense thirst, and collapse, marked by extreme feebleness of pulse, coldness and pallor of surface, cold perspirations, and tendency to famt. Besides these symptoms, distressing hiccough usually supervenes, and the bowels may become loose. The character of the vomit depends on cfrcum- stances. Generally, however, it comprises mucus (which is often mingled with altered blood), bile, and of course such matters as have been swallowed. The supervention of collapse, which forms so marked a phenomenon of the affection, is preceded by heat of skin and other febrile sjinptoms, which, however, soon subside. When the case ends fatally, death is mostly due to prostration ; and the patient usually retains consciousness to the last. The date at which death supervenes varies generally between one and six or seven days. If recovery take place, it is usually protracted. 2. In the commoner and milder forms of acute gastritis, the symptoms are essentially the same as those which characterise the graver attacks : namely, heat or aching in the region of the stomach ; tenderness on pressure in the epigastrium, with more or less rigidity of the abdominal muscles, especially the recti, and the endeavour to obtain ease by bending the body forwards, and restraining the action of the diaphragm ; irritabihty of stomach, with tendency to eructation and to reject by vomiting whatever is taken into it ; anorexia, thirst, and febrile disturbance. Besides which, the tongue is usually coated, and there is headache, ^ith intolerance of Hght, depression of spirits, and disturbed sleep. The sj-mptoms are sub- ject, however, to great variety, and even the most characteristic of them may be absent. Pam ui the stomach may fail wholly, or exist as a mere sensation of warmth, or it may be replaced by a \iolent craving for food. Ingestion of food, however, in such cases does not usually give the anticipated rehef, and often brings on pain and induces vomitmg. Irritabihty of the stomach may be extreme ; on the other hand, it may be indicated by fr'equent eructations only. Under any cfrcumstances, however, the taking of food or di"ink, except in moderation, ^ill probably ensure its rejection and bring on epigastric pain. The vomit consists of ropy and tenacious mucus, mixed with matters which have been swallowed, and (if the vomithig have been prolonged) with bile. Blood in small quantities may be contained in it. The breath is febrile or offensive, and not un- fr'equently fetid. The eructations occasionally have the odour of sulphm-- etted hydi'ogen. Thfrst is generally a marked featm-e, but now and then is wholly absent. The temperature is usually elevated above the normal, GASTEITIS. 647 Tjut rarely exceeds 100° ; it presents variations during tlie day, and, for the most part, an afternoon or evening rise. Tlie patient often feels chilly, and even has distinct rigors. The skin is hot, but disposed to be moist at times. In most cases the tongue becomes covered early ynth. a thick whitish or brownish creamy fur, through which the congested fungi- form papillae protrude ; but it may be abnormally red and clean, and then often dry, glazed, and fissured. In some cases it is little changed from the normal. Taste is usually perverted ; and there is often a sensation of bitterness or a metalhc flavour. Headache is usually very severe, of an aching or throbbing character, and limited to some particular region, Li some cases it is difficult, if not impossible, to distinguish it from that of megrim. Chiefly when the headache is h'ontal there is disturbance of vision and photophobia. The patient is commonly more or less irritable and restless, yet depressed ; he is often drowsy, yet miable to obtain re- freshing sleep — his rest bemg disturbed by dreams, Fm-ther, the action of the heart frequently becomes enfeebled, the pulse quick and small, the extremities cold ; and there may be palpitation, faintness, dyspncea, and confusion of mind. Associated with gastric inflammation there is often disturbance of the bowels, generally flatulence, and either constipation, griping and purging, or irregularity of action. These disturbances, how- ever, are in many cases due to concurrent inflammatory implication of the m.ucous membrane of the bowels. In some cases the symptoms of the milder forms of acute gastritis scarcely differ from those of enteric fever ; while in some they are little more than such as constitute an ordinary sick headache ; and in others amount collectively only to that vague sense of illness to which the term ' malaise ' is commonly applied. In young childi-en, drowsiness and other cerebral phenomena, such as coma and convulsions, are not mifre- quent accompaniments of the gastric disorder ; and it is among them that diarrhoea is chiefly common. When gastritis arises in the course of other affections its symptoms are liable to be overlooked, 3, The symptoms of chronic gastritis necessarily present a considerable resemblance to those of the acute disorder, but are on the whole more vague, and merge into those included in the collective term dyspepsia. The patient, moreover, is in many cases liable to remissions, duruig which he appears to enjoy comparatively good health. In other cases he ails contmuously. Febrile symptoms, on the whole, are shght, and often altogether absent ; thirst, anorexia, vomiting, and uneasiness or pain in the epigastrium and between the shoulders, are all more variable and . generally less severe than in the acute disorder; vomiting, however, of an abundance of glairy mucus is often a characteristic phenomenon ; the tongue varies in its condition, as it does in the acute affection, and often gets furrowed or intersected with fissure-like depressions ; the breath is offensive ; the bowels usually are confined ; and the patient becomes restless, irritable, nervous, and hypochondriacal, but rarely suffers so . severely from headache as those who labour under the more acute dis- order. With its continuance emaciation and debihty come on, with 648 DISEASES OF THE DIGESTIVE OEGANS. defective circulation, coldness of extremities, and tendency to palpitation and faintness. Numberless other symptoms and consequences, of more or less importance, are commonly, and no doubt in the main correctly,, attributed to chronic gastritis. For the most part, however, they consti- tute no essential part of it, and are comiected with it only as they are wdth many other affections in which the processes of nutrition are pro- foundly involved. Treatment. — -1. Li the treatment of severe acute gastritis local mea- sures are of great importance. Leeches (twelve, twenty, or more) may be applied to the epigastrium ; or warm fomentations may be employed,, or ice, or mustard poultices and other counter-irritants. Which of these applications should be selected must depend on the severity, or stage, or other conditions affectmg the case. The irritability of the stomach renders the introduction of food and medicine in bulk into that organ impossible or undesirable. A little ice may be sucked, or ice-cold water or milk sipped ; and opiates in large doses should be administered. If given by the mouth they should be m the form of pill, powder, solution of morphia, or undilute liquid extract of opium. The association of opium with bismuth or magnesia is often very efficacious. The best mode, however, of introducing opiates is undoubtedly by subcutaneous in- jection. 2. In less severe cases, local bleeding need scarcely ever be resorted to, but warm fomentations and counter-irritants are of benefit. Here also the use of ice, or minute quantities of ice-cold water, often affords much rehef. And generally it is desirable to avoid as far as possible the administration of food or drink until irritability and pain have in great measure subsided. Li some cases opium is of great value; but generally it is not called for. Bismuth, magnesia, lime-water, nitrate of silver,, effervescent alkalies, and hydrocyanic acid are often very beneficial. When constipation is present, or there is evidence of implication of the bowels, purgatives are valuable, especially perhaps castor oil, calomel in combination with rhubarb, and enemata. When food is given it should be of light quality and easily digestible. Milk and farinaceous substances are most suitable. Later on, animal broths, fish, and chicken may be allowed. Alcohohc drmks are not desirable, unless there be marked ten- dency to depression or collapse. Under similar circumstances ammonia is often ser^dceable. 3. Chronic gastritis usually requires much attention to hygienic con- ditions. The patient should be enjoined to take moderate and regulated exercise, to seek change of air and scene, to keep good hours, and generally to adopt such a mode of life and such habits as are conducive to health.. The diet should be strictly regulated, but it is difficult to lay down definite rules mth respect to such regulation. The patient's own experience is usually an important, if not the best, guide. He should carefully avoid all those articles of diet which he has found to be prejudicial to him, how- ever wholesome theoretically we may suppose them to be. Milk, well- cooked farinaceous substances, fish, fowl, and well-roasted mutton and ENTEEITIS. 649 beef ill small quantities, are probably on the whole tlie most suitable. Pounded raw beef is often well borne. Salted meats, rich and bigbly seasoned dishes, pork and veal, should be especially eschewed. Tea often disagrees. Alcohol is seldom beneficial, and should only be used spar- ingly and in a dilute form. The particular beverage to be employed must depend on circumstances. As to medicinal treatment, the bowels should be regulated by occasional laxatives or mild purgatives ; and tonics (especially quinine or nux vomica in combination with hydrochloric acid, and calumba or gentian associated ^^ith alkahes and rhubarb, or bismuth) effervescing medicmes, lime, silver, zuic, hydrocyanic acid, belladonna, opium, and pepsine, have all been found more or less useful luider different circumstances and in different cases. III. ENTEEITIS. Causation. — Acute inflammation of the bowels, like the corresponding affection of the stomach, presents every degree of severity. The simplest, or catarrhal, form may be caused by the local action of irritating ingesta, or those external conditions which are commonly instrumental in exciting idiopathic inflammations. Young children, mainly about the time of teething, are specially liable to it ; and it is said to be common in scarla- tina and other specific fevers. Occasionally it becomes chronic, and is then apt to be associated with morbid states of other organs, to which uideed it is often secondary. The stomach especially, mider these cir- cumstances, is frequently the seat of some chronic morbid process. But enteritis in the usual sense of the term (the ' phlegmonous enteritis ' of CuUen) is rarely of idiopathic origin : it is generally the result of some mechanical injury, and thus complicates strangulated hernia, mtussus- ception, the impaction of gall-stones and other foreign bodies, and intes- tinal stricture. Morbid anatomy. — 1. Acute catarrhal inflammation of the bowels is characterised anatomically by congestion, tumefaction, and dryness of the mucous membrane, speedily followed by the more or less abundant secre- tion of mucus, which is ropy or watery, irritating, and sometimes mixed with blood. When the inflammation assumes a chronic foi'm the mucous membrane becomes condensed and hardened, congested, and studded with black pigmentary deposits. There is often atrophy of the Lieber- kiihnian follicles, with granular or fatty degeneration of their epithelial contents ; and atrophy, or even enlargement, of the solitary and agminated glands. 2. Occasionally, under conditions which are not well miderstood, membranous pellicles in patches arise, especially in the large intestine, in comiection with chronic enteritis. They consist of corpuscular elements cemented together by a coagulable exudation, and are for the most part prolonged by rootlets into the Lieberkiihnian folhcles. Their development usually is attended with much greater congestion and thickening of the 650 DISEASES OF THE DIGESTIVE OEGANS. mucous membrane than is the simple catarrhal affection, and not un- frequently hemorrhage, suppuration, or gangrene ensues. In the large intestine the pellicular inflammatory patches are sometimes linear, some- times irregularly polygonal or stellate, and occupy, for the most part, the prominent ridges of the mucous membrane, especially the ridges of the intersaccular constrictions. In some cases, while still occupying the more prominent parts, they form a coarse irregular network over large tracts of surface ; in other cases they coalesce into uniform patches of considerable extent. In the small intestine pellicular inflammation may be found, either affecting only the free edges of the valvulte conniventes, or spread over large are®. Cases sometimes come under observation in which patients pass per anum shreds of false membrane, or even membranous casts of the bowel, of soft texture, various thickness, and a dirty greenish or brown hue. This discharge is generally, if not always, the consequence of dysenteric ulceration. 3. The morbid changes discoverable after death in phlegmonous enteritis are such as are produced by intense inflammation of a hmited tract of bowel. The affected part, which is mostly in the small intestine, and may vary m length from an inch or two to two or three feet, is as a rule much dilated. Its serous surface presents a general dusky red, slaty, or purplish black colour, due to the condition of the parts mternal to it ; it is marked, too, by lines or patches of more or less intense superficial congestion, may present blotches of subserous extravasation, and is often covered to a greater or less extent with adherent lymph. Its mucous and submucous tissues are mostly somewhat thickened and softened, some- times only moderately congested, but presenting spots and streaks of extravasation, sometimes black from combined congestion and escape of blood, sometimes pale and infiltrated with lymph or pus, sometimes dis- tinctly gangrenous. And its middle coat, sharing in these changes, is also more or less swollen and soft, congested or oedematous, or the seat of some form of inflammatory exudation. The inflamed tract usually presents fairly well-defined limits, termmating abruptly below in pale and healthy but contracted and nearly empty bowel, above m bowel which may also be healthy, but is dilated like the diseased portion, and filled like it with f^cal contents. The diseased intestine frequently contains, in addition to fsecal matter, sanguineous exudation, or a thick pitchy fetid fluid ; and traces of the same may often be discovered m the contracted bowel below. Symptoms and progress. — 1. Catarrh may affect the lower bowel only, causmg mild dysenteric symptoms ; but very often it begins in the upper bowel, or stomach, and spreadmg thence downwards gradually traverses the whole length of the intestinal canal, causing in its progress uneasiness, aching, and griping — frequently attended with nausea and sickness while the inflammation is still high up, with diarrhoea and expulsive pams and efforts when it reaches the large intestine. The tongue generally is more or less furred and dry, the breath offensive, and the appetite impaired ; but these symptoms vary, and are often absent, especially when the large ENTEKITIS. 651 intestine alone is affected. Some degree of general febrile disturbance, indicated by beat and dryness of skin, sense of cbilliness, increased fre- quency of pulse, lassitude and beadacbe, is usually attendant on tlie local disorder. In cbildren, in wlioni inflammatory affection of tbe gastro- intestinal mucous membrane is sometimes associated with aplitli^, the disease not mifrequently causes serious results and death, either from the debility which follows persistent diarrhoea and vomiting, or from the supervention of convulsions and coma. It is obvious that the symptoms of this disorder differ but little from those assigned to the commoner varieties of gastritis ; but gastritis and enteritis are usually associated, and their respective characteristics consequently get intermingled. The symptoms of the chronic disorder vary greatly, but may be briefly summarised as combinmg, m various proportions, imperfect digestion of the alimentary matters received into the intestine, excessive secretion of watery mucus, increased peristalsis with griping pains, looseness of the bowels, discharge of watery, yeasty, or otherwise mihealthy and offensive evacuations, and innutrition from imperfect absorption of food. 2. The symptoms which attend enteritis with the formation of mem- branous pellicles are not special ; they vary, on the one hand, between those of diarrhoea and dysentery, and on the other hand between those of mere coHc and typical enteritis ; moreover, the affection is often overlooked from the fact that it is apt to occur as a complication of the later stages of many grave disorders, as, for example, acute pneumonia, Bright's disease, cirrhosis of the hver, and cerebral affections. 3. The symptoms of phlegmonous enteritis are, even when the disease is unattended with any of the mechanical lesions which so often compli- cate it, liable to considerable variety — the variations depending mainly on the degree of inflammation and its extent, and on the situation of the affected portion of bowel. The principal factors in producing the charac- teristic symptoms are mflammation, on which the various febrile pheno- mena depend ; and paralysis of the inflamed tract of bowel, which permits of its passive dilatation by the accumulation of its contents, opposes a more or less complete bar to their transit, and thus induces, on the one hand constipation, on the other vomiting. Heat of skin, rigors, and quickness and hardness of pulse, not mifre- quently mark the onset of the attack ; but the invasion is in many cases insidious and unattended with obvious febrile symptoms. There is mostly some dryness and clammmess of the mouth, if not absolute thirst ; and the tongue, which is occasionally pretty clean at the beginning, generally soon gets thickly coated, and ultimately dry. A special feature of enteritis is the association of the abdominal pain and tenderness of peritonitis with the tormina of colic. Pain and tender- ness are certainly present m most cases, at least in the beginning, and in dependence upon them the dorsal decubitus so characteristic of peritoneal inflammation. They are sometimes, however, scarcely appreciable from first to last, and generally subside in the progress of the case. It can readily be understood that, when the peritoneal surface is largely involved, 652 DISEASES OF THE DIGESTIVE OEGANS. pain and tenderness will generally be proportionately severe ; tliat when an extensive length of bowel is affected there will be correspondingly extensive uneasiness and tenderness ; and that when, as sometimes happens, the serous surface is not inflamed, or the affected portion of bowel is small, pain and tenderness may be not only limited in extent, but no greater than we find them in colic or simple ulceration of the mucous membrane. It may be observed that limited pain and tenderness are very commonly referred to the region of the umbilicus. Tormina are often at the onset very agonising, and are then probably due ui some measure to the spasmodic movements of the inflamed bowel ; but they continue after paralysis is established, in consequence of the violent but ineffectual efforts of the bowel above to overcome the impediment which the disease produces. But tormina are sometimes scarcely recognisable,, and frequently, like pain, cease comparatively early. Constipation and vomiting are among the most important symptoms of enteritis. Constipation, in the uncomplicated affection, is due simply to want of contractile power in the mflamed length of gut. It is there- fore not necessarily absolute : there is no reason why the attack should commence with constipation, or why the bowel below the seat of disease should not empty itself in the progress of the case, or even why a certain amount of faBcal matter should not slip through the inflamed region into the healthier bowel below. Nevertheless the inflamed bowel is really a substantial impediment, constipation is a striking incident m the disease,, and purgatives as a rule fail to produce a purgative effect. The vomiting of enteritis is probably at the commencement mainly functional, but ulti- mately it is due, like the constipation, to intestinal obstruction. In the first instance, no matter where the obstruction, the vomited matters are merely the secretions of the stomach mixed with alimentary substances ; but soon bile is added, and before long glairy mucus and bile alone are discharged. Then the eructations become fetid, and the fluid brought up is turbid and brownish, and by degrees comes to resemble the contents of the lower part of the small intestine ; but it becomes fetid also — far more fetid, indeed, than the contents of a healthy bowel ever are. This dis- charge of ' stercoraceous ' matter by the mouth is due, not to inverted peristaltic action, but to the fact that the general contents of the distended bowel are gradually churned up, as it were, and intermingled, by the constantly recurring peristaltic movements of their muscular walls. Hiccough is often a distressing symptom. Tympanitis is probably always present ; slight at the beginning, but increasing as the case x^ro- gresses, until the belly becomes greatly distended, tense, and drum-like. It is due mainly to the distension of the inflamed bowel and that above it with fffical matter and flatus. But now and then it is connected with rupture of the distended intestine and escape of gas into the peritoneal cavity. The pulse usually is accelerated and hard at the beginning, but varies in different cases in frequency, volume, and strength, and is sometimes nearly normal in character ; but as the fatal issue approaches it gets ENTEEITIS. 653 more and more feeble, and sometimes at length wholly imperceptible at the wrist. It generally also becomes quicker, but sometimes slower, and not unfrequently irregular. The temperature of the skin is usually in the first instance elevated, and the surface dry ; but even then sweats are apt to break out, especially •during the colicky paroxysms ; subsequently the temperature falls, the extremities and face get cold and pale or livid, with sometimes a slight tinge of jaundice, and all parts of the surface bathed m profuse cold sweat. The internal temperature, however, often continues high to the last, notwithstanding the coldness of the extremities, and general coolness of the surface. The expression is generally indicative of anxiety and -distress, and the features are pinched and shrivelled. The patient as a rule retains his senses throughout his illness, and even up to the moment of death ; but this event is often preceded by a period of quiescence or lethargy, and occasionally by slight rambling and partial miconsciousness. There is generally almost complete suppression of urine. Enteritis in its most violent form is an extremely dangerous, and in- deed generally a very rapidly fatal malady. Death may occur within twenty-four hours, and is rarely delayed beyond a week. Treatment. — The treatment of the milder forms of enteritis is so inti- mately connected on the one hand with that of inflammatory affections of the stomach, and on the other with that of diarrhoea and dysentery, that the reader may be safely referred to the articles on those subjects for all necessary details. As regards the treatment of the more severe forms of the disease, two main principles seem to be fairly well established : namely, first, to reheve pain, and prevent as far as may be all movements of the bowels ; second, to avoid every attempt (at least mitil all grave symptoms have ceased) to force the bowels by the administration of purgatives. Constipation, lasting for a few days, or even prolonged for a week or two, m itself is generally a matter of very little consequence ; it is, however, a matter of very serious consequence, to intensify the pain from which patients are already suffering, to fret and irritate inflamed ■ organs, and to subject to unwonted violence bowels unnaturally soft, enfeebled, and ready to undergo laceration. Clearly, if patients are to get well, their recovery must in the first instance depend on the recovery by the diseased bowels of their healthy tone and capability of peristaltic .action, and on the relief of pain and irritation. For these purposes, opium in large and frequent doses is generally our most valuable re- source. No absolute rule can be laid down with regard to the quantity of this drug to be given at one time, or the frequency with which the dose should be repeated ; the patient should, however, be got well luider its influence and kept under its influence. For many reasons it is best ad- ministered by subcutaneous mjection. But our treatment need not be limited to the use of opium. The abstraction of blood is often of the greatest value. This is most efficacious early in the disease, and may be effected either by the opening of a vein 654 DISEASES OF THE DIGESTIVE OEGANS. in the arm, or by the application of ten, twenty, or thirty leeches to the surface of the belly. Warm but light applications, and hot fomentations, generally soothe ; and sometimes mustard plasters and similar mild comiter-irritants give relief. In the same way enemata of warm water or gruel are at times useful. To relieve nausea and vomiting, ice, hydro- cyanic acid, alkalies, lime-water, bismuth, carminatives, and the like may be tried, and may be of much efficacy ; but when the vomiting is simply the consequence of over-distension of the bowels, as it sometimes is late in the disease, such remedies necessarily fail. The extreme prostration which so early manifests itself is a strong indication of the need of food and stimulants ; but their exhibition by the mouth tends to increase dis- tension, already probably painful, and to promote sickness ; and under such circumstances they are little likely to be absorbed. It is obvious, indeed, that alimentary matters, if given by the mouth, must be given in very small quantities, and in a form suitable for their ready absorption. They are best administered in the form of enemata. IV. ULCEEATION OF THE STOMACH. Causation. — The occurrence of excoriation or superficial ulceration in the course of ordinary gastritis has already been referred to. Such lesions have rarely, however, any special importance, and as a rule speedily undergo spontaneous cure. But the stomach is also liable to become the seat of ulcers which tend to spread widely and deeply, are productive of serious symptoms and sometimes of death, and the origin of which is to some extent enshrouded in mystery. These ulcers are seldom observed before the age of ten or fifteen, but subsequently to that period they seem to increase in frequency with advancing life, not, indeed, absolutely, but in relation to the numbers of persons living at each successive period. They appear to be two or three times more common in females than in males. They are often associated with amenorrhoea and anasmia, or chlorosis, and in both sexes (but more especially in men) with the cachexia which follow from habits of drinking and dissipation, and from syphilis. It is possible that these conditions of the system may be the actual causes of the ulceration ; it is more probable, however, that they tend to promote the spread and retard the healing of ulcers which have begim in the first instance independently of them. Virchow considers that ulcers originate mainly in affections of the vessels con- nected with the diseased areae, especially embohsm or degenerative change in the arteries, attended with arrest of circulation and necrosis, or ob- struction of branches of the portal system of veins, followed by interstitial hemorrhage. But it seems not improbable that the superficial ulcers which form in gastritis, and which as a rule readily heal, may under certain circumstances remain open, and be irritated into active enlarge- ment. The progressive spread, and unwillingness to heal, of gastric ULCEEATION OF THE STOMACH. 655 ulcers, are readily explained by tlie constant irritation to which they are subjected by the ingestion of food, the pouring out of gastric juice, and the movements of the stomach in digestion. Morbid anatomy. — Gastric ulcers vary in size from that of a four- penny-piece up to that of the palm of the hand. The smaller ones are usually circular or oval in shape ; the larger are more or less irregular, either from being formed by the coalescence of several smaller ulcers, or in consequence of irregular extension. When small an ulcer usually appears as if it had been made by punching out a bit of the mucous membrane. Its edges are more or less perpendicular ; and the tissues entering into their formation are infiltrated, indurated, and probably thickened to some Httle distance around. Its floor may be smooth, flocculent, or even superficially gangrenous ; and may be formed, accord- ing to the depth to which the ulcer has reached, by either the submucous,, tissue, the muscular coat, or simply the serous membrane. In an ulcer of large size the tissues which surround it are usually considerably thick- ened and indurated from inflammatory overgrow^th, and often much congested ; the edges, which are specially thickened, usually slope down- wards to the floor of the ulcer, which thus becomes smaller than the superficial area of ulceration ; sometimes, however, they are perpen- dicular ; sometimes undermmed, and overhanging. The floor of a large ulcer may be formed like that of a small one by any of the gastric tunics except the mucous membrane itself ; but it may be formed also by the substance of the liver, pancreas, or any other organ or tissue which has become adherent to the stomach, and involved m the progress of the ulceration. The floor may be smooth, irregular, and flocculent, or sloughy, or may present granulation-like bodies due to the projection of the lobules of the eroded pancreas. Gastric ulcers not unfr-equently cicatrise. The surrounding thicken- hig then dimmishes, the sloping edges become undistinguishable, on the one side from the contiguous mucous membrane, on the other from the floor of the ulcer. The ulcerated surface contracts, radiating puckers form, and the central raw area grows smaller and smaller, and at length heals. The result is an opaque, whitish, smooth, tough, depressed area, surrounded by more or less obvious radiating folds of mucous membrane, and often attended with marked and it may be serious deformity of the stomach. It is not uncommon to find ulcers partly healed, or cicatris- ing at one part while undergoing extension elsewhere. Unfortimately gastric ulcers do not always heal. In many cases they remain quiescent ; in many they slowly extend ; in many they end in perforation. Perforation sometimes takes place at once into the perito- neum ; but sometimes the base of the ulcer previous to perforation be- comes adlierent to some neighbouring part, so that, while extravasation of the contents of the stomach into the peritoneal cavity is prevented, a communication becomes established with the transverse colon, or small intestine, with the pleura or lung through the diaphragm, or A\'ith the external air through the abdominal parietes. In other cases some artery 656 DISEASES OF THE DIGESTIVE OEGANS. (the splenic, coronary, gastro-epiploic, or one of their branches), or even the hepatic artery, or portal vein, becomes eroded, and profuse hemorrhage ensues. Gastric ulcers are usually solitary, but occasionally two, three, or more are present at the same time. They may occur at any part of the stomach ; but are more frequent in the pyloric than in the cardiac half, in connection with the posterior than the anterior wall of the organ, and in the neighbourhood of the smaller than in that of the larger curvature. Perforation is believed to be elatively more frequent in females than in males ; and is a not uncommon termination of ulcer, especially in young women. Symptoms and progress. — The symptoms which attend gastric ulcer present much variety. In a few cases the disease proves fatal by perfora- tion or hemorrhage without having ever been attended with symptoms to attract attention to the stomach as the seat of disease. In most cases, however, the patient suffers from dyspeptic phenomena, of which the most common and characteristic are pain, vomiting, and hsematemesis. As ulcer of the stomach is mainly a chronic disease, so the symptoms to which it gives rise generally assume a chronic character. They creep on for the most part gradually, probably sometimes intermitting for a while, often presenting exacerbations, but, on the whole, tending to become more and more pronounced. At first possibly the patient complains of distension, flatulence and uneasiness, especially after food, and of impairment of appetite ; but soon the uneasiness becomes pain; and sickness presently supervenes. The pain varies somewhat in intensity and character. It usually begins in, and may remain limited to, the epigastrium, which becomes tender on pressure ; or it is referred to the region of the spine corresponding to the last two or three dorsal and first two or three lumbar vertebrae, or to the interscapular region — the muscles on either side often being tender ; or it occupies the umbihcus, or some other point or area in the neighbourhood; and generally, when it is severe, it radiates from its point of chief inten- sity, upwards towards the oesophagus, backwards to the loins, or down- wards and laterally over the greater part of the abdominal cavity. The pain, when severe, is of a burning, boring, or shooting character, often attended with a sense of soreness ; it is aggravated by taking food, and in some cases occurs only then. It usually comes on a few minutes after ingestion, but is occasionally delayed half an hour or an hour after- wards. It is doubtful how far the situation of the pain serves to indicate the situation of the ulcer ; but both Dr. Budd and Dr. Brinton are inclined to beheve that pain occurring chiefly in the pit of the stomach indicates the presence of an ulcer in the anterior wall of the stomach, and that pain in the back imphes a corresponding situation for the ulcer. Further, Dr. Brinton regards the decubitus of the patient as suggestive in this respect— the patient lying as a rule on that aspect of the body which is farthest removed from the seat of ulceration. Vomiting may be absent from first to last ; it usually comes on, how- ULCEEATION OF THE STOMACH. 657 ■ever, during the j)rogTess of the case, for the most part subsequently to the pam ; and is then very persistent. The attacks are determined by the taking of food, usually come on a little later than the pain, and not mifrequently by emptying the stomach cause the pain to subside. The vomiting may be attended with violent spasmodic efforts, or may be effected in the manner of simple regurgitation. Hemorrhage is a frequent consequence of gastric ulcer — taking place sometimes from the congested mucous membrane which bomids it, sometimes from the general surface of the ulcer, sometimes from a vessel which has undergone erosion. In the last case especially the bleeding is apt to be very profuse, and to be repeated from time to time ; and consequently large quantities of blood .are vomited and subsequently passed by stool. The long continuance of dyspeptic symptoms, with pam induced by taking food and having the characters which have been described, and with vomiting coming on pretty constantly at some variable period after ingestion, is alone strong presumptive evidence of the presence of a gastric ulcer. And if to these be added the occurrence of profuse liasma- temesis, there can be little room for doubt. The most frequent termination of gastric ulcer is no doubt in conva- lescence. There is, however, a great tendency for healed ulcers to break out again, and consequently for patients who seem cured to have relapses. When the disease ends fatally death may be due to simple asthenia — the patient sinking, worn out by the combination of long-continued pain, vomiting, and want of food ; or it may be caused by the sudden loss of a large quantity of blood, or by the repetition, at longer or shorter intervals, of smaller but still copious hemorrhages ; or it may result from perforation. When perforation takes place into the peritoneal cavity, sudden intense abdominal pain and collapse occur, speedily followed by general peritonitis ; .and the patient usually dies in from five or six hours to two or three days after the occurrence of the accident. When, however, perforation takes place into any of the hollow viscera or other cavities than that of the peritoneum, the symptoms which arise are usually much less sudden and grave, though still in many cases leading sooner or later to a fatal result. Treatment. — Attention to diet is of the utmost importance in the treatment of gastric ulcer. The patient must be nourished ; and yet all the digestive actions of the stomach are inimical to the cure of the lesion. We must consequently be especially careful as far as possible to avoid •overloading the stomach or causing gastric pain, or uneasiness, or vomit- ing. With this object it is important to administer as little food as is compatible with the maintenance of life, and to give it in small quantities .at a time, and at short intervals ; it is important also to select food of such a kind as will impart nourishment without causing undue irritation of the stomach ; and, in reference to this matter, it may be observed that few articles of diet are so suitable as milk, which may be thickened, if necessary, with biscuit powder, arrowroot, or similar substances. Milk, however, sometimes disagrees, and then recourse must be had either to farinaceous substances mixed with water, or to animal broths and jellies. u u 658 DISEASES OF THE DIGESTIVE OEGANS. Pounded raw beef flavoured with sugar or currant-jelly may be employed in some cases vatb great advantage. Liquids are generally ill borne when hot ; and hence it is usually best to administer them tepid or cold. Hot tea and coffee especially are injurious. As the case progresses towards recovery eggs may be given, and tender, easily digested meats. Alcoholic stimulants should, if possible, be avoided ; if given, they should be m a dilute form and cold. In some cases it is necessary to feed the patient for a time by means of nutrient enemata only. The chief medi- cinal agents which have been employed for the cure of ulcers are nitrate of silver, bismuth, the carbonated alkahes, and opium. It is certain that the combination of bismuth, in doses varying from ten to twenty grains, with opium is often very efficacious in relie^nng pain and vomiting, and apparently m promoting the cure of the ulcer. Iron and the vegetable tonics are mdicated when the more distressing symptoms have been re- lieved and the patient seems convalescent. "When hemorrhage or any other serious complication occurs, special measures will be needed. Counter-irritation and other external treatment applied to the epigas- trium are often serviceable. V. ULCEEATIOX OF THE BOWELS. Causation and onorhid anatomy.— 1. Intestinal ulcers are much more common, and various in character, than those of the stomach. Their causes for the most part are equally obscure. In many cases, no doubt, simple inflammation of the mucous membrane is followed by excoriation ; which either rapidly heals and gets effaced, or, in consequence of con- tinued irritation, becomes a veritable ulcer. Such ulcers may arise from simple mechanical irritation. They are roundish or irregular in form, vary in size, and present congested and weU-defined margins, and irregu- larly excavated shreddy greyish surfaces. The margins and the sur- rounding tissues are in some cases considerably thickened and indurated, in others present Httle obvious departure from the normal state. Ulcers of this kind are not unfrequently met with m the duodenum, and in many cases are not improbably due to the same causes (whatever they may be) as the so-called ' chronic ulcers ' of the stomach. They are also occa- sionally met with here apparently as the result of extensive superficial burns. The large intestine, however, is their most common seat ; and they are produced here for the most part by the mechanical irritation of retained faeces or intestinal concretions. They are often found in the cfecum and its appendage, where such accumulations are very apt to form ; but they may be developed at any part of the larger bowel. In cases of long retention of faeces, whether fi'om simple constipation or from stricture, it is not rare to find the mucous surface studded with tracts, varyuig from one to many square inches in area, and consisting of groups of circular ulcers, from half an inch in diameter downwards, separated from one another bv a network of congested and partly undermined bands of mucous ULCERATION OF THE BOWELS. 659 membrane. Again, such ulcers may arise in any part of the intestine, whether large or small, from the effects of the passage or impaction of gall-stones or other solid bodies, especially when impaction occurs above a stricture or other such impediment. 2. Li other cases ulceration is connected with the formation of a mem- branous pellicle ; a linear, stellate, or irregularly polygonal patch of mucous membrane becomes congested and swollen, and soon covered with an opaque whitish or buff-coloured exudation, which is friable and granular, and extends by rootlets into the Lieberkiihnian folhcles. This, after a time, separates, leavhig sometimes a somid surface, sometimes a slight excoria- tion, or even a distinct ulcer, with a greyish or yello"ndsh floor and a well- marked margin of congestion. These ulcers may be met with in any part of the bowel, but are much more common in the large than elsewhere. In the small intestine they affect chiefly the free edges of the valvul© conniventes ; m the large, either the }oi'ojecting ridges formed by the intervals between the sacculi, or those corresponding to the longitudinal muscular bands. Sometimes we find extensive tracts of congested bowel studded or intersected with patches or bands of membranous exudation, or consecutive ulceration, or both intermmgled. This condition is met with under various circumstances : especially perhaps in pneumonia, and many chronic affections, such as Bright's disease, cirrhosis of the liver, cancer and chronic phthisis. 3. Sometimes ulcers originate in foci of submucous suppuration, as occurs in pytemia, or in patches of deep-seated sloughing hke ordinary boils. Among the latter may perhaps be reckoned the ulcerative inflam- mation of the folhcles of the colon, which Eokitansky describes, and is beheved to constitute the early stage of dysentery. The folhcles enlarge to the size of a tare or pea, become surromided by a halo of congestion, and then undergomg suppuration form each an ulcerated opening, which eventually enlarges and constitutes a circular ulcer, with overlapping edges. 4. Ulceration may be due to the formation and detachment of a super- ficial slough. Circumscribed patches of intense congestion or extravasation appear in the substance of the mucous membrane, which, shortly dying, come away bit by bit, or in mass. The above process is often effected with Httle obvious change in the immediately surrounding parts, and the resulting pits are for the most part speedily effaced. This affection is not micommon in small-pox, typhus, and other such diseases. It frequently involves only the valvulae conniventes, or the correspondhig projections of the large intestme. It may be due to sudden arterial obstruction. 5. But sloughuag, to a much more serious extent, is sometimes met with, especially in the large intestine : patches of mucous membrane become Hvid, brown, or nearly black vnth congestion ; and their central arese assume a grey or ashy colour, get shrunken, depressed, and softened, and break down mto a soft, shreddy substance, which partly becomes detached, and partly adheres to the floors of the excavations and to their not yet broken-down edges. The process tends to spread. V u 2 660 DISEASES OF THE DIGESTIVE ORGANS. It is not pretended that aU non-specific ulcers arise in one or other of the modes here enumerated, or that they necessarily maintain in theii" ulterior progress the distinctiye characters of then- origin. Yet, indepen- dently of their exciting causes and early pecuharities, aU ulcers are apt after a time to present certain common varieties of appearance, dependent mainly on the processes "which are actually taking place in them. Thus, when they are healing, we find the general surface smooth and clean or granulating, the edges httle thickened or congested, perhaps puckered, and probably sloping to the ulcerated area, with which they are in fact continuous ; when they are sluggish, the edges are tumid and rounded, probably overhanging, and the general surface smooth, when they are spreading, the sm-rounding mucous membrane presents more or less in- tense congestion and swelling, and the immediate margin is either floccu- lent and ash-coloured, or presents a vivid red, raw, bleeding waU, or forms a ring of distinct gangrene, and the floor is irregular and flocculent. The base of an intestinal ulcer is generally constituted by the submucous tissue, but not imfi'equently the transverse muscular fibres are exposed ; and when an ulcer tends to perforate the bowel the muscular coat itself becomes opaque, softened, and in part destroyed. The above accoiuit apphes mainly to indi'\'idual ulcers. But very often, and much oftener in the large than in the small intestine, many ulcers are present at the same time, and tend to increase either in number or in size or in both of these respects, and to coalesce. And then, according to the stage to which the lesion has advanced, we meet in different cases with either a number of ulcers separated from one another by an imperfect net- work of mucous membrane ; or interlacing networks of ulceration and mucous membrane ; or islets of mucous membrane in an expanse of ulceration ; or, lastly, extensive tracts from which the mucous coat has been wholly removed. In these cases the transverse muscular fibres are often fi'eely exposed, and the remains of mucous membrane are red, swollen, and rounded, and in the form of tubercle-like excrescences. The aflected bowel, moreover, is frequently much contracted, and the muscular walls h}-pertrophied. This is not the place to discuss the important subject of specific ulcera- tion of the bowels. Yet specific ulcers constitute by far the most for- midable class of intestinal ulcers. The more important of them are the following : — Fu'st, syphihtic ulcers : these have not been certainly recog- nised in the alimentary canal excepting m the neighbourhood of its inlet and outlet ; sj-philitic ulceration of the rectum is a well-recognised, and for the most part very intractable, lesion. Second, the ulcers of enteric fever : these affect mainly Peyer's patches, and are most abundant and large in the lower part of the ileum ; they not unfrequently involve also the sohtary glands of the large intestme, especially in its upper part. Third, tubercular ulcers, which originate for the most part in the same glands and situations as enteric-fever ulcers. And, fourth, the varioxi.s kinds of ulcer due to the breaking doT\ai of carcinoma and other varieties of malignant disease. ULCEKATION OF THE BOWELS. 661 Many intestiiial ulcers cicatrise and leave behind them little or no trace of their existence. In other cases, however, and indeed in a large pro- portion of them, results of more or less serious importance follow. Some- times, as we see in the rectum, when a vast continuous surface has been destroyed, the wound never heals ; and, even in cases where the destruction has been much more limited, the ulcer may assume the characters so often presented by chronic ulcer of the stomach, and be ready, if it cicatrises, to break out again and again. But generally, when a large ulcer heals wholly or m part, especially if it has involved the whole circumference of the bowel, some degree of contraction of the bowel, or stricture, results. In many cases hemorrhage takes place either from the congested surfaces or margins of ulcers, or from vessels perforated in their progress ; and such hemorrhage may be so frequently repeated, or so abundant, as to prove fatal. In many cases, also, perforation of the bowel takes place. This accident is usually due to a sudden tear in the floor of an ulcer, which has got miusually thin, and undergone softening, or become weakened m some other way ; and not unfr'equently depends immediately on some violence inflicted from without, or some midue pressure from withm, such as may result from over-dis- tension, or violent peristaltic raovement. The rupture usually takes place at once into the peritoneal cavity, causmg extravasation of fsecal matter and generally fatal peritonitis. But not unfrequently uiflammation arises on the peritoneal aspect of the ulcerated bowel ; adhesion takes place between it and some neighbouring viscus ; and consequently the threatened perfo- ration becomes, for a time at least, averted. In many cases, a communi- cation becomes estabHshed between the bowel and some neighbouring hollow organ — a result preceded either by the formation of adhesions or by the development of a circumscribed abscess between the two organs. The latter mode of communication is especially Hable to take place when the ulcer opens on the mesenteric aspect of the small intestine, or in the corresponding part of the larger bowel, and consequently into the con- nective tissue, with which the bowel is in these situations closely invested. Thus, we occasionally find contiguous portions of the small intestine communicating with one another, or the small intestine with the trans- verse or some other part of the colon ; the rectum, sigmoid flexure, or ileum with an ovarian cyst, the urinary bladder, or vagina ; the duodenum or transverse colon with the gall-bladder ; the stomach with the trans- verse colon ; or, lastly, almost any part of the intestinal canal with the external surface. Symptoms and progress. — The symptoms of ulceration of the bowels are so constantly associated with those of the different morbid states of the system on which it depends, or those due to the various compli- cations which follow upon it, that we seldom have the opportunity of studying them in their simple form. It may be stated generally : that ulceration of the bowels is often attended with febrile symptoms, which assume, if the disease becomes chronic, a distiactly hectic character ; that the affected bowel is often tender on pressure— a characteristic which is especially observable if the ulceration be extensive, or occupy the caecum 662 DISEASES OF THE DIGESTIVE OEGANS. or some other part of the large intestuae ; that there is ahiiost necessarily some impairment of nutrition marked by emaciation, debility, and feeble- ness of circulation ; that there is more or less abdommal soreness, aching, or griping ; and that, above all, there is something abnormal in t^e action of the bowels and in the evacuations. The symptoms will vary according to the seat of disease. If the ulcer be high up, and especially if it be in the duodenum, the symptoms will approximate to those of gastric ulcer ; there will probably be pain coming on some time after food, and vomiting, but no material interference with the function of defascation. If the ulceration occupy the central portion of the small intestine, there may be nothmg beyond gradually increasing emaciation, and occasional colicky pains, to indicate that the bowels are affected ; and indeed extensive ulceration may be present even in the lower part of the ileum without occasioning any obvious modification of the stools ; there may, indeed, be constipation from first to last. Usually, however, if there be ulceration in the last-named situation, and especially if the large intestine be involved, diarrhoea may be looked for. The stools are then generally liquid, and contain an abnormal quantity of the fluid secretions of the bowels, and not mifrequently blood ; they are, moreover, often peasoup-like in colour and consistence, and more offensive than in health ; further, they are usually passed much more frequently than natural, and the patient suffers from frequent colicky pains and tenesmus. As the ulceration approaches nearer and nearer to the lower part of the large intestine, the evacuations assume more and more of the so-called ' dysenteric ' character. They are then passed with extreme frequency and great tenesmus ; are scanty, mucous, often sanguinolent, and not mifrequently entirely free from true faecal matter. The latter may be only passed occasionally in small hard lumps, invested in mucus ; indeed, constipation, so far as regards the passage of faecal matter, is often one of the most troublesome and distressing symptoms of ulceration of the rectum and lower part of the colon. It is in the dysenteric form of the disease, moreover, that the evacuations become most offensive, the fetor sometimes being putrid and almost insufferable. Besides the slight oozing of blood which tinges the evacuations in dysenteric diarrhoea, hemorrhage to a considerable amount sometimes takes place ; and this may be either continuous or recurrent, and sufficient to destroy life. Many of the communications which have been described as taking place between the intestine and other organs as a result of ulceration are doubt- less of little practical importance ; but some are dangerous, or present features of clinical interest. Among the latter may be especially men- tioned : communications between the stomach or duodenum and the colon, which lead to the occasional or constant vomiting of actual fasces and to the escape of undigested food into the large intestine ; and com- munications with the urinary bladder, which occasion the escape of flatus and fasces into that viscus, with other consequences which are easy to imagine. Eupture into the peritoneum generally causes fatal peritonitis. ULCEEATION OF THE CECUM AND EECTUM. 663 Treatment. — Our aims in treating ulcers of the bowels should be : first, to promote the healing of the ulcers and prevent as far as possible the local mischances which are apt to follow ; second, to check abdominal discomfort and diarrhoea ; and, third, to support the patient's strength. It is of course doubtful how far remedies given by the mouth can act locally on ulcers low down in the bowels, and how far, therefore, substances like bismuth, nitrate of silver, iron, copper, mineral acids, and the like can promote cicatrisation ; still they are often employed with this object, and sometimes apparently with benefit. But it is of great importance that the bowels should be kept at rest, and violent peristaltic movement as far as possible restramed. Purgatives, therefore, should be in great measure, or wholly, eschewed ; while astringent medicmes (iron, copper, lime, chalk, tannic acid, or vegetable astringents) will probably prove serviceable. Opium is especially valuable ; and the compound kino powder and the combination of aromatic chalk powder with opium are usefu.1 preparations. It is important, however, to note that opium cannot always be taken in these cases ; for chronic ulceration of the bowels is often attended with an irritable state of the mucous membrane of the mouth and stomach which the use of opium is apt to augment. If this drug cannot be employed, it may be replaced to some extent by other sedatives, such as hyoscyamus, belladonna, Indian hemp, or hydrocyanic acid. Opium may often be given with advantage in the form of enema or suppository. It is obvious that ihe various measures which have just been enumerated, while they check peristalsis, act with equal efficacy in fulfilling the second indication of treatment — namely, the arrest of diarrhoea. The maintenance of the patient's strength must be effected by the use of tonic medicines and the careful administration of suitable food and stimulants. The form of tonic must be adapted to the special requirements of the case, and to the other details of treatment it may be considered necessary to adopt. As regards food, this should be well cooked, well masticated, easy of digestion, given in moderate quantities, and at regular if not frequent intervals. Farina- ceous foods are m many cases most suitable ; but eggs, fish, and fowl may often be used with advantage. Butcher's meat is sometimes wholly inadmissible. VI. PEEFOEATING ULCEES OF THE C.ECUM AND EECTUM. {Typhlitis, Perityphlitis, and Periproctitis.) There are certain parts of the bowels which are especially liable to become the seat of non-specific forms of inflammation and ulceration, or to be involved in inflammation origmating in their neighbourhood : these are the duodenum and the large intestme — more particularly the caecum and lower part of the rectum. As to the duodenum, we have already pointed out that it is not unfi-e- quently the seat of ulcers which resemble chronic ulcers of the stomach, 664 DISEASES OF THE DIGESTIVE OEGANS. and of iilcers arising in connection with extensive burns of the skin. We may add that from its situation and attachments it is Hable to become perforated from Tvdthout by abscesses of the gaU-bladder and Hver, and by abscesses originating, no matter how, m the upper part of the retro- peritoneal tissue. So, also, the large intestine, from its peculiar relations with the peri- toneum, and from the extent to which it is in many places devoid of peritoneal covering, and continuous, therefore, with the sub-peritoneal connective tissue, and thus brought into almost immediate connection with the various organs lying beneath the parietal peritoneum, is pecuharly apt to be involved in extraneous inflammation and suppm-ation. For similar reasons (at least in great measure) inflammation originating here is hable to induce inflammatory thickening and abscess m the surrounding tissues.. A. Typhlitis. Perityphlitis. Causation and morbid anatomy. — The terms ' typhhtis ' and ' XDeri- typhhtis ' (the former signifymg inflammation of the walls of the caecum,, the latter inflammation of the tissues surroimding it) are commonly employed in reference to those cases in which mflammation of the csecum or its vermiform appendage involves, either by perforation or by simple extension, the connective tissue of the iliac fossa or the peritoneal ca^dty. Ulceration of these parts very frequently takes place (in enteric fever and phthisis to wit) mthout causing the special phenomena of typhlitis. There is reason, indeed, to beUeve that in most, if not all, cases where in- flammation spreads fr'om the cfecmn to the surrounding tissues, its spread is referrible to ulcerative perforation. The causes of the lesion in question are no doubt various. It may be due to the extension of tubercular,, typhoid, or dysenteric ulcers, to simple but extreme distension of the caecum, to the fretting of its surface by accumulated fsecal contents, to the mechanical effects of bristles, pins, or bits of bone which have been acci- dentally swallowed, or to the lodgment of intestinal concretions. Con- cretions are mostly found in the vermiform appendage, and are the usual causes of perforative ulceration of this part. They vary fr^om the size of a pea to that of a date-stone, are sometimes of a waxy consistence and lustre, sometimes brown, opaque, laminated, and for the most part faecal, sometimes composed mainly of earthy phosphates, but consist in all cases of an admixtm-e in unequal proportions of ordinary faecal matters and the secretions from the mucous sm'face, and are occasionally developed around small extraneous bodies. In some cases the ulcer perforates that portion of the bowel which is devoid of peritoneal covering. Faecal matter then escapes into the sur- rounding tissues, leading to more or less extensive inflammation and m- duration. If the escape be shght, inflammatory swelling alone may take place, and after a while subside. Often, however, an abscess forms, which enlarges more or less rapidly, and then extends in a direction determined in great measure by its original seat : in one case descending into the pelvis and opening into the rectum ; in another passing out ^ith the TYPHLITIS. 665 pjTiformis muscle and presenting in or below the buttock ; in another running along the ingumal canal into the scrotum, or along the psoas aiid iliacus muscles into the upper part of the thigh ; in another forming a swelHng in the groin immediately above Poupart's ligament, and possibly diffusing itself over a wide area between the abdominal muscles. In most cases no doubt it presents itself m the iliac region superficial to the position which the cfficum normally occupies. An abscess of this kmd may get cured by discharging its contents either through the orifice in the caecum which gave rise to it or through an opening at any one of the spots which have been enumerated ; or, burrowmg extensively, it may form a sinus or series of sinuses which are never obliterated. The communication between the abscess and cscum is sometimes maintained ; at other times it closes more or less speedily, and the abscess appears henceforth to be independent of the bowel. In some cases (especially if the part affected be the vermi- form process) local peritonitis precedes or accompanies the perforation, which would otherwise have been direct into the general peritoneal canity ; and a circumscribed abscess forms, the indications and progress of which differ little, if at all, from those of the abscesses previously considered. In other cases rupture takes place directly into the peritoneal ca"vity, and fatal peritonitis is excited. Circmnscribed abscesses themselves may rupture ultimately into the peritoneum. The most common form of fatal typhlitis is that connected with per- foration of the vermiform appendix — an accident which occurs mamly in early Hfe, and apparently oftener in males than in females. Symiitoms and inogress. — The symptoms of typhlitis are, in the first instance, pam, tenderness, and swelling in the region of the caecum, to- gether with signs of inflammatory fever, and sometimes rigors. The local symptoms are for the most part those which may be caused by inflam- mation of whatever origin occupying the venter of the ileum. If an abscess forms, but extends downwards into the pelvis, or remains deep- seated, the case is naturally obscure. If, however, it tends to point anteriorly, the falness and hardness get more and more pronounced, and gradually develop into a fluctuating hemispherical protuberance over which the integuments become cedematous and congested. Sometimes, even at this stage, the swelling gradually subsides and disappears, owing to the abscess having discharged itself into the bowel ; but more frequently it still enlarges and ultimately opens externally, discharging a greater or less amount of fetid pus, sometimes ha\dng a ftecal odour, sometimes con- taming faecal matter and bubbles of gas. The further progress of the case may be towards either recovery, or the formation of successive abscesses or fistul^e, or the establishment of an artificial anus. When peritonitis arises from perforation of the Cfecum or its appendix, its occurrence raay be quite sudden and mipreceded by any form of premonitory symptoms ; but occasionally it is heralded by localised uneasiness or pain, or las we have pointed out j supervenes m the course of well-marked perityphlitis. The functions of the alimentary canal are by no means necessarily disturbed to any great extent in typhlitis. Sickness is often absent. 666 DISEASES OF THE DIGESTIVE OEGANS. Constipation is not unfrequently present during the early period of the disease ; while diarrhoea is apt to supervene at a later stage. But none of these symptoms has any particular uniformity or value. It may be remarked that, from the close proximity of the caecum to important veins and nerves, typhlitis is apt to induce j)ainful neuralgic symptoms and cedema of the right lower extremity. Its duration is necessarily very uncertain. Sometimes the patient speedily recovers, sometimes he Imgers indefinitely with a constantly discharging abscess or a succession of abscesses. If, however, perforation take place into the peritoneum, death rapidly follows. Although inflammation beginning in the caecum is a very common and important cause of inflammatory swelling and suppuration in the right iliac fossa, it must not be forgotten that this part is also a common seat of inflammation and abscess from other causes, and further, that such abscesses are liable to form communications with the ctecum, and hence still further to simulate primary typhlitis. Among the affections here referred to may be enumerated : inflammation of the ovary and connective tissue in its neighbourhood ; idiopathic abscesses of the venter ilii, or in the course of the psoas muscle : psoas abscess from caries of the spine ; renal abscess ; and all descending retro-peritoneal abscesses, whether from the interior of the spinal canal, the pleura, lung, or liver. Treatment. — The treatment of typhlitis is in principle, and indeed in most of its details, the same as that of enteritis and other forms of intes- tinal ulceration. It consists mainly in keeping the bowels quiet by the aid of opium, and in the use of local applications. It is almost more important in typhlitis than in any other affection to avoid opening medi- cines : for, especially if the disease be in the appendix, rupture into the peri- toneum is in many cases prevented solely by slight adhesions. This danger often continues, indeed, for some time after the local inflammation seems to have subsided ; and caution, therefore, should be exercised in respect of the use of purgatives for some time after apparent restoration to health. If the bowels need to be relieved simple enemata are the safest agents, and are usually sufficient. The local measures to be employed comprise leeching, fomentations, and the application of ice ; and, if an abscess form, its speedy evacuation. Those who have once suffered from typhlitis are liable to recurrences of the disease, and require to take great care in respect of diet, exposure to cold, and other conditions likely to act injuriously. B. Periproctitis. Causation and morbid anatomy. — Inflammation and suppuration about the lower part of the rectum are even more common than the corresponding affections of the caecum ; and their causes are equally various. In many cases this affection is traceable to ulceration (per- forative or other) of the mucous membrane ; in others it probably originates in the connective tissue which surrounds the rectum. Further, the rectum (again even more frequently than the c^cum) gets involved in inflammation and suppuration originating in the various pelvic and DYSENTEKY. 607 even distant organs. Abscesses, in fact, arising in the abdominal cavity or its walls, or implicating tliem, are always apt to gravitate into the pelvis, and to communicate with, the rectum. Eectal abscess is frequently connected with the presence of tuberculosis. Symptoms and progress. — Inflammation in the neighbourhood of the lower part of the rectum necessarily produces tumefaction and indura- tion, which may usually be readily detected by digital exammation per anum, or by their presence in the perineum in the immediate vicinity of the anus. In connection with the swelling there are always more or less severe pain and tenderness, which often prevent the patient from sitting down, and are greatly aggravated during the act of deffecation. If sup- puration take place, the swelling rapidly increases in size, and the abscess presently opens either mto the rectum (usually a little within the internal sphincter) or externally by the side of the anus, or in both of these situations, and discharges exceedingly fetid pus. Simple inflamma- tion around the rectmn may subside spontaneously ; but an abscess almost invariably results in the formation of a fistula, which is a very obstinate affection, and rarely yields excepting to direct surgical treat- ment. When an abscess opening into the rectum is connected directly "udth suppuration of some remote organ, the ultimate prospects of recovery are by no means satisfactory. The treatment consists in the application of fomentations, poultices, or leeches, and the opening of the abscess as soon as the presence of pus is ascertained. The bowels, moreover, should be regulated either by laxatives or by enemata. VII. DYSENTERY. Definition. — We have already, in describing inflammation and ulcera- tion of the bowels, discussed the various inflammatory processes which take place in the large intestine, and considered the symptoms to which they give rise. These affections, especially if they mvolve its lower segment, always induce so-called ' dysenteric ' symptoms, and are usually mcluded in the generic term ' dysentery.' But dysentery is also the name of one of the most widespread and fatal of diseases— a disease which, under special circumstances, assumes an endemic or even epidemic character, and is hence not unnaturally regarded as a specific disease, in the same sense as ague and enteric fever are specific diseases. Causation. — Dysentery prevails largely in tropical regions, and more especially in those places which are low and swampy, and surcharged with decaymg vegetable matter — in regions indeed which are, for the most part, malarious and breed intermittent fevers. It occurs, however, under conditions and in places which are not productive of ague ; it has been in all ages one of the greatest scourges of armies in the field, of beleaguered cities, and of starving populations. According to Sydenliam ^nd others of our older writers, it was once a formidable disease in this 668 DISEASES OF THE DIGESTIVE OEGANS. country ; ■whence in an aggravated and epidemic form it has now almost entirely disappeared. It is probable, however, that enteric fever formed a large x^roportion of the cases then termed dysenteric. From its frequent coincidence in area of distribution with ague it is by many regarded as being, equally with that disease, a product of the malarial poison. But the facts that aguish districts are not necessarily also dysenteric ; that dysentery, even in an epidemic form, occurs in places and under circum- stances which never yield ague ; and that ague and dysentery no more graduate into one another than do enteric and typhus fevers, render this view of its origin untenable. The influences of foul water, polluted air, insufficient nourishment, and exposure and over-fatigue in its production are unquestionable, but whether as exciting causes or merely as predis- posing causes is by no means clearly established. There is reason, how- ever, to believe that polluted drinking water is an especially active agent in the induction of the disease, but whether by the mtroduction of a specific poison is, at least, doubtful. We are inclined to regard dysentery as both of non-specific origin and non-infectious ; and, on these grounds, introduce its description here. Morbid anatomy. — The morbid anatomy of dysentery has been abun- dantly described, but the descriptions which have been given of it are various, and do not admit of being readily reconciled. Some of the most trustworthy of recent observers, such as Parkes and Baly, regard it as a disease essentially of the solitary glands of the large intestine, which rise up in the form of hemispherical buttons, varying from the size of a millet- seed downwards, and occasionally attaining the bulk of a split pea. As- sociated, however, with glandular hypertrophy there is always more or less intense congestion of the general surface of the mucous membrane, which becomes sepia-coloured, reddish-browai, or almost black ; together with inflammatory infiltration of its substance and of the submucous tissue, which may consequently acquire a collective thickness of one- quarter or even one-third of an inch. It must, we think, be admitted that dysentery commences with con- gestion, more or less intense, and infiltration, more or less conspicuous, of the mucous membrane, in which changes the solitary glands not im- probably take a predominant share. This inflammation (at all events in the first instance) usually occurs in scattered patches, which are linear, stellate, or irregularly roundish or polygonal, are specially liable to in- volve the prominent folds, and are sometimes limited to them. The patches may be discrete, or they may run together, forming an irregular netw^ork, or they may coalesce completely over a more or less extensive area, and even throughout the whole length of the large intestine. It usually happens that, in addition to the interstitial inflammatory changes here adverted to, the affected surface becomes early covered with a thin, opaque, granular film, or with such films in patches. These can generally be readily removed from the subjacent surface, bringing with them ad- herent casts of the Lieberkiihnian follicles. They consist, in fact, mainly of an inflammatory overgrowth of the intestinal follicular epithelium. DYSENTEEY. 669 If the dysenteric attack be slight, the morbid process may cease at this point, and convalescence become established without any material injm-y to the bowel. But if it be severe, further changes speedily ensue. These present considerable variety, but consist essentially in the formation of sloughs and (by the separation of these) of ulcers. The sloughs vary in colour, size, shape, and arrangement. They may be yellow, like those of enteric fever, or ash-colom-ed, or black. They are sometimes circular and distinct, studding the surface more or less uniformly and thickly ; some- times they occur m irregular groups, and constitute patches of various, and often considerable, extent ; sometimes they so run together and are so arranged as to constitute a network, the interstices of which are formed by isolated patches of mucous membrane ; sometimes extensive tracts of surface are imiformly and completely destroyed ; and m all cases there is a tendency for the morbid process to spread, either by simple ulceration, or by the burrowing of pus beneath the mucous surface, or by sloughmg. With the separation of the sloughs ulcers are left, sometimes with ragged, sometimes with abrupt, and often with swollen and congested margins, and with floors formed either by the submucous tissue or by the transverse muscular fibres. The subsequent progress of the morbid process varies. In some cases more or less perfect cicatrisation ensues ; in some, the ulcers assmne a chronic character, and remain open, and with little alteration, for an indefi- nite period ; and in either of these cases there is a tendency to the recur- rence of active uiflammation under slight provocation. When the disease lapses into the chronic form, the affected bowel is apt to remain irritable, to become permanently contracted, and as regards its muscular coat sometimes greatly hypertrophied. In mast be added : that perforation of the bowel is an occasional complication of dysentery ; that inflammation sometimes pervades the whole thickness of the intestinal walls, extending even to the peritoneal aspect ; that more or less hemorrhage from the in- flamed or ulcerated surface is almost invariable, while in some cases it is so abundant as to cause death ; and that the cicatrisation of dysenteric ■ulcers not unfr'equently causes stricture. Dysenteric inflannnation may occupy any part of the large intestme, or the whole of it, and may be prolonged for a considerable distance up the ileum. It is most common, however, in the lower part of the colon and in the rectum, and is usually most severe and most advanced in these situations. Other lesions besides those of the bowels are often met with in dysentery. The most common are engorgement of the lymphatic glands in relation with the uaflamed mucous membrane, and congestion of internal organs, more especially the liver, spleen, kidneys, and lungs. In association with the dysentery of tropical climates abscess of the Hver is not unconunon. This complication is referred by Dr. George Budd to portal pyjemia, taldng its rise fr'om the diseased mucous membrane of the bowel. Hepatic abscess, however, sometimes originates simultaneously with the dysentery, sometimes precedes it ; and hence it seems more probable that the two 670 DISEASES OF THE DIGESTIVE ORGANS. lesions are concurrent effects of the same cause, and not dependent the one on the other. Symptoms and progress. — The symptoms of dysentery comprise those of pyrexia and those due directly to the morbid processes going on m the large intestme — the latter being mainly determmed by the excessive irrit- ability and tendency to spasmodic contraction of the larger bowel, and by the fact of the constant discharge into it of the morbid products of the diseased mucous surface. In the milder forms of the disease, the patient, after suffering, perhaps, for a short time from heat and dryness of skin, clamminess of mouth, and vague griping pains, is attacked almost suddenly with an uncontrollable impulse to evacuate his bowels, and probably passes a solid motion with unusual ease — the mass being invested in a greater or less abundance of greyish or colourless mucus. The usual sense of relief, however, does not follow, and he probably finds himself compelled to sit straining at stool, with fits of spasmodic violence, during which he discharges small quantities of offensive mucus, and probably a minute fgecal lump or two. With the continuance of the affection the febrile disturbance continues : the tongue probably becomes coated ; a constant sense of uneasiness, heat, or burning pervades the anus and adjoming parts of the rectum, and perhaps the rest of the large intestine. The patient suffers from frequent tormina, and im- pulse to evacuate the bowels — the efforts being attended with much tenes- mus, and the discharge mainly of small quantities of mucus. This may be stained with ftecal matter, and is often intimately mixed with blood, and may consequently present very much the appearance of pneumonic expec- toration. But, notwithstanding the almost constant efforts at defascation, there is, so far as actual ffecal matter is concerned, almost complete con- stipation. A few scybala only are passed from time to time. Cases of this kind may subside in the course of a day or two, and seldom last longer than a week or ten days. Nevertheless some irritability of the bowels, uneasiness after defaecation, and tendency to constipation, may trouble the patient for a considerable time after he seems to have regamed in other respects his ordinary good health. In the more severe forms of dysentery the symptoms are similar in kind, but much more intense. The disease is usually ushered in with high fever, often with alternate chills and flushes of heat, sometimes with dis- tmct rigors, and occasionally even with convulsions. The skin is hot, the pulse accelerated ; there are febrile pains and headache, anorexia, thirst, and dryness and furring of the tongue. In this, as in the former case, the intestinal affection is usually first indicated by the occurrence of griping pams, which are presently followed by the evacuation of the contents, often solid, of the lower bowel. But soon the griping becomes frequent and severe, calls to stool are incessant, and the patient suffers from almost constant tenesmus. The matters discharged from the bowels are at first a whitish, broAvnish, or olive -coloured glairy or jelly-like mucus ; but this soon gets sanguinolent, and not imfrequently intermingled with consider- able quantities of dark and maybe clotted blood. After a while the dis- DYSENTEEY. 671 charges commonly assume those characters which give them a resemblance to ' meat-washings ' : they become thin, watery, tiu'bid, reddish, and dirty- looking, and contain brownish or blackish particles, which are frao-ments either of altered blood-clots or of sloughy mucous membrane. It is at this time also that the patient frequently passes soft membranous peUicles, which are either tracts of mucous membrane detached in bulk, or portions of false membrane. Dysenteric evacuations are further characterised : by a pecu- liar and almost insupportable fetor, which increases in intensity with the supervention of sloughing ; by contaming a large quantity of dissolved albumen ; and by the occasional presence of small soHd faecal lumps or scybala. They sometimes become purulent. The fi-equency with which the bowels act is often very remarkable. In some cases the patient seems for a length of time never to cease dischargmg small quantities of fluid. The bowels are often relieved four or five times in the hour, and some- times as many as ten or twenty times in the same period. The quantity of fluid passed, however, is not necessarily in relation with the frequency with which the bowels act. In many cases, especially at the beginnmo-, the discharge is scanty ; but later on considerable quantities of serous fluid, or blood, or both, are apt to escape, and the total bulk of these discharges in the twenty-foiu' hours is hence often very large. Ansociated T\ith tenesmus and ahine flux are burnmg pam within the anal orifice, and a constant sense of the lodgment there of something which needs to be got rid of ; there is also more or less burning pain and tender- ness on pressure in the course of the large intestine and especially of those parts which are chiefly involved. At first probably the abdominal parietes are rigid and retracted ; but before long flatus accumulates and the abdomen consequently gets enlarged and tjonpanitic ; the tongue becomes thickly coated; the patient complains of thirst, loathes food, and not mifrequently suffers from nausea and vomitmg ; the mine is seantv and high-coloured, and its discharge sometimes attended with pain or diffi- culty ; the febrile excitement which ushered in the disease gets replaced by a condition of profomid depression ; the skin may yet be hot and dry, but the pulse becomes small, feeble, and rapid, the face anxious, and the patient restless, sleepless, and desponding. Cases which end favourably usually manifest signs of amendment from the sixth to the tenth day ; these consist in abatement of fever and other general sjTnptoms, and gradual cessation of tenesmus and the pecuHar dysenteric stools. But convalescence is usually much protracted ; and some time elapses before the bowels completely regain their normal tone. In cases which end fatally the pulse mcreases in rapidity, loses fulness and power, and often becomes scarcely perceptible ; the surface tends to grow cool; the face and extremities acquire a shrunken and dusky as- pect ; the tongue becomes dry and brown or black ; hiccough and vomitiuo- come on ; and the abdomen grows more and more tympanitic. Althouo-h probably contmuing restless and desponding, the patient often retains his senses perfect to the last ; sometimes, however, he becomes delirious (in some cases, indeed, delirium comes on early), and he may then pass into €72 DISEASES OF THE DIGESTIVE OEGANS. a state of stupor or coma. It very commonly happens that, with the mcrease of tympanites, the abdominal pain, colic, and tenesmus all sub- side and even disappear wholly. The symptoms which precede death, and the mode of death, are necessarily modified to some extent by the special circumstances of the case ; they are, for example, somewhat different in such cases as are attended with profuse hemorrhage from what they are in those in which intestinal perforation takes place, or which are complicated by hepatic abscess, or where the patient sinks mider the influence of the uncomplicated disease. Under all circumstances, how- ever, the immediate cause of death is asthenia. Many cases of acute dysentery, instead of taking either of the two courses which have been considered, become chronic ; and the disease continues, with occasional remissions and exacerbations, for an indefinite period. The patient is then an almost constant sufferer from colic and tenesmus, and the discharge of offensive liquid stools, containing little true fgecal matter, and from retention, often to a very uncomfortable extent, of his solid fseces ; he complains of abdomuial tenderness and uneasiness ; his tongue is in some cases dry, glazed, and fissured, in others coated, in others almost normal ; and his appetite presents equal variations ; more or less sickness is often present ; and he becomes emaciated, weak, anaemic, anasarcous, and often hectic. If an hepatic abscess be present, the symptoms, or many of them, are aggravated, and probably the indi- cations of hepatic tumour are presently superadded. Chronic dysentery varies greatly in its severity, and in some cases, even though lastmg for years or throughout life, is, excepting from the discomfort which attends it, of comparatively little importance. As a rule, sporadic dysentery is not a very fatal disorder ; but the epi- demic form is usually attended with a high mortality ; and although, even here, the ratio of deaths to attacks is sometimes small, the cases are so numerous, and the total mortality usually so high, that it is justly regarded as one of the most fatal of epidemic diseases. Treatment. — There is little unanimity of opinion with regard to the treatment of dysentery ; some authors strongly advocate the copious ab- straction of blood, if not by venesection, at any rate by leeches ; some place their chief reliance on calomel in large doses ; some regard ipeca- cuanha as almost a specific ; some pin their faith to purgatives, some to opiates ; while, on the other hand, each of these remedies has been con- demned. Of the immediate relief which follows the abstraction of blood there is probably little doubt ; but it is obvious that the marked tendency to asthenia which exists in dysentery supplies a powerful argument against the indiscriminate and excessive use of blood-letting. As a rule, it is doubtless unnecessary ; but if employed it should be employed early, and preferably effected by the application of leeches to the tender regions of the abdomen. Calomel has been administered (as it was formerly m cholera) in large doses with reputed success ; it has, however, fallen into disuse, and probably deservedly. Ipecacuanha has enjoyed a long but various reputation. It was formerly regarded as an almost unfailing specific, DYSENTERY. 673 and at the present day is very highly esteemed. There are at least two antagonistic principles on which it is administered. By Trousseau and other French authorities it is given in doses of ten or twelve grains of the powder every ten minutes or so, until copious vomiting results — the -essence of the treatment being, according to them, the production of a powerful evacuatmg effect upon the stomach ; by English army surgeons, on the other hand, it is recommended to be given in a large dose (twenty five to thirty grains), which is to be repeated at the end of eight or ten hours ; but to be given, guarded by opium, and with every precaution against sickness, in order that the remedy may act directly, or indirectly through the system, on the affected mucous surface. Bretonneau advo- cates the use of saline purgatives in large doses, and in this advocacy he is strongly supported by Trousseau. Opium and astringents are often ■employed ; but the former (except in infinitesimal doses) is strongly con- demned by the last author. It may, we think, be fairly asked whether there are any good grounds for beheving that dysentery is more amenable to treatment, specific or non- specific, than other forms of enteritis are ; and whether there is sufficient reason for adopting a radically different treatment from that which has been found generally useful in enteritis ? In acute and severe cases we should be disposed in the first instance : to apply hot fomentations to the belly, and if there be much local pain and distress, to abstract blood by means of ten, twenty, or thirty leeches ; to exhibit opium, or opium with ipecacuanha, in doses sufficiently large or sufficiently frequently repeated to relieve the tormina, tenesmus, and abdominal pain ; and to use enemata •either simply to wash out and cleanse the lower bowel, or to soothe it, or for the purpose of applying astringent or other medicaments directly to its surface. We should prefer, in the early stage of the disease, small enemata of gruel containing laudanum, or opium or morphia suppositories. The patient's diet should consist of milk, gruel, broths, eggs, and such- like articles, together with such a proportion of alcoholic stimulants as the case may seem to need. If sickness be present, it must be treated with ice, and such remedies as are generally useful in relie%dng siclaiess. "When the dysentery passes into the chronic state, the use of astringent medicines and of vegetable tonics is indicated. The former may comprise •copper, lead, iron, and tannin, together with other vegetable astringents, the latter a wide range of vegetable infusions. At this period also enemata are likely to be serviceable ; of which those containing copper, lead, tainiin, sulphate of zinc, or nitrate of silver have been strongly recommended, in the belief that they have a direct beneficial action on the diseased mucous membrane. We believe it to be a good plan to Avash out the bowel night and morning with as large an injection of warm water or gruel as can be introduced without pain, and then to insert a morphia suppository. In treating dysentery it must not be forgotten that in both acute and chronic cases ffecal matter tends to accumulate above the diseased portion of bowel, and that this needs froni time to time to be removed. For this purpose it may be necessary to administer an occa- X X 674 DISEASES OF THE DIGESTIVE OEGANS. sional purgative. In mild cases of the disease it is often well to commence the treatment with a dose of castor oil, and to continue it with mild astringents, such as compomid kino powder, Dover's powder, or aromatic chalk and opium. VIII. PEEITONITIS. Causation. — Peritoneal inflammation is common in both sexes and at all periods of life. It is due to various causes. In some cases it is idiopathic, or the result of exposure to cold and wet, or generally to those exterior conditions to which inflammations of other organs are so commonly traceable. Idiopathic peritonitis may attack the robust and healthy ; it is more common, however, in those who are anemic, debilitated, or broken down in constitution, and in those who sufi'er from obstructive diseases of the heart, lungs, or liver, and especially hi such as are labourmg mider chronic Bright's disease. In many cases peritonitis is due to the simple extension of inflammation from neighbouring parts. It is thus developed, in the course of enteritis or gastritis, in connection with inflammatory affections of the liver, spleen, kidneys, or bladder, and in dependence on pleurisy, pericarditis, or inflammation of the abdommal parietes. The most fruitful causes, however, of grave peritoneal inflam- mation by simple extension are inflammation of the ovaries, uterus, and other pelvic organs in females, and especially that form of uterine inflam- mation which follows upon parturition. In many cases, again, peritonitis is caused by mechanical injury : sometimes by external womids ; more frequently by the perforation or rupture of some viscus, and the extrava- sation of its contents or of foreign matters into the peritoneal cavity. Among such cases may be enumerated : ulcerative perforation of the stomach and duodenum ; perforation of the small intestine (usually the ileum) by tubercular, tj-phoid, or other ulcers ; perforation of the caecum, vermiform appendix, colon, or rectum, consecutive to tubercular or t}-phoid ulcers, dysentery, or mere over-distension ; rupture of an hepatic abscess, of the gaU-bladder or common bile-duct, of an hydatid cyst, or of a psoas, renal, or other abscess ; rupture of the uterus or ovarian cysts ; and, besides these, the laceration, from external violence, of the hver, spleen, kidneys, intestine, or bladder. Further, peritonitis is a frequent con- comitant of abdominal tubercle or carcinoma, and a not uncommon result of pyemic or metastatic processes. Morbid anatomy. — The morbid changes which take place in the in- flamed peritoneum are precisely similar to those attending inflammation of other serous membranes. They consist in dilatation of the minute vessels, with accumulation of blood within them, and infiltration and thickening of the subserous tissue ; and in inflammatory hyperplasia of the epithelial investment, with effusion from the subjacent vessels of modified plasma of the blood, of which part coagulates on the surface, forming, with entangled corpuscles, a false membrane, and part (mainly PEEITONITIS. 675 fluid) accumulates in the cavity. The first visible indications of peritoneal inflammation consist, in most cases, in more or less intense capillary congestion, which is usually observed to extend in bands (determined by the pressure of the organs against one another) along the intestmes ; and in loss of polish, due to commencement of inflammatory exudation. With the advance of the disease, the congestion becomes more intense, and patchy, and sometimes complicated with subserous extravasations ; and the soHd inflammatory exudation increases in quantity. This forms in the first instance a thin, greyish, granular lamina ; but as it increases in thickness it acquires a more distinctly yellow tinge, and becomes, accord- ing to its quantity and position, ribbed, villous, papular, or honeycombed. The false membrane varies in thickness from a delicate film to a quarter or half an inch or more ; and in quality from a mere pulp to a coherent elastic lamina. It usually acquires toughness with age ; and the deeper- seated portions are always tougher than the more superficial. It tends to accumulate in the dependent parts of the peritoneal cavity, and to cause adhesion between neighbouring organs. The fluid eflused in the course of peritonitis is often small in quantity, and, subsiding into the pelvis and lumbar regions, apt to escape detection ; on the other hand, it is sometimes very copious, and causes much abdominal distension. It is chiefly abundant in chronic cases. It is usually opalescent, containing exudation-corpuscles, and fibrinogen, which readily coagulates. The spaces occupied by the fluid are commonly traversed by filaments, bands, or bridles, of coagulated lymph. Peritonitis, even when of local origin, generally soon involves the whole of the peritoneal surface. In some cases, however, it remains localised. Thus it may be confined to the neighbourhood of the liver, spleen, cfecum, or pelvic organs. The great omentimi not unfrequently effectually limits its spread. Convalescence from simple peritonitis is attended with absorption of the dropsical eftusion, subsidence of the in- flammatory congestion, and organisation of the false membrane, with its gradual conversion into connective tissue. The usual consequences are that the peritoneal surface gets thick and opaque, and the viscera united to neighbouring parts and compressed by the contracting adventitious membrane. Thus the liver and spleen become adherent to the diaphragm ; and the small intestines grow together, and are not unfrequently welded into an apparently homogeneous lump. Further, the liver and spleen, and other organs in a less degree, are apt to get studded with opaque fibroid patches which may attain a thickness of ^ inch or more, and present an almost cartilaginous consistence and aspect. In many cases peritonitis becomes suppurative. Sometimes, as in the puerperal variety, the inflammation presents this character universally and from the beginning : the eflused lymph is more abundant, opaque, yellow, and pulpy than in non-suppurative cases, and obvious pus is poured out into the peritoneal cavity. Where inflammation results from the perfora- tion of some viscus or sac and the escape of irritating matters, general peritonitis of the ordinary adhesive character is often at once excited, and X x2 676 DISEASES OF THE DIGESTIVE OEGANS. thus the effused matters become confined to some limited district. In such cases a circumscribed abscess frequently follows, which may possibly undergo cure by the discharge of its contents either externally or into the bowel. But in some cases groups of such abscesses form ; and sinuses extend in various directions — either among the peritoneal adhesions, or in the substance of the mesentery, meso-colon, great omentum, and other such parts ; and fistulous openings may be established in various situa- tions. General suppurative peritonitis may of course result from the escape of fascal or other irritant matters into the peritoneum, especially if the escape be sudden and profuse ; in which case, if the accident be not immediately fatal, the false membrane becomes exceedingly thick and tough, and the general surface acquires the usual characters of that of a chronic abscess. Occasionally in peritonitis, as in other serous inflammations, copious hemorrhage from the newly-formed vessels of the adhesions takes place into the serous cavity. In connection with this subject we may draw attention to the fact of the not unfrequent formation, independently of general peritonitis, of circumscribed abscesses in the abdominal cavity, the causes of which are sometimes obvious, sometimes obscure and undiscoverable. These may occur in any situation ; but they afl:ect some localities more than others, and especially the neighbourhood of the stomach, the iliac regions, and the cavity of the pelvis. In the first of these situations they may lie between the stomach and the liver or diaphragm, or between the cardiac end of the stomach and the parietes, simulating splenic disease, or be- tween the stomach and the transverse colon, or may occupy the cavity of the lesser omentum ; and they may open either through the outer abdo- minal walls, or into the stomach or colon, or through the diaphragm into the pleura or lung, or in two or more of these directions at the same time. When occurring in the iliac regions they may either open externally or take any of the courses which perityphlitic abscesses are apt to take. If they occupy the pelvis they tend to open into the rectum or bladder, and in the female into the vagina. Symptoms and progress. — The symptoms of peritonitis are mainly those of fever in combination with acute abdominal pain, increased by pressure. They are liable, however, to considerable variety; and many others of more or less importance are usually superadded. The pheno- meijia of peritonitis differ greatly, indeed, in relation to the extent and intensity of the inflammation and to the circumstances under which it arises. Acute idiopathic peritonitis, although by far the least frequent variety, yet displays the symptoms and course of the disease in their simplest and most typical form. Its mode of onset varies. Sometimes the outbreak •of the local affection is preceded by a few days of vague sense of illness ; sometimes it is marked by the occurrence of febrile symptoms, and even of rigors ; sometimes the first indication of disease is sudden vomiting or purging, or both, or gradually increasing dysuria, or in females the PEKITONITIS. 677 occurrence of menorrliagia. But, whatever the initiatory symptoms, the patient before long complains of febrile disturbance, and of burning, aching, pinching or cutting pain, probably limited to some region of the abdomen, and increased by pressure or movement. The pain is usually in the first instance across the lower part of the abdomen ; and if the patient have not yet taken to his bed, he sits, moves and walks with his body bent into a stooping posture. Soon, however, the signs of peritoneal inflammation extend and increase in severity ; and at the same time the patient's general symptoms assume a more serious aspect. The abdominal pam becomes exceedingly severe, and is aggravated beyond endurance by the slightest movement. He takes to his bed, where he lies motionless on his back ; with his head and shoulders elevated, and his thighs and legs flexed so as to diminish as far as possible the pressure of the abdo- minal walls on the internal organs ; and breathuig by means of the inter- costal muscles only, and shallowly, with the same object. He not only shrinks from the pressure of the hand, but generally cannot bear even the weight of the bed-clothes, or of the poultices or fomentations which may have been ordered for his relief. The pain often is comparatively trivial so long as perfect rest is maintained ; but it breaks out afresh whenever a cough, sneeze, hiccough, or deep inspiration takes place, and is liable to periodical and in many cases frequent aggravations, due to the peristaltic movements of the bowels. In association with these phenomena there is generally distinct fever. The temperature may reach 104° or 105°, but is very often not above 100° or 101°. The skin is hot and dry ; the face flushed ; the pulse increased in frequency and sharp- ness ; the respirations augmented to 30 or 40 in the minute ; and the tongue coated and clammy, if not dry. Vomiting is often present, but is no necessary feature of the disease ; and thirst is usually complained of. The bowels are generally constipated, but are not unfrequently loose. The urine is scanty, high-coloured, and sometimes retained ; or there may be irritability of the bladder with painful micturition. The presence of marked intercostal respiration indicates involvement of the upper part of the abdominal cavity ; interference with micturition points to implication of the pelvic peritoneum. Further, there is reason to believe that the occurrence of vomiting or diarrhoea is referrible in some cases to inflammation of the serous surface of the stomach or bowels. If the disease take a favourable turn, which indeed at the end of a few days it usually does, the severer symptoms gradually remit : abdominal pain and tenderness subside, vomiting ceases, the respirations become natural, and the temperature and pulse return to their normal condition. If, on the other hand, the case be about to prove fatal, important changes in the symptoms supervene ; the abdomen becomes distended, partly from effusion of fluid, mainly, however, from accumulation of gas in the intestines ; pain and tenderness, though sometimes continuing and even becoming aggra- vated, very frequently undergo great diminution and sometimes cease entirely ; sickness probably increases, and hiccough supervenes ; the tem- perature falls, the extremities get cool or cold, the face pale or livid, and 678 DISEASES OF THE DIGESTIVE OEGANS. pinched and anxious in expression, and the skin suffused with cold sweats ; the pulse increases in frequency, rising it may be to 130, 140, or 160 in the minute, and gets small, thready, and weak ; the respirations quicken, reaching, perhaps, 40 or even 60 in the minute ; and the tongue becomes more thickly coated, and this and the lips dry. The patient, in fact, for the most part retaining his consciousness, falls rapidly into a state of pro- found collapse, in which he presently dies. Sometimes delirium comes on before the fatal event, and death may then be preceded by coma. The tendency to failure of circulation and to collapse is one of the most remarkable characteristics of peritonitis, as it is of enteritis. And it is important to bear this fact in mind ; for even in the early stage of the disease, when the pulse is little accelerated, and sharp, perhaps strong, and the patient appears to be suffering from what is termed ' the sthenic form ' of peritonitis, a little over- exertion, some unwonted effort, may readily induce dangerous collapse. It may be added that, while the presence of dropsical effusion adds to the distension of the abdomen, it does not, as a rule, materially aggravate the danger of the case ; and that, if sufficiently abundant, it may be detected either by its causing dulness and bulging in the flanks, or by the presence of fluctuation ; and further, that peritoneal inflammation con- stantly causes basic pleuritis, which may possibly be recognised during life ; and that peritoneal friction may also occasionally be detected either by the fremitus it occasions or by auscultation. Death may occur as early as the second or third day of the attack, or may be delayed to the end of a week or ten days. When, however, the disease is prolonged beyond this date, it usually lapses into the chronic condition ; in which, either inflammation of little intensity is kept up by the development of tubercles or some other cause, or the chronic symptoms are due to the formation of a circumscribed absceFS. Puerperal peritonitis differs from the idiopathic affection chiefly in the circmnstances under which it arises, in its usually rapidly fatal course, and in the fact that it is often associated with, if not dependent upon, pyaemia taking its origin in inflammation of the uterine mucous mem- brane. It generally begins within a few hours or a few days after par- turition, with severe rigors, attended with high elevation of temperature, and soon followed by intense pain across the lower part of the belly, and suppression or modification of the lochial discharge. The main points in its symptomatology, by which it differs from the simple form of the disease, are the speedy supervention of collapse, and the more general and early implication of the sensorial functions. Further, the symptoms are, in many cases, compounded of those of the local affection and those of pyaemia. Peritonitis from perforation is one of the most common and interesting forms of the disease, and by far the most fatal of them. When perfora- tion takes place in a person who appears to have been, up to the very moment of the accident, in the enjoyment of good health — as sometimes happens in cases of penetrating ulcer of the stomach, rupture of the urinary PEEITONITIS. 679 Madder, or perforation of the ileum in mild enteric fever, the symptoms iisiially are : sudden and intense pain in the region of the lacerated organ, speedily followed by all the local indications of violent peritoneal inflam- mation ; and extreme and immediate collapse, shown by pallor and cold- ness of surface, cold sweats, scarcely perceptible pulse, fainting, and vomiting. In some cases the patient dies of this primary collapse in the •course of a few hours ; and there may be little in the history or symptoms of such a case to distinguish it from one of Asiatic cholera, fatal before ±he supervention of diarrhoea ; or from one of sudden effusion of blood into the stomach and bowels, fatal without hsematemesis or mel^ena ; or from one of ruptured heart or internal aneurysm. But more frequently the patient rallies somewhat, and the collective symptoms of inflammation, fever, and peritoneal mischief become more clearly developed. Collapse, however, generally soon reappears, and the patient usually sinks after a period varying between twelve hours and two or three days. But the symptoms of perforative peritonitis are not always so intense and striking. Indeed, they are often exceedingly difficult of recognition, and vague, when they occur m the course of abdominal diseases, whose proper symp- toms tend to mask them ; for example, dysentery, enteritis, and those rare cases in which peritoneal suppuration causes perforation of the bowel from its serous aspect. By far the most common cases of masked per- forative peritonitis are those which occur in the second or third week of severe enteric fever, when the patient is prostrate with diarrhoea, and is duU, confused, and delirious, and to a large extent insensible to painful «nd other impressions. The evidences of perforation are then to be sought, not so much in obvious sudden collapse or intensity of abdominal pain, as in the general indications of failing strength — namely, increased weakness and rapidity of pulse, coldness of extremities, Hvidity of face, rand dimmution of intelUgence, and of power over the Hmbs and sphincters ; and in the supervention or increase of tympanites, with general abdominal tenderness, as shown by the expression and actions of the patient when pressure is made upon the surface of the abdomen. But although peritonitis from perforation is a well-nigh hopeless affection, there is reason to believe that it is not entirely hopeless. We have known of a 'Case in which the patient certainly sur\dved the accident for a fortnight ; and several cases have been put on record in which there are good grounds for believing that a cure was effected after the formation of an abscess and its discharge by the bowel or some other route. Peritonitis is not always the serious disease which has been above -described, hi a large number of cases it is, even if general, slight ; and in a large number of cases, also, it is of local origin, and continues localised. The symptoms of partial peritonitis are the same in kind as those of the more general and more severe affection ; but the local indications are limited to some comparatively small area, and the general symptoms, if there be no serious complications, are comparatively slight. It must not be forgotten that the adhesions which peritonitis leaves i)ehind are not unfrequently a source of discomfort or danger. In some 680 DISEASES OF THE DIGESTIVE OKGANS. cases the compression of the bowels which they induce keeps up a tendency to colicky pains and intestinal disturbance ; in some cases slowly contract- ing adhesions gradually compress a length of bowel and render it prac- tically impervious ; while in other cases, again, bridles or bands are formed, behind which coils of bowel are apt to slip and get incarcerated or strangulated. Peritonitis is liable to be confounded both with enteritis and with colic ; but is generally distinguishable from enteritis by the absence of intestmal obstruction, and from simple colic by the fact that the latter ia unattended with fever, and that its pain is usually relieved in some degree by pressure. The symptoms of abdominal abscesses, whether they be associated with peritonitis or not, are often very obscure. More or less feverishness. and constitutional disturbance are usually present, and also, as a general rule, special symptoms dependent on their seat and the organs with which they are in relation. Their main local indication is the presence of a tumour which is more or less tender and painful, and m which fluctuation may generally be more or less distinctly felt. Sometimes, owing to the- thiclmess and density of their walls, they are hard and unyielding, and. simulate solid tumours. They tend, of course, to enlarge and to point. And if they do not open externally sometimes rapidly disappear by burstmg mto the peritoneum or some hollow viscus. Under such cncum- stances either acute peritonitis is suddenly excited, or pus may suddenly be vomited, or discharged by expectoration, or escape by the bowel,, bladder, or vagina ; and communications may be established between, neighbouring organs leading in some cases to the vomiting of solid faeces^ in some to the discharge of ffecal matter from the urethra or vagma, in some to the escape of undigested food by the rectum. Such abscesses are often very chronic in their progress, and often lead ultimately to a fatal result. It may be difficult, at any rate for a time, to distinguish them from malignant growths ; and indeed abscesses not unfi'equently arise in connection with such growths. Treatment. — The principles of treatment in peritonitis are sufficiently simple : they are, the mamtenance of perfect rest, the administration of opium, and the apphcation of leeches and other remedial agents to the surface of the abdomen. The patient should be placed and propped up in that position which he finds easiest, usually upon his back, with his knees and shoulders elevated. His abdomen should be defended from the weight of bed-clothes by means of a suitable cradle. Opium or morphia should be given sufficiently frequently, and in sufficiently large doses, to assuage the patient's pain and keep it in abeyance, to quiet the action of the bowels,, and to promote comfort and sleep ; it may be given by the mouth, or by subcutaneous injection. If the case be severe and in an early stage, from ten to thirty or forty leeches should be applied to the surface of the abdo- men ; and bleeding should be promoted by fomentations or light poultices. Subsequently hot fomentations, turpentine epithems, mustard plaisters,. or bHsters may prove serviceable. On the other hand, cold apphcations. CIEEHOSIS OF STOMACH AND BOWELS. 681 (evaporating lotions, cold compresses, and ice-bags) have been largely advocated, and in many cases have proved of great advantage. It is im- portant, moreover, in many cases, to relieve accidental complications, sncli as nausea and vomiting, dysuria and the like. To meet the former mdi- cations, recourse must be had to ordinary anti-emetic measures ; to meet. the second, the catheter may need to be employed. It is of course essen- tial to maintain, so far as we possibly can, the patient's bodily strength • for which purpose nourishing diet, mainly in the fluid form, must be frequently administered in small quantities, and alcoholic stimulants, in amounts depending on the condition of the patient, combined therewith. If he cannot retain food on the stomach, it must be given by the rectum. It need scarcely be said that cases of peritonitis passing rapidly into col- lapse, and especially therefore cases of puerperal peritonitis, bear depletory measures less well than others ; and that hence such treatment is admis- sible only in quite their early stage. These cases, moreover, demand,, more than others, early and considerable stimulation ; and ammonia and ether, or similar agents, may be employed in addition to alcohol. When peritonitis is caused by perforation, our main reliance must be placed upon opium ; and here especially it is of vast importance that the movements of the bowels be restrained, that purgatives be religiously avoided, and that the stomach be not overloaded with nutriment. If the patient sur- vive for two or three days, some hope (remote, no doubt) may be enter- tamed of his final recovery. But in order to promote this consummation,^ it is always desirable to investigate carefully from day to day the condition of the abdomen, in order to detect the presence of any circumscribed. abscess there, and as soon as may be to evacuate its contents. IX. CIEEHOSIS OF THE STOMACH AND BOWELS. Morbid anatomy. — Fibroid infiltration or thickenmg (a condition alsO' termed ' cirrhosis,' and having a close anatomical relation with cirrhosis of the liver) occasionally takes place ui the walls of the stomach and intes- tines. Thickening, which diflers httle, if at all, from this, is usually present in the neighbourhood of chronic ulcers of the stomach. When occurring independently, all the coats of the stomach as a rule are impli- cated, but more especially the muscular coat and the submucous tissue — ■ the mucous surface being thrown into prominent folds over the affected area. The whole stomach is sometimes thus diseased, and is then usually diminished in size, tough, and retaining its form like an india-rubber bottle. But commonly the affection is limited to the neighbourhood of the pylorus, which then becomes constricted, and leads to general dilata- tion of the organ. The gastric walls, especially at the pyloric end, some- times attain a thickness of half an inch or an inch, and present to the naked eye most of the usual characters of scirrhus. The morbid growth, however, diflers from scirrhus in consisting wholly of fibroid tissue, and 682 DISEASES OF THE DIGESTIVE OEGANS. not possessing malignant properties. The intestines are much less fre- quently affected than the stomach. The symptoms referrible to cirrhosis are vague. They resemble, for the most part, those of the early stages of carcinoma. When the pylorus is obstructed, the symptoms of that condition necessarily manifest them- selves ; when the large intestine is involved, the phenomena of stricture presently supervene. X. TUBEECLE. {Abdominal Phthisis.) Morbid anatomy. — Tubercular disease of the mucous membrane of the stomach is so rare, and so little is known about it clinically or otherwise, that it is needless to do more than record the fact of its occasional occurrence. 1. Bowels. — The mucous membrane of the bowels, on the other hand, is one of its most frequent seats ; and, indeed, intestinal ulceration is, m a very large proportion of cases, of tubercular origin. Tubercle of the bowels occurs in rather more than one-half of the total number of cases of pulmonary phthisis, and rarely, if ever, independently of it ; it is fre- quently associated, also, with tuberculosis of the peritoneum and other abdominal organs. It affects primarily Peyer's patches and the solitary glands ; and in the small mtestine, therefore, is always most abundant and most advanced immediately above the ileo-cfecal valve, from whence upwards, even though it extend throughout the whole ileum and jejunum, it gradually diminishes. It attacks the caecum more frequently than any •other part of the large intestine, involving also the ileo-caecal valve and vermiform appendage ; but it may form patches throughout the whole length of the colon. The large and small intestines are affected with equal frequency, and are affected conjointly about twice as often as each is affected separately. The tubercles appear as grey granules, or yellow cheesy masses, in the substance of the glands, and generally soon luidergo softening, producing small, deepish ulcers with thickened, overhanging edges. When several tubercles have softened side by side, as occurs in Peyer's patches, the ulcerated area presents in the first instance a kind •of honeycombed appearance — the small ulcers being separated from one another by bridles of thickened mucous membrane ; and the general margin, which is also thickened, presents a suauous or scalloped outline. Tubercular ulcers generally tend to spread by the successive formation and softenmg of tubercles at their edges ; and thus often creep over a considerable area. The whole mucous hning of the caecum is sometimes destroyed in this manner ; and extensive tracts of ulceration often stud the surface of the colon at more or less distant intervals. In the small intestine tubercular ulcers have a remarkable tendency to spread trans- versely, and frequently form bands, from half an mch to an inch or more wide, occupying its whole circumference. In most cases the ulcerative process progresses up to the patient's death, and occasionally leads to ABDOMINAL PHTHISIS. 683 serious hemorrhage or to perforation. Sometimes the ulcers cicatrize more or less perfectly — some, indeed, cicatrizing while others are spreading or new ones forming. Tubercular cicatrization leads to considerable con- traction of the bowel and even to the production of stricture. Sometimes tubercles dry up or get absorbed without undergomg ulceration, leaving behind them pigmented cicatrix-like patches which have some resemblance to the scars left in the skin by superficial lupus. Extensive ulceration of the large intestine, presenting all the characters of chronic dysenteric ulceration, is often met with in cases of chronic phthisis, where there is no discoverable tubercle in any part of the bowels except the ileum, and where, therefore, it may be a question as to whether the ulceration is of tubercular origin, or has arisen in mere non-specific excoriation such as might be caused by the constant passage of irritating secretions from the tubercular bowel above. 2. The loeritoneum and abdominal lymphatic glands are often affected. Generally in cases of tubercular ulceration of the bowel, and certainly in all cases of extensive ulceration, grey granulations stud the serous surfaces ■corresponding to the diseased arese. But such formations are for the most part purely local, and of little importance. There are other cases, however, far less common, yet not unfrequent, in which the tendency to the growth of tubercles is general throughout the serous membrane, and in which ulceration of the bowel is not only not their starting point, but often altogether absent. Peritoneal tuberculosis is almost always associated with similar disease of other parts ; most commonly with pulmonary phthisis, but not unfrequently with tubercular affection of the bowels and other abdominal organs. It complicates a very large proportion of those cases in which the pleurte, spleen, liver, kidneys, uterus and Fallopian tubes, or brain is mvolved. Peritoneal tubercles are sometimes miliary and grey, and from the size of a poppy-seed downwards. Sometimes they form lobulated masses from the bulk of a tare up to that of a hazel-nut : presenting for the most part an opaqiae buff"- colour, often mottled with black points or patches ; and exhibiting a cheesy aspect and consistence, which are modified by the greater or less abundance of fibroid material which invests and permeates them. Sometimes, again, but much more rarely, there are found, lying between organs which are adherent, tuber- cular laminae of considerable thickness and extent. Peritoneal tubercles, indeed, rarely exist independently of the effusion of lymph and the presence of false membranes. The large tubercular masses are usually compara- tively few in number ; the miliary tubercles, on the other hand, are, as a Tule, thickly set and innumerable. Further, in the latter case the peri- toneal surface is often found covered with a layer of greyish transparent, adlierent, and toughish lymph, which not only invests the abdominal organs, but unites them more or less with one another, and in the sub- stance of which tubercles are disseminated as opaque grains. In association with the presence of tubercles all the usual phenomena .and sequels of simple inflammation, such as streaky redness, fibrinous ^effusion, and dropsical accumulation, are apt to manifest themselves ; 684 DISEASES OF THE DIGESTIVE OEGANS. sometimes, also, suppuration, sometimes profuse liemorrbage. Further, it occasionally happens that, durmg the progress of peritoneal tuberculosis involving the intestinal walls, perforation of the latter takes place. The most important of these phenomena from its frequency is undoubtedly ascitic effusion. The abdominal lymphatic glands are a frequent seat of tubercle ; mamly, however, the glands of the mesentery, and more especially those of them which are in relation with tuberculous intestme. Tubercle of these organs is mostly secondary to tubercle either of the intestines or of the peritoneum. It appears in them, and for the most part in their peripheral portions, in the form of minute, hard, grey points, which occur m groups and tend gradually to run together, and to form imbedded masses which soon undergo caseous change. Glands thus affected may suppurate and even rupture into the peritoneal cavity ; or they may get slowly converted into mortary or calcareous lumps. Tubercular glands are usually enlarged, sometimes, mdeed, attam the size of a pigeon's egg. When, however, they undergo calcareous change they contract and acquire an indurated capsule. Tubercular mesenteric glands sometimes, especially in children, collectively form masses easily detectable through the abdominal walls ; but there is little doubt that most of those cases of extreme enlargement of these glands which were formerly regarded as tubercular were really cases of lymphadenoma or some other form of malignant disease. Symptoms and progress. — 1. Bowels. — The symptoms of tubercular ulceration of the mucous membrane are in no degree specific ; but they vary according to the part of bowel affected. When the disease is limited to the ileum there is probably pain and tenderness in the region of the caecum, with frequent griping. The bowels may be confined or loose, but are more often, perhaps, irregular. When the large intestine is involved, the symptoms closely resemble those of chronic dysentery, and, indeed, are by no means necessarily distinguishable from them. The points of chief clinical importance in reference to intestmal tuberculosis are : first, that the disease is for the most part a progressive one, and that hence diarrhoea havuig once declared itself tends to become progressively more and more severe and intractable ; second, that during its progress the patient raj)idly undergoes extreme emaciation, becomes excessively feeble, and suffers in an aggravated form from night sweats, imperfect circulation (indicated by blueness of nose and coldness of extremities), and the other phenomena which attend rapid impairment of nutrition ; and, third, that it is usually associated with well-marked indications of tubercular disease in other organs. Hemorrhage, perforation, and stricture are not special to tuber- cular ulceration, and then- symptoms need not now be discussed. 2. Peritoneum. — The symptoms which attend the progress of peritoneal tuberculosis present much variety and are often vague and misleading.- Often, indeed, and not only in those cases in which the peritoneal affection is slight, or m those ha which it is as it were overshadowed by the pre- ponderance of disease in other parts, but in those cases in which it is the predominant or sole affection, they fail to indicate clearly the peritoneura ABDOMINAL PHTHISIS. 685 as tlie seat of disease. Fm-tber, tliey are so generally compHcated with s}Tiiptoms due to coexisting tubercular disease in otber organs, especially the lungs, pleui'a&, and intestmes, tbat it is impossible altogether to dis- sociate them from the latter. Most cases of tubercular peritonitis, attended with obvious symptoms, may perhaps be somewhat roughly arranged in two classes : the first (the acute class), in which the s\Tnptoms have a close resemblance to those of enteric fever ; the second (the cbronic class), in which the symptoms correspond for the most part with those of chronic peritonitis. In the acute form the patient, sometimes in the midst of perfect health, more often after an indefinite period of languor and loss of flesh and strength, begins to manifest febrile S}Tnptoms attended T\-ith remissions, and indicated by heat and dryness of sm-face, quickened pulse, pains in the limbs, loins, and head, diminution of the secretions, and perhaps drowsi- ness. At the same time probably the abdomen becomes hard, tumid, tender, and uneasy or pamful. Generally, also, there is chsturbance of the digestive functions : di-yness or furring of the tongue, thirst, loss of appetite, nausea or sickness, and constipation, diarrhoea, or irregularity of bowels. And possibly, with no material change in his symptoms beyond what may be due to increasing debiHty and emaciation, and the gradual supervention of' typhoid symptoms,' the patient gradually sinks, and at the end of a few weeks dies. Among the chief points by which this aflection may be distinguished from enteric fever are : the absence of rash, and of pain specially Hmited to the Cfecal region ; the probable presence of tubercular disease m other organs ; and the fact that the temperatm-e, although it may be much elevated and variable, does not present that regularity of morning remissions and evening exacerbations which are so characteristic of enteric fever. In the chronic variety of peritoneal tuberculosis the disease sometimes commences with symptoms of acute peritonitis ; sometimes it creeps on with the utmost insidiousness ; but in either case the symptoms gradually merge into those of chronic peritonitis, with which (unless our diagnosis be aided by the discovery of tubercular disease elsewhere) we cannot well avoid confoundhig them. During the progress of the disease a more or less difliised tumour is apt to be developed ( due for the most part to thickening of the great omentum), which may suggest the formation of a circumscribed abscess or a mahgnant growth. This, which is sometimes fi-eely movable imder the parietes, sometimes adherent to or incorporated with them, occasionally forms a transverse bar, in a hne -^-ith or above the umbihcus. In the last case inflammation, which usually goes on concurrently with the growth of tubercles, now and then spreads to the umbilicus, and to the skui and subcutaneous connective tissue around, and may lead to the belief that an abscess is about to point. Sometimes circumscribed ab- scesses form : mostly in comiection -u-ith the female jDelvic organs, and may either discharge themselves m the iliac regions, or open mto the rectum, or vagma. Ascites is very apt to ensue. The duration of chronic tuber- cular peritonitis may vary from a month or six weeks to a year or two. 686 DISEASES OF THE DIGESTIVE ORGANS. Tubercular peritonitis tends, as a rule, to a fatal result. Eecovery, however, and even permanent recovery, occasionally ensues. Treatment. — The general treatment of abdominal tuberculosis is identi- cal with that of pulmonary phthisis and generally of scrofulous disease. It comprises careful attention to hygiene, removal if need be to a more suitable climate, a good wholesome and nutritious dietary, and the use of cod-liver oil, iron, and vegetable tonics. If the mucous membrane of the bowels be specially affected, and the patient be suffering from exhausting diarrhoea^ treatment must of course be directed to relieve this condition. For the details of treatment in this case we must refer the reader to the articles on intestinal ulceration and dysentery. When the peritoneum is the part principally involved, abdominal pain may need to be relieved by the application of counter-irritants, fomentations, or even leeches ; sleep- lessness, weariness, and pain may require to be overcome by the use of opiates or other sedative or narcotic medicines ; and, further, nausea, sickness, diarrhoea, and intestinal obstruction may all in turn call for relief by the various measures on w^iich in such conditions reliance is usually placed. XI. TUMOUES. A. Non-Malignant Tumours. These are not uncommon, but on the whole are of little medical im- portance. Pedunculated fibrous tumours or polyiji are sometimes very small, very numerous, and of wide distribution throughout both the small and the large intestine. Sometimes, on the other hand, they are few in number or solitary, and then often attain large dimensions. The latter are occa- sionally observed in the ileum, but chiefly affect the lower part of the rectum. In the former situation they are believed to be in some cases the determining cause of intussusception ; in the latter they often produce irritation, bleeding, tenesmus, and other discomforts. Those only can be diagnosed and treated which are within reach, and for them removal is the only effectual remedy. Villous grou'ths are in many cases mahgnant. Some, however, and especially such as are met with in the large intestine, appear to be non- malignant. These usually occupy a limited and well-defined area, and sometimes encircle the bowel. The intestinal walls in the situation of the growth, and especially the mucous and submucous coats, are generally much thickened ; and from this thickened area as a base, close-set, elon- gated, complex villi take their origin. These growths frequently cause hemorrhage, which is occasionally serious ; and diarrhoea, which is some- times of a dysenteric character. When situated near the anus they may be removed by operation. TUMOUES. 687 B. Malignant Tumours. Morbid anatomy. — Malignant growths conunence, sometimes iii the mucous membrane of the stomach or intestines, sometimes in the peri- toneal tissue, sometimes in the mesenteric or retro-peritoneal glands. In the first ease, the disease usually takes its origin at some particular spot ; whence it spreads over a greater or less extent of the contiguous mucous membrane, then gradually involves the whole thickness of the parietes, and ha'sang reached the serous lamina, diffuses itself in a greater or less degree over it, and further implicates the mesenteric or other glands. In. the second case, the growth tends rapidly to generalise itself over the surface of the serous membrane, and to infiltrate the subserous tissue ; but it is often a long time before it penetrates the muscular wall of the stomach or bowels. Sooner or later, however, this is mvaded at points, and then the mucous membrane becomes involved. The lymphatic glands necessarily also suffer. When the disease begins in the mesen- teric or retro-peritoneal glands these gradually enlarge ; and presently the morbid growth extends from them into the surroundmg connective tissue, infiltrates it, and thence spreads to the serous membrane on the one hand, and to the intestinal walls on the other. It will thus be seen, that, although the site in which malignant disease commences exerts an important influence over its distribution and consequences, the ultimate tendency is m each case to its general diffusion. 1. Scirrhous cancer, originating in the walls of the stomach or bowels, causes thickening and induration of the parts which it affects. If it attack the submucous tissue, this becomes greatly hypertrophied ; and presently, the superjacent mucous membrane getting incorporated with it, its natural structure gradually disappears, and its free surface, at first perhaps thrown into rigid folds, grows irregular and nodulated. Whilst this process is going on the muscular wall becomes mvaded ; the morbid growth extends along the inter -muscular septa, con-s'erting them into irregular but thick vertical scirrhous bands, and the muscular tissue thus divided mto strands at first hypertrophies, and subsequently undergoes fatty degeneration. At length the subserous and serous tissues get impHcated ; they, like the mucous tissue, become dense, hard, and thick, and small wheal-like ex- crescences or nodules spring up upon the free surface. Sooner or later in the progress of the case erosion and destruction of the affected mucous membrane takes place, and a smooth excavated ulcer results ; in some cases sloughs form, and the destruction is more rapid and irregular ; and frequently carcinomatous nodules sprout up from the edges and floor of the ulcerated surface. Sooner or later also adhesions form between the affected viscus and neighbouring organs, and along them the morbid pro- cess may be proi^agated. Peritoneal scirrhus always commences in the form of hard, lenticular, white spots, measuring a hne or so in diameter, which, though projecting above the surface, tend specially to invade the subserous tissue. They are in the first instance scattered thinly or irregularly, but soon become 688 DISEASES OF THE DIGESTIVE OEGANS. aggregated in parts or generally, and then coalesce so as to form patches of various sizes. These may be uniformly smooth, or may still present traces in their surface or outline of their mode of development. They rarely, however, form outgrowths, and not very often invade subjacent organs ; rarely, too, do they become more than a line or two thick, except where they involve folds or processes of peritoneum. The appendices epiploicas become converted into small hard lumps, the mesenteric and other like duplicatures thickened and indurated, and the great omentum contracted into a thick band, stretching transversely across the abdomen in the course of the transverse colon. Scirrhous cancer, indeed, whether affecting the gastro-intestinal tube or the peritoneum, tends rather to cause contraction and thickening than outgrowth, and thus, as a rule, leads to constriction of the cavities or canals which it involves, and especially therefore to constriction of the cardiac or pyloric orifice or other parts of. the alimentary tube. 2. Colloid cancer most commonly takes its origin in the serous lamina, whence it spreads to the mucous membrane. When appearing first in the latter tissue, it causes, as other forms of cancer do, more or less consider- able thickening, and manifests itself at the surface in the form of scattered masses, which have a resemblance either to the wheals of urticaria, or to groups of herpetic or eczematous vesicles. Like scirrhus, itj^^invades the muscular coat — running along the intermuscular septa, and causing the muscular tissue to become thickened and hypertrophied ; then attacks the subserous tissue and the serous membrane itself, causing these also to become thickened ; and finally produces at the free aspect groups of vesicles, varying individually, perhaps, from the size of a mustard-seed to a scarcely visible point. At the mucous surface the affected patches become eroded and excavated, but remain pretty smooth, and discharge in abundance the transparent glairy fluid with which the interstices of the cancerous matrix are filled. Colloid cancer of the peritoneum, in its early stage, appears in the form of groups of vesicles, which are elevated above the general surface, and spread sometimes in tortuous and anasto- mosing lines as though taking the course of the lymphatic vessels, some- times by forming scattered, isolated, more or less pedunculated growths. The morbid process tends to spread both in surface and in depth. It always involves the sub-peritoneal tissue, which may attain very consider- able thickness ; and it extends thence most frequently to the muscular and mucous coats of the stomach and intestines, less frequently to the substance of the mesenteric glands, pancreas, liver, spleen, and other viscera. In extreme cases nearly the whole of the peritoneum is affected ; it is then irregularly thickened — the various duplicatures being especially hypertrophied, and the great omentum either converted into a large lobulated mass, or contracted, as it is in scirrhus, into a thick, irregular, transverse band. In the progress of the disease erosion of the surface is apt to take place, and the glairy fluid which it yields is discharged in some abundance into the abdominal cavity. 3. Encephaloid cancer, when affecting the abdominal organs, is TUMOUES. 68& characterised, as it is elsewhere, by its softness, milkiness, and rapidity of growth. If it commence in or beneath the mucous membrane of the stomach or howel, on the one hand it soon invades the mucous and submucous tissues, and on the other spreads to the muscular coat, and through this to the tissues on the outer aspect of the \dscus. The extension of the growth hoth in thickness and in surface is usually very rapid, and before long results in the formation of a lobulated tumoiir, which often attains a very considerable bulk. The encephaloid mass is of course liable to undergo all those interstitial changes to which encephaloid cancer is usually liable ; but especially it tends to ulcerate. Ulceration begins, as a rule, early, and is almost invariably attended ■v\dth sloughing of the cancerous mass, which becomes consequently deeply and irregularly •excavated. But while this is going on the edges of the ulcerated chasm still furnish lobulated outgrowths, and moreover such outgrowths not unfrequently take place from the ulcerated surface itself. In some cases encephaloid tumours give rise from their mucous aspect to a pile of highly vascular ^411ous outgrowths, constitutmg the so-called ' villous cancer.' Encephaloid cancer of the peritoneum appears in Lhe form of discrete nodular outgrowths, which are small and rounded, and differ from those of scirrhus not only m their greater softness but in their greater prominence. They are hemispherical, spherical or pyriform, and often distmctly pedunculated. Li its further progress encephaloid cancer presents great varieties. In some cases it seems, like scirrhus, to invade more particularly the substance of the peritoneal folds and to involve subjacent organs ; and under such circumstances we sometimes find the mesentery converted into a thick, plicated, cancerous mass, with the can- cerous growth extending from the mesenteric attachment over the surface of the intestines, or the greater or lesser omentum or the subperitoneal tissue of other regions affected m like manner. In other instances it tends rather to form outgrowths which may be small and clustered, or discrete, rounded and massive. In the former case the whole peritoneal surface may be found beset vnth small lobulated or bunch-of-currant-like excrescences, and the great omentum converted into a large loose mass of such bodies. In the latter case the tumours, though stiU probably abun- dant, are isolated ; and, while many no doubt are small, others attain the size of an orange, or even a child's head. So far as we know, the melan- otic variety of encephaloid cancer always manifests itself in the latter form. 4. Epitlielioma affects the rectum and anus almost exclusively. It is sometimes of primary origin, sometimes due to extension from the uterus or vagina. 5. Adenoid cancer, or cylindrical epithelioma, which has a close re- semblance to encephaloid, is not uncommon in the intestine. It is probably more common than any as a primary disease of the mucous membrane, and is especially apt to cause stricture. 6. Sarcomatous and lyniphadenomatous growths may be regarded clinically as mere varieties of encephaloid cancer. Still they present some Y Y 690 DISEASES OF THE DIGESTIVE OEGANS. peculiarities of habit. Sarcomatous growths are exceedingly uiacommon, and arise mainly in the substance of the walls of the stomach, where they constitute tumours of considerable size, which tend to ulcerate, and com- port themselves generally as do encephaloid tumours. Lymphadenoma is especially a disease of the lymphatic glands and textures ; and hence, when the abdominal organs are its seat, the abdominal glands usually reach an enormous volume, and the spleen undergoes more or less con- siderable enlargement. In its further progress the morbid growth involves the connective tissue around the already diseased glands ; and hence the substance of the mesentery and other similar folds of the peritoneum become thickened and infiltrated, and nodular outgrowths sometimes appear upon their surfaces. As the affection still progresses the morbid growth creeps fi'om the mesenteric attachment on to and around the small intestine, confinmg itself almost, if not quite, exclusively to the peritoneal membrane and subperitoneal tissue ; and thus the intestine, while re- maining pervious and probably healthy as to its mucous membrane, becomes converted into a thick- walled rigid cylinder. The large intestine and even the stomach may be similarly affected. Whenever carcinoma or any other form of malignant disease affects the peritoneum, stomach, or bowels, it may spread by continuity to almost any neighbouring organ ; and hence the liver, pancreas, and spleen are liable to be invaded when the stomach or peritoneum in the vicinity is its seat, and the various pehdc organs when the rectum is diseased ; and further, the mesenteric and retro-peritoneal Ijinphatic glands, or some of them, when secondarily affected, often develop into large tumours. Such tumours are produced most rapidly, and attain their largest dimensions,, when the disease to which they are secondary is some soft form of malig- nant disease. There are certain parts of the gastro-intestuaal tube which are more liable than others to be the primary seat of malignant disease. They are the stomach and certain tracts of the large intestme. Of these the stomach is miTcli the most frequently affected ; and, although no portion of its surface enjoys absolute immunity, there is no doubt that its pyloric extremity most frequently suffers. When the cardiac orifice is the seat of disease, the adjoining portion of the oesophagus is commonly afl'ected. When the pylorus suffers, the morbid process usually encircles that portion of the stomach which adjoins it, but rarely extends into the duodenum. The effect of malignant disease upon the stomach is in many cases to cause irregular contraction and deformity, and especially to cause stricture at the cardiac or pyloric orifice. If the pylorus be alone affected and resist the onward transmission of food, the stomach often becomes preternaturally dilated ; if, on the other hand, there be impediment to the entrance of food from the oesophagus, the organ necessarily shrinks. Of the large intestine, the parts most liable to suffer primarily are first, the rectum, and second, the sigmoid flexure ; and here, as at the orifices of the stomach, the disease tends to circumscribe the tube and to cause stricture. It may be added that while all parts of the gastro-intestinal TUMOUKS. 691 canal are apt to be implicated in the progress of malignant disease com- mencing in the peritonemii or lymphatic glands, the lower part of the rectum is especially liable to become involved in the extension of uterine, vaginal, or other pelvic growths. Further, it must not be forgotten : that malignant disease, whether of the stomach or bowels, may be attended with rupture into the peritoneal cavity or the establishment of com- munications with adjoining hollow organs ; that hemorrhage (sometimes profuse), with foul or fetid discharges, is apt to take place from the con- gested or ulcerated mucous surface ; and that (especially when the peri- toneum is largely involved) peritoneal inflammation, ascites, or obstruction to the return of blood from the lower extremities, frequently supervenes. Of the various forms of malignant disease affecting the organs under consideration, scirrhus is undoubtedly the most common ; scarcely aiiy of them, however, is absolutely rare. Taking all forms together, it may be said that they mostly occur after the age of forty — a rule, however, which is more absolute as regards primary gastric or intestinal disease than that of the peritoneum ; indeed malignant disease of the peritoneum (especially in connection with similar affection of the ovaries) is not uncommon in young adult females. Sex, on the whole, exerts but little influence numerically. Carcinoma of the stomach is one of the most frequently fatal forms of malignant disease. Symptoms and pi'^'ogress. — The symptoms referrible to malignant disease of the several organs now under review simulate those of the in- flammatory (mainly chronic) affections of the same organs. And the differential diagnosis between them often depends, less on the presence or absence of specific symptoms, than on a careful consideration of the history of the case and a close observance of the phenomena which it presents, and their relation to one another. Thus malignant disease of the stomach has many features in common with chronic gastritis and gastric ulcer ; malignant disease of the bowels many in common with chronic ulceration of the bowels and its various sequelae ; and malignant disease of the peritoneum many which it shares with chronic peritonitis, tubercular peritonitis, and even simple ascites. But malignant disease is always remarkably insidious in its progress ; and vague symptoms of ill-health, with loss of flesh and strength, usually manifest themselves long before the patient quite recognises the fact that he is ill, or can quite define the character of his sufferings. The patient, therefore, is generally ill and often markedly cachectic before the specific signs of gastric, intestinal, or peritoneal mischief reveal themselves. Again, the course of a case of malignant disease is always progressively from bad to- worse ; and this progressively downward tendency is connected as a rule, not simply with the aggravation of the ordinary symptoms due to pro- gressive impairment of function of the organ primarily affected, but with the supervention of complications connected with the special properties of malignant disease, such as the involvement of the liver and other abdominal organs in the morbid growth and the development of disease in more remote organs. The appearance of a tumour and its manifest YY 2 692 DISEASES OF THE DIGESTIVE ORGANS. increase in bulk and change in form, in association with the various phenomena above enumerated, leave little room for doubt. Febrile symptoms, thirst, and dryness or foulness of tongue are no necessary accompaniments of the disease. 1. Stomach. — The special symptoms of malignant disease of the stomach are as various as those of ordinary dyspepsia. They comprise mamly loss or capriciousness of appetite, pain, and vomiting. Anorexia is a very constant and ordinarily a very early symptom ; but it is variable in its presence, and is sometimes absent from first to last. Occasionally the appetite is excessive. Uneasy feelings (weight, and fulness) in the region of the stomach, are frequently complained of, especially after taking- food. In most cases also there is absolute pain, variously described as aching, burning, cutting, or stabbing, and referred either to the epigas- trium or interscapular region or to other neighbouring situations. This comes on in paroxysms, which are probably at first ' feAV and far between,' but increase in frequency, duration, and severity with the progress of the disease. It is often brought on or increased by the ingestion of food, or by pressure applied to the epigastrium. Pain, however, like anorexia, is sometimes of little severity, and occasionally wholly wanting. Eructation is a common but unimportant symptom. Vomiting, however, supervenes, sooner or later in tlie great majority of cases. This is mostly caused by the taking of food, and comes on at different periods after it ; if the cardiac orifice be contracted the food is usually returned at once or after a short time (as in other forms of oesophageal obstruction ) by regurgitation ; if the pylorus be affected the vomiting is often delayed for an hour or two or more than that ; when the stomach is irritable vomiting may (as in gastric in- flammation) take place almost immediately after food has entered the stomach. The vomited matters in the earlier periods of the disease are chiefly altered ingesta combined with mucus and the acid secretions of the stomach. Later on (especially if ulceration have taken place) small quan- tities of blood escape from the diseased surface, and, mingling with the contents of the stomach, give to the vomited matters a sooty or coflee-ground appearance. The persistence of this kind of vomit is very characteristic of gastric carcinoma. Profuse discharge of blood, with haematemesis and melsena, occasionally takes place, but is not nearly so frequent relatively as it is in cases of simple ulcer. When sloughing occurs, the vomited matters are often extremely offensive. It is very common, especially when the pylorus is the seat of disease, for them to contain sarcinte and the torula cerevisise. The detection of a tumour depends partly on its size and partly on its situation. A tumour at the cardiac orifice or cardiac extremity can rarely be felt, however large or extensive it may be ; and one situated in the posterior wall or lesser curvature is less easy of recog- nition than one occupying the anterior surface or the larger curvature or the pylorus. The situation of perceptible tumours varies somewhat. They mostly occupy the epigastric or right hypochondriac region, but are sometimes found in the neighbourhood of the umbilicus. Unless they have become firmly adherent to the abdominal walls in front, or have TUMOURS. 693 blended with the pancreas or other enlarged glands behind, they are usually movable to some extent under the abdominal walls, both during the act of forced inspiration and (if the patient is lying down ) in rotation of the body from side to side. They are often irregular in shape, gene- rally very hard, and not mifrequently lifted up with the aortic pulsations. They are usually also resonant on percussion. Constipation is almost always present. The special symptoms which ensue when rupture of the stomach mto the peritoneal ca^^ity takes place, or when a com- munication becomes established with the transverse colon, need not be detailed. 2. Bote els. — ^Tlie symptoms referrible to malignant disease of the bowels are yet more vague in their mdications than those which attend gastric carcinoma. There is generally irregularity of action, sometimes looseness, sometimes constipation, and it may be the occasional discharge of mucus or modified blood. At the same time there is often pain : partly of a colicky character and comiected with unwonted movements of certain portions of the bowels ; partly burning, aching, or cuttmg, and referrible to some particular region. Malignant disease of the large mtestine, and more particularly of the sigmoid flexm'e and rectum, produces as a rule more or less impediment to the action of the bowels, and finally stricture. In this case also, associated .with symptoms of obstruction (precedmg them, accompanying them, or following them), mucous, sangumolent, purulent, and fetid discharges, occasionally even profuse hemorrhages, occur. Further, if the rectum be the seat of disease, the case is apt m its progress to be complicated by the formation of com- munications between the bowel on the one hand, and the vagina, bladder, or urethra on the other. In malignant disease of the bowels, equally as in mahgnant disease of the stomach, the presence of a distinct permanent tumour is a fact of capital importance. This may often fail of recog- nition ; moreover, phantom tumours, due to accumulation of flatus or ffeces, are in such cases specially apt to arise and disappear from time to time and puzzle the physician. When the lower part of the rectum is affected, the presence of a tumour may generally be readily detected by digital examination. 3. Peritoneum and glands. — The symptoms of peritoneal and of glan- dular malignant disease are necessarily very various and easy to be mis- understood. These affections are in a large proportion of cases associated with similar disease of the stomach, bowels, liver, uterus, or ovaries, and not unfi-equently supervene upon them ; and hence their special symptoms are liable to be confounded with and masked by those of the latter lesions. On the other hand, many of the symptoms commonly attributed to malig- nant disease of the stomach and other abdominal organs are strictly refer- rible to involvement of the peritoneum and lymphatic glands. Among the symptoms which attend the affections now mider discussion must be enumerated nausea, vomiting, loss of appetite and constipation, diarrhoea, or irregularity of the bowels, together with abdominal uneasiness and pain. The most significant point, however, is the progressive enlargement of the 694 DISEASES OF THE DIGESTIVE OEGANS. belly with the presence of a growing tumour or tumours. These present all varieties of character ; they may occur in any region ; may be movable or fixed ; may vary in size and shape ; may be hard and resisting, or soft and almost yielding a sense of fluctuation ; and, especially when they are developed in the neighbourhood of the coeliac axis and superior mesenteric artery or over the aorta, may pulsate as distinctly as many aneurysms do. And hence, notwithstanding the important evidence which their presence furnishes, they may be confounded, at some stage at least of their progress, with circumscribed abscesses, hydatid tumours, floating kidneys, or even aneurysms. In cases where (even if the malignant growth be very abun- dant) the individual tumours are small, the presence of peritoneal out- growths may altogether escape detection. We may draw attention to the fact that often, when no other signs of tmnour are distinguishable, the presence of the thickened and contracted great omentum, which has been shown to occur so frequently in scirrhous and colloid cancer, may be recog- nised as a more or less irregular bar extending horizontally from imder the margins of the left ribs across the upper part of the umbilical region to the neighbourhood of the umbiUcus. In the progress of the disease the peritoneal affection often becomes complicated by ascites, peritonitis of a sub-acute character, involvement of the gastro-hepatic omentum with obstruction of the vena portfe or common bile-duct and consequent jaun- dice, or anasarca of the lower extremities ; and occasionally also the kidneys get affected, the ureters obstructed, or the pelvic organs mvolved. Treatment. — The treatment of the above affections can unfortunately only be palhative. When symptoms are chiefly referrible to the stomach they must be treated, and may for a tune be benefited, by such measm-es as have been recommended for gastric ulcer. When the intestines mainly are involved, diarrhoea may need to be restrained by astrmgent medicines, constipation to be overcome by mild laxatives, such as castor oil and the like, or by enemata. And pain, whatever its seat or source, may often be relieved by counter-irritation, fomentations, or leeches. Opium in such cases is generally invaluable, and in most cases becomes at length indis- pensable — relieving discomfort and pain, soothing the mind, and giving sleep. The patient should of course be sustained by appropriate aliment in sufficient quantities and, if necessary, by stimulants. The quality of the food and the mode of its administration must be determined by the special requirements of the case ; but generally it should be wholesome, easily digestible, and administered in small quantities and at frequent intervals. Milk, eggs, beef-tea, broths, fish, and the like are among the most suitable articles of diet. PAEASITES. 695 XII. PAEASITIC AFFECTIONS. A. Tape-ivorms and Cyst-worms. iCestoda or Tceniada.) 1. General Account. The general term cestoda or taeniada includes tape-worms and cyst- worms. Of these, though many species are known to exist, four only are of interest and importance to the practical physician. They are the taenia soHum, tfenia mediocanellata, tsnia echinococcus, and bothriocephalus latus, with their respective cystic representatives. All the tfeniada pass through two phases of existence. Li the one the characteristic head or scolex of the animal, developed m connection with a cyst or bladder-like body, and devoid of sexual organs, lies imbedded in the solid tissues of the liost, or creature that harbours it. In the other, the animal, or rather colony of animals, in the form of a tape-worm or strohilus, occupies the alimentary canal. In this condition it still pre- sents at its upper extremity a scolex or head by which it adheres to the mucous membrane, while its tape-like body is divided into a series of quadrilateral elements, or idroglottides, each of which when mature con- tains male and female organs, and must be regarded as a distinct animal. To trace the cycle of events in the life-history of the t^niada it will be convenient to commence mth the ripe proglottides, within which are produced enormous numbers of fertile eggs, in the ulterior of each one of which a peculiar six- hooked embryo is developed. These proglottides usually become detached fi'om the rest of the strobilus, escape from the anus of the host, and either then or previously discharge their ova, which become scattered broadcast. Of these fertile ova some find their way sooner or later into the alimentary canal of some appropriate animal. Then the six-hooked embryo bursts its shell, migrates through the intes- tinal parietes, and continues its wandermgs rm.til it reaches some spot suitable for its further development, where it gradually undergoes those changes which result in the formation of the perfect cystic scolex. The further fate of this scolex depends mamly on that of its host. It cannot migrate, but lies passive in the ca\"ity which it forms for itseH, and there at length perishes rmless before that occm-rence its host become the prey of some other animal. In this event the scolex enters the aUmentary canal, and under the new conditions which then surround it at once enters on a new career of hfe. It fixes itself to the mucous surface, it loses its vesicular expansion, and fi'om its caudal extremity the strobilus or chain of sexually reproductive proglottides is gradually evolved. Thus two dis- tinct hosts as a rule are needed for the completion of the cycle of existence of these creatures; the one (usually a vegetable feeder) for the asexual period of its existence, the other (very commonly a carnivorous animal) for the period of its sexual acti^dty. It follows from the above statements 696 DISEASES OF THE DIGESTIVE OEGANS. that tlie OTa of tlie tape-worm, even if set fi-'ee "^-itliin the alimentary canaL probably never get hatched until after their escape from it. Fm-ther, it may be regarded as a general rule, that the same species of animal is not liable to suffer from both the cystic and the sexual forms of the same- cestode. Man is in some degree an exception, for he is apt to harbou.r both the taenia sohum and its vesicular representative — the cysticercus- cellulosfe. Considering, ho'wever, that patients affected with this tape- worm are not usually also affected with the cysticercus, and conversely,, and that man, moreover, is an omnivorous feeder, there is good reason. to beheve that the exception is apparent rather than real, and that he derives the two forms of the parasite in the orthodox way from inde- pendent sources. 2. Tcenia Solium, Tcenia MediocaneUata, and Bothrioceijlialiis Latus. a. Tcenia solium and Cysticercus cellulosce. — The taenia sohum is one of the most common of human tape-worms. In its perfect condition it usually measures from seven to ten feet long, but often exceeds that length. Its head or scolex, which is about as large as a small pin's head, or, to be more exact, between -^ and ^ inch in diameter, is succeeded by a delicate thread-like neck, which, gradually becoming broader and flatter and wrinkled transversely, merges ere long in the distmctly jointed body. The joints or proglottides are, in the first instance, much broader than they are long ; but gradually with their increase in size this relation ceases ; and although they still get broader, their length throughout the greater part of the strobilus exceeds then' breadth. Towards the lower extremity, the quadi'ilateral joints measure on the average a quarter of an inch wide by half an mch long. The globose head presents four pro- jecting suctorial discs placed at equal distances upon and a little above the equator; and springing ft'om its pole a rounded elevation, or rosteUum, the margin of which is fm'nished with a double circle of hooks. The apparently homogeneous neck may be seen under the microscope to be transversely wrinkled at a very short distance from the head. The sexual apparatus becomes first visible about a foot below. It comprises, male and female organs opening by a common apertm-e in the lateral edge of each joint — the apertures of the successive proglottides occupying; alternately opposite sides. At about two feet from the head, the ova become impregnated, and shortly afterwards enter the uterus, which occupies a large portion of the body of the proglottis, formmg a longi- tudinal central canal with several horizontal diverticula on either side. The egg is globular, about y-J-jj inch m diameter, presents a remarkably thick brownish shell, both concentrically and radially striated, and when ripe contains a six-hooked embryo. The taenia sohum is essentially an inhabitant of the small intestine, to the mucous surface of which it fixes itself by its booklets and suckers. It is usually, as its name implies, solitary ; but two, three, or more, are not imfrequently associated, and occasionally much larger numbers. TAPE-WOEMS. 697 From the time of its entrance into the bowel mitil it reaches its full development a period of three or fom' months usually intervenes ; and it may live in the bowel for many years, during which time it is constantly shedding its ripe proglottides and dis- charging ova into the alimentary canal. The cysticercus celluloscB is chiefly known as a denizen of the flesh of pigs, in which it is sometimes present m vast num- bers, rendermg the pork ' measly.' And it is almost exclu- sively to the use of such pork in an un- cooked or imperfectly cooked condition that the development of taenia solium in the human intestme is due. Li the compara- tively rare cases in which the cysticercus infests the body, it seems to Fig. 55.— T^sia Solium ajtd Cysticercts, a, b, c, d. Different parts j)f Tape-worm (Nat. size) cellulosse (Nat. size), g. human ^o^^ above X about 50. e. f. Cysticercii& Head of Cysticercus x 25. Ji. Head of ditto- Sucker X 250. j. Hooklet attached x 250, A: Egg X 250. seems occur mainly in the muscles, connective tissue, brain, eye, and serous membranes. It exists under the form of a round or ovoid vesicle, about the size of a pea or bean, but sometimes attaiuiag that of a marble, formed of a transparent elastic membrane, contammg a clear limpid fluid. Springing from one side of this vesicle is a wrinkled cylindrical neck, terminating m a head precisely similar to that of the taenia sohum. The neck and head protrude externally after death, and may be made to pro- trude by pressure during life ; but in the ordinary lining state, they are retracted within the vesicle, lying coiled up against one side of it. The conversion of the six-hooked embryo mto the perfect cystic scolex occupies about two and a half months ; and the scolex may remain living ui the tissues of its host for many years. b. Taenia mediocaneUata, and Cysticercus tcenia m. c— This tape- worm, which was formerly confomided with the last, is equally common. It presents a general resemblance to it both anatomically and m habit ; but it presents also characteristic differences. It attains a greater length, its joints are longer and broader, and its head also is two or three times as thick. The head, moreover, is furnished with four large round pig- mented suckers, but with neither rostellum nor armature of booklets ; the 698 DISEASES OF THE DIGESTIVE OEGANS. Fig. -56. — T^siA Medioc-Os'ellata. «, 6, c. DifEerent parts of Tape-worm (Xat. size), d. Head x 10. e. Egg x 250. uterus, thougli exhibiting tlie same general arrangement as that of the t^nia soHum, is characterised by much more numerous and finer transverse pro- cesses ; and the ova, instead of being round, are oval, the long diameter dif- fering Httle from the diameter of the egg of the tfenia solium, the short diameter measuring about -^-3-0 inch. The cysticercus of this tape-worm seems especially to affect the ox, and it is, therefore, to the eating of imperfectly- cooked beef that the introduction of the scolex into the intestines is due. The cysticercus is a smaU oval vesicle, similar to that of the cysticercus cellulosae, but smaller than it, and foi-nished with a neck and head, of which the latter is identical with that of the adult sexual strobilus. It is not known to affect the human being, c. Bothriocephalus lakes. — This tape- worm is limited in its range to certain European countries, especially Belgium, Holland, Poland, Prussia, Paissia, Sweden, and Switzerland. It is the largest of all tape- worms — not unfi-equently attaining a length of twenty-five feet and upwards, and a breadth of more than half an inch at its widest part. The head is ovoid in form, measm-ing about -^-^ inch m length by -^ in breadth, and presenting two opposite longitudinal deep grooves or suckers, but no booklets. The neck, which is comparatively narrow, soon be- comes transversely wrinkled ; and as it mdens out and retreats from the head, the wrmkles di^dde it into successive segments. The segments gradually increase in all then- dimensions, but for the most part continue of greater width than length ; and are specially characterised, not merely by their general form, but by the facts that the genital pore is placed in the centre of each flat surface, and that the uterus forms a small rosette, of which this pore is the centre. The ova never become matured within the uterus, and usually escape thence into the bowel, while the proglottis is still a portion of the strobilus. After the discharge of their ova, the joints di- minish in size, and become shrivelled and elon- gated. The eggs are of oval form, measuring about y^rr ii^^h by -jip , and have a firm brown shell, which opens by a lid at one end. The embryo on its escape from the egg is provided with cilia, which it soon loses, Fig. 57. — BoTHEiocEPHALrs Latus. «, 6. Different parts of Tape--norm. c. Head X 10. d. Egg x 250. TAPE-WOEMS. 699 and then presents the common six-hooked character. The cysticercus of this tape-worm has long heen beheved to infest some fish or other aquatic animal. The correctness of this surmise has been established by Dr. JBraun/ of Dorpat (a locality where the worm is comparatively common), who, on examining the fish brought to market, discovered that the muscles, with the liver and other viscera, of the pike and eels were in large pro- portion abundantly infested with the scolices of this parasite. Moreover, on feeduig dogs and cats with the infected tissues, bothriocephali were developed m their bowels. Symptoms. — The symptoms to which tape-worms give rise are on the whole trivial and unimportant. Many of those who are infested by them enjoy perfectly good health ; and many more make them the scapegoats of all the ailments (imaginary or other) h'om which they happen to suffer during the residence of these parasites within them. Among the symptoms which are referred to their presence are : pain and discomfort in the belly, capricious appetite, variable condition of bowels, itching at the nose and anus, depression of spirits, emaciation, and hysterical, epileptic, or other nervous phenomena. The list might easily be extended ; but when we consider that, notwithstanding all the evil influences which have been at- tributed to them, they are probably never diagnosed or even suspected to be present mitil their joints have been detected in the stools, it is obvious how vague and on the whole how apocryphal all these influences are. The only way in which the presence of tape-worms can be recognised is by the discovery of their joints either in the stools or about the anus or on the body-lmen, and of their eggs by the microscopic examination of the faeces. The cysticercus cellulosae causes no symptoms unless it be lodged in some dehcate or vital organ, such as the eye or cortex of the brain, and even then the symptoms are not specific. Treatment. — Many remedies have been employed for the purpose of getting rid of tape-worms ; but those on which reliance is now chiefly placed are the male fern, the bark of the pomegranate root, kousso and kamala. The liquid extract of male fern may be administered in a dose of fi-om 30 to 120 mmims early in the morning on an empty stomach, and be followed shortly by a full dose of castor oil. And if this procedure prove ulsufficient, the treatment may be repeated either on the next day or from time to time at short intervals. The other varieties of vermifuge are employed in much the same manner. The decoction of pomegranate root is given in large quantities — a pmt or more, for example — in two or three portions at short intervals. Kousso is administered similarly, ex- cepting that the powder from which the infusion is made is usually drmik with the infusion. The dose of this is from four to eight ounces. These drugs rarely fail to bring away large portions of the worm ; but no absolute cure is effected, unless the head be brought away as well. This, Jiowever, from its small size, is very apt to escape detection. It is conse- quently of great importance to make a careful inspection of the evacuations ' Virchow's Archiv. 700 DISEASES OF THE DIGESTIVE OEGANS. which are passed subsequently to the administration of vermifuge drugs. In order to prevent the development of tape-worms in the intestine, it is necessary that flesh, and especially those kinds of flesh which are known to harbour their vesicular representatives, should always be eaten in a well-cooked condition. Underdone and merely smoke-dried beef and pork should certainly be avoided. With respect to the cysticercus cellulos^e, unless it occupies some superficial part, and thus lies Tvdthin reach of surgical treatment, we can- do nothing for the patient's relief. The ova of the tagnia solium are probably taken into the stomach with uncooked vegetables, salads and the like, and hence those who wish to guard against them should content themselves with cooked vegetables only. 3. Tcenia EcMnococcus and Hydatid. The tania echinococcus is only known to affect the dog and the wolf, and is usually found m them m large numbers, adhering to the mucous ^ membrane of the duodenmn and jejunum. It is peculiar in comprising in its perfect form four joints only, and in having a length of little more than a quarter of an inch. The first joint is that which includes the head. This measures about ^^ inch wide, and is furnished with four suckers, and a central rostellum, provided with a double coronet of liooldets, which vary from thirty to forty m number. The fourth segment, which is as long as the other three joints together, is usually alone furnished with sexual organs and a marginal reproductive papilla. The eggs, like those of the t^nia solium, are globular and thick-walled. PrG.58.-T^xiA rpi^g cysticercus or larval form of this tape-worm, com- iliCHESOCOCCUS, "^ a. Tffiniaxio. Hionly kuown as an hydatid, is one of the most dangerous b. Ovum X 250. ^Q ijfg Qf all parasites. It differs from the cysticerci of other tape-vv^orms in the fact that it is capable, on the one hand, of almost indefinite increase of size, on the other of almost indefinite multiplication by the formation of gemmae. Its favourite haunt is the Uver, next to that the subperitoneal tissue, and then probably the lungs, kidneys^ and brain. It is found also m the heart, muscles, and bones ; and m- deed has occasionally been detected in almost every organ and tissue of the body. In its early condition it is a small globular cyst, with trans- parent laminated walls and finely granular contents. At a later stage the cyst has acquired considerable dimensions, the walls have become thick and the contents fluid. The walls are formed of two portions : an outer, comparatively thick, which is transparent, elastic, tremulous,, and beautifully laminated ; an inner, which is thin, dehcate, and composed mainly of delicate ceUs, often containing oval or globular refractive bodies. The fluid contents are limpid, colourless, of low specific gravity, and peculiar in containing a considerable quantity of salt, and, as a rule, no. TAPE-WOEMS AND HYDATIDS. 701 Fig. 59.— Hydatid Cyst x 100. albumen. In some cases the hydatid experiences no other change than increase of size. Much more commonly, however, it undergoes further -development. This consists princi- pally in the formation of other cysts in the substance of its walls, some- times towards the outer aspect, sometimes in the mid-region, some- iimes towards the inner aspect, and then often in connection with the •cellular lamina. These secondary ■cysts in many cases repeat in their growth all the characters of the parent hydatid. In many they xemain permanently devoid of the outer laminated wall. But whether they contmue thus simple or not, and especially in the former case, their contents often undergo gradual ■conversion into one or several echmococci or scolex heads — the cysts then forming what are sometimes termed brood-capsules, and remaining per- manently of minute, if not microscopic, size. The results of these processes going on almost indefinitely are very various. Thus, in some cases, an hydatid tumour as large, perhaps, as a child's head, consists of one hydatid <3yst only, with a larger or smaller number of brood-capsules, springmg budlike from its inner surface ; in other cases an indefinite production of barren hydatid cysts takes place, so that the original cyst becomes filled with innumerable daughter cysts, each of which has, like its parent, the •capacity for growth and the production of new cysts by gemmation ; in other cases agam (and these are the most common) the parent hydatid ultimately contains both barren and fertile cysts. Occasionally the hyda- tids formed in the walls of the primary cyst, instead of projecting at its inner surface, and finally getting shed into its cavity, project outwards and thus form separate tumours ; and occasionally also, in the liver, the hydatid growth forms a multilocular mass, in which it may be assumed that the walls of the separate cysts are, as it were, fused together. The scolex or echinococcus in its Hving condition is a rounded or ovoid body from -^^-^ to 2^ inch m length, attached by a depression at one extremity to a cord which fixes it to the wall of the brood-capsule, and presenting at the other extremity an orifice commmiicating with a central vertical canal, at the bottom of which lie the retracted rostellum and booklets, and on the sides of which is seated the inverted suctorial region. When the animal is dead all the latter organs are protruded, and the form which it then presents is as nearly ' as possible that of the first joint of the taenia ; the small vesicular body is surmounted by a kind of quadrilateral expansion, the angles of which are occupied by suckers and from the centre of which arise the rostellum and the crown of booklets. The latter vary in length between y^Vo- ^-nd -g-L inch. The growth of hydatids is for the most part very slow ; they enjoy, however, a long life. 702 DISEASES OF THE DIGESTIVE OEGANS. often continuing to grow and multiply for five, ten, fifteen years or more, and it may be during the whole period of the life (however much pro- longed) of their host. In many cases, however, they (hke all other imbedded parasites) un- dergo spontaneous dissolution ; in which case the tumours shrink ; the cyst walls get flat- tened and compressed agamst one another ; the echinococci break down, shedding their /^ hooklets ; the surrounding tissues become thickened and indurated ; and an abundant deposit of calcareous matter pervades the capsule and even the hydatid mass. For the symptoms and treat- ment of hydatid tumours we must refer to the diseases of the several organs in which they occur. We need only mention here that no drug that we know of given by the mouth is capable of affecting these creatures injuriously ; and that, in reference to prophylaxis, the chief if not sole source from whence we derive them is the excrement of dogs. Fig. 60.— Echinococci. a. G-roupof Echinococci still attaclied to ruptured brood- capsule X 100. b. Hooklets x 500. B. Bound -uvrms. [Namatoda.) 1. General Account. These are elongated romid worms, XDresenting a distinct integument marked with fine transverse rugae, a perivisceral cavity, a distinct alimen- tary canal, provided with a mouth at one extremity, and for the most part an anus on the ventral aspect close to the opposite extremity, and sexual organs. The sexes are always separate ; in the male (which is smaller than the female) the genital pore opens in immediate relation with the anus ; in the female, the vaginal orifice is usually situated about the middle of the ventral aspect. It is certain that some species of this sub-class of parasites need (like the tasniada) two successive hosts for the completion of their cycle of existence. The trichina spirahs, for example, passes an asexual life imbedded in the voluntary muscles of the pig or man ; and there, unless the affected flesh become the food of some other animal, after a while it dies. If, hoAvever, the trichinous flesh be eaten, the cysts in which the trichinfe are contained become dissolved ; the animals are set free, rapidly acquire sexual organs and copulate ; ova are developed and fer- tilised and hatched while still in the uterus ; and the living embryos on their birth, instead of remaining in the bowel, undergo an active migration KOUND-WOEMS. 703 through its walls and ere long reach the tissues in which they are to become imbedded. As regards the ascaris lumbricoides, there is good reason to believe : not only that the ova which are shed in vast numbers into the intestinal canal are never hatched there ; but that they are taken into the body of some other animal, probably one of the invertebrata, within which (possibly imbedded in the parenchyma) the worms complete one phase of their exist- ence. There is reason even to doubt whether the common thread-worms multiply in the region which they infest — whether the ova which they discharge so abundantly be- come hatched within the anus. Dr. Eansom, indeed, suggests that in many cases (among young children espe- cially) there may be a kind of reinfection due to the con- veyance of the ova from the anus to the mouth by the j&ngers. Among the nematode worms are included the Ascaris lumbricoides, the Oxyuris vermicularis, the Dochmius duo- denalis, the Trichocephalus dispar, the Trichina spiralis, and the Filaria sanguinis Iwminis, which will now engage our attention ; the Filaria medinensis, whose effects are surgical; and several others, including the Strongylus gigas, which are of rare or doubtful occurrence in man. IH ■-iife*. 2. Common Bound-worm. {Ascaris Lumbricoides.) This well-known worm varies in size : in the female from 10 to 14 inches long, and from 1^ to ^ inch thick ; and in the male from 4 to 6 inches long, with a correspondingly small diameter. The worm is cylindrical, tapering to either end, white with a brownish or reddish tinge, and invested in a firm elastic integument. The ova, of which each female discharges, on the average, 160,000 daily, are oval, measuring ^^ inch by ^^ inch. They have a thick, firm, nodulated shell, and contain, as ordinarily passed from the bowel, no trace of embryo. This ascaris is found in some few animals besides man. In man its special habitat is the small intestine ; but it is apt to wander, and thus to reach the colon on the one hand, or the stomach on the other ; and, indeed, it has been known to find its way into the hepatic or pancreatic duct, and also into the nose or larynx. It has been asserted that it occasionally per- forates the wall of the bowel, and thus finds its way into the peritoneum, or some sinus or abscess. It is now, however, generally held that when found in such situations it has simply passed thither through an acci- dental perforation. The number of ascarides present at the same time Fig. 62.— Eg_ Ascaris lumbrr coides X 250. Fig. 61.— Ascaris lumbricoides (Nat. size). 704 DISEASES OF THE DIGESTIVE OEGANS. rarely exceeds five or six. But authentic cases are on record in which the bowels have been infested with hundreds and even thousands of them. The time durmg which a worm remains a denizen of the bowels is pro- hably never more than a few months. Symptoms. — Lmumerable symptoms have been referred to the pre- sence of these parasites, as to that of the tfenise ; but there is no doubt that in the great majority of cases they give no indication whatever of their presence, which is not even suspected mitil one or more have been discharged. The symptoms which might reasonably be referred to them are those of mtestinal irritation, which in children are always liable to be attended with some degree of fever and cerebral disturbance. When these worms are harboured in large numbers there is no doubt that they may induce very grave gastro-enteritic symptoms, but symptoms which are in no sense characteristic. Occasionally, too, a mass of them causes complete occlusion of the bowel, as any other concretion may do. In all ■cases where these worms are suspected to be present, and always before a cure can be safely announced, the faeces should be subjected to micro- scopic examination ; when, if they be present, the innumerable eggs which are discharged can scarcely be overlooked. Ascarides are occasionally vomited. Treatment. — Various remedies have been employed with the object •of getting rid of ascarides, and among them those which are m common use against tape-worms. The mucmia pruriens also was formerly much esteemed. The remedy now mainly relied upon is santonica, and more especially its active principle, santonin, of which from one to three grains may be given twice daily to a child, and about twice that quantity to an adult. Violent purgatives are of little or no use ; an occasional laxative may, however, be given with advantage during the course of treatment by santonin. 3. Common Thread-icorm or Seat-icorm. [Oxyuris Vermicular is.) This creature is minute, fusiform, white, and, as its popular name implies, thread-Hke. The female varies from |- to -J inch in length, and presents a comparatively long attenuated caudal extremity. The male is about half the length of the female, and its caudal extremity is simply fusiform. The ova are oval, but unsymmetrical, measuring ^Iq inch by -xto'o- They present a firm shell with three laminffi, of Avhich one is absent at one of the poles. At the time of deposition they contain a developing embryo. Thread- worms ' are probably the most common of all intestinal parasites ; they infest persons of all ages, but children much more frequently than adults. They occur habitually in the colon alone, and indeed are limited almost -exclusively to the rectum. They are often present in enormous numbers. Fia. 63.— Thbkad- WOEM. <{. Female and 6. ilale X 10. c. Actual length of female, d. Egg X 250. WHIP-WOEM. DOCHMIUS DUODENALIS. 705 The females are apt to migrate through the anus, and to deposit their eggs on the skin and among the hairs in its vicinity ; they occasionally also find their way into the vulva, vagina, and urethra. Symptoms. — The chief symptoms to which oxyurides give rise is troublesome itching about the anus, coming on mainly in the evening ; it is often intolerable, especially if they have migrated into the vulva or urethra. Children affected with them are said also to suffer from itching at the nose ; and many of the functional disturbances which have been attributed to the presence of more formidable parasites have also been attributed to them. The diagnosis of thread- worms can easily be verified by their discovery and that of their ova in the faeces. Treatment. — Local measures are usually amply sufficient for getting rid of thread-worms. The injection of a strong infusion of green tea, quassia, or any other bitter, or of a solution of perchloride of iron or salt, repeated if need be from time to time, is usually efficacious ; the use of mercurial ointments or other parasiticide applications in and around the anus may be serviceable for the destruction of the ova in these situa- tions ; in addition to which measures occasional purgatives may be ad- ministered, and the patient put under a course of tonics. 4. Wliip-ioorm. [Trichoceplialus Dispar.) This is said to be not micommon. But it is rarely met with in this covmtry. It is especially characterised by having a comparatively thick cyHndrical body, termmating anteriorly in a delicate filiform process, which forms about two-thirds of the entire length of the parasite. The male measures about one and a half inches long and the female about two inches. The latter is very prolific. The eggs are oval, about ^^ inch by ttW' pointed at either end, and presenting a firm brownish-yellow shell. The normal habitat of this worm appears to be the caecum, to which it attaches itself by burying its tbread-Hke neck in the substance of the mucous membrane. It does not appear to give rise to any symptoms, and, '^^cephalus "^"dk- indeed, its presence can only be diagnosed by the discovery ^^"' £ ■ ^y o JO J J ^^_ Female. 6. Male 01 ova 111 the lasces. (Nat. size), c No treatment is needed ; the measures most likely, ^^^ ^ ^^^' however, to be efficacious in effecting its dislodgment are those already discussed in relation to tlie ascaris. 5. Dochmius Duodenalis. [Sclerostoma Duodcnale.) The dochmius duodenalis occurs mainly in hot countries. It is espe- cially prevalent in Brazil and in Egypt, where it causes the so-called ' Egyptian chlorosis ; ' and is not uncommon in Italy. It was unknown in Switzerland until, during the progress of the works connected with the St. Gothard Tunnel, it was discovered to be the cause of a serious and z z 706 DISEASES OF THE DIGESTIVE OEGANS. fatal form of anaemia which largely prevailed among the labourers. It thus acquired a new and special interest in the eyes of Europeans. The dochmius is cylindrical in form, and measures when full-grown about four-tenths of an inch in length. The males and females are equal in this respect ; but the former are much more slender than their com- panions, and may be additionally distinguished, even with the naked eye, by the coroUa-Hke expansion of the caudal extremity, whence (under the microscope) the hair-like double penis may sometimes be seen pro- jecting. The oral orifice, which is turned towards the dorsal surface, is large, strong, somewhat quadrilateral in shape, and armed with eight teeth. The females are very prolific ; and the eggs, which are only hatched after their escape from the bowels, are oval, ^^ by xwo i^^h in measurement, and not altogether malike those of the thread-worm, excepting that they are symmetrical, and that at the time of their discharge they do not contain manifest embryos. The worms attach themselves firmly by the mouth to the mucous membrane of the duodenum and upper part of the jejunum ; so firmly, indeed, that m endeavour- mg to detach them the mouth may easily be torn off and left behind. They wound the surface deeply, suck the blood (on which they live) like leeches, cause submucous ecchymoses, and also more or less abundant hemorrhage into the bowels. The numbers present at any one time vary from many hundreds downwards. Dr. Tarona, of Varese, counted as many as 1,250 specimens in the evacu- i-iG. 65.— DocHJurs ations of a single patient, after the administration of the a. Female.' &. Male, ethereal extract of male fern. X 10. c. Actual Yhe symptoms due to these parasites are mainly pro- gressive anaemia and debility, which may continue for years, and often sooner or later terminate m death. The severity and danger of the symptoms depend of course on the number of worms pre- sent ; and, it may be added, on the frequency with which they are re- cruited. The nature of the patient's illness may be readily determined by examination of the fseces. Treatment. — Since the disease is propagated mainly, if not solely, by drinking-water in which the ova or embryos of the parasite are contamed, it is especially important, in all places where it is knowTi to jprevail, to have special regard to the purity of the water drunk, and as a general rule to have it well filtered or boiled before drinking. For the expulsion of the worms, various vermifuge remedies have been employed. The oil of male fern appears to have been specially serviceable in this respect. h TEICHINA SPIRALIS. TEICHINOSIS. 707 6. Trichina Siyiralis. Trichinosis. The tricliina spiralis was known only as an occasional inhabitant of the muscular tissue, and regarded as a mere pathological curiosity, until the year 1860 ; when a case that came under the observation of Dr. Zenker, of Dresden, con- clusively showed that, however harmless the en- cysted parasite might be, the gravest s}'niptoms, and even death itself, might be caused, after its reception mto the bowels, during the processes of reproduction which ensued there, and of migra- tion of the young animals mto the voluntary muscles. Smce that period the ' trichina disease ' or trichinosis has been fully recognised and fre- quently observed. The trichina spiralis is met with in the mus- cular tissue in the form of a minute worm, measuring about ^ inch in length. Its anterior extremity is somewhat pointed, its posterior thick and romided ; it presents immature sexual organs and lies coiled up in the mterior of an oval cyst. This cyst, which is no essential part of the para- site, but forms around it after it has taken up its j-kj. ee. quarters, measures about -^ inch in length, is ^^^ thick-walled, laminated, transparent and gene- rally studded externally, especially about the poles, with granular calca- reous matter. The trichina-cysts occupy the striped muscles of the body, and are often especially abundant in those of the larjoix. The heart, however, is rarely if ever mvolved. They appear in the muscles as mmute white grains, distinctly visible to the naked eye, of which the long diameter corresponds to the direction of the fibres. Their apparent size is usually increased by the fact of the development of groups of fat-cells in relation with either extremity. The numbers present vary, of course, in different cases. In a cat experimented upon by Leuckart each omice of muscle was calculated to contain 325,000 trichina ; and on the basis of this calculation Dr. Cobbold estimates that a man of medium bulk may easily harbour 20,000,000. He could probably hold many more without much incon- venience. The length of time durmg which these larval trichinae retam their vitality is very uncertain. There is no doubt, however, that they may live in the muscular tissue for many years, and that they retain life after the death of their host, and even after the putrefaction and disin- tegration of his tissues. They do, however, perish in situ sooner or later, and then usually midergo calcareous changes. Tricliinje have been discovered in the flesh of various animals besides man, but mainly in that of the pig ; and indeed it is fi'om the use of trichinous pork that man becomes affected. The trichina-capsules swallowed with the flesh z z 2 -Tekhixa. spiralis Encysted Trichina 708 DISEASES OF THE DIGESTIVE OEGANS. are dissolved by the gastric juice, and the contained parasites are set free. These then undergo rapid development and attain sexual maturity — the female ultimately acquiring a length of ^ inch, the male a leng-th of not more than yL inch. The ova are hatched within the uterus ; and the living embryos, escaping thence into the intestinal canal of the host, at once commence active migration. They attach themselves to the mucous membrane, eat their way through the intestinal walls, and either continue to burrow through all the tissues which lie between them and their destination, or, what is more probable, find their way into the small vessels and lymphatics of the bowels, and are thence conveyed all over the organism. They have been found during this period in almost all parts of the body — in the intestinal walls, abdommal cavity, mesentery and mesenteric glands, connective tissue, and in an as yet unencapsuled condition in the muscular tissue itself. The progress of events above described is very rapid. The immature trichinas taken into the stomach become mature on the second day ; on the sixth and following days, up to the end of the second or even third week, the embryos are born and commence operations ; they jDrobably reach their destination in the course of a week or two, and by the end of a month or a little more have come to the conclusion of their labours. Symptoms and progress. — The symptoms which attend the deve- lopment and migration of tiichinse are on the whole very remarkable and suggestive of the disease. They comprise, in the first instance, those of gastro-intestinal disturbance ; in the next those of general muscular in- flammation ; and, associated with these, febrile phenomena. Within a day or two, or at most a week, after the ingestion of trichi- nous flesh, symptoms not unlike those of enteric fever manifest them- selves. The patient suffers from thirst and loss of appetite, with perhaps nausea and sickness ; and from colicky pains in the abdomen, with con- stipation or irregularity of the bowels, or actual diarrhoea. His tongue is coated ; and there is more or less mental and muscular prostration, with elevation of temperature, and acceleration of the heart's action. These symptoms, which are ill-defined in the beginning, become aggravated day by day during the first week or ten days of the patient's illness, and in some cases culminate in those of fatal enteritis or peritonitis. More commonly, however, about the end of this time they undergo some re- mission and then gradually subside. But while they are in progress, and even it may be in progress of amendment, other symptoms due to the ^nigration of the parasites develop themselves and soon overshadow them. These consist mainly in gradually increasing pain and tenderness, swelling and stiffness of the voluntary muscles, together with oedema of the sub- cutaneous connective tissue, copious perspirations, and aggravation of debility and febrile disturbance. The pains have some resemblance to those of rheumatism, but they occupy the fleshy parts of the limbs and trunk and not the joints. The general stiffness, tenderness, and swelling lead to flexion and immobility of the limbs, and it may be to impediment to the due action of the muscles of the tongue and larynx and of those TEICHINOSIS. 709 concerned in respiration. Dropsy, which is one of the earliest indications of the migration of the parasites, commences m the face, particularly in the eyelids, then attacks the extremities, and subsequently probably be- comes general, involving even the serous cavities. Hoarseness, or loss of voice and dyspnoea, are not rmcommon. The temperature presents great differences. In some cases it rarely, if ever, rises above the normal. In severe cases, however, it may reach 104°, 105°, or even 106°, but then varies greatly and irregularly from day to day, and always presents con- siderable morning remissions. The total dm-ation of the disease varies. In mild cases the patient recovers in the comse of a month ; in many cases recovery is delayed to the end of six weeks or two months ; and occasionally the patient con- tinues ill for three or even fom- months. The trichmous disease varies greatly m severity — its severity depending mamly on the number of living parasites which the patient receives into his bowels. Li some instances there are few or no symptoms to attract attention ; in some outbreaks, where many persons have been attacked, the mortality has been very light ; while in others the death-rate has been twenty or twenty-five per cent. Death may result from enteritis, peritonitis, or pneumonia, or from the debility which the progress of the disease gradually induces ; and may occur at any time between the fifth or sixth day and the end of the sixth week. The presence of trichmosis in its acute stage may possibly be confirmed by the discovery of parasites in the intestinal discharges, or by the ex- traction by means of a suitable instrument (harpoon) of fragments of striped muscular tissue. The under part of the tongue has been specially recommended for exploration. No symptoms attend the presence of the encapsuled parasites hi the muscles. The diseases with which trichinosis is most liable to be confomided are enteric fever, acute tuberculosis, and acute rheumatism ; but the distinctions between it and them are obvious. Treatment. — We have not, so far as is known, any power to destroy trichina, whether in the intestines or in the substance of thehving fi-ame. It is of course possible that remedies useful against other intestmal para- sites may be useful against these, supposing their presence to be detected sufficiently early to justify us in attempting to dislodge them. As a general rule, therefore, we can only treat trichinosis on the same principles as we treat other affections made up of local inflammatory conditions and general fever. But we can also employ prophylactic measures ; and these are, fortmiately, sufficiently simple. They consist in the avoidance of pork which presents the characteristic appearances of the disease, and especially of pork which is not well and completely cooked. The mere toasting to which ham and bacon are frequently subjected is insufficient to destroy the "sdtality of the trichina. Smoked ham and German sausages are, unless they have been cooked, sources of considerable danger. It is mainly in Germany, where pork, raw, smoke-dried, or imperfectly cooked, is a common article of diet, that trichmosis is known to occur. 710 DISEASES OF THE DIGESTIVE OEGANS. 7. Filaria Sanguinis Hominis.^ Ill the year 1870, Dr. Lewis, of Calcutta, observed that certain minute naematoid worms were constantly present in tlie urine of persons suffering from cbyluria ; and two years later he published a short monograph, in which, whilst confirming his former statements, he showed that the blood- of chyluric patients contained the same parasite in more or less abundance. Later, namely in 1875, he wrote a paper demonstrating the presence of the same animal in the blood and diseased tissues of persons suffering from that form of spurious elephantiasis of the scrotum, labia, and legs which we have already described under the name of elephantiasis lymphangiectodes. This parasite, to which he gave the name of ' filaria sanguinis hominis,' measures on the average gJo^ inch in diameter and ^ inch in length ; has a rounded anterior extremity, a pointed tail, a definite structureless envelope, with slightly granular contents, and no sexual organs. The total absence of these organs showed of course that the filaria were immature ; and it was important therefore to endea- vour to ascertain the character and habitat of the parent worms, and the source of infection. Filariffi much like the above have been many times observed FIG. 67.-FILARIA SAXGI.TMS Ho.nxis X 250 (afterin the blood of the lower aiiimals, Dr. Lewis). more especially dogs, in France, China, and America. In such cases both MM. Grube and Delafond and Professor Leidy have discovered in the right ventricle of the heart mature worms varying from 5 to 7 inches in length, with a diameter ranging from ^-^ to -^ inch ; and in the last of Dr. Lewis's papers above referred to he gives an account of a series of original investigations with regard to the prevalence of a similar parasitic disease in the pariah dogs of India. He shows that a considerable number of them present in their blood haematozoa which are identical in appearance with those found in man ; excepting that they are a little smaller, and do not appear to possess the same distinct structureless en- velope. And on dissection he found : 1st, that along both the oesophagus and the thoracic aorta were firm fibrous-looking tumours, varying from the size of a pea to that of a walnut, within each one of which were from one to six worms of a pinkish tinge — the males varying between one and two inches in length, and between -V ^^^^ to ii^*^^^ i^^ diameter, the females measuring from 2 to 3^ inches long, and from -^^ to ^ inch thick ; and 2nd, that also studding the aorta were nodules, from the size of a millet-seed to ' Dr. T. E. Lewis, On a Hcematozoon inliabiting Human Blood : its Relation to Chyluria and other Diseases, Calcutta, 1872 ; The Indian Annals of Medical Science, No. xxxiv. July 1875 ; and The Lancet, vol. ii. 1877 ; also Dr. Cobbold, The Lancet, vol. ii. 1877. 9 FILAKIA SANGUINIS HOMINIS. 711 that of a pea, contaiumg immature but growing worms from -^^ inch in length upwards, and scar-hke depressions, due to either the death of the parasite or its migration and to consequent retrogressive changes. Since the above observations were made, Dr. Bancroft, of Queensland, late in 1876 and early in 1877, discovered, almost by accident, first in a lymphatic abscess in the arm and next in a hydrocele of the cord, mature female filaris in length, appearance, and structure not miHke those found by Dr. Lewis in the pariah dog, but apparently a good deal thinner. A little later (August 1877) Dr. Lewis fomid m dissecting a ' nevoid ' scrotal tumour removed from a patient whose blood con- tained filarise two mature specimens of the worm. With these were found ova, thm-walled, oval in form, and measurmg h'orn ^iVo ^^ yoV o i^ch in the long diameter. La this as well as in former dissections numerous embryos were discovered in the diseased tissues. He has also found them in great abundance in the renal arteries and veins and in the substance of the kidneys. A very interesting paper upon the filaria, fi'om the pen of Dr. Manson, was read before the Pathological Society in December 1880 ; wherein he reviews the observations in regard to the worm published by previous observers, and supplements them by an account of his OAvn investigations. The following is a brief statement of his more important facts and inferences. Many of the lower animals are largely affected by different species of filarii© ; and in many parts of the world, but more especially in tropical and subtropical regions, human beings are in large proportion infested by the filaria sanguinis hominis. The adult filariae, for the fig. es.—a. Pemaie most part, take up their abode in the lymphatic vessels, fcobbofd)'.^^!? wherein, if nothing occurs to disturb or injure them, they Ovum x 250 (Cob- live and procreate for many years. They are naturally viviparous, and discharge their young in large numbers into the lymphatic vessels. The embryos not being thicker than blood-corpuscles, and being very active in their movements, readily pass along these vessels, and through ■successive lymphatic glands, into the thoracic duct, and thence into the blood, vdth which they are distributed all over the body. But occasionally they abort, and unhatched ova are discharged, which bemg several times as thick as the embryos, are unable to pass through the narrow channels of the" lymphatic glands, and so (constituting emboli) block them up. This abortion, when once it has occurred, is apt to occur frequently, and thus tends, sooner or later, to cause more or less serious and widespread obstruction of Ijonphatics. Generally in the lower animals, and to a considerable extent in man, the presence of filariae causes no symptoms whatever, or at most, occasional slight attacks of febrile disturbance ; and persons may harbour them for many years, or for life, without any suspicion 712 DISEASES OF THE DIGESTIVE OEGANS. of the fact ever being excited. In some cases, however, the distmctive symptoms of filarial disease arise : being determined by the fact that groups of lymphatics become obstructed, either as Dr, Manson thmks by embolic ova, or by inflammatory or other changes caused by the parasites. Then lymphatic oedema with dilatation of the distal lymphatic vessels and spaces and overgrowth of connective tissue ensues ; and consequently^ according to the region mvolved, we get elephantiasis or lymph-scrotum, or the condition of the kidney or bladder which causes chyluria. In the great majority of cases the lymph which escapes from the diseased tissues, and that which is mingled with the urine, contam embryo filarige in greater or less abiuidance, and occasionally also ova. As regards the relation of the young filariaB to the blood, it is a remarkable fact that it is an almost invariable rule that they are totally absent during the day ; that they begin to make their appearance at six or seven o'clock in the evening ; that they then rapidly increase m numbers until they attain their maxi- mum ; and that they generally disappear about eight or nine o'clock in the morning. Where they hide during the day, or what becomes of them then, is miknown. They never, however, in the blood, undergo any further development. This nocturnal habit of the embryo filarise led Dr. Manson to suspect that there is some relation between this and their further development ; that, uiasmuch as they are incapable of such development within their host, and there is no mode beyond the fitful and uncertain one of disease by which they can escape unaided, their normal removal from the body for the purposes of sexual development might be effected through the agency of some nocturnal blood-sucking insect. On investi- gating the subject he found that, at any rate where he conducted his inquiries, it is due to the operations of a particular form of mosquito. He was able to trace the transference of the embryo filari&e, with the blood in which they were contained, to the stomach of this insect, and also to observe certain developmental changes taking place in them during their sojourn there. Beyond that he was unable to go. There is little doubt,^ however, that sooner or later the parasite, thus prepared, finds its way directly or indirectly, and through the medium of drinking water, into the stomach of its future host, which it pierces, and then proceeds upon its rambles until it finds a suitable residence. There are many reasons for belie^dng that chyluria and lymphangiec- todes, originating in this country, and in temperate cHmates, are inde- pendent of parasitic disease. No doubt our present knowledge of the subject is insufficient to justify us in asserting that this is the ease ; but it may be observed that any affection causing obstruction of lymphatics is likely to be followed by pathological changes and symptoms resemblmg those due to the obstruction of these vessels by parasitic influence. DEGENERATIONS. OBSTEUCTIONS OF THE STOMACH. 71B Xni. DEGENEEATIVE AFFECTIONS OF THE STOMACH AND BOWELS. Degenerative changes of the mucous membrane play, no doubt, an important part in the various chronic disturbances of the stomach and bowels, to which the terms dyspepsia, diarrhoea, and the like are usually applied. They follow upon chronic inflammation and other persistent lesions of the alimentary mucous membrane, and occasionally depend on the presence of certain forms of cachexife. They comprise mainly : fatty degeneration and wasting of the glands, associated either with general atrophy of the mucous membrane or with increased development of fibroid tissue ; and lardaceous change, Lardaceous degeneration affects the small intestine much more fi'equently than the stomach or the larger bowel, and probably never occm's except in association with advanced lardaceous disease of the liver, spleen, or kidneys. The villi chiefly suffer. The sjonptoms referrible to the different kinds of degeneration do not at present admit of identification. XIV. OBSTEUCTION OF THE STOMACH. Causation and morbid anatomy. — Many of the morbid conditions which have already been described mvolve more or less serious impedi- ment to the due performance of the mechanical functions of the stomach, and consequently to the due transmission of its contents onwards ; and indeed the symptoms arismg from obstruction form an important part of their clinical history. Obstruction occurs chiefly at the pyloric and cardiac orifices ; it may^ however, arise in some intermediate part. It may be due to mere fibroid thickening or cirrhosis ; to malignant disease ; to the cicatrization of large ulcers ; to the pressure of external tumours ; to accumulation of hair, cocoa-nut fibres, or other solid matters which have from time to time been swallowed ; to paralysis or spasm. The consequences of obstruction at the cardiac orifice have already- been considered under the head of oesophageal disease : they are dilata- tion and hypertrophy of the oesophagus, and contraction and atrophy of the stomach. In pyloric obstruction the food which is received into the stomach tends to accumulate within it, and thus to involve its dilatation and hypertrophy. The dilatation under such circumstances is sometimes enormous. If the impediment occupy some intermediate position, its in- fluence over the form and fmictions of the stomach wiU, according to- circumstances, approximate either to that of cardiac or to that of pyloric 714 DISEASES OF THE DIGESTIVE OEGANS. obstruction. In some cases habitual starvation causes more or less per- manent general contraction of the stomach ; in some cases habitual over- eating Qr accidental or ill-understood conditions involve extreme dilatation of the organ, and occasionally such dilatation is very rapidly developed, and acute in its progress. Both of these states are apt to be attended with many of the phenomena of pyloric stricture. Symptoms and progress. — The symptoms of cardiac obstruction are, mainly, ability to perform the act of deglutition, and in succession to this act uneasiness, referrible to the situation of the cardiac orifice, and the rejection of the matters swallowed by a process which generally has more xesemblance to eructation than to vomiting. The patient probably has a good appetite, but cannot gratify it, and suffers from all the usual symptoms of starvation. In most eases the obstruction is partial only, and more or less food finds its way into the stomach. In some the re- tention of food in the dilated oesophagus lasts for a considerable time, and the retained matters prior to their rejection midergo putrefaction or fermentation, and become mixed with mucus secreted from the surface of the tube. The epigastric region shrinks and becomes concave, owing to the necessary contraction of the starved stomach. The symptoms referrible to obstructive disease of the pylorus are, in many important respects, different from the above. The patient can swallow with ease, and anything that is swallowed finds its way without difficulty into the stomach ; whence (according to the degree of impedi- ment present) it is in part transmitted more or less slowly onwards, in part, after a while (it may be half an hour, an hour, several hours, occasionally even several days), and after having caused more or less gastric uneasiness, rejected by vomiting. The characters of the vomited matters depend largely upon the length of time they have been retamed. If they be discharged shortly after ingestion, they consist mainly of partially digested food mingled vvdth the normal secretions of the stomach ; if after a long interval, they have generally undergone putrefactive or fermentative changes, are fetid, abnormally acid, and probably contain sarcinse or the yeast-fmigus, or both. Their quantity varies considerably, and some- times amounts to several pints. The appetite li'iG. 69.— sarcina vextriculi is more likely to suffer in pyloric than in cardiac ^ 5*'^- obstruction, but is not unfrequently retained. The dilatation of stomach which attends this affection reveals itself locally by protrusion of those parts of the abdominal surface with which the organ lies in contact, and probably by displacement of the diaphragm upwards. If it be moderate, it causes fuhiess of the epigastric region only ; if it be considerable, the body of the organ descends, forming a loop between the pyloric and cardiac orifices, and the chief distension then probably occupies the umbilical and hypochondriac regions — the epigas- trium presenting a comparative depression. In some cases the dilated OBSTRUCTION OF THE STOMACH. 715 stomach occupies nearly the whole of the anterior part of the abdomen, and it may reach the pubes. That the distension is due to the stomach is shown : partly by its situation ; partly (if it be considerable) by its looped form ; partly by observing the peristaltic movements, which are generally easy of recognition and admit of bemg readily excited ; and partly by the evidences which palpation and percussion give of a large •cavity containing air and fluid. The symptoms due to general contraction of the stomach are especially: inability to take food, excepting in small quantities; irri- tability of the organ ; and tendency to vomit shortly after the ingestion of food. Simple dilatation of the stomach differs little, if at all, in its symptoms from incomplete pyloric obstruction. In all of the above cases, starvation, emaciation, asthenia, and the pheno- mena which attend these conditions, supervene with more or less rapidity- Further, various complications are apt to arise in their course and to prove fatal, among which may be mentioned gastritis and peritonitis. Treatment. — The treatment of ob- struction must vary somewhat m dif- ferent cases, in dependence partly on the site of obstruction, partly on its cause. If it be at the cardiac orifice, the careful passage of bougies may serve to maintain an available passage ; and, failing this, the question of making an opening into the stomach at the epigastrium, and of feeding the patient through this opening, may be entertained. If it be at the pyloric orifice, or if the case be one of simple dilatation, it may become necessary under certain circumstances, casually or periodically, to empty the distended organ by means of the stomach-pump, and even to wash it out with antiseptic solutions, or to let off some of the gaseous accumula- tion by acupuncture through the abdommal walls. In all cases it is important to give food in small quantities at a time, and m the fluid or semi-fluid condition, in which form it most readily passes through a narrowed or strictured orifice. In cases of pyloric disease or passive dilatation, it is further important : that the stomach be not overburdened with food, and hence that this be administered in a concentrated form ; that putrefaction and fermentation be obviated by the use of appropriate remedies, such as creasote and the hyposulphites ; and that tendency to vomit and gastric uneasiness be met by the measures elsewhere recom- mended for these purposes. Lastly, it is often necessary to feed the patient per rectum. For an adult, it is not generally expedient to admmister thus more than 3 or 4 ounces at a time, or to repeat the operation oftener than twice or thrice in the twenty-four hours. If for any reason it is deemed Fig. 70.— Yeast-puxgtjs x 500. 716 DISEASES OF THE DIGESTIVE OEGANS. advisable to use a larger quantity, say half a pint or more, it is probably best, in order to insure its retention, to follow the practice adopted by Dr. Newington, of first injecting the fluid high up mto the rectum, and next plugging the bowel mth a moist sponge the size of the fist passed above the internal sphuacter, and attached to a string or tape by which it may be withdrawn. XV. OBSTEUCTION OF THE BOWELS. The affections which are here to be treated of present many features in common with enteritis, and their description is not unfrequently included in the description of that disease. Enteritis does indeed occur at some period or other in the course of most of them ; but their special claim to form a group apart consists in the fact of the existence in all of them of some mechanical impediment to the transmission of the contents- of the bowels, in coimection mth which enteritis is apt to supervene. They are : stricture, compression and traction, twistmg, mternal strangu- lation, impaction of foreign bodies, and intussusception. It will be con- venient to preface our observations under these heads with some remarks upon their common factor, constipation. A. Constipation. Causation, morbid anatomy, and symptoms. — It may doubtless be accepted as a general rule that persons enjoying robust health, and un- disturbed in the due performance of their various functions, have an alvine evacuation at least once daily. Yet many, who at any rate seem equally healthy, have their bowels habitually reheved every two or three days only, or even but once a week or fortnight. Cases are not altogether rare in which some degree of good health has been maintained for many years, although faecal evacuations have during that time occurred only at intervals of six weeks or two months. Cases, indeed, are on record in which the interval between successive evacuations has been extended to a period of three months. In most cases, however, retention beyond the usual period is apt to produce not only local luieasmess, such as fulness, heat, tendency to piles, and flatulence, but also some degree of general disturbarogress. — The symptoms of these affections are almost, if not quite, identical with those of stricture. It is impossible, mdeed, to make any absolute clinical distinction between them. Obstruction of the small intestme, however, is as a rule more early followed by vomiting than obstruction of the large intestine ; and it may occasionally be pos- sible, by careful examination of the surface of the abdomen, to ascertain whether abnormal distension is due entirely to dilatation of the smaller bowel, or mainly to distension of the colon. In those cases m which old adliesions have formed around the lower part of the ileum, a tumour may sometimes be felt in the right iliac fossa ; and in these same cases there mav be (extending over many months or even over many years) progres- sive dilatation and hypertrophy of the small intestine, and progressive contraction and atrophy of the large intestine, associated with gradually increasmg frequency and \iolence of peristaltic action, colic, nausea, and -sickness, the habitual discharge from the bowels of thin, yellow, fetid •evacuations, and slowly developed emaciation and debility, terminating at length in death from asthenia. D. Torsion or Twisting. Causation and morbid anatomy. — Cases are occasionally met with in which after death a loop of bowel is found to be twisted, enormously dilated •and congested, and full of fetid pitchy stuff, consisting partly of faecal •matter, partly of the bloody secretioai of the affected mucous membrane. The portions of bowel most Hable to torsion are the csesum and sigmoid flexure. The causes of torsion are obscure ; but, at any rate, the accident .appears to arise suddenly : the affected loop becomes twisted, once or «ven more than that, upon its axis, and is at once rendered more or less OBSTEUCTION OF THE BOWELS. 721 impervious ; and, wliat is still more important, the trunk-vessels which supply it becoming similarly twisted and occluded, congestion, inflamma- tion, gangrene, and paralysis of the bowel necessarily ensue. When the twist is of the sigmoid flexure, the loop of bowel sometimes undergoes such enormous distension as to measure a yard in length, and three or four inches m diameter, and may occupy the whole of the front of the abdomen. The mucous membrane and sub-mucous tissue become thickened and black with congestion and extravasated blood ; and the peritoneal aspect acquires a slaty hue, and gets studded with patches and streaks of congestion and inflammatory exudation. The contents have already been described. The bowel below the lesion is usually contracted and empty, while that above it is for the most part dilated, and may pre- sent patches of congestion and contain matters which have regurgitated from the diseased tract. Symptoms and progress. — This aflection is sudden in its onset, and in most cases rapidly fatal — the patient sometimes dying in the course of a day or two, rarely sur^iving for a week. The symptoms are in the main those of strangulated hernia. The patient generally suflers at first from severe abdominal pain, attended with constipation, vomiting, and rapid flatulent distension of the belly. And although febrile phenomena may occur, he very rapidly falls into a condition of collapse, Avith falling tem- perature, clammy perspiration, feeble and irregular pulse, sighing respira- tion, great muscular debility and restlessness, and withal more or less drowsiness. Generally the urine is scanty or suppressed ; the bowels completely obstructed ; and the patient sensible to the last. It is remarkable that vomiting and hiccough are often absent in a greater or less degree, at any rate are not prominent symptoms ; and that notmthstanding the enormous distension of the abdomen, there is fre- quently little or no absolute pain, exceptmg early in the disease, and little or no tenderness. Lideed, the patient often, as in colic, is relieved by pressure or friction. When the torsion mvolves the sigmoid flexure, the long tube may easily be mtroduced mto the diseased bowel ; and the nature of the case may possibly be diagnosed partly by this fact, partly by A\itlidrawing some of the contents. E. Internal Strangulation. Causation, and morbid anatomy. — This arises from similar causes to those which produce ordinary strangulated hernia, namely, constriction or nippmg of a portion of bowel by the edges of some natural or artificial orifice through which it protrudes, with consequent arrest of the circula- tion of blood through it, and impediment to the passage of fsecal matters along it. Such orifices are the foramen of Winslow, congenital or acquired perforations in the mesentery, meso-colon, great omentum, or other peritoneal duplicatures, or apertures, formed with the aid of neigh- bouring parts by bands of fibroid tissue extending from one point of the peritoneal surface to another. 3 a 722 DISEASES OF THE DIGESTIVE OEGANS. Hernial protrusion through the foramen of Winslow is exceedingly rare^ Perforation of the various peritoneal duplicatures, with passage of bowel through the perforation, is much more common, and often the result of " laceration from violence. This accident is most frequent in connection with the mesentery ; biit it occurs also in connection with the great omentum, the meso-colon, the fold belonging to the vermiform appendix, the suspensory ligament of the liver, and the broad ligament of the uterus. There is no part of the peritoneal surface to which bands capable of pro- ducing strangulation may not be attached ; but there are certain structures and certain conditions of parts with which they are specially apt to be connected. Thus the vermiform appendix often adheres to neighbouring structures, such as the mesentery, small intestine, colon, and ovary, forming a kind of loop ; diverticula of the ileum become attached, usually by the apex, to the mesentery or some other adjoining part, or are pro- longed to the imibilicus by a cord — a remnant of foetal life. Again, such bands are often connected with the mesentery, the parts concerned in old ruptures, or the pelvic organs — more particularly the uterus. Fallopian tubes, and ovaries. It may further be noted that strangulation occa- sionally results from the slipping of a loop of intestine under the loAver edge of the unusually elongated mesentery of a portion of bowel hanging low into the pelvis, or under the pedicle of an ovarian or uterine tumour. Finally, there are rare cases of internal strangulation in which the bowel protrudes into a lacerated bladder, uterus, vagma, or bowel, or through an acquired or congenital communication between the peritoneum on the one hand, and the pericardium or one of the pleurae on the other. The small intestine is much more frequently strangulated than the large ; and of the large intestine the parts most liable to this accident are those which are most freely movable, especially the sigmoid flexure and the c^cum. ' Internal strangulation occurs at any age, but generally above thirty. It seems, however, that strangulation from bands connected with the vermiform appendix and diverticula are most common at a com- paratively early age. The syniiJtovis of internal strangulation are identical with those of ordinary strangulated hernia, and so like those which have already been described as the symptoms of torsion and the severer forms of enteritis, that there is no need to give any special account of them. F. Impaction of Foreign Bodies. Causation and morbid anatomy. — The ordinary intestinal contents, no matter how indigestible, unwholesome, or imperfectly commmuted the ingesta from which they are derived may be, very rarely cause by their accumulation permanent intestinal obstruction ; yet it is doubtless the fact that undigested masses of food do sometimes in their passage along the small intestine move with difficulty or become temporarily impacted, and so produce pain and sickness and even symptoms of obstruction. Hard foreign bodies of comparatively small size (coins, bits of bone, teeth, marbles, plumstones, and the like) generally traverse the intestine without causing OBSTEUCTION OF THE BOWELS. 723 inconvenience ; and occasionally sliarp bodies, such as pins, prove equally innocuous. They are all, however, a source of danger, especially in the presence of strictures, above which they are apt to become lodged ; or from the fact that they may slip into diverticula or the vermiform appendix, or (if they be hard and pointed) may perforate the intestinal wall, and cause, according to the seat of perforation, fatal peritonitis, circumscribed abscess, or fistula. Further, an accumulation of such bodies, as for example a large number of cherry-stones, may become welded into a mass sufficiently bulky to obstruct fatally a perfectly healthy bowel. Insoluble matters in the form of powders or fibres, when habitually swallowed even in small quantities, often concrete into hard masses. These sometimes are round or oval, and may then be termed intestinal calculi, sometimes form hollow casts of the portion of the gut in which they lie. The former are probably always found in the large intestine ; the latter rarely, if ever, occupy any other part than the rectum. Among the substances here referred to are peroxide of iron, carbonate of magnesia, imperfectly cooked starch, and oat-hairs derived from articles of food made from oats. Among cases of exceptional rarity must be named those of persons who have been in the habit of swallowing knives, pins, string, hair, or cocoa- nut fibres. These things are generally found accumulated either in the stomach or in the upper part of the small intestine, and when fibrous usually become felted and form masses which take the shape of the cavi- ties in which they lie. It must not be forgotten also that lumps of indurated faeces occasionally lodge in the caecum, sigmoid flexure, or some other part of the colon, and remain thus lodged, without causing obstruction, for months together, or even for an indefinite period. Such lumps may be situated above a stricture, or may lie passive in a sluggish and dilated bowel as a sequel probably of prolonged or habitual constipation. They may be recognised as ffecal by their position, their mobility and tendency to descend, and especially by their doughy consistency and freedom from marked tenderness. But the usual cause of fatal impaction, and that with which we now have more especially to do, is the escape of biliary concretions from the gall-bladder into the small intestine. The concretions here referred to are single stones or masses of coherent stones of considerable bulk, varying at a rough estimate from three to four inches in circumference, and from one inch to two, three, or even four in length. It is obvious that concretions of this magnitude can scarcely escape from the gall-bladder ]3er vias nahtrales ; and indeed there is no doubt that their discharge is in all cases effected through an ulcerated opening between the gall-bladder and duo- denum. When such a body has got into the duodenum it is carried on. with the other contents of the bowel by the ordinary peristaltic movements. But its mere bulk prevents it from moving rapidly ; besides which it pro- vokes, by its shape, size, and hardness, irritation if not inflammation in the mucous surface over which it passes, and spasmodic contraction of the muscular walls. It hence continues its progress fitfully onwards, until finally it becomes permanently arrested, sometimes in the jejunum, but 3 A 2 724 DISEASES OF THE DIGESTIVE OEGANS. more commonly in the ileum, especially in its narrowest part, just above the ileo-caecal valve. Then all the effects of complete obstruction, con- joined with those of enteritis, supervene : the bowel below becomes empty, that above diotencled and generally more or less inflamed ; while at the seat of obstruction and in its immediate neighbourhood the inflammation becomes intense, speedily extends to the peritoneal surface, and not rarely ends in gangrene and perforation. GaU-stones seldom if ever lodge in any part of the large intestine ; and when large ones are found there they have probably gained an entrance directly by ulceration between the gall- bladder and transverse colon. Gall-stones are usually a product of the later periods of Hfe ; and hence obstruction from them can scarcely be looked for excepting in advanced age. It occm^s, indeed, rarely before the age of fifty, and much more frequently in women than in men. Symptoms and progress. — The spnptoms due to the impaction of gall- stones are as nearly as possible identical with those of internal strangula- tion or enteritis. These cases, however, are amongst the most violent in their symptoms and the most rapid in their course of all cases of intestinal obstruction. Dr. Brinton calculates their average duration at five days. A clue to the nature of the case may sometimes be furnished by the occurrence of precm'sory symptoms due to the passage of the cal- culus along the bowel, and by the detection of the hard mass itself in transitu. The age and sex of the patient are also suggestive. There is not necessarily or even generally in these cases any history of hepatic colic or other indication of hepatic affection. G. Intussusception. Causation and morbid anatomy. — By this term is meant the descent or prolapse of a portion of the bowel into that which immediately succeeds it and is continuous with it. As the result of this accident we find the nor- mal coTU'se of the intestine interrupted by a kind of knot, m which three successive lengths of tube lie almost concentrically one within the other — the uuiermost bemg the portion of bowel which has descended, the outermost the portion into which the descent has occurred, the middle or intermediate length that which unites the lower extremity of the former with the upper extremity of the latter. The last is of course inverted, and has its mucous aspect facing outwards and m contact with that of the outermost layer. In the descent of the inner two lengths of bowel the mesentery belongmg to them is necessarily dragged down with them into the pouch which they form, and by the traction which it exerts tilts the double tube or invaginated portion of bowel so that the lower orifice, uistead of lying in the axis of the containing bowel, faces and rests upon some portion of its circumference. The several layers are generally trans- versely corrugated, and this condition is always most marked in the middle tube. The immediate effects of intussusception are : first, obstruction to the passage of the intestmal contents ; and, second, impediment to the circulation of blood through the inner two cylinders of involved bowel, to OBSTEUCTIOX OF THE BOWELS. 725 which the stretched and compressed mesentery belongs. Nevertheless the obstacle which an intussusception opposes is often mcomplete ; for it is certam that in a good many cases fa?cal matters pass pretty constantly through it. The obstruction to the circulation soon renders the mucous and muscular coats of the inner two tubes black or nearly so with conges- tion and effusion of blood ; and the serous surface acquires a slate colour. At the same time these parts become much swollen, and sanguinolent serum or blood escapes from the mucous membrane into the interval between the opposed surfaces of the outer two tubes, into the central canal. and into the bowel below the seat of disease. At a somewhat later period coagulable lymph is secreted from the opposed serous surfaces of the middle and internal layers, and these may consequently become agglutinated ir their whole length. In most cases an intussusception increases for a time more or less rapidly, owing to the active peristaltic movements of the several segments engaged. This mcrease is so effected that that portion of the bowel which formed the lowest point of the invaginated mass in the first instance continues to form its lowest pomt to the end of the chapter ; in other words, the middle tube of an intussusception mcreases in length at its upper end only, and at the expense of the outer tube. The length of bowel engaged in an intussusception varies widely. Including in one measurement the inner two tubes only, it may be said to range usually from two or three inches up to three or four feet. Dr. Peacock records a case in which there were good grounds for believing it to have been no less than twelve feet. Intussusception may arise at any part of the mtestinal canal, but it occm's in different parts with different degrees of frequency. Jejunal and ileal intussusceptions are met with almost exclusively in adults, and form collectively about one-third of the total number of fatal cases. These are usually attended with speedy strangulation of the bowel, and run a rapid and for the most part rapidly fatal course. Ileo-cfecal invagination occurs largely among young children, including babes of a few months old. Ac- cording to Dr. Brinton, half the total number of these eases are in children under seven years of age. This is the most common form of the disease, accounting for more than haK the total number of deaths. It commences with the descent into the ca^^ty of the ctecum of the lips of the ileo-cfecal orifice, which henceforth form the lower extremity of the invagination. As this mcreases the descending ileo-caecal orifice carries do^^Tl with it more and more of the ileum to form the central tube, and inverts first the caecum and then a gradually increasing quantity of the colon to form the inverted or middle layer; and, stiU descendhig, finally, in some cases, reaches the rectum, or even protrudes from the anus. It is in this variety that the greatest length of bowel may be engaged ; m it the transverse folding of the several layers of intestine is usually well shown, especially in the middle tube, which is often also much convoluted and twisted ; and in it complete strangulation and complete obstruction to the passage of fasces are comparatively rare. Intussusception commencing in the colon is of somewhat unfrequent occurrence ; and still more rare is 726 DISEASES OF THE DIGESTIVE ORGANS. intussusception of the rectum. The rarest form of all, probably, is that due to the descent of the ileum through the ileo-cffical orifice. If the patient survive sufficiently long, various consequences are apt to ensue. The inflammation, which by its products unites the opposed serous surfaces of the inner two layers, may spread beyond its primary seat, and cause general peritonitis. Or, after these layers have become united, a further descent of bowel may take place into the portion already invagi- uated. Or the invaginated bowel may by its extremity fret the wall of its contaming tube, causing ulceration and perforation. It may even protrude bodily into the peritoneal ca-saty. But by far the most interesting and important event is the sloughing and separation of the included layers of bowel. This occurs almost exclusively in those cases in which the smaU intestine is alone engaged, and the strangulation of the contained bowel is most complete. This, first deeply congested, soon becomes gan- grenous, and then, after a while, getting detached either bit by bit or in mass, gradually works its way downwards, and is expelled. The separation of the slough generally leaves the upper extremity of the outermost tube firmly united at the neck of the intussusception with the lower extremity of the healthy bowel above. But during the process of separation the adhesions are apt to rupture, and faecal matter to extravasate into the peritoneal cavity. The discharge of the invaginated bowel usually occurs between the twentieth and thirtieth day : but it may take place as early as the sixth or seventh day, or be delayed for a year or two. The results of separation seem to be favourable in about half the total number of cases. In the remainder death often results sooner or later from stricture. Symptoms and progress. — The occurrence of intussusception is attended with sudden and severe abdominal pain of a griping or twisting character, usually referred to the neighbourhood of the umbilicus. This generally ceases m a short time, but, after an interval, recurs temporarily, and then perhaps continues to recur and remit alternately. There is not necessarily any abdominal tenderness, and indeed the patient frequently finds rehef, as in colic, from pressure on the abdominal parietes. Sympathetic vomiting may be an early symptom, but in the beginning is often absent. Constipation usually follows upon the sudden attack of pain ; but sometimes there is actual diarrhoea, and generally more or less abundant discharge of blood furnished by the congested bowel. The symptoms which mark the subsequent progress of the case depend partly on the situation of the intussusception, partly on the degree of strangulation. In ileo-csecal uivagination strangulation is rare, and consequently the case tends to be protracted. In this event the symptoms are apt to be ill- defined ; paroxysms of pain are often slight, and recur at distant intervals ; constipation may exist at the beginnmg only, or may recur fifom time to time, or may never be distinctly present ; there is generally vomiting. As the case progresses, however, the pain often increases in severity ; the vomiting becomes more or less incessant, and probably stercoraceous ; the alvine evacuations either contmue to pass or become re-established ; blood and mucus are discharged in variable quantities ; and even dysenteric OBSTEUCTION OF THE BOWELS. 727 -diarrlioea may come on. And then, after a longer or shorter period, sometimes two, three, or four months, the patient, who has been gradually getting emaciated and feeble, dies of simple exhaustion. When the small intestine is the seat of disease, strangulation usually takes place at once, and its occurrence adds the symptoms of enteritis to those of mere invaguaation. The case, therefore, speedily assumes a very threatenmg aspect. Febrile symptoms manifest themselves, the abdomen becomes tender, incessant vomiting comes on, the bowel gets occluded, but at the same time probably blood in some abundance is discharged per ■ anum. With such symptoms the patient, as in simple enteritis or mternal strangulation, may speedily succumb ; but sometimes, at a moment when the disease appears still to be progressing unfavourably, the constipated bowel begins to act, offensive stools, mixed with blood and mucus, begin to be discharged, vomiting diminishes or ceases, febrile phenomena abate, and, after a longer or shorter time of dysenteric symp- toms, a sequestrum is voided in the form of a dark fetid mass. A further indication of the presence of intussusception is the discovery of a tumour. No doubt, this cannot always be detected ; but it is most likely to be found in cases of ileo-csecal or coHc invagination. That the •tumour is due to intussusception may be gathered: partly from its posi- tion ; partly from its form ; partly from the fact of its gradual enlargement and change of position ; but above all fr'om its hardening and enlarging .and then subsiding under the influence of peristaltic movements. The tumour arising fr'om ileo-caecal invagination is generally discovered in the left lumbar and iliac regions. If the tumour descend into the rectum, or protrude externally, its nature may of course be readily recognised. The distinctions which have been drawn between invagmations of the small intestme and those of the large (to wit, that in the former case the symptoms are usually more sudden and severe, vomiting earlier and more persistent, constipation more complete, discharge of blood per anum more profuse, inflammation ^more intense, and death more rapid) are no •doubt true of most cases, but they are not to be relied upon absolutely ; for it occasionally happens that invaginations of the small intestine assume a chronic character, and still more fr'equently that those of the large take an acute course and even end in the detachment of the invagi- nated portion. The percentage mortality of intussusception is very large. It must be observed, however, that in arri^ing at this [conclusion we necessarily exclude all those cases in which intussusception isjfound acci- dentally after death from other diseases, and those (which we beheve to occur now and then ) in which intussusceptions form during life and dis- appear agaiii after the temporary production of symptoms of more or less severity. The average duration of cases fatal from enteritis appears to be .about five days. 728 DISEASES OF THE DIGESTIVE OKGANS. H. Concluding Bemarks in reference to Symptoms. Before dismissing the subject of intestinal obstructions it maybe con- venient to consider some of the more important points upon which our discrimination of cases that come before us must depend. 1. Pain is a prominent symptom in most cases of obstruction. It is due sometimes to peritonitis, sometimes to coKc, sometimes to both of these causes. It varies m intensity in different cases, and may be almost entirely absent. Pain of peritonitic quality attends those cases of obstruc- tion which are accompanied by enteritis, and is apt to subside as tympanitis supervenes and the fatal event approaches. Colicky pains constitute one of the most characteristic and at the same time one of the most distressing symptoms of intestinal obstruction. They come on in paroxysms, and are attended with more or less violent peristaltic move- ments of the bowel above the seat of obstruction, which are often distinctly visible through the abdominal parietes, and may even from their course and point of apparent cessation furnish a clue to the seat of impediment. These pains may be present in a marked degree in all forms of obstruc- tion, but are most severe and most constant in the cases of longest duration — m those, therefore, in which enteritis is either not present at all or comes on late. 2. Vooniting'^^is rarely if ever entirely absent. At first it is merely sympathetic. But after a while it is due to mechanical causes. The bowels above the seat of the obstruction get distended by their contents,, which are partly the ingesta, partly the secretions of the mucous surface. These, by the combined effects of simple overflow, peristaltic action, and pressure from without, regurgitate into the stomach, and then become voided, constituting what is called stercoraceous vomit. This may be peasoup-like and fetid from decomposition, but is never derived from the large intestine or truly ftecal. Vomiting is generally an early symptom of intestinal obstruction, and in cases of acute progress may continue to the end without cessation. Yet even in some of these it intermits, and may be absent for a comparatively long period. In chronic cases its occurrence is extremely variable, but it generally becomes frequent and stercoraceous towards the close of life. Vomiting is. an earlier, more constant, and more severe symptom, in proportion to the nearness of the seat of obstruc- tion to the stomach. In obstruction of the large intestine it is usually long delayed, and may never be a promment symptom. 3. Constipation \&, of course, one of the most characteristic phenomena of obstruction ; yet ftecal matters will often pass with little difficulty even through a tight stricture, especially of the small intestine. Nor must it be forgotten that generally at the time at which complete obstruction is established, the bowel below contains larger or smaller quantities of faeces, which may be removed naturally or by injections. Scybala are sometimes found post mortem in the large intestine below a complete obstruction of many weeks' standing. Nevertheless, insuperable constipa- OBSTRUCTION OF THE BOWELS. 729 tion coming on suddenly is a striking feature of internal strangulation and of the lodgment of gall-stones ; insuperable constipation coming on gradually or Avitli premonitory stages, of stricture and compression. In intussusception also there is generally sudden constipation of varying duration ; but the invaginated mass, especially when the large intestine is involved, is rarely quite impervious, so that before long, at all events in chronic cases, the transmission of faecal matters is resumed. In intussus- ception, moreover, blood is apt to be passed at an early period by stool ; and is generally passed in abundance when the small intestine is the part affected. 4. Tumour and sliape of belly. — The belly usually becomes before long- tense and tympanitic in consequence of the accumulation of gas in the parts above the seat of obstruction ; and the form of the stomach or of certain convolutions of the bowels may sometimes be distinctly mapped out. Careful attention to the form of the belly, to the visible movements of the organs beneath, and to the sounds elicited by percussion will often aid us in determining the seat of disease. Still, too much reliance must not be placed upon these phenomena, for certain lengths of bowel become in such cases so enormously distended that they not only conceal all the other viscera, but a coil of small intestine may equal in diameter a dis- tended colon, and either of them may simulate the stomach. The detec- tion of a lump is an indication of capital importance. It may be due to the presence of a gall-stone or some other concreted mass lodged in the bowel ; it may (in cases of stricture) be a malignant tumour ; it may be the evidence of intussusception. 5. The condition, of the urine is a matter of interest. In some cases of obstruction there is almost total suppression ; in some there is an abundant limpid discharge. Dr. Barlow, who first observed this difference, attri- buted scantiness of urine to the obstruction being high up in the bowel, and to the consequently little available surface left for absorption ; plenti- fulness of urine to the opposite conditions. Dr. Brinton, accepting Dr. Barlow's facts, referred the deficiency of urine to the abundant vomiting which attends the one class of cases, and the copious secretion of that fluid to the comparative absence of vomiting which is usual in the other class. Mr. W. Sedgwick, however, argues that the diminution or sup- pression of the urinary secretion is related to the suddenness and in- tensity of the symptoms, and is due to the influence of the sympathetic system. On the whole there is reason to believe that diminished secre- tion, which is often only temporary, characterises mainly those cases in which the symptoms are sudden and acute ; and almost necessarily, therefore, in larger proportion cases involving the small intestine than cases involving the large. 6. Duration of life. — Complete obstruction occurring in the rectum or colon may not prove fatal for several weeks or even several months. Death as a rule supervenes earlier in proportion as the impediment is situated near the stomach. When, however, enteritis is associated with obstruction, then, wherever the obstruction may be, the progress of the 730 DISEASES OF THE DIGESTIVE OEGANS. ■case is always rapid, and, dating from the commencement of enteritic symptoms, rarely occupies more than a week, often only three or four -ith enlarge- ment of the organ due to distension of its vessels, mamly its veins and capillaries, with blood. When this is general the liver structure presents a uniform deep-red hue, and blood escapes in abundance from the cut surface. Li cardiac or mechanical congestion it is the hepatic veins and their minute branches occupying the centres of the lobules which are chiefly if not exclusively involved. These become dilated and full of blood, and the liver consequently often undergoes considerable increase in bulk. If sections of the organ be made at this time it will probably be found that the centres of the lobules are deeply congested while their peripheral parts are pale. With the progress of the disease the hepatic texture undergoes important changes : in consequence of the increasuig dilatation of the intra-lobular hepatic veins the cells which lie in then- meshes undergo atrophy and perhaps finally disappear ; the cells immediately bounding this region often become deeply jaundiced and the seat of granular biliary pigment, and hsmatoidine crystals are occasionally deposited ; and the peripheral cells of the lobules get distended with oil. In this stage the liver is often larger than natural, though probably smaller than it was at 3 D 2 772 DISEASES OF THE DIGESTIVE OEGANS. first ; it is apt to be somewhat granular on the surface with a more or less thickened capsule ; it presents some degree of induration ; and on section the surface is found to be thickly studded with small circles or festoons of an opaque buff or bright yellow colour, interwoven with discs or small lobulated patches of intense, perhaps black, congestion. The appearance has been not unaptly compared to that of the sectional surface of a nut- meg. In connection with atrophy of the cells of the central parts of the lobules, a development of fibroid tissue tends to take place, and thus a con- dition allied to cirrhosis may ultimately be developed. Symptoms and progress. — The symptoms of congestion of the liver or ■of the congestive hepatitis which takes place in the course of obstructive cardiac or pulmonary disease are : uniform enlargement of the organ, which probably descends an inch or two below the lower margin of the right ribs, .and encroaches also to an abnormal extent on the right half of the thoracic cavity ; pain and fulness in the hepatic region, with considerable tender- ness on pressure or percussion ; pain or tenderness on lying on the right side ; pain also on lying on the left side from the tendency of the liver to drag ; and pain on drawing a deep breath or coughing. Slight jaundice is apt to supervene and to persist after all other symptoms of hepatic affection, excepting enlargement of the organ, have subsided. It is in these cases that hepatic pulsation is occasionally observed. Hepatic engorgement comes on as a rule late in the progress of cardiac and pul- monary diseases, and although it often subsides under treatment it is very apt to recur, and then to become permanent. When the congestion has Taecome chronic and the liver shrunken and indurated, ascites and other consequences of portal obstruction, as in ordinary cirrhosis, are apt to ensue. The treatment of hepatic congestion is mainly of course that of the pulmonary or heart disease which causes it. In other respects it may be regarded as identical with what has already been prescribed for inflam- mation of the ducts of the liver or the earlier stages of acute hepatitis. VI, MOEBID GEOWTHS, A. Tubercle. This affection is much more common in the liver, in connection T;?ith tuberculosis of other organs, than is generally supposed, but has no clinical importance. Miliary tubercles are most frequently met with, and are often present in considerable numbers ; but, owing to their close approximation in colour to the hepatic lobules and their extreme minute- ness, are apt, excepting they be at the surface, to elude detection. Occasionally tubercles of the average size of a pea or bean are observed. These always present a central cavity full of broken-down tissue and biliary colouring matter, with a capsule of yellowish or greyish tubercular growth. MOKBID GEOWTHS OF THE LIVEK. 773 B. Syphilis. Morbid anatomy.— Syphilitic disease is recognised post mortem chiefly by the presence of gmnmata, which have ah'eady madergone retrogressive changes. These are opaque, huff-colom-ed, dense, tough masses, romided or irregular in form, and varying from about the size of a pin's head to that of a chestnut. They are rarely solitary, and are often grouped in clusters of considerable bulk. They are incapable of enucleation, and are imbedded in dense fibroid or cicatricial tissue, which is continuous, on the one hand, with the bodies just described, on the other hand, with the surrounding hepatic texture. They are mostly solid ; but occasionally, when one is permeated by a duct, the latter is broken down into a cavity within it. Wherever these masses with the surrounding cicatricial tissue are present, the hepatic surface which corresponds to them is thickened, drawn in, and sometimes very deeply indented — facts which prove the chronic nature of the affection, and that much contraction of tissue has attended its progress. Not unfrequently, in cases where many of these tumours are present we also find dense masses of cicatrix-like tissue, which are either free from obvious tumours in their interior, or which in place of them present merely a few opaque or gritty particles. The conditions above described are, however, only the last phases of a more acute syphilitic affection. The influence of the syphilitic virus on the liver is in the first instance to cause interstitial inflammation, which, as we have shown, has considerable resemblance to that of the early stage of ordinary cirrhosis. This affection may be general throughout the liver, or confined to certain are® ; and it is in connection with it that, sooner or later, gummata make their appearance. These are due to the active proliferation of certain of the cell-elements of the newly formed fibroid tissue, which increase in number and diminish in size, and collectively form tumours having a close resemblance to granulation- tissue or tubercle in the early stage. These growths then rapidly de- generate in their central parts, while they increase peripherally, so that at an early period they present caseous masses surrounded by a thin rim of living cell-growth. After a while they cease to enlarge, and the whole mass undergoes caseous degeneration. Gummata may occur in any region ; they are common on the convex surface of the liver, and especially, as Virchow points out, in points exposed to injury. They are common, also, in the neighbourhood of the transverse fissure, and may there seriously interfere with the permeability of the ducts and vessels. They usually vary individually in size between that of a pea and that of a walnut ; but they may be larger or smaller, and are often aggregated. Such aggregations may attain the size of the fist. Although interstitial hepatitis is a common result of congenital or hereditary syphilis, the firm cheesy masses just described are rarely discovered in that variety of the disease. Symptoms. — The symptoms which may be looked for in hepatic syphilis are those of cirrhosis in its various stages, especially, therefore. 774 DISEASES OF THE DIGESTIVE OEGANS. ascites, intestinal liemorrliage, and jaundice. But it must be admitted that syphilitic disease is, from first to last, often unattended with symptoms, and that it is not mifrequently discovered post mortem in cases where its presence during life had never been suspected. When, however, the gummatous growths obstruct the vena portte or the hepatic ducts, the symptoms due to such lesions will necessarily manifest themselves with considerable, and perhaps sudden, intensity. The detection of irregu- larity of form, or hard rounded or nodulated but sluggish tumours, in the liver is an important aid to diagnosis. The chief grounds, however, for suspecting the presence of syphilitic disease in this organ would be the association of symptoms of hepatic disorder and presence of tumour with a history of syphiKs and "visible indications of its presence in a constitu- tional form. Treatment. — In addition to the treatment suitable for cirrhosis and its consequences, the use of antisyphilitic remedies is obviously indicated in the treatment of hepatic syphilis. C. Non-malignant Groicths. Under this head we may make a brief reference to two varieties of morbid formations which have little more than a pathological interest. These are simple cysts and cavernous tumours. The latter are small, blackish, spongy masses, rarely exceeding the size of a filbert ; replacing definite portions of hepatic substance ; and consisting of irregular inter- communicating vascular spaces, separated fi'om one another by trabeculse of fibrous tissue covered -^dth pavement epithelium. Simple cysts vary from scarcely visible points up to the size of an orange. They are some- times sohtary, and are then usually situated about the middle of the anterior edge of the liver. Occasionally they are present m enormous numbers, when they display all grades of size and varieties of grouping. They are generally thin- walled, and in some cases give evidence of their enlargement by the coalescence of neighbouring cysts ; they are lined with pavement epithelium, and usually filled with clear serous fluid. The smaller cysts sometimes contain yellowish or brownish colloidal masses like those found m renal cysts. Cysts, however numerous they may be, rarely, if ever, induce hepatic symptoms ; it is possible, of course, that the presence of one of large size in relation with the anterior edge might be detected by manual examination ; as a matter of fact, however, they are rarely, if ever, recognised during hfe. The most interesting point in connection with them is the fact of their comparatively fi'equent association with cystic developments in other organs, more especially in the kidneys and spleen. They must not be confounded with hydatid cysts. D. Malignant Groicths. Morbid anatomy. — Malignant tumours of the hver are usually secondary to similar growths originating elsewhere in the body, and especially, perhaps, to such as are developed in the other chylopoietic MOEBID GEOWTHS OF THE LIVEE. 775 viscera. Not unfrequently, however, they are primary. No age is •exempt from habihty to the disease ; yet it rarely occurs before adult age, -and is most common in persons of middle and advanced life. It has been met with in young children, and in them is probably always a ^secondary manifestation. The influence of sex is unappreciable. Malignant disease appears in the liver in two forms : either as isolated tumours or as a more or less general infiltration. In the former case the tumours vary in size from that of a good-sized orange, or even a cocoa- nut, down to minute granules, which the naked eye may fail to recognise. Their general form is globular, unless the coalescence of neighbouring masses, or accidental circumstances, have led to their irregular develop- ment. When they involve the surface of the liver, those arese of disease which are immediately subjacent to the capsule, and which are generally circular, assume a peculiar cupped appearance, due to the presence of a prominent tumid peripheral ring, circumscribing a central concave de- pression. This cupping is very characteristic, and may frequently be recognised in tumours not more than a line or two in diameter as readily as in such as have attained the bulk of a chestnut or orange. There is usually well-marked vascularity of the superficial aspect of these tumours, and especially of their peripheral portions and of the liver- structure immediately surrounding them. The tumours grow at their margins, partly by progressively invading the healthy tissues bounding them, partly by the formation in their immediate neighbourhood of new foci of disease, with which they gradually coalesce. But while the marginal growth is in progress, the central portions fall into degeneration. This may be fatty, caseous, or even calcareous, or connected with hemorrhagic extravasation. Occasionally the central portions undergo liquefaction, and become converted into cysts containing a milky or watery fluid. These several forms of degeneration do not, as a rule, occur indiscrimin- ately ; each one, in fact, indicates to some extent an inherent peculiarity in the tumour in v/liich it occurs, and which is shared more or less by all the other tumours which are in genetic relation with it. It is to the combination of active peripheral growth with central retrogression and necrosis that the superficial cupping to which reference has been made is mainly referrible. Malignant tumours may occur in any part of the hepatic substance; and. may vary numerically from one or two to an innumerable multitude. In the former case they are usually primary, and it is here that probably the greatest size of growth is attained. In the latter they are generally secondary to growths elsewhere. The diffused or infiltrating form of malignant disease is much rarer than the other. In this case we find the liver generally, or large portions of it, greatly enlarged, but retaining their normal shape ; the enlargement being due to the abundant dissemination of small growths, more or less indistinctly defined from the liver-tissue, and tending to rmi together, so as to give to both the outer and the sectional surface of the affected organ a spotty, reticulate, or uniformly morbid character. Sometimes, indeed, the naked eye fails to detect in the enlarged liver any traces of normal 776 DISEASES OF THE DIGESTIVE OEGANS. hepatic tissue. The presence of distinct rounded tumours may be associated with the condition here described. Of the several forms of mahgnant disease which attack the liver, the carcinomata are the most common. The variety of cancer most fre- quently met with is the encephaloid, of which several sub-varieties, not, however, calling for description, exist ; scirrhus is more rare ; and still rarer than scirrhus are melanotic cancer and colloid cancer. Most of these appear under the form of isolated scattered masses. Sarcomatous malignant growths are comparatively unfrequent. The most common and interesting of them is the melanotic variety, which is usually secondary to similar disease of the choroid coat of the eye, or of pigmentary nsevi.. Melanosis is usually very widely distributed throughout the organ ; the tumours are small and tend to coalesce ; and the condition above de- scribed as ' infiltrating ' is apt to be produced ; the liver often becomes enormously enlarged, and assumes, from the intermingling of melanotic spots with spots of colourless growth and remnants of hepatic texture, an appearance which has been aptly likened to that of granite. Melanotic masses of considerable bulk, however, are not uncommon. Other forms of sarcoma (spindle-celled sarcoma, for example, and the closely related myxoma) have been discovered in the liver, secondary to similar growths in remote organs. True epithelioma of the liver is scarcely more than a. pathological curiosity. Cylindrical-celled epithelioma, however, or ade- noma, secondary, for the most part, to gastro-intestinal disease of the same kind, is of much more frequent occurrence. Its tumours are scarcely distinguishable, excepting microscopically, from those of ordinary carci- noma. Lastly, lympho- sarcoma, or lymphadenoma, is often developed in the liver. This may form independent tumours, like carcinoma, but seems specially to affect the capsule of Glisson and the interlobular tracts ; so that, in some cases, it involves the liver by ramifying through it with the portal vessels, in some it follows the ordinary distribution of the fibrous growth of atrophic cirrhosis, but in either case is apt to develop here and there into manifest tumours. Other forms of malig- nant disease besides lymphadenoma are liable to invade the liver from the transverse fissure. In cases of gastric or peritoneal cancer especially, the small omentum is very commonly infiltrated with cancerous growth, which thence propagates itself along Glisson's capsule, surrounding and compressing, or otherwise involving the veins and ducts. Again, the lymphatic glands in this situation are often affected secondarily to hepatic or other neighbouring mahgnant disease, and may by their enlargement implicate the same channels. Symi)tovi8 and progress.— T\xq symptoms which attend malignant disease of the liver are in the main identical with those of cirrhosis and other structural diseases of the same organ. They comprise : alterations in the form and size of the organ, with local pain or uneasiness ; impedi- ment, mechanical or other, to the due performance of the hepatic functions ; mechanical interference with the functions of neighbouring organs ; and general impairment of nutrition. Increase of size and MOEBID GEOWTHS OF THE LIVEE. 777 alteration of shape furnish important indications of the presence of hepatic mahgnant tumours. The increase may be either uniform, or, as. is more commonly the case, dependent on the formation of rounded pro- jecting lumps, which may often be readily distinguished by the hand. Mere increase of size, however, is not so indicative of the morbid condi- tions in question as is rapid progressive increase ; nor is the simple fact. of the presence of irregularity from outgrowths so suggestive as the progressive enlargement and development of such excrescences, and the existence of a certain degree of hardness and resistance which is not usually observed in mere cystic formations. It must be borne in mind, however, that malignant disease is often present in a liver which is not noticeably altered in form or size : the growths may be few and small, or they may occupy the posterior part of the organ, or the liver itself may be concealed by the overlapping of distended and adherent bowel, or by other conditions. And, further, tumours of the stomach, or of the retro-peri- toneal glands, or even of the abdominal walls, may seem from their position to be of hepatic origin. Pain is, no doubt, a frequent attendant on hepatic malignant disease. Sometimes it is excruciating, and apt to come on in paroxysms ; but it is often absent, and may be totally absent from first to last. Jaundice, usually due to obstruction of some of the hepatic ducts, makes its appearance sooner or later in a considerable number of cases. It is rarely intense, unless the main duct be involved ; and hence it is chiefly in those cases in which the disease attacks the lesser omentum, and extends thence into the transverse fissure, that deep jaundice becomes developed. Jaundice, however, is by no means a neces- sary result, and is not unfrequently absent from the most extreme cases — cases in which the whole hepatic texture seems to be replaced by the morbid growth. Ascites is perhaps even more rarely than jaundice a direct consequence of malignant disease of the liver. It is often, no doubt, developed during the progress of the case, and may be due, as in cirrhosis, to impediment to the flow of blood through the portal vessels ; but it is usually comparatively small in amount, and dependent either on peritoneal inflammation or on other abdominal complications. When,, however, the portal vein is distinctly obstructed, the ascites may be con- siderable, and other consequences of portal obstruction, such as mel^na,. may ensue. In most cases ascites is absent. As regards neighbouring organs, the pressure of the enlarged and possibly painful liver is apt to induce functioiial disturbance of the stomach on the one hand, and pain and difficulty of breathing, and perhaps cough, on the other. General impairment of nutrition, debility, and emaciation are usually marked phenomena of the progress of the disease. Scanty secretion of urine, with abundant deposit of vermilion or carmine -coloured urates, is commonly observed. In most cases malignant disease of the liver is associated with similar disease of other organs ; and the symptoms which the patient presents are^ therefore, of complicated origin. This fact, while it maybe of the greatest value in enabling us to form a correct diagnosis of the malady under whicli 778 DISEASES OF THE DIGESTIVE OEGANS. lie is labouring, often renders it difficult to determine how much and which of his sufferings are due to the hepatic lesion. As of malignant disease generally, so no doubt of that affecting only the liver, it may be regarded as generally true : that the symptoms are insidious and progressive ; that the disease has usually made considerable progress before the suspicion arises that the patient is ill ; that this suspicion is first aroused, either by the gradual creeping on of emaciation, debility, and cachexia, or by the slow supervention of gastric symptoms, or by a sense of fulness, heat, or pain — continuous or paroxysmal — in the hepatic region, or lastly by the discovery of obvious tumours. During the further progress of the case all the symptoms of this period of invasion are apt to become commingled, and the special phenomena which we have attributed to the declared disease to supervene. It must not, however, be forgotten that malignant disease of the liver may prove fatal without having ever been attended with some of those symptoms which would seem to be most typical of it : not only, as we have pointed out, may there never be obvious tumour, hepatic pain, jaundice, ascites, or distinct impairment of the digestive functions, but the so-called ' cancerous cachexia ' may never be distinguishable, and the patient, instead of emaciating, may remain in good flesh, or even become fat. From the difficulty of determining the date at which it commences, it is impossible to determine, even approximately, the duration of hepatic malignant disease. Nor is it important to do so. It is sufficient for prac- tical purposes to know : that when once the disease has given clear evidence of its presence, the patient rarely survives beyond twelve months ; and that generally his death occurs within six or eight months. The natural cause of death is gradually increasing asthenia ; but the fatal ■event is apt to be accelerated by the occurrence of peritonitis or other complications. Treatment. — Medical skill is powerless to arrest the progress of the morbid growths under consideration. All that the physician can do is, to relieve pain and uneasiness by opium or other sedatives, or by local measures ; to check vomiting ; to obviate constipation ; and generally to aim at relieving the various symptoms which distress the patient ; and by hygienic and other measures to maintain, as far as possible, his general health and strength. VII. HYDATIDS OF THE LIVEE. Morbid anatomy. — These parasites affect the liver more frequently than any other organ ; they are not uncommonly developed, however, in various parts of the sub-peritoneal connective tissue, more especially that of the pelvis. In the liver hydatid tumours are usually solitary ; but sometimes two or more are developed there simultaneously ; and occasionally also such tumours in the liver are associated with other similar tumours elsewhere in the abdominal cavity. Their size varies : they are not unfrequently met with as large as a child's head, and containing several pints of fluid ; but they are slow in attaining these dimensions ; and, although the exact period HYDATIDS OF THE LIVEE. 779 ■during which they Hve and grow is uncertain, there is no doubt that it occasionally extends to at least ten or fifteen years, possibly even to twenty or thirty. They are for the most part globular in form, unless bands or ligatures, or other accidental conditions, have interfered with their develop- ment. In the liver they most frequently involve the right lobe, a fact pro- bably due simply to its comparatively large size. Hydatids appear to originate in the hepatic substance, which becomes displaced by them in the course of their development, and at the same time the seat of fibroid growth and induration in the layer which immediately surrounds them. By this means a kind of fibrous capsule is formed. In most cases there is no com- m.unication between the hydatid tumour and the liepatic ducts ; sometimes, however, a large, and even a primary, duct may be fomid leading directly hito the cavity, and its open continuation and that of some of its branches, studded with the orifices of their numerous tributaries, may then be seen ramifying upon its walls. The normal event of hydatid tumours, and one which is fortunately far from uncommon, is the death of the parasite, and the degeneration and contraction of the tumour. This has already been sufficiently described ; it may, however, be added that haematoidine ■crystals, derived from the biliary colourmg matter, are frequently met with in such degenerated cysts. Other events of not uncommon occurrence are the rupture of the cyst by accidental violence and its suppuration. Symptoms and inogress. — Hydatid tumours are rarely attended with pain, or even uneasiness, excepting by reason of their bulk and the pressure they exert on neighbouring parts, or in consequence of the supervention of inflammation. Generally, indeed, the patient's attention, or that of his friends, is first attracted by the discovery of gradual and at the same time more or less unsymmetrical abdominal swelling. So that, when the case first comes under medical observation there is generally an obvious tumour in some part of the abdomen, and the question is consequently not so much whether or not a tumour is present, as what the nature of the existing tumour is. Uninflamed hydatid tumours, which abut upon the surface, usually appear as rounded, tense, elastic swellings, free from pain or tenderness. They often fluctuate distinctly, and are not mifrequently attended with the peculiar hydatid thrill, first described by Brian9on and Piorry. This, which -is best recognised by placing the left hand flat upon the tumour, and then percussing sharply with the fingers of the right hand, consists in a peculiarly long-sustained tremor, reminding one of that experienced on an iron railway- •bridge during the passage of a train over it. It is due to the same cause as the ordinary ascitic thrill, but its distinctive character depends on the ■extraordinary elasticity of the hydatid membrane, and the consequent fineness and long persistence of vibrations excited in it. It is an interesting and important fact that this peculiar thrill may often be ■elicited with marvellous distinctness in peritoneal hj^datid tumours no larger than a pigeon's egg, which are so tense and hard and thick-walled that they feel like solid masses, and but for this thrill might be taken for 780 DISEASES OF THE DIGESTIVE OEGANS. malignant or other neoplasms. The nature of the swellmg, however,, may generally be placed beyond the possibility of doubt by tapping. The fluid which comes away from the living hydatid cyst is transparent and colourless like water, limpid, containing an excessive quantity of chloride of sodium, and as a rule neither albumen nor fibrinogen. Its specific gravity varies from about 1008 to 1013 ; and its reaction is neutral or slightly alkaline. Further, it may contain echinococci or microscopic hydatids. The position of the tumour will necessarily vary with its seat of de- velopment. If in the liver, it perhaps most commonly projects forwards — occupying the scrobiculus, or this with more or less of the adjoining-; abdominal regions ; but it may also protrude directly upwards, pushing the heart before it upwards and to the left ; or it may displace the right half of the diaphragm, together with the base of the lung, at the same time distending the lowermost zone of the right side of the chest ; or again it may be developed in the posterior region of the liver, and so elude detection. It is impossible to lay down any rules with regard to the situation of hydatids when they originate in other parts of the abdominal cavity. Suffice it to say : that they are often multiple and movable ; that they may, according to circumstances, assume the position of renal, omental, ovarian, uterine, aneurysmal, or other growths ; and that it is with these mainly, especially if they be cystic, and with hepatic swellings, more especially abscesses and dilated gall- bladders, that hydatid tumours may be confounded. When displacing the right lung upwards, and distending the corresponding part of the chest, they may simulate pleuritic effusion. Further an hydatid cyst may be separated from the surface by a considerable thickness of the tissue in which it origi- nates, or by an exceedingly thick and dense capsule, and hence may be mistaken for a solid tumour ; or, owing to the simultaneous development of several cysts, or to various other accidental circumstances, it may appear nodulated or multiple, and may present different degrees of consistence and elasticity at different points, and so may easily be taken for a lobulated malignant growth, or for a compound ovarian or other cystic tumour. The diagnosis of a contracted and degenerated cyst, even if occupying a situation readily accessible to examination, would, without the guidance of a clear history, be exceedingly difficult, if not impossible. Hydatid tumours are not always unattended with symptoms : they may^^^ from their bulk or situation, interfere seriously with respiration ; they may cause vomiting and other dyspeptic phenomena ; they may compress the hepatic ducts and so induce jaundice, or the portal vein causing ascites, or the inferior cava leading to anasarca of the lower extremities and probably congestion of the kidneys ; and hence by the gradual supervention o£' asphyxia, asthenia, or other conditions, death may after a while ensue- The sudden rupture of hydatid tumours, with the escape of their contents- into the peritoneal cavity, is usually followed by rapidly fatal peritonitis. The symptoms due to suppuration are sometimes obscure, sometimes very well-marked ; they are those, however, which usually attend extensive. HYDATIDS OF THE LIVEK. 781 -suppurative inflammation. The hydatid cyst in fact becomes converted into an abscess, and comports itself in its further progress exactly as any other large hepatic abscess. It increases more or less rapidly in size, and •after a while discharges its contents either at the external abdominal sur- face, into the pleura, through the lung, into the pericardium, into the stomach, intestine, or abdominal cavity, or into the hepatic ducts and thence into the duodenum. Other rare terminations have been met with, such as by perforation of the vena cava, or right auricle of the heart. The proof that an hepatic or abdominal abscess is of hydatid origin rests on the dis- covery of hydatid membranes, echinococci or their debris in the pus which escapes. The booklets, which are peculiarly indestructible, should especi- ally be looked for. Treatment. — No medicinal treatment avails either to cause the death of hydatids or to arrest their growth. For the cure of the disease we must look to local measures only ; and these consist mainly in the evacuation of the contents of the cysts. The puncture of the cyst with a bistoury, or a trocar and cannula sufficiently large to admit of the escape of the cystic progeny of the parent hydatid, is a procedure which has been largely adopted. It is obvious, however, that it can only be employed with safety when the cyst is adherent to the abdominal parietes, and the escape of the contents into the peritoneal cavity thus prevented. It can only be justifi- ably had recourse to, therefore, when the cyst has undergone inflammation or suppuration and has consequently got united with the surface over it ; or after measures have been taken to ensure the formation of adhesions. Among methods which may be adopted to effect this object are : first, incision through the abdominal parietes mitil the cyst is exposed ; second, the gradual destruction by caustic of a limited area of the abdominal walls down to the parietal peritoneum over the intended seat of operation ; and, third, Trousseau's method of multiple acupuncture. In all such cases it is essential that the patient should be kept at rest, and the abdominal wall in close apposition with the subjacent cyst- wall by means of pressure, in order to ensure the formation of adliesions and their maintenance when formed. A better plan for evacuating the contents of those cysts in which suppuration has not yet occurred, is that which was strongly recom- mended some years since by Moissenet, and has since been successfully employed in this country, and especially in the Middlesex Hospital by Drs. Greenhow and Murohison. It consists in the employment of an exceed- ingly fine trocar and cannula. The minute puncture made by this instru- ment rarely permits, even if no adhesions be present, of the escape of any appreciable quantity of the hydatid fluid into the peritoneal cavity, and is rarely, therefore, followed by grave peritoneal complications. In order, however, to guard against such accidents, it is well to select some prominent and central portion of the hydatid protuberance for puncture, to refram from removing the whole of the contents at one operation, and after the operation to keep the patient at perfect rest and the punctured parts in close apposition by means of a compress and bandage. It is further desir- 782 DISEASES OF THE DIGESTIVE OEGANS. able to preclude the entrance of atmospheric air, and for this reason also,, if the aspirator be not employed, to be content with the partial evacuation of the cyst. In consequence of the operation the hydatid collapses, and falls away from the walls of the adventitious cyst in which it is contained. The space thus formed becomes filled to a greater or less extent with serous exudation which soon gets turbid ; and the hydatid bathed in the unwonted fluid generally soon perishes. The cyst, shortly after paracen- tesis, may become nearly as tense as it was originally ; but generally it begins to shrink again before long, and then gradually undergoes cure. The operation may not need to be repeated. Occasionally it fails to have any curative effect, even after having been several times performed. Another method of treatment has been recommended by Dr. Althaus, and successfully practised by Dr. Fagge and Mr. Durham. The details are furnished by Dr. Fagge in the following words :— ' Two electrolytic needles are passed into the tumour one or two inches apart, they are then attached to two metallic wires, both connected with the negative pole of a battery of ten cells. A moistened sponge forms the termination of the positive pole, and is placed on the patient's skin at a Httle distance from the point of entrance of the needles. Its position is changed from time to time during the operation. The current is allowed to pass for about ten minutes. At the end of this time the needles are gently withdrawn and the seats of puncture covered with adhesive plaister.' The above operation is often attended with some escape of fluid into the abdominal cavity, and some rise of temperature with other febrile symptoms. And as Avith simple paracentesis, so here, the immediate effects are not always obvious. The operation may need to be repeated. It has been recommended by some that after the evacuation of more or less of the contents of the cyst, a solution of iodine, perchloride of iron, bile or some other antiseptic or parasiticidal fluid should be injected; and this practice has in some cases been successful. It is obvious, however, that the injection of irritating fluids is apt to induce inflammation and suppuration, which are in themselves very undesirable ; and it is at least doubtful whether the death of the parasite is more surely attained by this procedure than it is by the simple evacuation of the fluid contents. If unfortunately peritoneal inflammation ensue, it must be combated by appropriate treatment. If suppuration of the cyst take place (and this is an accident for which we must be prepared), it will be also necessary to accommodate our treatment to the altered condition of things. But especially the local treatment will need some modification. It will then at all events be desirable, so soon as we are satisfied that the cyst is adherent, that a free opening be made, and the contents, inclusive of the hydatid cysts, freely evacuated. "Whether, however, that opening should be made with the trocar and cannula or the knife ; or whether it should be allowed to close or be kept open ; and in the latter case whether the contents should be allowed to escape by means of a drainage-tube or not ; or whether the cavity should be washed out with some disinfectant solution ; are points on which it is difficult to express oneself absolutely. The exigencies of cases FATTY LIVEE. 783' as they arise necessarily call for modifications in the details of treatment. It is needless to discuss the treatment of the numerous other accidents and complications which are apt to manifest themselves during the course of hydatid disease. VIII. FATTY LIVEE. Causation. — The deposition of fat-globules in the hepatic cells is not- necessarily an indication of disease. It is frequently observed to a small extent in health ; and sometimes indeed to a large extent in healthy per- sons who lead sedentary lives, or feed largely, especially those whose diet comprises an excess of fatty matter, or who have a tendency to obesity. That abundant deposition of fat, however, which constitutes what is meant by ' fatty liver,' is usually associated with various morbid states either of the system or of the liver itself. Among the former of these we may enumerate chronic alcoholism, heart disease, malignant cachexia, and especially pulmonary phthisis ; among the latter cirrhosis, lardaceous degeneration, and the indurated condition which supervenes on chronic cardiac or pulmonary affections. Morhid anatomy. — In the early stage fat-globules of small size are found scattered in the substance of the hepatic cells ; at a later period many of the globules have enlarged, partly by coalescence, partly by fresh deposition, and may then considerably exceed in size the nuclei around which they cluster; at a still later period complete coalescence takes place, and the cells distended with their oily contents assume very much the appearance of the cells of adipose tissue. The deposition of fat always commences at the periphery of the hepatic lobules, and is very often limited to that part ; and even when the change becomes universal it is still this outer zone which chiefly suffers. The presence of fat in any abundance renders the affected portion of the liver coarse, soft, dull, and opaque— the yellowaiess due to bile and the redness due to blood alike disappearing in a greater or less degree. Further, the tissue often becomes distinctly greasy, the fat adhering to the knife and fingers. It often happens in cirrhosis that the isolated nodules of hepatic substance are loaded with oil. In lardaceous change scattered patches of hepatic tissue are not unfrequently similarly affected. lii cardiac and chronic lung disease the deposition is mostly limited to the peripheral parts of lobules ; and indeed it is owing mainly to the contrast between the outer fatty and anfemic zones and the centrpj deeply congested arete, that the term ' nutmeg ' has been applied to this form of hepatic affection. It is not uncommon to find the fatty and the congested regions of the lobules separated from one another by a line of deep jaundice. In the fatty liver of phthisis and other wasting diseases, the fatty accumulation may still be mainly peripheral, and the liver may consequently present something of the nutmeg character ; but not un- frequently the organ is pretty generally involved. Under these circum- stances it presents a nearly uniform pallor, dulness of aspect, and softness, and its bulk is generally very largely increased. The enlargement of the 784 DISEASES OF THE DIGESTIVE OKGANS. fatty liver is as nearly as possible uniform. The fat consists mainly of olein and margarin, with traces of cholesterine. Its amount varies ; in extreme -cases from 43 to 45 per cent, of the hepatic substance has been found to consist of fat, and indeed after removal of the water Frerichs has found no less than 78 per cent, of the residue to be fat. Symptoms. — It is natural to believe that excessive accumulation of fat in the liver would seriously affect the functions of that organ ; and many •different symptoms have been ascribed to it. We are bound, however, to confess that we have never met with a case in which hepatic or other derangement has been clearly attributable to it. And, indeed, it must not be forgotten that fatty accumulation is frequently associated with structu- ral changes in the liver ; and that when under such circumstances hepatic symptoms are present, they are probably referrible to these associated lesions. The enlargement due to fatty deposition in the liver may often be recognised during life, and occasionally the augmented bulk of the organ produces fulness, weight, and uneasiness in the side. Treatment. — When fatty liver depends on actual disease, it is essen- tially by treating the disease that we must hope to remove the hepatic accumulation. When we have reason to believe that enlargement of the liver, in persons who are fairly healthy, is due to fatty deposit, our treat- ment must be guided by our knowledge of their habits and tendencies, and must necessarily be mainly hygienic. It is very seldom, however, that we shall be called upon to make fatty liver a distinct object of medical treatment. IX. LAEDACEOUS LIVEE. Causation. — This affection is secondary to those morbid conditions of the system in which general lardaceous disease takes its origin : especially -chronic phthisis, tertiary syphilis, caries of bone, and other conditions attended with prolonged suppuration. Morbid anatomy. — The lardaceous change takes place first, according to Eindfleisch, in what he terms the arterial zone of the hepatic lobules, that is, midway between the centre and periphery, implicating both the minute arteries and capillaries of the part, and the hepatic cells. But soon the morbid process extends to the central portions of the lobules, and after a time the periphery becomes equally involved. The change is attended : with great thickening of the affected vessels, and the acquisition by them of a peculiar homogeneous pellucid character ; and with con- siderable enlargement of the hepatic cells, which lose all trace of granules, . bile-pigment and nucleus, and become irregular or botryoidal vitreous- looking lumps which after a while break down into irregular fragments. The lardaceous liver, like the fatty, undergoes uniform enlargement in all its dimensions. It becomes smooth, heavy, and of somewhat doughy consistence ; and, if uniformly affected, presents a remarkably homo- geneous sectional surface, of a greyish tint, with a peculiar glistening, or rather, perhaps, semi-translucent aspect, which has some resemblance to GALL-STONES. 785 that of bees'-wax. It is equally free from biliary and vascular congestion, and from moisture. The lardaceous change is not unfrequently associated with fatty deposit, sometimes with cirrhosis, sometimes with syphilitic disease. The size which the lardaceous liver may reach is almost unlimited. It has been met with weighing from ten to fifteen pounds. Its enlargement, however, is a slow process, and may go on for years. Symptoms. — The circumstances which in combination justify the diag- nosis of this affection are the slow but continuous uniform enlargement of the liver, wdthout pain or obvious hepatic symptoms ; the long continuance of some one of those morbid conditions which we know to be conducive to lardaceous degeneration ; and the coetaneous enlargement of the spleen , and involvement of the kidneys. There is no doubt that patients with lardaceous liver manifest, as a rule, marked cachectic symptoms ; but there is little evidence to show that these are dependent in any peculiar degree upon the hepatic disease. It is true that a slight icteroid tinge occasionally manifests itself after a while, and that the bile in the gall- bladder and ducts is usually pale and watery ; but, on the other hand, there is never obvious pain in the region of the liver, never deep jaundice, rarely ascites, and (beyond the occasional presence of bile-pigment in the urine) nothing in that secretion distinctly to indicate impairment of hepatic function. The greater number of cases in which lardaceous disease manifests itself no doubt end fatally ; but there is reason to believe with Frerichs that, if the change be not far advanced, the arrest of the morbid process upon which it is dependent may be followed by the restoration of the lardaceous organs to the condition of health. The treatment of lardaceous degeneration merges in the treatment of the disease which produces it. X. GALL-STONES. Very little of practical importance is as yet known with respect to the variations in quality and quantity of the bile, and the influence of these variations on the action of the bowels, the assimilation of alimentary matters, and the general health. We know, no doubt, that when the bile Avhich enters the duodenum is deficient in quantity, fatty matters are im- perfectly assimilated, the evacuations are fetid, and the bowels usually constipated ; and we have reason to believe that, when there is an exces- sive discharge of bile, bilious diarrhoea and vomiting may be excited ; but, on the other hand, we know that in many diseases, whether of the liver itself or of the general organism, the bile is found post mortem deviating widely from its normal condition, and yet there have been no sjmiptoms during life which could be distinctly referred to this deviation. There is one abnormal condition of the bile, however, of great practical interest, which reveals itself to us, not directly by any of the consequences just 3b 786 DISEASES OF THE DIGESTIVE OKG-ANS. enum erated, but by the formation of concretions which bring with them special symptoms and special dangers. Causation. — The origin of gall-stones is obscm-e. It is easy, of course, to understand their increase of size by the accretion of additional solid matter ; but it is not generally easy to determine the cause of the first step in their development, namely, the formation of a nucleus. In some rare cases this has been fomid to be a fragment of a needle, a dead ento- zoon, a small blood-clot, or (according to Dr. Thudichum) portions of the epithelial lining of the gall-ducts. In the majority of cases it consists of a mass of concreted biliary colouring matter. Concentration and stag- nation of bile have doubtless some influence over the production of gall- stones, as is shown by their much more frequent formation in the gall- bladder than in the hepatic ducts, and probably also by their comparative frequency in cases of carcinoma, and other organic diseases of the liver. It is not clear that the tendency to biliary calculi is inherited, or that it is ever traceable to any dyscrasia, notwithstanding the statements which are made to the effect that it is generally associated with gout, renal calculi, or other maladies. On the other hand, we know that gall-stones occur much more frequently in women than in men, and chiefly in per- sons above the age of thirty. They are not unfrequently met with, how- ever, at earlier periods of life, and occasionally even in infancy. There is reason to believe that they specially aflect persons of sedentary habits. The influence of diet is unknown. Morbid a72atom^.— Gall-stones vary in size from mere granules up to masses moulded to the form of the gall-bladder, and measuring three or four inches in length, fi-om one to one and a half inches thick, and weigh- ing between one and two ounces. When they are minute (less in size, say, than a poppy-seed), they are usually spoken of as bihary gravel. Gall- stones may be solitary ; but they are much more frequently multiple, and,, indeed, many have been found at one and the same time scattered through- out the biliary ducts, and several hundreds in the gall-bladder. When occupying the latter cavity their size has necessarily some relation to their number ; at all events, when they are very numerous, they cannot possibly be large ; whereas solitary calculi, and calcuH occurring in groups of two or three, often attain considerable dimensions. The forms which they assume depend mainly on their relations, during growth, to the surromid- ing parts. In the commencement they may be rounded or amorphous accumulations of biliary colourmg matter, or even rhomboidal tablets of cholesterine. But with increase of size some modification takes place. They may acquire a branched or coral-like form in the smaller bile-ducts ; in the larger ducts or in the gall-bladder they may either form roundish masses, or accommodate their general shape to that of the cavity which contains them ; but when, m the gall-bladder, the simultaneous develop- ment of many calculi takes place, they mutually interfere with each other's growth, and, instead of assuming a globular form, become polyhedral or faceted, or flattened one against the other. In this manner the bladder may get uniformly distended with a pyriform mass of closely-packed, GALL-STONES. 787 mutually-fitting gall-stones ; and, indeed, it generally happens that, when its cavity appears to be occupied by a single large calculus, this consists of at least two or three, and generally more, well-articulated but distinct masses. Gall-stones are usually smooth, but sometimes granular or tubercu- lated, and vary in colour from milk-white, through yellow or brown, to deep reddish- or greenish-black. Their specific gravity ranges between '8 and 1*15 ; they are as a rule, however, heavier than water, and sink in it, excepting when they have undergone desiccation. In some cases they are so soft and friable as readily to fall to powder between the finger and thumb ; and generally they are sufficiently soft to admit of being readily crushed into irregular fragments, or of being cut with a knife. They are usually soapy or greasy to the touch. As to their general structure, they sometimes consist of a simple tuberculated accumulation of pigmentary matter, sometimes of a nearly homogeneous waxy mass. In most cases, however, three regions may be more or less obviously recognised : — namely, a central nucleus, which, as has already been stated, is mostly pigmentary and often irregular in form and shrunken ; a zone of variable thickness aromid this, which is more or less homogeneous in texture, but marked with radial lines ; and a cortical lamina, also of variable thickness, which is usually concentrically striated. These several regions are further characterised by differences of colour. The chief constituent of gall-stones is cholesterine, and this forms on the average from 70 to 80 per cent, of the entire mass ; but in addition to this, biliary coloming matter, biliary acids, and lime are found in various proportions. Other ingredients are so rare or so small in quantity as scarcely, from a clinical point of view, to be worth consideration. They are chiefly the fatty acids, uric acid, earthy phosphates, alkaline salts, and mucus. Calculi consist sometimes almost entirely of pigmentary matter, sometimes mainly of carbonate of lime with some admixture of phosphate^ and sometimes of pure cholesterine. Moreover, the different laminfe often differ in composition, the outer shell of large calculi frequently presenting an excess of earthy salts. The consequences of biliary calculi are various. In many cases they form in the gall-bladder, and slowly grow there until, moulded to its shape, they entirely fill it ; the gall-bladder contracts upon them, ceases to perform its proper functions, and becomes merely the capsule of what then probably proves to be an inert mass. Sometimes the presence of these bodies irritates the mucous membrane of the bladder into inflamma- tion, and, it may be, into suppuration and ulceration. Slight attacks of inflammation doubtless arise occasionally and subside again without further result. But when the inflammation is of a more intense character the cavity of the bladder may be converted into an abscess which dis- charges itself either ^;er vias naturales, or by some abnormal channel ; or its walls may become generally thickened, pulpy, and deeply congested ; or at some point or other be fretted by its contained calculi into an ulcer which, gradually eating its way through the parietes (then probably glued 3 E 2 788 DISEASES OF THE DIGESTIVE OEGANS. to some neighbouring part), forms a sinus or diverticulum which, like the abscess, may open in one of several directions. The' most common routes are externally through the abdominal walls, into the duodenum, and into the transverse colon. But the opening may also take place into the stomach, peritoneum, pleura, or lung. In many cases a gall-stone becomes dislodged, and slips into the cystic duct, whence it may pass slowly onwards until it reaches the duodenum. The duration of this process is very variable ; in some cases it is over in a few hours, more frequently it occupies several days. The stone generally travels by fits and starts, and may be either temporarily or permanently arrested in any part of the channel along which it passes. If arrested in the cystic duct, it probably leads to its complete closure and to the enforced disuse of the gall-bladder, which may then either shrivel away or dilate into a mucous or serous cyst ; if arrested in the common duct, it probably sooner or later obstructs the flow of bile, which then accumulates in the gall-bladder and ducts ramifying in the liver, and distends them. Fur- ther, in either of these situations, the presence of the stone may fret the surface against which it lies, and cause ulceration and possibly perfora- tion, and thus lead to the formation of a local abscess, or to general peritonitis, or to some abnormal communication with the duodenum, colon, or portal vein. When once a gall-stone has descended from the gall-bladder, other stones, if they exist, are apt to follow ; and moreover their passage is generally more readily and speedily effected than that of their pioneer. Sijm])toms and progress. — The presence of gall-stones in the bladder or hepatic ducts does not necessarily cause symptoms, and in a large number of cases is from first to last unattended with sym]3toms. Gall- stones may, however, occasionally be recognised, in consequence of form- ing an irregular, hard, and sometimes crepitating lump in the situation of the gall-bladder. When their presence excites inflammation, we may look for tenderness, pain and fulness, in the same neighbourhood, together with febrile disturbance. The pain is sometimes intense and paroxysmal, and lasts for months or years ; and may be associated with so much gastro-intestinal disturbance, and progressive debility and emaciation, as to suggest the presence of malignant disease. But, unless any more dis- tinctive phenomena arise, the exact nature of the affection can scarcely be diagnosed positively. Such phenomena are : the formation of an abscess superficial to the bladder in the abdominal parietes, and the ultimate escape of gall-stones with the other contents of the abscess ; and the dis- charge of gall-stones through an ulcerated opening into the duodenum or colon, and their escape with the fasces, or their arrest in the small intestine, followed by enteritic symptoms. It must not be forgotten, however, that each of these phenomena may arise without having been preceded by any clear indications of inflammation of the gall-bladder. The symptoms most characteristic of the presence of gall-stones are those which depend on their dislodgement and subsequent passage along the cystic and common ducts. They resemble in many important respects GALL-STONES. 789 those due to the transit of a renal calculus along the ureter, alid are mainly : severe pain, coming on suddenly, and lasting with irregular intermissions and exacerbations a few hours or several days ; faintness, nausea, and vomiting ; and the consequences of impediment to the escape of bile into the intestines. The pain (frequently termed hepatic colic) varies in intensity, situation, and quality. Sometimes it is comparatively slight, sometunes so severe that the patient writhes and cries out with agony; its character is aching, cutting, tearing, or burning, and it is generally attended with an unbearable sense of tightness, constriction or cramp. It is usually referred to the pit of the stomach or to the umbilicus, whence it extends to the back between the shoulders, to the chest or to the shoulder-tip, or down into the lower part of the abdomeii. But its situation is often somewhat indefinite, and may be such as to simulate the passage of a stone along the ureter. There is seldom any material tenderness, and pressure sometimes affords relief to the pain. Hepatic colic is said to be further characterised by often coming on suddenly two or three hours after a meal, at the time when the passage of food along the duodenum excites the flow of bile from the gall-bladder and biliary passages. It often comes to a sudden end in consequence either of the slipping back of the stone into the gall-bladder, of its arrest at some point in the course of the cystic or common duct, or of its escape into the bowel. The faintness, nausea, and vomiting are not in necessary relation with the severity of the pain ; the patient may be simply chilly, or he may have severe rigors ; he may merely feel faint, or he may fall mto a state of actual syncope or collapse, with cold and pallid surface, profuse per- spirations, and imperceptible pulse ; he may complain simply of nausea, or he may suffer from severe and protracted vomiting. The syncopic attack has proved fatal. A gall-stone may pass on from the bladder to the duodenum with all the above symptoms, and yet cause no material stoppage of bile. In a large number of cases, however, its presence in the common duct is followed by retention, which reveals itself by the vomit (if it continue) ceasing to be bilious, by the stools acquiring a pale clay colour, by the urine in from twelve to twenty-four hours becoming tinged with bile, and by the development a little later of general jaundice. The supervention of jaundice, after such symptoms as have been detailed, is almost pathognomonic of the passage of a biUary calculus, or at all events of a foreign body, along the common duct. The diagnosis cannot, how- ever, be regarded as positive unless the calculus be discharged per anum. And hence, in all cases of suspected hepatic colic, it is important to ex- amine the fffices carefully from day to day. This should be done by dilut- ing them with water, and passing them through a sieve with sufficiently small meshes to retain any small solid bodies which may be present in it. If the pain and other symptoms continue for any length of time, inflam- mation is likely to arise at the seat of disease ; and tenderness and fulness may then come on, together with febrile disturbance. And even after the escape of the calculus, pain and fever, and even jaundice, may continue for some little time. The passage of one biliary calculus is often, if not 790 DISEASES OF THE DIGESTIVE OEGANS. generally, succeeded at irregular intervals by the passage of others — the later attacks, however, being as a rule both milder and of shorter duration than the first. This repetition of similar attacks is a further indication of the nature of the patient's malady. It is a point of some practical im- portance that when a stone lodged in the common duct becomes dislodged a renewal of hepatic cohc usually takes place ; and that hence the sudden recurrence of such an attack in a patient suffering from retention of bile is a hopeful sign. A calculus may completely occlude the common duct, certamly for a year, and then be discharged, with the restoration of the patient to health. On the other hand, death occasionally results, even before the coming on of jaundice, from rupture of the duct, and sudden intense peritonitis, or from profuse hemorrhage. The passage of biliary gravel, which has been sometimes discovered in the ffeces in large quanti- ties, and inflammation of the neck of the gall-bladder, may present many of the symptoms which attend the passage of calculi. The consequences of the arrest of gall-stones in the small intestme have been described under the head of intestinal obstruction ; those of their long-continued or permanent retention in the common duct 'mil be con- sidered under that of obstruction of the hepatic ducts. Treatment. — The general treatment of gall-stones is very unsatisfactory ; we can neither dissolve them nor remove them ; nor if they have once formed can we prevent them from becommg larger. And even as regards prophylaxis, all that can be said is that those whom we believe liable to them should eschew all such habits as seem likely to engender them. They should hve wholesomely and abstemiously, and take a sufficiency of exercise daily. The habitual use of alkaline waters has been recommended, but the evidence in favour of their virtues is valueless. For the paroxysm of hepatic colic, our main reliance must be placed upon morphia or opium, given in sufficiently large doses, and sufficiently frequently, either by the mouth or hypodermically, to relieve the patient's suffermgs. Belladonna has also been largely recommended, mainly with the object of relaxing spasm, and so aiding the onward passage of the stone ; but it is certainly not so beneficial in its effects as opium. The inhalation of chloroform, short of producing insensibility, often affords sigual relief. To assuage the vomiting, Dr. Prout long ago recommended the use of copious draughts of warm water, containing from one to two drachms of carbonate of soda to the pint. This practice is still largely followed, and beHeved to be effica- cious. In addition to these remedial measures, the warm bath, hot fomen- tations to the epigastrium, and counter-irritants may generally be employed with advantage. XI. OBSTRUCTION OF THE HEPATIC DUCTS. Causation. — Obstruction of the hepatic ducts is an incident of common occurrence, and considerable importance, in a large number of the morbid conditions of the liver, which have already been discussed ; it is also the most frequent cause of long-continued and intense jaundice, if not actually OBSTEUCTION OF THE HEPATIC DUCTS. 791 the most frequent cause of jaundice ; and on these grounds demands special ■consideration. The causes of obstruction are, in some cases, inflammatory thickening of the mucous membrane of the ducts, or accumulation of inspissated mucus or other kinds of inflammatory exudation ; in some the presence of stricture ; in some the growth of polypoid tumours ; in some the impaction of calculi or other foreign bodies. In other cases they are to be sought in inflammatory infiltration of the tissue of the lesser omentum or of Glisson's capsule, or in the development in these situations of syphilitic, carcinomatous, or other growths involving or compressing the ducts. Further, tumours springing from the stomach, pancreas, or neighbouring parts, and aneurysms, may press upon the common duct and obstruct its channel. Morbid anatomy. — Obstruction may take place in any of the ducts at any part of their course ; and the effects on the ducts behind the impediment, and on the liver- substance with which they are in relation, will be the same in kind wherever the obstruction is situated : the bile becomes arrested in its flow and altered in character, the implicated ducts undergo dilatation and other changes, and the liver-cells whose products they receive become jaundiced, fatty, and sometimes disintegrated. If complete obstruction take place in the common duct, the dilatation of ducts which ensues is almost universal ; the common duct not unfre- quently attains the size of the duodenum, and the ducts ramifying through- out the liver acquire proportionably large dimensions. The condition of the gall-bladder under such circumstances varies ; sometimes it shrinks or shrivels up, sometimes it retains pretty nearly its normal bulk, sometimes it becomes, like the rest of the excretory apparatus, enormously distended. The consequences of obstruction, as respects the biliary fluid, are that it generally gets thin and watery, and at the same time of a dark green or brown colour. But it may also become turbid from admixture with mucus or pus ; sabulous from the deposition of solid matter — pigment, or choles- terine ; grumous from containing blood ; or, when the bile ceases to form or to flow, transparent, colourless, and viscid. The last kind of fluid may be met with in the gall-bladder when, after closure of the cystic duct, it dilates (as occasionally happens) into a mucous cyst. The consequences, as regards the walls of the ducts, are also various. In most cases they thicken ; but in some they become attenuated ; in some inflammation with excess or modification of secretion takes place, in some ulcerative destruc- tion. In the last case, perforation of the common duct may occur, with the development of an abscess in its vicinity, or rupture into the peritoneum ; or more or less general destruction of the walls of the bile-ducts may ensue, with the formation in their place of irregular biliary channels, bounded by the eroded hepatic tissue, and communicating, it may be, with branches of •the portal vein. Such channels may be converted into branching abscesses. The effects of obstruction on the liver generally are, in the first instance, gradual and uniform increase of bulk, which may be maintained for several months ; and then gradual atrophy, the organ however not so much shrinking in all its dimensions as becoming wrinkled, thin, and flabby 792 DISEASES OF THE DIGESTIVE OEGANS. in consistence. The hepatic texture becomes soft, loose, oedematous (yielding on pressure a considerable quantity of thin greenish fluid), and jaundiced, or before long of a dark greenish hue. On microscopic examina- tion, the hepatic cells are usually found deeply bile-stained, and often containing granular pigment and oil-globules. In some cases the cells after a time undergo degeneration ; and all that remains of the hepatic texture may then be the framework of connective tissue, vessels, and the like, together with a greater or less abundance of free oil-globules, granules of precipitated pigment, and cell-nuclei. The tissues moreover usually yield an abundance of leucine and tyrosine. It has been assumed throughout the foregoing account that the ob- struction is complete and permanent. But obstructions are often merely temporary, and, whether temporary or permanent, are not unfrequently incomplete ; under either of which circumstances there will be more or less important modification in the progress and consequences of the secondary pathological lesions. Symptoms and lorogress. — It is always important, for the sake both of prognosis and of treatment, but often quite impossible, to determine the ex- act cause of obstructive jaundice. Our diagnosis in each case must rest on a careful consideration of its history and progress and on a close investigation of the phenomena which come under our immediate observation. It is not, however, so much with this subject that we have now to deal as with the special symptomatic consequences of obstruction. These, which have already been pretty fully considered, may be divided mainly into those dependent on absence of bile from the alvine evacuations, those due directly to the changes gomg on in the liver, and those arising from the accumu- lation of bile and effete matters in the blood. The consequences of the absence of bile from the bowels have been sufficiently discussed. Alteration in the bulk of the liver is a sign of considerable value. Its primary enlargement is indicated on the one hand by the gradual rise of the hepatic dulness into the chest, on the other hand by the gradual emer- gence of its lower edge from under the ribs and its extension for two or three inches below its normal level. If the gall-bladder also midergo dis- tension, it may generally be recognised as an elastic or fluctuating swelling coming out from beneath its accustomed notch. It is important, however, to bear in mind, that, owing in great measure to the great length it is apt to attain under these circumstances, its apex may be displaced, even if the liver be little or not at all enlarged, far below or far to the right of its normal position ; and further that, owing to its extreme mobility and tendency to retreat from the fingers, it often fails to yield any sense of fluctuation, and may be mistaken for a solid rounded tumour springing from the liver or in its vicinity. In rare cases the distended common duct has itself been felt as a fluctuating tumour. When the later atrophic changes set in, the enlargement of the liver ceases, and the organ undergoes slow diminution in bulk ; but this change reveals itself less by general shrinking than by diminution of thickness — the free edge often becoming peculiarly thin, so OBSTKUCTION OF THE HEPATIC DUCTS. 793 tliat, if the abdominal walls be flaccid and spare, it may often be readily- grasped between the finger and thumb. Some degree of fuhiess, weight, tenderness, or pain is not mifi'equent in the situation of the liver, during the progress cf its enlargement ; especially, of course, if inflammatory changes supervene. The jaundice of complete obstruction is generally very intense. It first reveals itself by the presence of bile pigment in the urine at the end of from twelve to thirty-sis hours after bile has ceased to flow into the bowels. Yellowness of the conjunctivaa and skin usually supervenes in the course of the third day. If the obstruction continue, the intensity of the jaundice rapidly increases, and after a time tends to assume a greenish or brownish tint. The colour is hable to variations of intensity even when no dis- charge of bile into the bowels takes place, and by no means necessarily increases with the duration of the case ; indeed, it not unfrequently happens that it undergoes manifest diminution durmg the later periods of the disease. It is chiefly in jaundice from obstruction that we may look for the occurrence of many of those additional phenomena which have already been adverted to, such as yellow vision, itching, cutaneous eruptions, and petechial and other forms of hemorrhage ; and it is with this alone that xanthoma has any connection. As a rule, there is no elevation of temperature ; and there is no necessary affection of the tongue or loss of appetite. It is almost needless to say that, in those cases in which the obstruc- tion is temporary only, m those in which the obstruction of the mam duct is, and remams, incomplete, and in those in which (as in hypertrophic cirrhosis) the impediment to the escape of bile involves some of the minuter tubes only, the symptoms will vary more or less widely from those which have just been detailed ; especially the evacuations will pro- bably still contain bile, the hver will undergo little or no enlargement, the jaundice will be slight, and the other symptoms which associate themselves with these conditions will be developed slightly or late, or not at all. The duration of life in cases of jaundice with complete obstruction varies a good deal. In some the patient dies in the course of a few weeks ; in some he survives for periods varying between six and twelve months ; while occasionally life is prolonged to two, three, or more years. The causes of death also are various. It is due sometimes to rupture of the hepatic or common duct, or of the gall-bladder, with consequent peritonitis; sometimes to the supervention of hepatic inflammation mtli suppuration and some one or other of their results ; sometimes to intestinal or other hemorrhage ; sometimes to so-called ' biliary toxaemia ' ; most frequently, however, it results from gradually increasing emaciation and debility. Further, patients enfeebled by this disease are apt to be attacked with pneumonia, dysentery, dropsy, or other complications, and to be thus carried ofi". In some cases recovery takes place even after complete obstruction has lasted for a considerable length of time ; the indications of 794 DISEASES OF THE DIGESTIVE OEGANS. this event being the reappearance of bile in the feces, the gradual disap- pearance of pigment from the skin and urine, and in association therewith general improvement in the patient's health. Treatment. — In the treatment of jaundice from obstruction our first object should of course be to remove the mechanical obstacle to the escape of bile from the liver. This, however, can never be effected but by indirect measures, and in a large proportion of cases never effected at all. But in reference to this subject we must refer the reader to those articles which deal with the various conditions to which obstruction may be due. The question we have here specially to consider is — How shall the jaundice and the consequences it entails be best treated ? Unfortu- nately, we can do httle, and that Httle is mainly hygienic. The patient's bowels should be regulated if necessary by mild laxatives ; the functions of the kidneys and of the skin (by which emunctories bile is now almost solely elimmated) should be promoted by the use of diluents, diuretics, warm clothing, and warm baths ■i;\TLth rubbmg or shampoomg ; his appe- tite should be sustained and his gastric digestion improved, if need be, by vegetable tonics or stomachics, with which the carbonates of the alkalies may often be beneficially combined ; his general health should be maintained, partly by the exhibition of vegetable tonics and iron, partly by the habitual use of nutritious unstimulating food from which fatty matters and alcohol are as far as possible excluded, partly by attention to hygienic conditions, more especially to warm clothing, the avoidance of chills or sudden vicissitudes of temperature, change of scene, moderate exercise and early hours. Of particular remedies it may be observed that Frerichs recommends lemon-juice as a valuable diuretic in these cases, and that Dr. G. Harley advocates the use of inspissated ox-gall in gelatine capsules to be given in doses of from five to ten grams two or three hours after each meal. When complications arise (gastric catarrh, diarrhoea, hemor- rhage, or head-symptoms) they will probably need each its appropriate treatment. In those cases in which the gall-bladder becomes excessively distended, the question as to the propriety of puncturing it may arise. The operation is obviously one not to be lightly entertained, or to be per- formed without the most ample precautions. XII. JAUNDICE WITHOUT OBVIOUS OBSTEUCTION OF DUCTS. Causation. — The varieties of jaundice here referred to are more particularly those which occur in the specific febrile disorders, such as jellow fever, ague, relapsing fever, and pyaemia. It is possible, too, that under the same head must be included the jaundice which occasionally attends pneumonia, rheumatism, snake-bites, phosphorus-poisoning, and those other morbid conditions of the Hver in which the secreting cells are directly involved. The jaundice which is said to arise under the mfluence of strong mental disturbance, and that of new-born babes, may possibly MALIGNANT JAUNDICE. 795 «,lso be placed in tlie same class. It must be remarked, however, that there is still considerable iincertamty in respect of the intimate pathology of the jaundice attending these various affections ; it is very probable that obstruction of the smaller ducts, or, as Virchow holds, catarrhal obstruction of the intestinal portion of the common duct, may eventually prove to be the cause of jaundice in some of them ; there seems little doubt that ua others it is actually due to changes gomg on in the colouring matter of the blood ; and it is possible that occasionally it may be the consequence, as Frerichs holds, of an abnormal diffusion of bile, arismg in some alteration in the supply of blood to the liver, and defective metamorphosis or con- sumption of bile in the blood ; or, as Dr. Murchison believes, of excessive reabsorption of bile with or without excessive secretion. Morbid anatomy. — In most of the cases here referred to the liver is found post mortem to be pale and anemic, and soft or flabby, and the hepatic cells either normal, or, as in phosphorus-poisoning, highly granular or studded with droplets of oil ; in some the generally pallid tissue presents patches of still more marked pallor, which are often separated from the surrounding parts by wide but irregular zones of slight congestion. The appearances, as a rule, are certainly not very striking, and scarcely indica- tive of serious hepatic disease. Symptoms. — The jaundice is almost without exception very sHght ; it -creeps on gradually ; it does not attam any intensity in the skin ; and the pigment passed with the urine is in small quantity. Moreover, the motions almost always still contain bile. There is no doubt that in many of these •cases the symptoms which the patient presents are extremely grave. Yet there is no good reason to believe that as a rule they are due in any impor- tant degree to the hepatic disorder ; for while the grave symptoms are usually such as characterise the disease which the jaundice complicates, those cases in which jaundice appears are not generally more serious than those from which it is absent, and the jaundice does not as a rule bring vsdth it any specific symptoms. Treatment. — The forms of jaundice now under consideration seldom call for special treatment. Their presence, however, may furnish a hint as to the desirability of employing laxatives, and promoting the actions of -the skin and kidneys. XIII. MALIGNANT JAUNDICE. {Yelloio Atrophy of the Liver.) Definition. — There is one form of disease in which jaundice is associated with a remarkable group of symptoms, which for convenience, if not on other grounds, may be separated from the cases just considered ; it is that which is sometimes termed malignant jaundice, and to which Eoldtansky has given the name of ' yellow atrophy of the liver.' Causation. — Cases of malignant jaundice have been observed chiefly in adults, and in women more frequently than men. But children are now and then attacked with it. We have seen a typical case in a child iwo and a half years old. Moreover, in a large proportion of cases, the 796 DISEASES OF THE DIGESTIVE OEGANS. patient has been attacked during pregnancy. It is also a remarkable fact that the onset of the disease appears to ha've often been determined by some sudden and intense mental emotion. Among other assigned causes may be enumerated syphilis, typhus, and miasm. Symptoms and progress. — Malignant jaundice frequently comes on without premonitory signs ; but in a considerable number of cases it is ]Dreceded for a few days, or even a few weeks, by slight gastro-intestinal catarrh, with which probably, sooner or later, some degree of jaundice is associated. Among the earliest specific symptoms are vomiting, especially the vomiting of coffee-ground fluid due to gastric hemorrhage, intense headache, irritability, and restlessness. To these soon succeeds delirium, which is sometimes low and muttering, sometimes noisy, and frequently violent and maniacal. The patient's manner is agitated, his limbs are generally tremulous, and in a large proportion of cases convulsions soon come on. These vary in character ; they may be general or local ; and may present the features of simple rigors, or assume an epileptoid or tetanic form. After a short time, the condition of delirium or convulsion passes into one of quietness and stupor, which gradually deepens into pro- found coma, usually attended with dilated inactive pupils, and stertorous breathing. But, besides the remarkable combination and sequence of symptoms here enumerated, other phenomena present themselves which are of considerable significance and importance for diagnosis. The pulse during the earlier period of the disease, or that of excitement, is charac- terised by remarkable and sudden variations in frequency, but is generally abnormally quick ; with the supervention of coma, however, it gets more uniformly rapid, and at the same time more and more feeble, until pro- bably it can be no longer felt at the wrist. The tongue soon becomes coated, and generally before long assumes the typhoid character ; it gets dry and brown or black, and sordes accumulate upon the teeth. There is often some uneasiness and tenderness in the hepatic region, and in addition gradual diminution in the area of hepatic dulness can often be detected by careful examination. The bowels usually are confined ; and the motions passed in the course of the disease present a gradual diminu- tion, and at length, may be, total absence of biliary colour. The urine probably is secreted in normal quantity and acid ; but it becomes jaundiced in a greater or less degree, urea and phosphate of lime dimmish, and sometimes disappear, to be replaced by leucine, tyrosine, and extractive matters, which, when the urine cools, tend to form a greenish-yellow sediment. The skin is usually cool and dry. The jaundice, which some- times precedes, sometimes follows, sometimes appears simultaneously with, the other initial symptoms of the disease, increases in depth with the duration of the malady, but rarely, if ever, attains a high degree of intensity. Two features of striking importance are, the total absence of febrile temperature, and a general tendency to hemorrhage. The latter shows itself by hsematemesis, the appearance of petechiae and bruise-like extravasations beneath the skin, or discharges of blood from the nose,. bowels, or other mucous surfaces. MALIGNANT JAUNDICE. 797 The most characteristic phenomena in the clinical aspect of malignant jaundice are, in combination, slight jaundice, grave cerebral disturbance, hemorrhage from and mto various organs and tissues, profound change in the composition of the urine, absence of fever, and an almost invariably fatal issue. Death may supervene within twelve or twenty-four hours, but generally occurs between the second and fifth day, and is rarely delayed beyond a week. Morbid anatomy. — In all typical cases of the disease the post-mortem conditions are remarkable and characteristic. The most obvious change is in the liver. This may be of natural size, but is usually shrunk to half or even one-third of its normal bulk— its surface then being wrinkled and flabby. On section it is found to be of a nearly uniform pale yellow colour, with little or no indication of the constituent lobules, or evidence of vascular injection. Frerichs says that in some cases the lobules are separated from one another by a dirty greyish-yellow substance. The bile-ducts and gall-bladder usually contain either colourless mucus, or a thin fluid, only very slightly tinged with bile. On microscopic examina- tion, the hepatic cells are found to have disappeared more or less com- pletely — in some cases not one is discoverable ; and in their place may be observed either simple granular matter, or this mterraingled with oil- globules and precipitated bile-pigment. Leucine and tyrosine also may be recognised in the hepatic substance and hepatic veins. There is usually enlargement of the spleen. The only other morbid phenomena of import- ance are : occasional fatty change of the glandular epithelium of the kidneys ; extravasations of blood ( usually petechial) beneath the surface of the peritoneum, pleurfe, and pericardium, in connection with the gastro-intestinal and other mucous membranes, and occasionally in the substance of the lungs, liver, spleen,- and kidneys ; and the presence in the blood (which does not as a rule display any change visible to the naked eye) of large quantities of leucine and urea. The nature of the malady under consideration is by no means satis- factorily established. By some it is regarded as a primary disease of the liver. Frerichs, who (following Bright) takes this view, looks upon it as a parenchymatous inflammation of the organ, attended -ndth little exudation, but with obstruction to the passage of blood through the vascular network at the periphery of the lobules, and consequent degeneration and death of the hepatic cells. According to this view, the jaundice and other charac- teristic symptoms of the disease are secondary to the hepatic lesion. Some, on the other hand, look upon the hepatic affection as the con- sequence of some general blood-disease, due either to the absorption of some noxious chemical substance, or to the presence of a poison of organic origin ha^dng some affinity with those of the infectious fevers, or of pyasmia. In the latter point of view some of the graver symptoms would be referrible to the primary disease of which the hepatic disorder is a con- sequence ; but others might still be attributable to the morbid condition of the liver. It v/ould not be difficult to adduce plausible arguments either against or for either of these hypotheses. We may, however, point 798 DISEASES OF THE DIGESTIVE OEGANS. out tliat while, on the one hand, there is nothing in the clinical pheno- mena of these cases to indicate their inflammatory origin, there is, on the other hand, ample proof, from the occasional supervention of the symptoms of malignant jaundice in cases of occlusion of ducts, that extensive de- struction of the secreting structure of the liver, with suppression of bile, is fully competent to induce all the phenomena of the disease under con- sideration. We must confess, indeed, that, while not quite committing ourselves to the inflammatory origin of the hepatic changes, we are dis- posed to regard the disease as primarily hepatic. Treatment. — Nothing can well be less satisfactory than our knowledge in reference to the treatment of malignant jaundice. Active purgation has been recommended, especially in the early stage ; it is difficult, how- ever, to understand why. Again, those who look upon the disease as of inflammatory origin advocate the local abstraction of blood, and other antiphlogistic measures, during the inflammatory stage. But unfor- tunately this, if it exist at all, exists only during that preliminary period in which there is nothing to distinguish cases of malignant jaundice from cases of catarrhal aflection of the biliary ducts. Considering that in this disease there is a large accumulation of effete matter in the blood, on which it seems probable that some of the grave symptoms are dependent, there are grounds for the employment of diuretic and diaphoretic measures. In the absence of more obvious indications, we must either do nothing or treat the more prominent symptoms : that is, so far as we are able, check vomituag, arrest hemorrhage, overcome constipation, promote the action of the skin and kidneys, soothe during the stage of excitement, and during that of stupor and coma and failing strength employ counter- irritants and stimulants. XIV. DISEASES OF THE PANCEEAS. A. Introductory remarks. — Very little of clinical value is known about the diseases of the pancreas. This is due : partly to the com- paratively small size and deep situation of the gland ; partly to the fact that its functions have much in common with those of the salivary and duodenal glands, and even with those of the liver itself ; but chiefly, perhaps, because it is rarely affected excepting secondarily or in associa- tion with diseases of neighbouring organs. In reference to the diagnosis of pancreatic disease, we must recollect : that this organ is situated in front of the aorta and behind the stomach, deep in the epigastric region, and on the level of the first lumbar vertebra ; that any tumour which may be developed in it will be dis- coverable in this situation only (a situation, however, which may be equally affected by aneurysms of the aorta or coehac axis, or by tumours involving the posterior wall of the stomach, or originating in the retro- peritoneal glands), and will probably be immovably fixed there ; and that any pam and tenderness which may attend its lesions will probably be DISEASES OF THE PANCEEAS. 799 referred to the depth of the epigastric region and to the back, in the situation of the upper lumbar and lower dorsal vertebrae. We must also recollect that the fmiction of the organ is to secrete a large quantity of fluid, which differs little from ordinary saHva in either its chemical com- position or its office, and is an important agent m the emulsification of fat, in the conversion of starch into dextrme and sugar, and in the reduction of albuminous matters into a form favourable for assimilation. It may therefore be reasonably beheved that the retention or suppression of the pancreatic fluid will be attended with more or less serious impair- ment of nutrition ; and, if the food contam much starch or fat, -udth the unwonted appearance of starch or fat in the evacuations. The abundant discharge of fat by stool, indeed, has been not unfrequently noticed in cases in which the pancreas has been seriously diseased. B. Hypercemia and inflammation. — Of these conditions but little can be said. They are occasionally recognised post mortem, but for the most part in cases where no suspicion of pancreatic disease was entertained during life. Abscesses are sometimes discovered m the gland, and occasionally large abscesses ; but they are usually small and of pyemic origin. Catarrhal inflammation of the duct is probably not uncommon in connection with the same affection of the common hepatic duct, and may, like that, lead to temporary or even permanent obstruction. In chronic ulcer of the stomach the subjacent pancreas not unfrequently^ becomes implicated in the course of the extension of ulceration ; and thus its eroded substance may after a time form the floor of the ulcer. C. Morhid growths. — The pancreas is often the seat of such forma- tions ; but they are rarely, if ever, of primary origin within it. They are sometimes a consequence of the generaKsation of mahgnant tumom's, but are much more frequently due to extension of disease from the stomach, retro-peritoneal glands, or peritoneum. It is, however, in carcinoma of the pyloric extremity of the stomach that the pancreas most frequently becomes involved. Of the several varieties of mahgnant disease to which it is hable, scirrhus is the most common ; but the encephaloid, colloid, and melanotic forms have each been met with. D. Calculi are occasionally discovered in the pancreatic ducts, and more especially in the principal duct. They have the same chemical and other characters as other salivary calculi — consisting mamly of phosphate of lime -Rath some animal matter, and varying from mmute granules up to the size of a filbert. When small they are sometimes present in vast numbers ; when large they are usually solitary, and more or less com- pletely obstruct the duct in which they he. E. Obstruction of the pancreatic ducts. — When these channels get blocked up. whether by calcuH or stricture, or by their compression by, or involvement in, malignant or other growths, the ducts behind undero-o gradual dilatation from the accumulation of secretion withm them. The chief enlargement occurs in the principal duct, which becomes elongated and tortuous, irregular in form, and sometimes sufficiently dilated to admit the finger. The secondary ducts also dilate, but m a less degree • 800 DISEASES OF THE DIGESTIVE OEGANS. and the whole organ consequently increases in bulk, and on section appears at first sight to be made np of a congeries of cysts— the secreting tissue between them being more or less atrophied. Solitary cysts, apparently due to the dilatation of obstructed ducts of small size, are occasionally discovered in otherwise healthy glands. Their only patho- logical importance arises from the fact that they may, from their size and situation, be readily mistaken for tumours or cysts of much more serious import. They may attain the size of an orange. F. Symptoms and treatment. — It would be a waste of time to discuss the diagnosis of the above lesions ; the special phenomena to be looked for as indicative of pancreatic disease have already been sufficiently con- sidered ; and, for the recognition of additional features special to each variety of lesion, the practitioner must be guided by his general know- ledge of pathology and of the pathology of the pancreas. In the great majority of cases pancreatic disease will doubtless remain undetected during life. It would be equally a waste of time to enter upon the discussion of the treatment of pancreatic affections. 801 Chap. VL— DISEASES OF THE GENITO-URINARY ORGANS. Section I.— DISEASES OF THE KIDNEYS. I. INTEODUCTOKY EEMAEKS. General Physiological and Pathological Considerations. The urinary organs comprise the kidneys, ureters, bladder and urethra. The diseases of all these parts are of high interest to the physician ; but those of the kidneys and ureters come more especially under his observa- tion and treatment, and it is mainly to them, therefore, that attention will be directed in the following pages. The sole function of the kidney is to separate from the blood, in association with water, a number of effete, waste, and surplus matters which are constantly being added to the blood from various sources. But the urine, as it escapes from the urethra, contams in greater or less ]Droportion certain additional matters (mucus and the like) which are yielded to it by the various mucous surfaces over which it passes, and by the glandular organs which open upon them. The urine, thus constituted, varies in composition within wide limits, even in health. In disease, where the nutritive and destructive processes are variously modified, and where the functional activity of important organs is in different degrees diminished, impaired, or exalted, the composition of this fluid undergoes still greater variations ; and, indeed, there are some cases (as, for example, that of diabetes) in which, the kidneys remaining sound, the nature of the disease under which the patient labours is revealed almost solely by the peculiarities which the urine presents. But especially the composition of the urme is largely and importantly modified by diseases of the urinary organs, which tend on the one hand to impede the discharge from the blood of the proper urinary constituents, and on the other hand to add to the mine matters which are wholly foreign to its normal constitution. It is ob^dous, therefore, that the careful investigation of the urine may be expected to throw important light, not only on the varying processes connected with healthy nutrition, but also on the pathology of many of those morbid conditions in which the kidneys are not distinctly implicated, and above all on the nature of the diseases of the kidneys themselves, and of the several organs in relation with them. But, again, when the urinary organs are the seat of disease, and oppose (as they then generally do) a more or less complete obstacle to the elimi- nation of urea and other such products from the blood, it is clear that 3 P 802 DISEASES OF THE GENITO-UEINAKY OKGANS. this fluid must soon become surcharged with effete and presumably in- jurious matters of a specific kind, and that we must, therefore, expect specific morbid consequences sooner or later to ensue. It is also clear that many diseases of these organs must be attended with both local and general indications and symptoms which are totally independent of the functional derangements which are associated with them : local phenomena, such as pain and tumour ; general phenomena, such as inflammatory fever and some forms of cachexia. The morbid phenomena, therefore, which are associated with, and result from, diseases of the kidneys may be properly and conveniently divided : first, into those which are special to these organs, and depend directly on the impairment or perversion of their normal functions ; and, second, into those which in a certain sense are common to these and other similarly affected constituent portions of the body. In accordance with the foregoing observations, we propose to give a brief account : first, of the composition of the urine in health and disease ; second, of the specific consequences of the retention of urea and other such matters in the blood ; and third, of the non-specific morbid pheno- mena which attend and characterise lesions of the urinary organs. A. Characters and Composition of the Urine. The urine is a transparent, limpid, straw- or amber-coloured fluid, of saline taste, and for the most part of acid reaction, which deposits, on standing, a filmy cloud of mucus, and occasionally an opaque, reddish, powdery sediment. Its acidity increases for a few days with exposure to the air, and at the same time urates, uric acid, and oxalates are deposited. Then it undergoes putrefaction ; becomes alkaline and ammoniacal ; earthy matters, mcluding crystals of triple phosphate, fall ; and bacteria and torulfe make their appearance in it. The quantity passed in twenty-four hours fluctuates within wide limits : it may, however, be reckoned usually at between two and three pints in the adult, but may range from one to four pints. The specific gravity also presents a wide range : it commonly Hes between 1015 and 1025, but temporarily may fall to 1005 or less, or rise to upwards of 1030. The acidity which, when the urine is emitted from the bladder, is an almost unfailing characteristic of it, is liable to a good deal of variation of in- tensity ; and, indeed, as Dr. W. Eoberts shows, that which is secreted an hour or two after meals is generally alkaline, although its alkalinity is commonly masked by its admixture in the bladder with acid urine already there or subsequently added to it. The acidity depends mainly on the presence of acid phosphates and urates, and in some degree also on traces of lactic, oxalic, and other acids. The degree in which the specific gravity of urine exceeds that of dis- tilled water depends on the solid matters (the special urinary constituents) contained in it. The proportion which these hold to the watery con- stituent may be approximately estimated, according to Trapp's formula, l)y doubling the last two figures of the number indicating the specific UKINE IN HEALTH AND DISEASE. 803 gravity. Thus 1000 parts of urine with a specific gravity of 1015 contain 30 parts of sohds ; and 1000 parts of urine with a specific gravity of 1025 contain 50. Hence the amount of sohd matter in healthy urine usually varies from three to five per cent. It is generally, however, far more important to know the actual amount of solid matter that is passed daily than the ratio which the solid matter holds to the very variable quan- tity of water with which it is mixed. This knowledge can be gained by collecting and mixing all the urine passed in the course of twenty- four hours, and then examining quantitatively a measured portion of its bulk, or, more readily though less accurately, by the method above given. The solid matters of the urine are very numerous ; and they vary largely, both in the relative proportions m which they are excreted and in their aggregate amount. The urea especially is remarkably modified by age, sex, diet, and other circumstances, so that the amount which may be taken as the average may be halved or doubled independently of any impairment of health. The following table is designed to show at a glance the relative proportions of the chief constituents contained in an average specimen of the urine of an adult, and the total quantities of each which might in such a case be discharged in twenty-four hours. The specific gravity is assumed to be 1025, and the temperature 32°. Urinary constituents Per-ceutage composition Daily aggregate in gi-air.s Water Urea .... CHjN.,0 Uric acid . . . C^H^N^O, Kreatinine . . . C^H^NjO Hippuric acid . HC^HgNbo Pigment, mucus, ~| odorous matters, I Extractive . xanthine, &e. J Total organic matters Chlorine SuliDhuric acid .... Phosphoric acid .... Potash ...... Soda Lime Magnesia Total fixed salts .... 95-000 2-500 -042 -075 -075 •600 3-292 -500 •150 •250 •175 •600 •018 •015 1-708 19000-0 500-0 8-5 15-0 15^0 120^0 658-5 100-0 30-0 50-0 35-0 120-0 3-5 3-0 341-5 General total 100-000 20000-0 or 45^ oz. The variations in the quahty and quantity of the urine in health arc so wide that it is often extremely difficult, and sometimes impossible, to be certain, from the examination of this fluid alone, whether it should be regarded as healthy or morbid. When matters are added to it which are wholly foreign to its composition, and cannot be ascribed to the influence of special articles of food or other substances which have been received into the blood, no doubt as to its morbid character can be entertained. 3f2 804 DISEASES OF THE GENITO-UKINAEY OKGANS. Again, when, independently of external conditions and habits of life, the urine habitually deviates largely from the mean, whether in the direction of excess or diminution, as regards either its total bulk or the amomit of any of its more important constituents, no doubt as to its unhealthiness is possible. And again, when sediments form habitually, even though the sedimentary matters be normal constituents of the urine, and the chemical composition of the urine itself reveal no appreciable departure from health, the unhealthy condition of the secretion is indisputable. In the following account of the urine, which is intended to be mainly pathological, and from which, therefore, some physiologically important constituents will be omitted, it will be convenient, after briefly adverting to the physical characters of morbid urine, to embody such physiological and chemical remarks in reference to its normal constituents as are neces- sary for a clear comprehension of the pathology of this excretion. 1. Physical characters of morbid urine. — The quantity of urine passed differs very largely in difierent diseases. In some general affections, as- cholera and collapse (especially collapse connected with lesions of the abdominal organs), the urine is absolutely suppressed. In most febrile disorders, and in inflammations, it is diminished. In other cases, on the contrary, as after hysterical paroxysms, in the condition known as diabetes insipidus, and especially in diabetes mellitus, it becomes profuse. Again, the urine is generally greatly diminished when acute nephritis is present ; it may even be temporarily suppressed from this cause. On the other hand, in chronic renal disease it is often largely increased. Its discharge is occa- sionally arrested in consequence of obstructive disease of the ureters. The amount of solid constituents present is not necessarily in relation with the quantity of urine voided ; though no doubt, generally, the more scanty the urine is, the higher is its specific gravity, and the larger the ratio which the solid matters hold to the water. But, on the other hand, in most febrile diseases there is an actual increase in the total nitrogenous consti- tuents, even while there is a marked diminution in the total bulk of urine passed ; and in the profuse urine of diabetes mellitus the quantity of solid matters excreted is so large that the specific gravity often rises to 1040, 1050, or 1060. The urine in disease may have the same reactions as in health ; or, on the other hand, it may be preternaturally acid, or neutral, or alkaline. Alkalinity of urine may be caused by the presence either of ammonia or of fixed alkalies. Ammonia is due to the decomposition of urea, and appears only after the urine has been secreted by the kidneys. It mostly appears in connection with chronic inflammation of the mucous lining of the bladder and other parts,Jand the discharge therefrom of morbid mucus. The persistence of alkalinity due to the fixed alkalies, if it be not dependent on peculiarities of diet or on medicine, is generally connected with afl^ections characterised by anemia and debility. Acidity may be recognised by the use of blue litmus paper, which becomes red under the influence of acids, and alkalinity by the employment of red litmus paper, which is rendered blue by alkalies, or of yellow turmeric paper, which becomes brown. If UEINE IN HEALTH AND DISEASE. 805 the alkalinity be due to ammonia, the test-paper changed under its influ- ence returns to its original colour on bemg dried. As regards colour, smell, and the presence of turbidity or sediment, all that we deem it necessary to say will be incorporated in our subsequent account of those urmary constituents to which severally these conditions are mamly due. 2. Urea (CH4N,0, or CO(NHo)o).— This is by far the most abundant and important of the urinary solids. It is furnished by the destructive metamorphosis of the nitrogenous tissues of the body and elements of the food, and contains nearly the whole of the nitrogen which was originally incorporated with the substances from which it is derived. Its quantita- tive variations are so great during health that it is impossible, in a few words, to explain when and at what point such variations are to be regarded as morbid. Urea is almost always largely increased during the febrile stages of inflammatory and febrile disorders, and in diabetes. It should be observed, however, that the quantity of urea eliminated is not in direct relation with the intensity of fever. In some febrile diseases the urine contains no excess of urea ; and generally when the curves representing the daily temperature and amount of urea are compared, the only corre- spondence between the two will be found in the early stages of the fever, and the longer the disease lasts the greater will be their disagreement. Urea being formed mainly in the liver, it is very probable that the amomit of it eliminated is always largely influenced by the condition of the hepatic cells, and by the activity of the hepatic circulation. Thus in mahgnant jaundice it diminishes, and finally disappears wholly ; in jamidice, the result of phosphorus-poisoning, its temporary increase is followed by marked diminution ; and the same remark applies to the cases of simple jaundice and hepatic abscess ; in obstruction from gall-stones (notably durmg the period of hepatic colic), and in the subsequent atrophy of the hepatic parenchyma, there is likewise a diminution. So also is it in the various forms of cirrhosis, and in chronic congestion of the liver. Again, urea is diminished in nephritis and other inflammatory or struc- tural diseases of the kidneys, in anaemia, and starvation. Urea is a feeble base, and exceedingly soluble ; and has, therefore, under ordinary circumstances, no visible mfluence over the condition of the urine. It forms no sediment, and cannot be detected in it except by chemical pro- cesses. Under the influence of the mucus of the bladder, and some other circumstances, it is readily converted, with the aid of water, into carbonate of ammonia. Urea crystallises in white silky needles, or transparent four-sided prisms, the ends of which are often formed by one or two inclined planes. Such crystals may often be obtained by evaporating a drop of urine (especially febrile urine) on a glass slide. If an excess of colourless nitric acid be added to urine concentrated by evaporation, the mixture will become almost solid with crystals of nitrate of urea. These ■occur m rhombic prisms or plates which are colourless, and have a silky lustre. For the quantitative determination of urea various methods have been employed. The following are probably the best. 806 DISEASES OF THE GENITO-UEINAKY OKGANS. a.' With a solution of mercuric nitrate, urea forms a white gela- tinous precipitate, containing one equivalent of urea to four equivalents of mercuric oxide. The determination of urea by Liebig's method is based on this reaction. A standard solution of mercuric nitrate is pre- pared of such a strength that ten cubic centimetres are equivalent to one- gramme of urea. This is done by dissolving 71 "5 grms. of pure mercury in nitric acid, and dilutmgwith distilled water to one litre. Before urine is precipitated by this solution its phosphates must be removed by the addition of a mixture of one part of cold saturated solution of baric nitrate to two parts of a similar solution of baric hydrate. Further, if albumen be present, it must be separated by boiling and the addition of a few drops of acetic acid. The process is thus performed : — Two volumes of urine (say 40 c.c.) are mixed with one volume (20 c.c. ) of the baryta solution. After shaking well, the mixture is poured on a dry filter, and 15 c.c. of the clear filtrate (equal to 10 c.c. of urine) removed to a small beaker. Mercurial solution is- now slowly added from a burette so long as precipitation occurs. But to find the exact point when all the urea has been precipitated, it is neces- sary to employ some such indicator as sodic carbonate. Several drops of a solution of this salt are scattered over a white plate ; and by means of a glass rod a little of the mixture in the beaker is brought m contact with the soda. So long as there is any free urea present no change of colour takes place at the poirit of contact ; but as soon as the mercury is in excess, a yellow precipitate results. The moment, therefore, the yellow colour shows itself distinctly, enough mercuric solution has been added.. To attain an accurate result, the experiment should be performed a second time. Supposing 19 c.c. of the mercuric nitrate were required by the 10 c.c. of urine, this would mdicate a per-centage of 1"9 urea in the urine. If, however, it should be found that more than 20 c.c. are needed, the urine for the second examination must be diluted by adding half as much water as the excess of mercuric nitrate solution employed above 20 c.c. Thus, if 30 c.c. were required in the first precipitation, the excess is 10 c.c. ; therefore, 5 c.c. must be added to the 10 c.c. of urine before the second precipitation. If, on the other hand, much less than 20 c.c. have been used, then for every 4 c.c. less than 20, "1 c.c. must be deducted before calculating the per-centage of urea. b. A very easy method for the estimation of urea depends on the measurement of the nitrogen evolved when the urea is decomposed by a hypochlorite or hypobromite. Urea yields in this way all its nitrogen, less 8 per cent. Difierent apparatus are used ; but in all of them there are mechanical arrangements to bring about the gradual admixture of the urine with the test solution, and to collect the gas evolved. 5 c.c. of a 2 per cent, solution of urea yield about 37 c.c. of gas. The coUectmg tubes are generally graduated so as to express at once without calculation the per-centage of urea present in the urine experimented upon. The volume of gas given by, say, 5 c.c. of a 2 per cent, solution of urea, which ' 1 gramme = 15-432348 grains = the weight of a cubic centimetre of distilled water at 39-2° F. 1 litre = 1000 cubic centimetres = 61-024 cubic inches = 35-2754 fluid ounces. UEINE IN HEALTH AND DISEASE. 807 is about 37 c.c, is taken as indicating 2 per cent, of urea, and the col- lecting tube is graduated accordingly. 3. Uric acid (C5H4N4O3) and urates. — Uric acid is derived from the same source as urea, and is hable to shght fluctuations in quantity under much the same circumstances as urea. It is readily decomposed by oxi- dismg agents into several less complex substances, of which urea (to which it contributes the whole of its nitrogen) is the most important. It may, in fact, be regarded as representing a stage in the conversion of albuminous matter into urea. It is exceedingly insoluble in water, and hence, when free in the urine, forms a crystalline deposit. It is, however, generally combined with a base, especially ammonia or soda, and in this form is much more soluble, though still liable to form a sediment. The main interest, indeed, attaching to the presence of uric acid and urates in the urine resides in the fact of their tendency to be deposited, and to take part in the formation of gravel and calculi. Free uric acid often falls during the acid fermentation taking place in urine which is kept ; and, when met with in fresh urine, it is generally in consequence of the acid reaction of that fluid being excessive. It may be readily recognised by the characters of its crystals. These may form reddish grains visible to the naked eye, but are generally microscopic objects. The forms which they assume are various, and depend largely on the quality of the urine in which they are found. They are generally lozenge-shaped or rhomboidal, ■s\ath the angles more or less rounded, and vary in thickness, so as to form, on the one hand, mere films, on the other, short flattened cylinders or prisms. When abundant they are often grouped together into stellate or variously shaped clusters. If any doubt as to the nature of the deposit exist, it may be set at rest by con- vertmg it into murexide. This may be done by <^5^ placing a little of it in a porcelain dish, adding to it a drop or two of strong nitric acid, and heating the whole to dryness. If now, when the residue is cool, a rod dipped in caus- tic ammonia be applied to it, the beautiful purple colour", characteristic of murexide, is developed. Urates, comprising chiefly those of ammonia and soda, are often de- posited in an amorphous condition, forming a pow- dery sediment which clings to the vessel, and which, from its attraction for the colouring matter of the urine, varies in tint Fig. 71. Uric acid and urates x 500. 808 DISEASES OF THE GENITO-UEINAEY OEGANS. from a light fawn to pink. Like uric acid itself, they generally preci- pitate in acid urine, but, unlike uric acid, they mostly fall m concen- trated urme, especially when it becomes cool. The formation of uratic sediments often occurs in the urme of healthy persons, especially in cold weather ; it often, however, attends and indicates the presence of catarrh or other febrile states or derangements of the liver or other chylopoietic viscera. Amorphous urates are readily recognised by the fact that urine which is turbid from their presence becomes perfectly clear and trans- parent when boiled. Further, the addition of acids causes the formation of crystals of uric acid ; and murexide may be developed by the method ■already indicated. Urate of soda is occasionally present in the shape of small globular concretions beset with conical spikes. These form in the urme while it is yet in the urinary cavities, and are liable to cause much irritation, and to lead to the development of calculi. They have been especially observed in the case of children suffering from febrile symptoms. 4. Xanthine ( C5H4N4O2 ) is a waxy, white, non-crystallisable substance, almost msoluble in cold water. When heated with nitric acid it dissolves without evolving gas ; and the residue left on evaporation acquires when heated with caustic potash a beautiful ^dolet-red colour. 5. Cystine (C3H7NSO2, or C3H5NSO2) contains 25*5 per cent, of sul- phur. It is closely related chemically to taurine, and hence probably furnished by the liver. It is a neutral body, insoluble in water, and crystallises in hexagonal plates. It is dissolved by the mineral acids with decomposition, and by the caustic alkalies without. The best way to obtam the characteristic crystals is to dissolve the cystme in a solution of ammonia and allow the solution to evaporate. 6. Leucine (CgHigNOa) and tyrosine (CgHiiNOg). — These are formed u^nder the same conditions, and are generally associated to- gether. Pure leucine occurs in white crystalline scales, has a fatty feel, and dissolves in water. In the impure state, as observed in urine, it often assumes the form of round- ish concentrically marked yellomsh bodies which have some resemblance to fat-globules. If a small portion of leucme be saturated with nitric acid and the mixture carefuUy evaporated to dryness, it leaves an almost transparent residue which turns yellow or brown on the addition of solution of caustic soda, and yields an oily drop when reheated. Tyrosine forms a white, silky, ghsteiung mass, consisting of fine needle-like crystals, which are grouped in radiating clusters, and sometimes in dense globular masses. It gives a red coloration when boiled with Millon's reagent ; and a violet hue when gently warmed with Fig. 72. Cystine x 500. UEINE IN HEALTH AND DISEASE. 809 sulpliuric acid, and a drop of solution of percliloride of iron is added. The urine of patients suffering from yellow atrophy of the liver often deposits spontaneously a greenish-yellow sediment consisting of crystals of tyro- sine, and on evaporation yields numerous crystals of the more soluble leucine. 7. Colouring matters. — The normal pigments of the urine are derived fi'om the colouring matter of the blood, and, according to Schunck, are two in number. He names them respectively urian and urianine. They are of a dark yellow colour and syrupy consistence, have a high atomic constitution, and contain nitrogen. Their excess or deficiency has little special pathological importance. Another urinary pigment has been de- scribed by Dr. Thudichum under the name of urochrome. The pink colouring matter, however, iexmedi lyuvpurine or uro-erythrine, is a patho- logical product. Its chemical constitution and source have not been ascertained ; but it is common in febrile and inflammatory affections and in cases of organic disease, especially of the liver, and has a remarkable affinity for uratic sediments, to which it clings and imparts its special tint. Indican, the peculiar body by whose decomposition indigo-blue and indigo- red are obtained, has been ascertained by Schunck to be a normal con- stituent of urine. It is to this source that the occasional presence of indigo-blue in decomposing and morbid urine appears to be due. 8. Odorous matters. — The peculiar smell of normal urine is due to the presence of mmute proportions of certain volatile organic acids, which need not be specified. This smell is well marked when the urine is acid ; but when it is alkaline from fixed alkali the urme acquires a sweetish odour instead, and when alkaline from decomposition becomes ammoniacal. Diabetic urine has a peculiar sweetish smell. 9. Grape or starch sugar. Glucose. Dextrose. (CgHi206, HgO.) — A trace of this substance is frequently, if not always, present even in healthy urine. Occasionally it is found in excess under the influence of various morbid conditions of the system. Its habitual presence in quantity is the distinctive feature of the malady known as diabetes mellitus. Diabetic urine is usually of high specific gravity, has a sweet taste, very rapidly develops torvilse, ferments on the addition of yeast with the disengagement of carbonic acid gas, and (as one of the names of its saccharine constituent implies) rotates the plane of polarisation to the right. a. Qualitative tests for sugar. — Many tests for the presence of sugar, some founded on the facts above enumerated, have been devised. One of the readiest, though not the most delicate, is that known as Moore's test. It consists in boiling a mixture of equal parts of the suspected urine and of liquor potassae in a test-tube ; when if sugar be present a deep reddish- brown colour, due to the decomposition of the sugar, becomes developed. The chief objections to this test are, that in concentrated urine, and in urine containing albumen or blood, a distinct deepening of colour also takes place, and that if the reagent contains lead, as it often does when tept in glass bottles, the deepening of colour becomes, in urine contaming 810 DISEASES OF THE GENITO-UEINAEY OEGANS. albumen, somewhat intense. Dr. George Johnson has called attentioix to the fact that if, to the mixture of diabetic urine and liquor potassEe, made as for Moore's test, a few drops of a satm^ated aqueous solution of picric acid be added, boihng causes the fluid to acquire a characteristic purple or claret colour, which is more or less deep according to the amount of sugar present, and may be almost black. No change of colour, sa\dng that due to the yello\\Tiess of the picric acid, takes place in urme free from sugar ; but the minutest trace of grape-sugar evokes the charac- teristic reaction. The test is exceedingly dehcate. Another accurate and trustworthy test is that known as Trommefs or the copper test, which depends on the power possessed by grape-sugar of decomposing the salts of copper and throwing down the insoluble red sub-oxide. It may be applied as follows : — Mix the suspected urine with half its volume of solution of caustic potash or soda. If much precipitate be produced, it should be separated by filtra- tion. Then add a few drops of a dilute solution of sulphate of copper, and heat the mixture in a test-tube. Even before the boiling-point is reached (if sugar be present) the characteristic precipitate vdW begin to appear ; and as soon as this point has been attained the heat should be withdrawn^ since other substances besides sugar effect by prolonged ebullition a reduc- tion of cupric salts. The effect of this process on diabetic m-ine is that after a few seconds the mixture suddenly turns of an intense opaque- yellow colour, and in a short time an abundant yellow or red sediment falls to the bottom. The test is best applied by usmg a ready-made alkaline solution of tartrate of copper. h. Quantitative tests for sugar. — By means of a standard solution of the kind just referred to, Trommer's test may be made available for determining the quantity of sugar in urine. Fehling's solution, which is em- ployed for the above purpose, is thus prepared : — Dissolve 34"64 grammes of pure crystallised sulphate of copper in 200 c.c. of distilled water. Separately dissolve 173 grms. of pure crystals of Eochelle salt in 480 c.c. of solution of caustic soda (sp. gr. 1-14). Mix the two solutions and dilute up to a Htre. Ten c.c. of the mixture contain -3464 grm. of cupric sulphate or "108 grm. of cupric oxide, and represent "Oo grm, of pure anhydrous grape-sugar. This mixture has a great tendency to spoil by keeping. To obviate this it is advantageous to prepare the solutions as follows : — Dissolve 34"64 grms. of cupric sulphate in distilled water, dilute up to a litre, and keep in a separate bottle. Dissolve 173 grms. of Eochelle salt in 350 c.c. of distilled water, and heat to boiling : on cooling add 600 c.c. of solution of caustic soda (sp. gr. l*12j that has been pre- viously boiled, and make up to a litre with distilled water. The second solution is to be kept in a separate bottle, and to be mixed with the former in equal proportions when required for use. To estimate the amount of sugar present in diabetic urine dilute 10 c.c. of urine with distilled water up to 200 c.c. ; and pour into aMohr's burette. This dilution is to reduce the sugar below 1 per cent. Then place 10 c.c. of Fehling's solution, or 20 c.c. of the mixture last considered, in a small UEINE IX HEALTH AXD DISEASE. 811 flask, add distilled water up to 50 c.c, and boil the whole over a Bunsen's. flame — the flask restmg on some wire gauze immediately below the Mohr's burette. Then allow the diluted urine to flow slowly into the boiling copper solution until the blue colour has nearly disappeared. After this point the urine must be added more cautiously, and the flask well agitated after each addition. The precipitated sub-oxide settles rapidly on removing the flame, thus allowing any tinge of blue in the supernatant fluid to be readily seen on holding the flask obHquely over a white ground. So long as any trace of colour remains more urine must be added, and the boiling must be continued. To make sure that all the copper has been precipitated, a little of the test-mixture should be filtered and tested with ferrocyanide of potassium and acetic acid. The appearance of a bro"^T.i coloration or precipitate mdicates the presence of copper. "When once the exammation of the urine has been commenced it should be completed as soon as pos- sible, to prevent any re-solution of the sub-oxide. Supposing 60 c.c. of the diluted urine have been required by the 10 c.c. of Fehhng's solution,, then every 60 c.c. of the diluted urine, or every 3 c.c. of the urine itself (smce it has been diluted twenty times), contains "05 grm. of sugar, or about 1'6 per cent. Another method, known as K^iapiys, may be employed. It possesses certam advantages over Fehling's process. The test solution is easier to make, it keeps a long time without alteration, the analysis requires a shorter time, and the termination of the reaction is more easily determined. The process is based on the power possessed by grape-sugar of reducing to the metallic state the merciu-y contained in a boiling alkalme solution of mer- curic cyanide. 100 parts of sugar reduce 400 parts of cyanide. The standard solution is prepared by dissolving 10 gi-ms. of the cyanide in 600 c.c. of distilled water, addhig 100 c.c. of solution of caustic soda (sp. gr. 1-145} and diluting up to a litre with distilled water. 40 c.c. of the mercuric solution (containing '4 grm. of the cyanide, and equivalent to '1 grm. of sugar) are heated in a flask, and the diluted urine, as in Fehling's process,, slowly added until the whole of the mercury is precipitated. The mercury falls rapidly, and the completion of the process can be ascertained by brmging a drop of the supernatant fluid in contact with a piece of wet filter-paper which has been exposed to the fumes of hydrochloric acid, and subsequently to sulphuretted hydrogen. A trace of dissolved mercury gives at once a yellow or brownish coloration. Both of the above analyses should be repeated a second time in order to insure accuracy. The picric acid test may also be made available for the quantitative determination of diabetic sugar. 10. Amorphous pliosphate of lime (Ca3,2P04). — This precipitates only in alkaline urine ; it forms an amorphous sediment like that of the urates,, but does not carry with it the urinary colouring matter. The application of heat mcreases the precipitate, and not mifrequently causes it. It is dissolved, however, on the addition of a drop or two of nitric acid. It often forms an iridescent pellicle on the surface. S12 DISEASES OF THE GENITO-UEINAEY OEGANS. 11. Crystallised lohosphate (CaH,P04). — Dr. Eoberts regards this sediment, which is rare, as an accompaniment of grave disorders. It •occurs in rods and needles, which are often arranged in tufts and stars. Fig. 73. Phosphates x 500. 12. Ammoniaco-magnesian ijliosphate (H4NMg,P04) always falls in ammoniacal urine. Its crystals occasionally appear in slightly acid urme ; but are much more frequently observed in that which is alkaline, and then often associated with the amorphous phosphate. They are occasionally met with as an habitual constituent of freshly voided urine. The ordinary crystalline form is that of a triangular prism with bevelled ends. But this is liable to numerous modifications. 13. Oxalate of lime [Co^GoOi ^^^'2.^)- — The presence of oxalic acid in urine is not surprising considering that it, with carbonic acid, is one of those ultimate substances into which o rganic matters become reduced. Its presence is doubtless in the majority of cases due to such reduction, but sometimes it depends on the ingestion of articles of diet, such as rhubarb, which contain it. It occurs iu the urine in combination with lime, usu- ally forming small oblique octahedral crystals, and occasionally dumb-bell- shaped bodies. The crystals generally fall, entangled with the mucus, and when large may be seen as shining pomts with the naked eye. Their occasional presence is a matter of little importance ; but when they are of habitual occurrence there is reason to fear the formation of oxalate of lime calculi, and there is often some Pig. 74. Oxalate of lime UEINE IN HEALTH AND DISEASE. 813 obvious impairmeut of health. Oxalate of lime rarely occurs in alkaline or neutral urine. It is readily soluble in the mineral acids, and precipit- able from solution by excess of ammonia. 14. Carbonate of lime (CaC03) is sometimes deposited as an amorphous powder ui alkalme urine, and is occasionally found in the form of minute rounded calculi, with a well-marked concentric structure. 15. Albumen. — This substance is seldom met Avith in healthy urine, and its presence, in any quantity at least, is one of the most significant indications of renal disease. It is observed under various circumstances. Whenever suppuration occurs in connection with any of the urinary organs, and pus is discharged into the urine, albumen is present in small proportion. In many specific fevers and other febrile disorders albumi- nuria is hable to occur. In congestion of the kidneys, due to heart disease, bronchitis, or obstruction of the renal veins or arteries, again, albuminuria is frequently observed. The most important causes of this condition, however, are inflammation of the kidney, and those various chronic lesions which are usually comprehended in the term 'chronic Bright's disease.' It has occasionally been discovered in healthy urine shortly after a meal of eggs. The presence of albumen in the urine may always be recognised by its coagulation mider the influence of heat or nitric acid. To apply the former test, a portion of the urine should be placed in a test-tube and then boiled by means of a spirit-lamp. If it contain albumen, opaque flakes form in it, which render it turbid, and gradually fall to the bottom of the glass. If there be much albumen present, turbidity appears before the urine begins to boil ; if there be only a trace, actual ebullition is essential to its production. In the employment of heat one or two precautions are necessary to be observed. In the first place, albumen is not precipitated if the urine be alkaline, and hence such imne should first be acidified by the addition of a few drops of acetic acid. In the second place, in slightly alkaline or neutral urine, heat is apt to throw down a deposit of amorphous phosphates. These, however, dissolve on the addition of an acid. The nitric acid test may be applied either by dropping a few minims of strong- nitric acid into a test-tube charged with the urine to be experimented upon, when, if albumen be present, a more or less abundant white pre- cipitate will take place ; or preferably as follows : — Charge a test-tube to a depth of ^ or f inch with strong nitric acid, and then pour a small quantity of urine slowly down the side of the inclined tube so that it may rest on the acid without mixing with it. If albumen be present an opaque white cloud, disc-like in form, immediately appears in the plane of contact of the two fluids. This latter method of employing nitric acid is probably the most delicate of all qualitative tests of the presence of albumen. The fallacies which may arise in connection with the nitric acid test are : first, that the urine of patients who are taldng cubebs or copaiba is apt to become slightly turbid mider the influence of nitric acid ; second, that in concentrated urine, and such as is rich in urea, some deposition of urates or of nitrate of urea may occur ; and third, that the addition of a very mA DISEASES OF THE GENITO-UEINAEY OEGANS. minute proportion of nitric acid does not always precipitate albumen, while the addition of an excessive quantity may prevent its precipitation altogether. A saturated aqueous solution of picric acid also precipitates ;albumen. In order that it may act well picric acid should be present in relative excess ; it is advisable, therefore, in employing this test to mix equal bulks of urine and picric acid solution. Picric acid in excess does not re-dissolve precipitated albumen as nitric acid does ; but in other respects the fallacies to be guarded against are the same for both tests. A practical advantage attaching to picric acid is that it may also be used in the form of powder. Dr. Johnson recommends that a quantity about equal to a peppercorn should be added to an mch column of urine in a test-tube, and the mixture shaken until the powder is dissolved, when, if albumen be present, precipitation takes place. Dr. W. Eoberts has shown that a saturated aqueous solution of common salt, acidulated with about five per cent, of the dilute hydrochloric acid of the ' British Pharmacopoeia,' renders albuminous urine opaque and milky ; but that the opacity is not due to precipitation, and may be removed by dilution with water, or even with the urme which is being experimented upon. In this, as in the last case, equal bulks of urine and of reagent should be employed. This test may also be appHed, like the nitric acid test, by gently pouring the urine on to a quantity of the saline solution in a test-tube, so as not to allow of their admixture, when, as in the other case, an opaque white disc appears in the plane of contact. The relative quantity of albumen present in any ■specimen of urine may be roughly but conveniently estimated by boiling the whole of the slightly acidified portion placed in a test-tube, and then allowhig the coagulated flakes to subside. 16. Blood may be found in the urine in various proportions and in ■different conditions, and may be furnished by any part of the urinary -tract, from the kidneys downwards. The greater the quantity of blood passed, and the nearer its source to the external urethral orifice, the less will it deviate from the normal condition of blood, and the more readily will it be recognised. Its presence may be due to injury, congestion, in- flammation, carcinomatous and other Hke growths, concretions, or para- sites, involving either the substance or pelvis of the kidney, or some other part of the excretory apparatus, such as the ureter, bladder, or urethra. Hfematuria occasionally also follows the use of cantharides or other drugs, and is frequently met with not only in those febrile disorders (small-pox, •scarlet fever, and the like) which are attended with albummuria, but in purpura, scurvy, and other affections which assume a petechial character. When much blood is effused, it occasionally coagulates in the bladder ; and may even coagulate in the chamber pot. When present in smaller quantities and diffused uniformly throughout the urine, it imparts to it a slight degree of opacity or turbidity, and a tint resembling that of a dilute ■solution of the compoimd infusion of roses, or a peculiar smoky or dirty xeddish-brown hue, varying in depth and distinctness according to the ■quantity of blood present. Sometimes the urine resembles porter. On standing it usually deposits a grumous or coff'ee-ground-hke sediment. UKINE IN HEALTH AND DISEASE. 815 'The presence of blood is additionally proved by the detection of albumen in the urine by the usual tests, and by submitting a specimen to micro- scopic examination, when almost always blood-corpuscles will be readily detected, sometimes disc-like, sometimes globular, sometimes crenate, occasionally retaining their colouring matter, but usually colourless, having imparted their pigment to the fluid in which they float, hi a peculiar affection shortly to be described — paroxysmal haematuria — al- though the urine contains abundance of blood, distinct blood-corpuscles are rarely detected. And occasionally (as Dr. Mahomed has shown to be especially the case at a certain period in scarlet fever, prior to the occurrence of albuminuria and anasarca), the colouring matter of the blood alone transudes into the urine, where it may be detected either by the spectroscope or by the guaiacum test. The latter may be applied as follows : — Place a drop or two of the urine in a small test-tube, add one ■drop of tincture of guaiacum and a few drops of ozonised ether ; agitate, -and then allow the ether to collect at the top. If blood-pigment be present, the ether acquires a blue colour, leaving the urine below colour- less. No saliva must be mingled with the urine, and the patient must not be taking any salt of iodine.^ Further, unless the tincture be freshly prepared the reaction is liable to fail. 17. Bile. — The colouring matter of the bile and the biliary acids are found in greater or less abundance in the urine in cases of jaundice. The former may, according to its amount, impart merely a yellowish tint, scarcely or not at all distinguishable from that of normal urine, or any variety of shade between this and a deep olive-green. Bile-stained urine .seen by reflected light often looks almost black. The presence of biliary pigment in the urine may be readily detected by the addition of strong nitric acid, which produces, where the fluids first come into contact, an evanescent succession of green, blue, violet, and red tints. The test may be apphed, either by placing a few drops of urine and a few drops of nitric acid close to one another on a white porcelain surface, and then allow- ing them to come together ; or by putting a little nitric acid at the bottom of a test-tube, and pouring a small quantity of urine carefully on the top of it without allowing them to mix. In the former case the play of colours takes place at the line of mixture, in the latter in the horizontal plane of contact. Dr. G. Harley considers that the presence of the biliary acids in the urine is characteristic of jaundice from retention of bile. For their detection the following process ( a modification of Petten- kofer's) may be employed : — Add a few drops of syrup to the urine, and then shake briskly in a test-tube until a froth has formed. Next allow a drop of strong sulphuric acid to flow down the side of the tube. As soon as the acid reaches the froth a beautiful purple colour develops rapidly. The reaction is facilitated by gently warming the side of the test-tube. 18. Casts. — In almost all cases in which albuminuria or hfematuriais ' Mahomed, ' Med.-Chir. Trans.,' vol. Ivii. Fig Epithelial casts and cells from renal tubules x 250. 816 DISEASES OF THE GENITO-UEINAKY OEGANS. due to morbid conditions of the secreting structure of the kidneys, and' occasionally in speci- mens of urine which seem to be free from both blood arid al- bumen, microscopic cylinders which have been moulded in the urinary tubules, and are therefore termed casts, may be de- tected with the aid of the microscope. Of these several varie- ties may be distin- guished. The fol- lowing enumeration comprises the more common of them, a^ Epithelial casts consist of renal epithelium. Occasionally the epithelium differs little from the normal epithelium of the tubules. More commonly the cells are granular and degenerating or studded with oil -globules. In other cases the casts are formed mainly if not entirely of new-formed cells, which then assume an embryonic character, and have therefore more or less resemblance to pus-cells, h. Hyaline casts. These present two well-marked varieties ; of which one may be termed mucous, the other waxy. The former are exceedingly translucent and delicate, and consequently may ^,\ / .\ readily escape detec- tion. They are colourless, homo- geneous, or ground- <^ glass-like, with little or no refractive power, soft and flexi- ble. They present soft but definite edges, are generally narrow and often of considerable length. They are proteinous, but not fibrinous ; and are unaffected by acetic acid. The waxy casts also are transparent and homogeneous ; but they are highly refractive, and there- fore present well-marked shaded edges. Moreover they are brittle, are Fig. 76. Hyalixe Casts x . Mucous. 6 h. UEINE IN HEALTH AND DISEASE. 817 apt to present transverse fractures, and vary largely in diameter and length. Like the former, they are not acted on by acetic acid ; but they readily absorb biliary, blood, or other coloming matters, c. Granular casts. These Fig. 7". Granular casts x 250. Fig. 78. Fatty casts x 250. vary in size, but are often of considerable bulk, and are studded more or less thickly and irregularly with granular matter, which often renders them perfectly opaque. They are hyaline, generally waxy, casts which have either undergone granular degeneration, or are studded with degene- rating cells, or enveloped in their debris. Indeed compound granule- cells are often seen distinctly imbedded in them. d. Fatty casts are characterised by the presence of ob-^dous fat globules, which are some- times of considerable size. Such globules may be observed in either epithehal, hyaline, or granular casts. The fatty matter is not pure olein, but seems generally to be a mixture of this with cholesterine and some albuminous matter, e. Blood-casts. Generally in renal haBmaturia the casts consist, in a greater or less degree, of coagulated fibrine entangling the corpuscular elements of the blood. The basis of the casts is here purely fibrinous ; it is fibrillated, and dissolves in acetic acid. The blood- corpuscles may present pretty nearly their normal characters ; they are generally, however, compressed and angular, and are often broken down and individually midistinguishable. The casts are necessarily more or less deeply pigmented. Blood-corpuscles ^ or blood-pigment may be present in epithelial or hyalme casts. The various casts above described, and more especially perhaps the waxy and granular casts, occasionally contain crystals of either uric acid, oxalate of lime, or triple phosphate, or granules of urate of soda 3 G Fig. 79. Casts containing blood x 250. or 818 DISEASES OF THE GENITO-UEINAKY OEGANS. refractive globules looking like oil, but consisting of the crystalline bodies just named in combination with animal matter. As regards the sources of urinary casts, it is important to bear in mind that the convoluted tubes of the kidneys which are functionally the most important can scarcely yield them, inasmuch as they are of comparatively large diameter, and are separated from the straight or collecting tubes by the narrow loops of Henle. Indeed there is little doubt that casts found in the urine come exclusively from the loops of Henle and the straight tubes, that the descending limbs of the loops furnish the smallest, the ascending limbs those of intermediate size, and the straight tubes, and more espe- cially their terminal portions, the largest casts. On these and other grounds the significance of casts is less than is generally supposed. They are often absent in cases of albuminuria or chronic Bright's disease ; and mucous casts are occasionally observed in jaundice, and in cases in which there is neither albuminuria nor kidney disease, and even m health. Epithelial casts usually imply acute affections ; large hyaline, fatty and granular casts, chronic and degenerative disease ; while mucous casts have no special significance. 19. Mucus and 2) us. — Li normal urine but little mucus is present ; it falls as a scarcely perceptible cloud, and contains perhaps traces of vesical a,nd urethral epithelium, and in the female squamous vaginal epithelium. When, however, there is any mflammatory condition of the mucous lining ■of the urinary channels or reservoirs, the mucous secretion becomes in- creased, cells are discharged in excess, and immature forms, in other words, cells identical with those of pus, are produced in greater or less abmidance. The transition between mucus and pus is almost imperceptible. The dis- charge, if sufficiently abundant, renders the urine turbid and slightly albu- minous ; and a sediment, which may present a greenish-yellow hue, pre- sently forms. If the urine retains its acid reaction, this sediment is readily miscible with the urine ; if, however, it becomes, as it is very apt to become, alkaline, then the sediment becomes tenacious and ropy. The secretion of inflammatory mucus has a remarkable influence in promotmg the decomposition of urea ; the urine, therefore, in these cases has a great tendency to become ammoniacal, to deposit earthy phosphates, and to acquire irritant properties. The abnormal secretions here described are most commonly furnished by the inflamed mucous membrane of the pelvis of the kidney, or bladder. But it must not be forgotten that pure pus may be poured into the urinary passages, either from renal abscesses or in con- sequence of the rupture of some neighbourmg abscess into them, and that cells identical with pus-cells may escape from the renal tubules. Pus can he readily recognised by its microscopic characters. 20. Fat, excepting in connection Avtth renal casts, is of rare occurrence in the urine. The presence of fluid fat in the form of globules is said to have occasionally been observed. Crystals of cholesterine also have been met with. In a case of Dr. Murchison's, the cholesterine was traced to a pyonephritic cyst. The most interesting cases of fatty urine, however, are those in which this fluid presents a milky or chylous character, due to CONCEETIONS. ' 819 "the presence of fatty matter in a molecular or amorphous condition. In these cases the urine contains albumen, fibrine, and leucocytes, in addition to fat ; it hence tends to coagulate spontaneously ; it coagulates with heat ; a creamy layer rises to the top when it is allowed to stand ; and it may be rendered clear, and the fat be separated, by agitating it with ether. Many of the globules which are commonly regarded as fat, and look like it, are really composed of some of the crystalline constituents of the urine in combination with animal matter, as may be shown by the effects of reagents and the appearance of a cross when they are examined with polarised light. 21. Morbid growths. — Tubercle, carcinoma, and other growths are apt to arise in various parts of the urinary organs ; and it might hence be sup- posed that their characteristic elements should be occasionally discovered in the urine. It must be exceedingly rare, however, for such specific indications to be met with in connection with disease of the kidneys. In villous growths of the bladder, fragments, may, no doubt, be detached and occasionally be discovered in the urine. It must be borne in mind, how- ever, that the cells of the vesical epithelium have a great resemblance to typical cancer-cells, and may be easily mistaken for them. 22. Spermatozoa are sometimes present in the urine, and may be readily recognised in the sediment. Their presence is of little clinical importance, miless other symptoms combine to indicate the existence of abnormal spermatorrhoea. 23. Animal and vegetable organisms. — Hydatids are occasionally deve- loped in the urinary organs, or hydatid cysts may open into them. The urine under such circumstances may present actual hydatids or echinococci, or fragments of one or the other. The peculiar laminated character of the hydatid membrane, and the booklets of echinococci, are, under the micro- scope, quite unmistakable objects. In the endemic hsematuria of Egypt, the Cape, Natal, and other parts of Africa, the symptoms are due to the presence, in the veins of the pelvis of the kidney, ureter, and bladder, of a small unisexual parasite, termed the bilharzia haematobia. The presence of this affection may be recognised by the discovery in the urine of the ova and free embryos of the parasite (see later). The filaria sanguinis hominis is found in some cases of chyluria. Sarcinas have been observed in the urine when passed h'om the bladder. Lastly, bacteria and penicillium form rapidly in urine undergoing decom- position, and the yeast-plant in that of diabetic patients. B. Concretions. These may occur in the form of a fine sand, in which case they are termed gravel, or in masses varying from the size of a tare or mustard seed upwards, when they are known as calculi ; and may consist of any of the solid matters which have been described as occasionally separating from the urine, either separately or in combination. The most important of them are the uric acid, the uratic, the cystine, the xanthine, the oxalate of lime, the phosphatic, and the carbonatic, 3 G 2 820 DISEASES OF THE GENITO-UEINAEY OEGANS. Urinary concretions always contain more or less organic matter com- bined with their main ingredients, and in a large nmnber of cases the. nucleus has a different chemical constitution from the layers subsequently formed. Further, any foreign body, whencesoever derived, may form the nucleus around which urinary deposits accrete. 1. Uric acid concretions are the most common. They constitute five- sixths of the total number of renal calculi, and wholly or in part the great majority of those found in the bladder. Uric acid gravel consists of angular groups of crystals. Eenal calculi of this material are small, round or oblate -spheroidal, often tuberculated bodies, which vary in colour from pale fawn to deep reddish-brown. In the bladder they attain a large size. They are hard, have a specific gravity of about 1'5, and are formed in concentric laminae. 2. Uratic calculi are rare, and occur mostly in children under puberty. They are small, slate- or clay-coloured on the surface, smooth or granular, formed in thin, ill-marked laminge, and very friable. They are readily soluble in boiling water. 3. Cystine calculi are very uncommon. When pure they are yellow, transparent, wax-like, and soft ; the outer surface is somewhat crystalline, the sectional surface radiated. After long exposure to daylight they tend to assume a pale green colour. The circumstances which determine their formation are not kno-wn, but the tendency to them seems to run in families. 4. Xanthine calculi are also exceedingly rare, and have a close resemblance to those of uric acid. 5. Oxalate of lime calculi are next in frequency to those of uric acid. When in the kidney they are generally small, smooth, and of a dark colour. Here, however, but more particularly in the bladder, they often attain a large size, and are then usually tuberculated or spiny on the surface, con- stituting what are called mulberry calculi. These are laminated — the successive laminae presenting a wavy or crenated character. Oxalate of lime calculi are exceedingly hard, and, though generally dark, vary much in colour. When very pure they are occasionally milk-white. 6. Calculi of amorphous phosphate of lime, or bone-earth, and those of ammoniaco-magnesian phosphate, are both exceedingly rare. The fiisible calculus, which is composed of a mixture of these salts, on the other hand, is very common. This precipitate commonly takes place in ammoniacal urine, and hence is met with in the renal pelvis, or the bladder affected with chronic inflammation ; and hence, further, it is specially apt to occur when calculi of other composition are producing irritation. Phosphatic matter, indeed, rarely forms the nucleus of a calculus ; but it tends to accumulate on the surface of other calculi ; and, when once it begins to collect there, is rarely succeeded by any other form of deposit. Phosphatic calculi are light, loose-textured, imperfectly laminated or amorphous, and white, grey or dark-yellow. 7. Carbonate of Ihne very seldom forms urinary calculi in the human being. It takes part, however, in the formation of the minute, dark- CONSEQUENCE OF THE EETENTION OF UEEA. 821 coloured, laminated concretions (sometimes called corpora amylacea) which are met with in the prostate. Dr. Eoberts quotes a case of Dr. Haldane's in which it was proved by post-mortem examination that car- iDonate of lime calculi, presenting similar characters, may be formed in the pelvis of the kidney and passed with the urine. Calculi formed of blood, albumen, or fat have occasionally been met with, and Dr. Ord has discovered one consisting of nearly pure indigo. C. The Specific Consequences of the Retention of Urea and other effete matters in the blood. Structural disease of the kidneys, involving both organs generally, is attended with one important consequence : — namely, the prevention, in a greater or less degree, of the elimination of urea, uric acid, and other pro- ducts of the retrograde metamorphosis of nitrogenous matters, and their consequent retention in the blood and in the fluids which bathe the tissues. Following on this retention, and in part dependent on it, but in part, no doubt, dependent on the constant loss of albumen which commonly attends diseases of the kidneys, the blood undergoes deterioration ; it grows Avatery, poor in albumen and corpuscles, and at the same time fibrine becomes relatively increased ; the patient gets anemic and suffers from many of the usual consequences of antemia. But in addition to these phenomena, others of great gravity, and in the aggregate special to renal disease, sooner or later supervene. These have been attributed simply to the retention of urea, but the experimental introduction of urea into the blood seems to show that this substance has little or no poisonous property. It can scarcely be denied, however, that the phenomena in question are really referrible to the retention, either of urea or of some of the less oxydised matters which accompany it, namely, uric acid, kreatine, kreatinine, and the like. Frerichs maintains that some of them are due to the conversion of urea in the blood into carbonate of ammonia. The chief morbid phenomena here referred to are : thickening and contraction of the smaller blood-vessels ; hyper- trophy of the heart ; anasarca and other dropsical effusions ; local con- gestions and hemorrhages ; inflammation of different organs, mamly those of the thorax ; and, lastly, various functional diseases of the diges- tive and other organs, but, above all, of the central nervous system. 1. Thickening and contraction of the smaller blood-vessels. — 'Dr. G. Johnson showed some years since that in cases of chronic renal disease the walls of the minute arteries, both in the kidneys themselves and generally throughout the system, became extremely thick, and at the same time much contracted. He attributed the thickening to hypertrophy of the m.uscular coat, and the narrowing to the tonic contraction of this coat, and regarded the combined phenomena as an effort of nature to oppose the transmission of poisoned blood to the tissues. The thickening of the arterial tunics and the contraction of the arterial channels in chronic renal disease are now established facts. It has, however, since been main- tained, more particularly by Sir W. Gull and Dr. Sutton, that the thickening is the result not of muscular hypertrophy, but of a ' hyaline- 822 DISEASES OF THE GENITO-UEINAEY OEGANS. fibroid ' conyersion ; that it is in fact a change not unlike that which occurs in cirrhosis of the liver and sclerosis of other organs — a change which in a sense ma}' be regarded as degenerative. In these latter views, so far as we have stated them, we are disposed to concur. 2. Hypertrophy of the heart, independent of valvular affection, has long been recognised as one of the most characteristic consequences of chronic kidney disease. The hypertrophy is general, and associated with more or less dilatation ; but the changes are, perhaps, more obvious in the left ventricle than elsewhere. Dr. Quain has shown that the thickening of the walls is due in some degree to increase of the connective tissue, in other words to a kind of sclerosis ; there is no doubt, however, that it is mainly dependent on muscular overgrowth, and that the stimulus to this over-growth consists in some obstacle which the heart's action has. to overcome. But smce the valves and larger arteries are aU, for the most part, healthy, this obstacle is not presented by them. There are obvious reasons why the veins must be considered to be inoj)erative in the matter. We are compelled, therefore, to look to the small arteries and capillaries. And that the obstruction really does reside in these vessels is clearly shown by the high tension which by sphygmographic observa- tion has been proved to prevail throughout the arterial system in such cases. It was formerly believed that the obstruction was caused by some abnormal attraction between the capillary blood-vessels or the tissues out- side them and the morbid blood. It is, however, doubtless due to the contraction of the channels of the capillary arteries. Dr. Sibson has. sho^T^i that generally in these cases the contractions of the two sides of the heart are not quite synchronous, and that there is a tendency, there- fore, to reduplication of the heart's sounds. 3. Anasarca and other dropsical effusions. — Kidney disease is one of the most frequent causes of general anasarca. This condition often reveals itself first in regions in which the connective tissue is lax, as the scrotum, eyelids, and conjunctivae, and is often recognised in the face before it appears in the lower extremities. There is generally neither li\T.dity nor dilatation of vems ; but the swollen surface presents an anaemic, wax-like character. Its cause is somewhat obscure. It is evidently not passive, for there is neither venous obstruction nor venous hyper^emia ; nor again is there any ob^dous impediment to the healthy action of the IjTnphatic vessels. It must then be due either to some peculiar tendency in the serum of the blood to transude through the capillary vessels, or to the sweating of this fluid through the walls of the smaller arteries in conse- quence of the heightened pressure which the blood within thenl exerts. In reference to this question it should be mentioned that Dr. Mahomed has shown that in scarlet fever there is a stage, preceding the occm-- rence of anasarca and even the appearance of blood or albumen in the urine, durmg which high arterial tension prevails, as demonstrated by the resistance of the pulse to pressure and by the form of the pulse-trace, and during which also the colouring matter of the blood may sometimes be recognised in the urine. The anasarca is not merely subcutaneous, but may involve the tissues of the larynx, the pulmonary texture, and LESIONS OF THE KIDNEYS. 823 other parts of the system ; and is commonly associated with a dry skin and considerable diminution of nrine ; to which circmnstances and to co-existent anaemia the presence of dropsy is no doubt attributable. 4. Congestions and hemorrhages are among the consequences of kidney disease. The most important of them are : effusion into the substance of the bram, causing apoplectic symptoms ; effusions into the choroid and retinal coats of the eye (albuviiimric retinitis), attended with aching across the temples and at the occiput, and leading to atrophic changes and im- pairment of vision, or even absolute bHndness ; and extravasations into the lung-substance, producing the condition known as pulmonary apoplexy. The causes of these hemorrhages are, in part, the same that induce anasarca ; but in chronic renal disease there is a marked tendency to atheromatous and fibroid degeneration of arteries, and hence effusions of blood are in some cases due to rupture of diseased and enfeebled vessels. 5. Inflammatory affections are of frequent occurrence. The most common and serious of these are inflammations of the pericardium and pleurfe, of the larynx, bronchial tubes, and lungs. But inflammation may also affect the abdominal viscera ; and, indeed, no part is wholly exemj)t from liabihty to it. When anasarca is present it is of course common for an erythematous blush to make its appearance somewhere or other on the surface, and even for erysipelas or superficial gangrene to occur. 6. The functional consequences of renal disease are very numerous. Dyspepsia, nausea, vomiting, and diarrhoea, the former three especially, are common phenomena, even when the stomach is healthy. Palpitation and dyspnoea, or hurried respiration, are not unffequently observed in cases in which the heart and Imigs present little if any sign of disease. Amblyopia, deafness, drowsiness, headache, irritability, subsultus, hypo- chondriasis, and even maniacal disturbance and wakefulness, are all of them Hable to arise. But the most serious of the functional disturbances of the nervous system are coma and con^nilsions. These are generally preceded by some of the less grave mental phenomena above enumerated. The convulsions occur in paroxysms which ahnost exactly simulate those of true epilepsy, and, associated with coma, often succeed one another at short intervals until they terminate m death. Coma or apoplectic symp- toms may occur independently of convulsions. D. The non-specific Morbid Phenomena ichich attend on and characterise Lesions of the Kidneys. Other symptoms which attend and indicate the presence of renal dis- ease are totally independent of impairment or suppression of the proper functions of the kidneys. These are, symptoms which are determined ■by the locality of the diseased organ, and such as are referrible to it as a focus of inflammation or other morbid processes. Among the former may be comprised pain and tenderness, tumour, and the effects of pressure ; amongst the latter the general sjinptoms of mflammatory fever when the organ is uiflamed, the cachexia which attends the develo^nnent of mahg- nant disease, and the anaemia which results fit'om the continued escape of blood, or of that important element of the blood^albumen. 824 DISEASES OF THE GENITO-UEINAEY OEGANS. II. PYELITIS. Causation. — Inflammation of the lining membrane of the kidney may he excited in various ways. It seldom results from exposure to cold, or arises in connection with ordinary nephritis. It may, however, be induced by the use of certain medicinal irritants, such as cantharides and turpentme, which probably induce at the same time a similar condition in the Iming membrane of the bladder, and in the secreting tissues of the kidneys. But its most frequent cause is direct irritation of the mucous surface, due either to the constant fretting of a renal calculus or to the influence of unhealthy discharges or decomposing urine, as occurs in cases of long- continued obstruction of the urmary passages. Independently of the last condition, vesical inflammation is apt to creep by continuity along the ureters to the pelves, and thence to the infundibula and calyces. Morbid anatomy. — The anatomical signs of pyelitis are congestion, thickening and softening of the mucous membrane, sometimes associated with interstitial hemorrhage ; and the discharge from its surface of mucus containing shed epithelial cells and pus-like corpuscles, and, it may be, blood. If the affection be persistent or intense, other phenomena probably supervene ; the thickened mucous membrane may become opaque, yellow, or grey, and lose its vivid redness ; suppuration may arise ; false membranes may form ; or ulceration may take place. Further, the effect of the unhealthy products of the mucous surface upon the urine is to render it ammoniacal and to promote the precipitation of eartby phosphates, which are then apt to concrete on the inflamed surface. Other changes which are liable to ensue in the course of pyelitis depend on impediment to the escape of urine from the mflamed ca^dty : they are dilatation of the pelvis, infundibula, and calyces, and atrophy of the secreting structure. Again, inflammation may extend by continuity from the pelvis to the renal substance, and abscesses may consequently form in it. Suppurative pyelitis, especially if it be confined to one kidney, and pus can escape freely from it by the natural passages, may continue for years with little or no additional mischief ; and even if complete obstruction of the ureter arise, it is possible that the whole thing may become quiescent, the ex- panded, atrophied, and indurated renal substance losing all its functional power, and the pus in the dilated calyces and the rest of the renal cavity drying up into a creamy, putty-like, or mortary substance. In other cases, however (and this may happen whether the ureter be wholly or only in part obstructed), the renal abscess takes another course. It behaves, in fact, as any other abscess originating in the vicinity might behave. It first transgresses its original renal limits, and then forms sinuses which enlarge and burrow in various directions. Thus, it may perforate the diaphragm, and open into the pleura or lung ; or it may discharge in the loua ; or it may rupture into the peritoneum, or open directly into the adjoining colon ; or, descending along the psoas muscle, it may point under Poupart's ligament, or gravitate towards the lesser trochanter ; PYELITIS. 825 or lastly, passing into the pelvis, it may communicate there with the rectum, bladder, or vagma. Symptoms and progress. — -The specific symptoms of pyelitis comprise pain and tenderness in the loin, irritahihty of the bladder, and modifica- tion of the quality of the urine. The pain in the loin is a^Dt to shoot into the abdomen, and especially downwards to the labium or testis of the corre- sponding side and along the iinier aspect of the thigh. The tenderness reveals itself, and the pain is aggravated, during movement of the body ; but especially if the affected side of the abdomen be firmly grasped, or the thigh be flexed by its own muscular efforts on the abdomen, in which case the enlarging bulk of the psoas muscle presses on the inflamed organ. There is probably irritability of the bladder, with pain and scalding in micturition. The water is more or less turbid from the presence of mucus, or it contains x^us or blood, or both. It is usually acid ; but, after a time, is apt to become ammoniacal from the decomposition of urea, and then to deposit amorphous and crystalline phosphates. It does not necessarily con- tain renal casts. Their presence indicates of course simultaneous involve- ment of the secreting structure of the kidney. Sometimes the discharge of pus is profuse ; and both in this and m other cases the products of the uiflamed surface are not unfrequently passed intermittently : temporary obstructions probably taking place in the ureter, in consequence of which they are retained and accumulate in the renal cavity with aggravation of local s}iaptom3, and the urine becomes for the time comparatively clear and healthy. The general symptoms are mainly those of inflammatory fever. This assumes for the most part a remittent character, and is often attended with rigors. Vomiting and diarrhoea are not unfrequent. The symptoms, progress, and results of pyelitis difler m difl'erent cases. If one kidney only be affected the disease may continue indefinitely without any very serious impairment of the patient's health — indeed, the organ may become totally disorganised with httle or no obvious detriment to health ; but, on the other hand, the formation of an abscess is in any case attended with many risks, and its contmuance may cause death by slow exhaustion, aggravated probably by the presence of hectic fever or lardaceous degeneration, or by the supervention of some intercurrent affec- tion. ^Yhen, however, both kidneys are involved, as may happen in calcu- lous pyelitis, and as nearly always takes place when pyelitis is secondary to bladder disease, the symptoms w^hich the patient presents are neces- sarily greatly aggravated, and the probability of an early fatal issue is much increased^ For, m addition to the risks which attend disease con- fined to one kidney, we have now the additional risks which arise from the liabihty to retention of urea in the- blood, and those which flow from the comparatively wide extent of the inflamed district. The patient passes into a typhoid condition, attended with muttering delirium, and not unfre- quently complicated with epileptiform convulsions and coma. Accumulation of pus m the kidney may be suspected when the dis- charge of pus with the urine ceases suddenly and continues in abeyance ; it may also be suspected when, following upon symptoms indicative of 826 DISEASES OF THE GENITO-URINAEY OEGANS. pyelitis, rigors take place and at the same time throbbing pain and tender- ness manifest themselves in the region of one of the kidneys. The diagnosis of an abscess must be based partly on the persistence of the above con- ditions, partly on the presence of increasing fulness in the neighbourhood referred to. If the abscess point externally all doubt will be speedily removed. Under other circumstances many difficulties will necessarily present themselves. Treatment. — In the treatment of pyelitis it is of primary importance to ascertain its cause, and to remove or obviate it if possible. Thus, when it depends on retention of urine, from stricture, enlarged prostate, or paralysis of the bladder, our aim must be (if not to cure these lesions) at all events to empty the bladder periodically and if necessary to wash it out with antiseptic solutions ; when it depends on the presence of renal or vesical calculi, we must endeavour to remove them, or, failing this, to maintain rest ; if the inflammation be connected with gout, scrofula, or any other special cachexia, it wiU probably be well to modify our treatment accordingly. When pyeHtis is acute and the local symptoms are severe, it may be necessary to remove blood from the loin either by cupping or by leeches, and to use hot fomentations, poultices, ice-bags or equivalent applications. Counter-irritants, too, always excepting cantharides, may be employed. The administration of opium, in doses sufficiently large and sufficiently often repeated to reheve pam and procure ease and rest, is of essential im- portance. Moderate piu'ging, voluminous bland clysters, and hot baths are also valuable aids. When the disease assumes a more chronic cha- racter local measures become less important, and opiates also are compara- tively little needed. It may, however, still be desirable to give the latter hi small doses, or to administer some other form of sedative or anodyne, such as hyoscyamus, belladonna, or chloral hydrate. But tonics and nu- tritious diet now become our most valuable remedial agents ; among the former, quinine and the other vegetable bitters and iron (particularly the perchloride) and cod-liver oil, must be especially enumerated. If the urine be alkaline, nitro-muriatic acid or some other mineral acid may be- beneficially combmed with the other remedies. Buchu, pareira brava, and uva ursi, so much appreciated by surgeons in the treatment of chronic mflammation of the urinary bladder, are probably equally useful m the treatment of pyelitis. If the stomach be irritable, as it not unfrequently is, our treatment must be modified mth the object of overcoming this irritability. When there is clear indication of the formation of an abscess in or around the kidney, an early and free opening should be made into it, for by that means not only may the extension of the abscess in other directions be prevented, but the cure of the disease will not improbabfy be effected. III. CIECUMSCPJBED AND SUPPURATIVE NEPHRITIS. Causation. — The chief causes of the conditions about to be considered are : — obstruction of the renal arteries or arterioles by thrombi or ( in the CIECUMSCEIBED AND SUPPUEATIVE NEPHKITIS. 827 case of cardiac disease or pyaemia) by emboli ; extension of inflammation from the pelvis of the kidney or other neighbouring parts ; and accidental injury. Morbid anatomy. — The results of arterial thrombi or emboli are the- same in the kidney as elsewhere. If the obstructed vessel be of large or medium size, the district to which it leads becomes deeply congested, blood accumulates and stagnates in the arteries, veins, and capillaries, and escapes from them, by rupture or otherwise, not only into the intertubular tissue but into the Malpighian capsules and convoluted tubules. The affected district is at first of a deep red or reddish-black colour and well defined, resembling a patch of pulmonary apoplexy ; but gradually it be- comes decolourised and acquires an opaque, buff- coloured, cheesy aspect, when, if it be examined microscopically, the small vessels will be found loaded with pigment-granules and oil, and the epithelium of the tubules fatty and disintegratmg. Sometimes it softens, sometimes suppurates. But the disintegrated tissues may also undergo absorption, and a patch of cicatricial tissue result. In the embolism of cardiac disease and especially in that occurring in pyaemia, the infarctions are for the most part small and numerous, and speedily suppurate. In such cases, on removing the capsules, beads of pus each surromided by a congested halo may be seen, projecting from the surface of the organ ; and on making a vertical section small abscesses or groups of abscesses, similarly surrounded, may be ob- served extending in a radial direction from the periphery to the mucous surface. These may vary from mere points up to the size of a filbert or walnut. They originate in the intertubular spaces, but soon involve and destroy the tubules themselves and the other renal structures. When in- flammation extends from the pelvis of the kidney there is often general con- gestion mth enlargement of the organ ; but the special feature of such- extension is the formation, in both medulla and cortex, of minute close- set abscesses grouped in comparatively large and well-defined but not very numerous clusters. Abscesses of the substance of the kidney are attended with various results. Sometimes their contents gradually concrete into a material like thick cream or moist plaster of Paris, consisting of disinte- grated and fatty cells, molecular matter (partly earthy, partly oily), and cholesterine. In the most extreme examples of this kind of change the^ glandular substance of the kidney is hollowed out into a series of cavities, each one corresponding to a medullary cone and its associated cortical lo- bule, which are bounded externally, and separated from one another and from the pelvis, by thin fibrous laminte or dissepiments. Sometimes the abscesses open and discharge their contents into the infundibula ; some- times they extend beyond the limits of the kidney ; and then in either case the affection becomes indistinguishable, pathologically and clinically,, from suppurative pyelitis. Symptoms. — It would be almost impossible to lay down any definite rules for our guidance in reference to the diagnosis of the above affections. In a large number of cases the renal symptoms are necessarily masked by the graver morbid conditions with which they are associated. Thus when. 828 DISEASES OF THE GENITO-UEINAEY OEGANS. renal abscesses result from embolism, pyemia, or inflammation commenc- ing in the pelvis of the kidney, the febrile or typhoid symptoms referrible to the primary malady may perhaps become in some degree aggravated, the prospects of amelioration somewhat diminished, the fatal event hurried ; but probably nothing points specially to im.plication of the sub- stance of the kidney. Even if the urine be scanty or contain blood, albu- men, casts, pus-cells, or leucocytes, there is nothing to show that such conditions may not be the result of some other variety of renal inflam- mation. If large abscesses form, the symptoms and consequences will be those of suppurative pyelitis. The treatment of these cases (if they call for treatment) does not differ from that of pyelitis. IV. ACUTE BEIGHT'S DISEASE. [Acute Albuminous, Desquamative, or Tubal, Nephritis.) Causation.— This afl^ection maybe produced by many difl'erent causes. It may result from simple extension from the inflamed pelvis in pyelitis ; it may be due to the influence of cantharides and other poisonous sub- stances ; and it frequently accompanies erysipelas, pneumonia, and such- like grave inflammations, as also variola, measles, cholera, and other specific fevers. Its most important causes, however, are exposure to cold or wet, and the scarlatinal poison. It occurs also in pregnancy. Morbid anatoviy. — In acute Bright's disease the morbid process impli- cates in a greater or less degree all the renal textures and for the most part is generally diflused and involves both kidneys equally, [a] The vessels (and more especially those of the medulla, the Malpighian tufts, and the stellate veins on the surface) become congested ; and occasion- ally, undergoing rupture, discharge blood into the interstitial tissue, or into the Malpighian bodies and tubules, [b) Proliferation of the nuclei in the membrane which invests the Malpighian vessels, and of those belonging to the muscular walls of the arterioles, not unfrequently occurs. Lymphoid or embryonic cells sooner or later accumulate around the arteries and in the intertubular tissue. They are first seen as a rule along the larger branches ; and then accumulate about the bases of the pyramids, whence they spread partly into the medulla, but mainly into the cortex along the interlobular vessels. The process may thus reach the surface of the kidney, and by lateral extension implicate the connective tissue between the Malpighian bodies and convoluted tubules, (c) The epithe- lium of the renal tubules, and more especially that of their convoluted portions, gets cloudy and swollen, and there is a tendency to multipli- 'Cation of the nuclei. Consequently the tubules become distended and varicose, their channels get reduced in size or obliterated, and their •contents acquire unusual opacity. At a later period the cells tend to become fatty and to break down, to separate from one another and from the membrane beneath, and to be shed ; and new cells of embryonic <3haracter make their appearance among them. Lastly, the channels of ACUTE BEIGHT'S DISEASE. 829^ the urinary tubules become occupied in a greater or less degree by casts, which are either cellular, hyaline, or granular, or consist of blood in a more or less altered condition. But the diseased kidneys do not always, or indeed generally, present all the phenomena above described ; and especially it is an important fact, that in some cases the changes, even from the beginning, are mainly epithelial, while in others the interstitial tissue is from first to last the chief seat of disease. There is a tendency, however, in all cases, especi- ally if they are prolonged, for the morbid processes to become generalised. Partly for convenience of description, partly because they represent tolerably well-defined types, we shall describe three varieties of the disease. 1. Catarrhal inflammation is the name which may be given to the slight and for the most part evanescent affection which is often met with in poisoning by cantharides and other such substances, in connection with certain inflammatory or infectious disorders, and under many other cir- cumstances. In the first group of cases the tubal affection is associated with congestion or inflammation of the mucous membrane of the pelvis, and is for the most part limited to the medulla. In other cases, and indeed in most, the cortical tubes are mainly if not exclusively implicated. The naked-eye appearances are not very striking : there is enlargement and softening of the organ ; its capsule can be readily peeled off ; the stellate veins on the surface, the Malpighian bodies, and the medulla are all more or less congested ; while the cortex (if the cortex be the main seat of disease) is probably somewhat paler or more yellow and opaque than natural. 2. Another variety is that which arises mainly from exposure to cold and wet, and is observed in ordinary cases of acute idiopatJiic nephritis. In this the predominating features are (as in the last case) congestion and cloudy swelling of the epithelium. But the congestion is much more intense and general, and is not unfrequently associated with hemorrhage, either into the interstitial tissue, or, as is more common, into the renal tubules and Malpighian capsules ; and the cloudy swelling involves the contents of all or nearly all the convoluted tubes, and probably in a greater or less degree the epithelium of the loops of Henle. The kidney, conse- quently, is much enlarged — sometimes indeed to twice its natural bulk — and softened ; and its capsule admits of easy removal. The cortex is es- pecially thickened. The aspect of the organ varies : in some cases the congestion is so extreme and general that the whole of the secreting-^ structure, cortex and medulla alike, presents a deep red or claret colour ;, but more frequently the medulla is deeply congested, while the cortex, though studded with red points and streaks, is remarkable for its opacity and pallor, resembling in this respect a hepatised lung. If the disease persist, interstitial changes, which may at first have been indistinct or absent, are apt to supervene. 3. Scarlatinal nephritis difters in many important respects from the last. The first observable changes are in the glomeruli, small arteries, and convoluted tubes. The internal elastic lamina of the arterioles, but 830 DISEASES OF THE GENITO-UEINAEY OEGANS. mainly of the afferent brandies, and the walls of the Malpighian capillaries, undergo hyaline thickening, which is attended with more or less complete obstruction of their channels ; the nuclei connected with the Malpighian tufts (probably the epithelial nuclei) proliferate ; the muscular nuclei of the smaller arteries likewise multiply ; and at the same time cloudy swell- ing takes place in the epithelium of some of the convoluted tubes. Some- what later, at the end probably of a week or ten days, other phenomena •ensue. Lymphoid cells appear in the interstitial tissue, and occasionally in such excess that the diseased textures present the characters of adenoid iiissue ; and the epithelium of the convoluted tubes becomes more generally and distinctly swollen and cloudy. The scarlatinal kidney presents much "the same appearance as that last described, but on the whole is generally ■smaller and less congested. The results of acute Bright's disease are various. Sometimes at the end of a few days, a few weeks, or a few months, the morbid processes -come to an end, and the kidneys revert to their healthy condition, or to a condition which is practically healthy but in which a few Malpighian Ibodies and tubes remain permanently atrophic. In other cases the disease becomes chronic, the convoluted tubes remain obstructed by their accumulated and degenerating contents, or the interstitial nuclear growth ■changes into fibroid tissue, and some one or other of the conditions presently to be described ensues. Symptoms and lyrogress. — The symptoms of acute Bright's disease vary much in severity, and are sometimes so trivial as to escape notice. Es- pecially is this the case in many febrile and inflammatory disorders, where p)erhaps the only evidence of renal implication is the temporary presence ■of albumen and hyaline casts in the urine. The symptoms observed in severer cases consist mainly in fever, aching across the loins, an abnormal state of urine, and anasarca. The febrile phenomena comprise elevation •of temperature, sense of chilliness and occasionally rigors, quickness, ful- ness, and hardness of pulse, heat and dryness of skin, flushing of face, ■clamminess of mouth with coating of tongue, thirst, loss of appetite, nausea and not unfrequently vomiting, headache and pains in the limbs. From the commencement, probably, the patient notices that his water is scanty. A few ounces only may be excreted in the course of the day and night ; or there maybe complete suppression for many hours. What is passed is abnormally dark and often turbid or grumous ; its specific gravity is usually high ; it contains abundant albumen, often blood, and a diminished quantity of urea ; and, microscopically, it presents epithelial, hyaline, granular, or bloody casts. It often also contains amorphous urates and uric acid crystals. But notwithstanding the scantiness of the urine there is generally a constant desire to pass water, and a sense of heat or pain in the bladder and u.rethra. Anasarca comes on early. It usually mani- fests itself first in the face, particularly in the eyelids and conjunctivae, in the genital organs or about the ankles. But it soon becomes general, and may become enormous, especially in the specified regions, and in the most dependent parts. The surface at the same time tends to assume a ACUTE BEIGHT'S DISEASE. 831 peculiar pale waxy aspect. Dropsy is not limited to tlie surface, but takes place also into the serous cavities and into tlie tissues of different internal organs, causing, according to its seat, difficulty of breathing or other more or _ less serious consequences.. Besides pain in the loins there may be actual tenderness there ; and the pain may extend into the thighs, as in pyelitis. The symptoms, however, are by no means always in accordance with the above sketch. Sometimes anasarca is the first intimation that the patient or his doctor has that the kidneys are affected, and it is only on further enquiry that the urine is found to be abnormal. Sometimes growing anaemia and weakness alone point to the kidney affection, which the exami- nation of the urine then detects. Sometimes almost the first indication of disease is the presence of palpitation, orthopnoea, and lividity of surface, without any discoverable lesion of either the heart or the lungs. In some cases the urine is scanty, albuminous and bloody, and yet no anasarca, and scarcely any other indications of impaired health manifest themselves. And occasionally also, while all other signs of renal inflammation are present, the urine remains free from albumen. The progress and results of acute nephritis are very various. In a large proportion of cases recovery takes place, sometimes in a week or two, more frequently at the end of six or eight weeks, occasionally after the lapse of six or tAvelve months or more. The symptoms of returning health are chiefly restoration of the functions of the skin, subsidence of anasarca, and return of the urine to its normal quantity and character. At the begmning of convalescence, indeed, the urine is often in excess. The anasarca usually subsides before the urine gets quite free from albumen. It is not uncommon, however, especially after scarlet fever, for anasarca to persist even after the urine has become healthy. In a smaller proportion of cases, but unfor- tunately in far too many, the affection either ends fatally while it is still acute, or assumes a chronic and incurable character. The fatal event may occur at different periods, and may depend on one or other of the follomng causes : — namely, oedema of vital organs, as of the larynx, or lungs, pro- ducing dyspnoea, lividity, palpitation, asphyxia ; inflammation of the peri- cardium, pleurae, lungs, or peritoneum ; anaemia and debility ; and, lastly, cerebral symptoms, especially coma and convulsions. Treatment. — In the treatment of acute nephritis it is important to assuage if possible the inflammation which is in progress. For this purpose we may apply comiter-irritants, hot fomentations, or cupping-glasses to the loins, or abstract blood by leeches or cupping from the same part. The patient should be kept warm in bed and clothed in flannel ; warm or hot baths, or the wet pack, should be occasionally administered for the purpose of promoting the action of the skin ; and the boAvels should be kept moderately free by saline purgatives. The measures just enumerated un- doubtedly conduce to restore the functions of the kidneys, and it is on them we must rely if suppression of urine supervene. But, as is strongly urged by Dr. Dickinson, it is important also to remove from these organs the solid cylinders which are blocking up the tubules, and by their pressure obstruct- 832 DISEASES OF THE GENITO-UEINAEY OEGANS. ing the efferent veins. To this end the secretion of urine should, if possible , be promoted directly. It is uncertain how far diuretics are capable of effecting this purpose ; but, at all events, it seems judicious to encourage the patient to drink water and other simple fluids, and to administer- diuretic doses of the acetate or citrate of potash or other equivalent medicines. Digitalis is especially valuable. At a somewhat later period, when, in addi- tion to other symptoms, anaemia is present, vegetable tonics and the pre- parations of iron are often of great value. The perchloride of iron, which is a diuretic as well as tonic, is a favourite remedy. The patient's diet should be nutritious, but light, easily digestible, and consist mainly of milk and farmaceous substances. Alcohol in any form is rarely needed, and gener- ally likely to be injurious. If urfemic symptoms supervene active purgation by means of elaterium, compound jalap powder, or some other form of drastic purgative should be employed. Other complications must be dealt with on general principles. There is a great tendency for nephritis to recur, and great care therefore should be taken during convalescence. Iron and vegetable bitters, change of scene, and residence in a warm climate are often at this time of great service. V. CHRONIC BRIGHT'S DISEASE. A. Chronic Parenchymatous or Tuhal Nephritis [Large White Kidney and Fatty Kidney). Causation. — The causes of the sub-acute or chronic form of tubal nephritis, which we are now about to consider, are somewhat obscure. In a considerable number of cases the disease comes on, so far as we can see, spontaneously, or at any rate insidiously. But in some it is directly refer- rible to exposure to cold and wet ; and in most eases probably is a sequela of the acute inflammatory affections last described. It is a disease mainly of early life, seldom occurring under three or over forty. Morbid anatomy. — Anatomically the large white kidney is closely re- lated to, if it be not identical with, those forms of acute Bright's disease in which the pathological changes involve mamly the contents of the tubules. In this case as in those, the epithelium is swollen, cloudy or faintly granular from the precipitation of proteinous particles, distends the tubes in which it is contained, renders them more opaque than natural, and contracts or obliterates their channels ; in this as in those, the axes of the tubes become blocked up in a greater or less degree by mucous, colloid, or granular casts, while changes in the interstitial tissue are either absent or comparatively slight, or come on late. But congestion, which is an important condition in the acuter disorder, is absent here. The phenomena above described belong mainly to the convoluted tubes, are sometimes limited to them, and indeed may involve a certain proportion of them only. Not unfrequently, however, they also implicate the loops of Henle, and may even extend into the straight tubes. The Malpighian bodies usually remain healthy ; there may, however, be some multiplication of the nuclei of the capillaries of the CHEONIC BKIGHT'S DISEASE. 833 glomeruli, and some degeneration of the epithelium mvestmg them. The kidney thus affected is much larger than natural, sometimes twice its normal size, soft, and smooth on the surface ; and its capsule can be readily removed. Its enlargement is due to the increased bulk of the cortex, which is white or yellowish, opaque, and sometimes ivory-like. It may be absolutely devoid of blood, or may present only a few vascular points and streaks. The medulla for the most part remains healthy. Both kidneys suffer. With the continuance of the disease changes of more or less importance ensue. The swollen epithelium becomes fatty, and tends to break down, and when the change is advanced the tubules appear stuffed and opaque with fatty detritus. The fatty change may be general, in which case the cortical substance acquires a more or less uniform buff-colour ; or it may be irregularly distributed or more advanced in patches, when the organ looks as if it were sprinkled vntli bran. At this stage the Malpighian tufts are often studded with groups of fatty granules, or there is an accumu- lation of fatty detritus in the intervals between the tufts arid capsules ; and occasionally also fatty granules, in more or less abundance, occupy the mterstitial tissue. The ' branny kidney,' as it is sometimes called, is often smaller than the typical ' large white kidney,' and may present an indistinctly granular surface. In connection with this fatty change we sometimes find distinct increase of the interstitial connective tissue of the organ. The kidney then tends to become small, and granular on the surface, and to present some of the characters of the contracted granular kidney which wiU presently be described. Further, degeneration of the renal epithelium occurs in poisoning by phosphorus. It is sometimes also met with in diabetes and certain other disorders. Symptoms and progress. — The early symptoms of the disease mider consideration vary according to the circumstances under which it is de- veloped. If it be a consequence of scarlet fever, or of any other variety of acute Bright's disease, the ordinary phenomena of acute nephritis precede them, and either at once, or after a series of remissions and exacerbations, merge into them. A common history is that the patient after some acute attack gets apparently well, but does not wholly lose his albiuninuria ; and that he continues fahiy well, but with persistent albu- minuria, or hitermittent attacks of it, until at the end perhaps of some years characteristic symptoms come on. If it be of acute origm, lumbar pain, febrile phenomena, and smoky urine are amongst its primary symp- toms. But whenever the disease comes on as a late sequela of some acute form of nephritis, or independently of present inflammation, its S}Tnptoms creep on gradually. They are maialy scanty excretion of urine, rapid occurrence of general di'opsy, and speedy manifestation of antemia. In the early stage of the disease the urine is always diminished in quantity ; not unfrequently three or four ounces only are passed m the twenty-four hours ; and occasionally there is temporary suppression. Yet there is generally a good deal of irritability of bladder, and frequent desire to micturate. The urine, besides being scanty, is dark-coloured, of high 3h 834 DISEASES OF THE GENITO-UEINAEY OEGANS. specific gravity, and deposits a sediment. It contains a large quantity of albumen, and, under the microscope, presents more or less abundant casts, which are for the most part mucous or colloid, and if fatty changes have occurred granular, or studded with oily matter, or invested in fatty debris. Sometimes the casts are few in number or altogether absent. Uric acid crystals are often present, and sometimes very numerous and large. Urea is much diminished. Dropsy always comes on early, and soon becomes general and abundant, and, although liable to vary somewhat in degree, is, on the whole, very persistent. With the increase of dropsy the surface grows more and more pale and waxy-looking. The gradual supervention of anaemia is generally a striking feature of the disease. This is in part apparent only, and due to the presence of anasarca ; but it is referrible mainly to actual deterioration of the blood, determined in some degree by the daily abundant loss of albumen. As in ordinary anaemia, persons with delicate skin not mafrequently display a fallacious appearance of bloom in the cheeks. Together with the above symptoms patients suffer from debility, restlessness, dyspnoea, loss of appetite, vomiting, and other symptoms of gastro-intestinal disturbance. Among the sequelae or com- plications of the disease the following may be enumerated : — dropsical effusion into the pleurae, lungs, or glottis ; inflammation of the lungs, pleurae, pericardium, or peritoneum ; erythematous, erysipelatous, or gan- grenous inflammation of the dropsical skin, more especially of the lower extremities and external genital organs ; and hypertrophy of the heart. Lastly, uraemic symptoms are not unfrequent, especially headache and sickness, followed by convulsions or coma. It is important, however, to recollect that cardiac enlargement and albuminuric retmitis are less frequent, and as a general rule less pronounced, in this disease than they are in cases of contracted granular kidney. Patients may of course recover from this disease, and the milder the attack the more likely is recovery to ensue. Favourable symptoms are : increase in the amount and diminution in the specific gravity of the urine, disappearance of albumen, restoration of the functions of the skin, and subsidence of dropsy. Casts may continue in the urine after albuminuria has ceased. If a cure take place it is generally within six months. Eecovery is in many cases fallacious ; the patient improves to a certain point only (it may happen indeed that both albuminuria and dropsy dis- appear) and then after remaining pretty well for a time he has a relapse of which he dies ; or the disease is prolonged by alternate remissions and relapses for several years. Death usually occurs in from three to twelve months, generally withm six, either from extreme asthenia or from one of the complications which have been enumerated. But if we reckon the duration of the disease from the scarlatinal or other acute affection to which it may have been remotely due, it must be measvired by years, and may certainly be as much as ten or fifteen. CHEONIC BKIGHT'S DISEASE. 835 B. Chronic Interstitial Nephritis. {Contracted Granular Kidney. ' Gouty Kidney.) Causation. — Chronic interstitial nephritis is more common in men "than in women, and is met with almost exclusively in advanced life. It rarely occurs luider forty years of age ; but is sometimes observed even in young children. The causes which determine it are not well understood. There is reason to believe that the tendency to it is sometimes hereditary. It is certain, too, that it is often combined with wide-spread changes of a similar kind in other organs. It is frequently associated with gout, and there is some obscure but undoubted connection between it and chronic lead-poisonmg. Alcohol has certainly not the same tendency to produce this state of kidney that it has to cause cirrhosis of the liver. Nevertheless, there is good reason to believe that a small number of cases may be referred to abuse of drink. Again, it must, we think, be admitted, that the various inflammatory affections of the kidney already described, especially that originating in scarlet fever, and parenchymatous nephritis, tend in the course of years to produce a contracted granular condition of the organ, scarcely if at all distinguishable from that due to primary interstitial nephritis. Morbid anatomy. — The contracted granular kidney is in distinct ana- tomical relation with the scarlatinal kidney, inasmuch as in both of them the morbid process commences in and implicates essentially the renal vessels and interstitial texture — the affection of the tubules and of then* contents being secondary. Nevertheless, it cannot be pretended that they usually stand to one another in the relation of cause and effect. The typical contracted granular kidney is much smaller than the healthy organ, and occasionally not more than an ounce or half an ounce in weight. Its capsule is adherent, and on removal apt to carry with it small portions of the cortical substance. The surface is nodulated like that of a cirrhosed liver (the nodules being perhaps as large as hemp-seeds) and of a deep reddish hue. On section the cortex is found to be much reduced in thickness, the medulla atrophied, though in a less degree, and the texture of the organ generally dark-coloured and dense. Cysts of various sizes, and in more or less abundance, are often observed studding the secreting structure, but more especially the cortical portion. On microscopic ex- amination, the Malpighian bodies are seen to be largely changed, they are much reduced in size, their capsules are thickened and laminated, and their capillary tufts are welded into almost homogeneous lumps ; the convoluted tubes are atrophied, sometimes denuded of epithelium or lined with embryonic cells, sometimes stuffed with fatty contents, sometimes filled "tt^th hyaline casts, sometimes reduced to fibrous filaments or bands, scarcely distinguishable fi'om the surromiding tissues, sometimes con- verted into microscopic cysts lined or not ^dth distinct epithelium ; the loops of Henle and the straight tubes show less important changes, never- theless their epithehum may present fatty degeneration, they may be blocked up with hyahne casts, and occasionally some of them are converted 3h2 836 DISEASES OF THE GENITO-UEINAEY OEGANS. into strings of cysts ; the vessels, more especially the arteries, are much thickened, and at the same time reduced in calibre, while the larger ones are probably also atheromatous ; and finally, the connective tissue of the organ is more or less extensively hypertrophied. This fibroid growth occurs mainly along the interlobular vessels, extending vertically from the surface to the junction of the cortex and medulla, and then spreads hori- zontally so as to involve in the first place, and most importantly, the immediately contiguous Malpighian bodies and convoluted tubes, leaving the straight tubes which occupy the centres of the lobules comparatively free. This distribution explains both the special atrophy of the Malpighian bodies and convoluted tubes, and the granular condition of the surface of the organ — the depressions corresponding to the intervals between lobules, the elevations to the comparatively healthy central portions which contain the straight tubes. In the early stage of the disease, as in the early stage of cirrhosis of the liver, the kidney is little if at all diminished in size, the granulations on the surface are absent or only slightly developed, and a new growth of embryonic tissue may be observed in all those regions which subsequently undergo contraction and atrophy. The changes above described occasionally affect limited parts of otherwise healthy kidneys ; and often manifest themselves ultimately in the attenuated and compressed kidney- structure, seen in advanced hydro-nephrosis. Further, as has already been pointed out, the fatty and granular conditions are not un- frequently associated. In which case the kidney is larger and more irregular in form than the simple granular kidney ; its superficial granules are larger and paler ; and its cortex is mottled with whitish and yellowish patches, due to arese of fatty degeneration. The cystic kidney. — There is probably no essential distinction between the cystic kidney and that just described, notwithstanding that the former may attain the bulk of a bullock's kidney, and the latter is usually unnaturally small. It has been mentioned that in the granular kidney obvious cysts are of common occurrence. There is no limit, indeed, to their size and number ; the cause which produces them at one or two points in one case may be in general operation in another case, and hence in place of half a dozen we may have hundreds or thousands ; and instead of being no larger than a pea or marble many of them may attain the size of a pigeon's egg or a still greater bulk. In some of the more remarkable cases of this kind the kidney during life constitutes an easily recognisable tumour, and post mortem may have the aspect of a multilo- cular ovarian growth (consisting of little else than a congeries of cysts) probably measuring seven or eight inches in length, and weighing between two and three pounds. The contents of the cysts vary in character even in the same case. They are sometimes limpid, sometimes thick and treacly, sometimes solid and jelly-like. They may be colourless or straw- coloured, or may present any tint between this and a dark brown or red. They may be clear, turbid, or opaque. They usually contain albumen and the ordinary salts of the serum of the blood, but rarely if ever any special urinary constituents. The more viscid accumulations CHRONIC BRIGHT'S DISEASE. 837 probably contain colloid matter. Among microscopic constituents are observed in different cases granular or fatty matter, disintegrating cells, decomposing blood, and cholesterine. Further, the cysts are often lined with pavement -epithelium. There is reason to believe that they originate both in Malpighian bodies and in portions of renal tubules which, owing to inflammatory or degenerative changes, have been cut off from their connection with the rest of the secreting structure of the kidney. The abundant microscopic cysts observed in many cases of granular kidney certainly originate in convoluted tubules which, losing their epithelium or undergoing degeneration, become obliterated at points, distended in the intervals, and thus acquire a moniliform character. Another view, originally proposed by Mr. Simon, is that they arise in extravasated and overgrowing or dropsical renal epithelial cells. It is a curious fact that in some of the most typical cases of cystic kidney similar cysts have been abundantly present in the liver. Symptoms and progress. — The symptoms of granular kidney usually come on insidiously, and do not attract notice until the disease has made considerable progress. Indeed, it is often the occurrence of some com- plication that first calls attention to the presence of renal mischief. The patient, who had formerly enjoyed good health, gets thin, weak, and anaemic without obvious cause ; he suffers from dyspepsia, has loss of appetite, nausea, and perhaps actual sickness ; he complains of shortness of breath and palpitation ; he is liable to bronchitic attacks ; his eye- sight becomes impaired ; and he probably notices that he makes more water than he was accustomed to make, and that he has to get up several times in the night to pass it. At length he seeks medical advice, and the urine is found to be of persistently low specific gravity, and probably to contain albumen. In other cases attention is first seriously directed to the patient's condition by puffiness of the conjunctivae or eyelids, or swelling of the legs or scrotum. In other cases, again, the first clear intimation of disease is the supervention of severe sickness or diarrhoea, or paroxysms of extreme dyspnoea, or oedema of the larynx, or the deve- lopment of tremors not unlike those of paralysis agitans, or attacks of sudden blindness without visible optic changes and tending to remit, or uraemic convulsions, or an apoplectic seizure. The early symptoms, indeed, which are also in many respects those of the established disease, are multiform ; and they are frequently masked by the presence of associated visceral lesions, more especially of the heart, lungs, liver, in- testinal canal, and brain. Nevertheless there are certain phenomena which are specially characteristic of the disease and indicate its presence, and to these we will now direct attention. The urine is almost always abundant, pale, limpid and acid. Three or four pints, or even eight or ten, may be passed habitually during the twenty-four hours. Its specific gravity is low, varying from about 1003 or 1004 to 1010 or 1012, and it contains but little urea or other normal urinary constituents. Nevertheless the total amount of urea discharged daily is often fully up to the normal standard. Albumen, though 838 DISEASES OF THE GENITO-UEINAEY OEGANS. generally present, is in small proportion. It is sometimes, however, in excess ; sometimes wholly absent. Microscopic casts, too, are scanty, and may be readily overlooked ; they are for the most part hyaline and granular. The condition of the urine may, however, vary : sometimes because the renal disease is not one of pure interstitial nephritis, some- times as a consequence of temporary congestion or inflammation ; and late in the disease it is apt to become scanty, of comparatively high, specific gravity, and at the same time highly albuminous, maybe bloody, and deficient in urea. Owing to the abundant and long-continued diuresis, and the scantiness or absence of albumen, cases of contracted granular kidney are occasionally mistaken for cases of diabetes insipidus. Dropsy, so common in other forms of Bright's disease, is often absent in this ; and, even when present, is for the most part slight and variable and of late occurrence. It is sometimes limited to the conjunctivae. But occasionally it becomes extreme, especially in those cases where also the urine becomes scanty, and hence mainly towards the close of life. It is in association with the contracted granular kidney that thichening of the walls of the small arteries ' and hypertrop)hy of the heart mainly occur. The degree of these changes is generally proportioned to the length of time during which the renal disease has been in progress, and to the degree to which the kidneys have shrunk. The hypertrophic condition of the heart is generally revealed by its heaving pulsation and increased area of dulness ; and the general arterial affection by heightened tension of the larger arteries and incompressibility and prolonged tidal wave of the pulse. At a late period, however, the heart becomes weak. In association with the continuance of the conditions here discussed, the patient becomes more and more enfeebled and incapable of exercise, and probably emaciates ; he complains of dryness of mouth or thirst, loss of appetite, flatulence and nausea, and especially at a late period of constant and distressing sickness ; his bowels probably are variable ; he has attacks, of difficulty of breathing coming on mainly at night-time, and presenting a good deal of resemblance to those of ordinary asthma ; he suffers also, from headache, giddiness, or sense of oppression or weight, is often dis- posed to somnolence, and becomes apathetic. His skin is harsh and unperspiring, and his complexion probably sallow ; but he rarely becomes, distinctly anaemic, or suffers from lumbar pam. Many complications are apt to arise in the course of the disease, especi- ally towards its fatal close. Inflammatory affections are common, more, particularly inflammation of the pericardium and pleurae, oedema of the. glottis, bronchitis, and pneumonia. Functional nervous disorders also are extremely common, and among the most characteristic of them. They comprise (besides headache, somnolence, tremors, sickness, and delirium) epileptiform attacks or coma, which are frequently preceded by these or other nervous phenomena, and attacks of amaurosis without obvious affec- tion of the eyes, which are apt to come and go, but after a time to end in absolute blindness. Affections referrible to the circulatory organs, again, are of frequent occurrence ; epistaxis and bleeding from the stomach and CHKONIC BEIGHT'S DISEASE. 839 "bowels and other mucous membranes are often observed ; retinal hemor- rhage or albuminuric retinitis is far more common in this than in any other form of kidney disease, and is not unfrequently one of the earliest indica- tions of its presence ; m addition to the characteristic thickening of the smaller arteries, atheromatous and calcareous changes of the arterial system are commonly present, and partly from this cause, partly from excessive blood-pressure within the vessels, hemorrhagic effusion into the substance of the brain is very liable to occur ; again, thrombi are apt to form in the pul- monary arteries, leading to pulmonary apoplexy, and also in the systemic vessels and cavities of the heart. Lastly, it may be observed that granu- lar degeneration of the kidneys is occasionally associated with similar dis- ease in the liver and other organs, and that dysenteric ulceration not unfrequently supervenes. Chronic interstitial nephritis is essentially a disease of long duration. It may certainly continue for ten years or more. The causes of death have been sufficiently indicated in the last paragraph ; but the most frequent cause is uremic poisoning, sometimes with convulsions, more frequently with coma. C. Treatment of chronic Bright's Disease. The treatment of chronic parenchymatous nephritis is essentially the same as that of the acute disorder. Abstraction of blood, however, is less likely to be required. Perspiration should be promoted by the measures previously discussed or by the Turkish bath. The bowels should be kept freely open by saline purgatives. Diuresis should be solicited by bland drinks, alkalies, and digitalis. Moreover the stimulant diuretics, broom, juniper, squill, and nitric ether, which are unsuitable in the acute disease, may be given with advantage here. The rapid development of anemia points significantly to the use of iron, and there is no doubt that ferrugin- ous preparations, and especially the perchloride of iron, are more valuable in this than in any other form of nephritis. In dealing with cases of granular disease the incurability of the lesion must not be forgotten. If no special symptoms are present it may be de- sirable to promote the action of the skin by the wearing of flannel and the use of baths, to keep the bowels open by occasional mild purgatives, to give tone to the system by the employment of iron in combination with vege- table bitters, and to support strength by wholesome nourishing diet, not superabundant in quantity, and comprising a small proportion only of animal food. Late in the disease, when the urine becomes scanty, and dropsy or indications of uraemia present themselves, the promotion of urine and drastic purgation are called for. In all forms of chronic Bright's disease special symptoms require to be treated as they arise. For dropsy the most effectual remedial measures have already been enumerated. But when the accumulation of fluid is extreme it may need to be removed by surgical means. For this purpose ' acupuncture ' or the puncture of the skin with a needle in several places just above the ankle, or in the scrotum or some other dependent part, may be performed, or incisions may be made in the same localities. Or better 840 DISEASES OF THE GENITO-UEINAEY OEGANS. still, a fine trocar and cannula (according to Dr. Soutliey's suggestion) may be inserted, and retained in situ for some days without inconvenience. It must not be forgotten, however, that erythema and sloughing are apt to follow this slight operation, apparently from the irritating effects of the escaping serum on the integument over which it flows. To avert this danger it is well to anoint the surface previously with sweet oil. Uraemic poisoning may often be obviated or cured by the use of drastic purgatives. When convulsions are present the inhalation of chloroform often affords relief. It is needless to lay down rules with regard to the treatment of uremic asthma, urasmic dyspepsia, and the many other complications of chronic Bright's disease. In all cases when either convalescence is in progress or the symptoms are of a chronic character hygienic and tonic treatment is of the highest importance ; and especially residence in a genial climate, moderate out-of- door exercise stopping short of fatigue, wholesome unstimulating diet and early hours are likely to be beneficial. In conclusion it may be pointed out that in all varieties of Bright's disease the use of certain drugs is fraught with danger. Of these, opium, mercury, and cantharides are the most important examples. VI. CONGESTION OF THE KIDNEY. Causation.— Congestion is present in a greater or less degree in all in- flammatory affections of this organ, in many febrile diseases, and as a con- sequence of the action of certain irritant poisons. The form of congestion, however, which we are now about to consider is that passive congestion which arises in the course of obstructive cardiac and pulmonary diseases. Morhid anatomy. — This condition is characterised in its early stage by congestion, enlargement, and softening of the kidneys. The veins are especially overloaded and more particularly the stellate veins of the outer surface and those of the medulla. If the congestion continues, indura- tion takes place, due to slow increase of the interstitial fibrous tissue of the organ, and ultimately atrophy of the Malpighian bodies and of the other secreting elements, including fatty degeneration of the cortical epithelium. Symi)toms. — In this affection there is not generally much to attract attention to the condition of the kidneys beyond scantiness of urine, and the presence in it of albumen, and occasionally of blood, and of casts which are hyaline or granular, or formed in part or wholly of disintegrating blood-corpuscles. The albumen is generally scanty, but sometimes very abundant. The specific gravity is usually high. Inflammation readily supervenes. As a rule the general symptoms due to renal congestion are so inextricably intermingled with those of the disease to which the con- gestion itself is due, and which in fact they closely resemble, that they do not admit of separate recognition. Occasionally, however, ursemic poi- soning and other common consequences of Bright's disease are distinctly developed. TUBEECULAE DISEASE OF THE KIDNEY. 841 The treatment is mainly that of cardiac or pulmonary disease, as the 'Case may be ; and the employment of remedies calculated to relieve renal congestion, more especially purgatives, diaphoretics, and unirritating diuretics. VII. TUBEECULAE DISEASE OF THE KIDNEY. Morbid anatomy. — For the most part tubercles are developed in the kidney as a comparatively late event of general tuberculosis, give rise to few or no symptoms, and are of little clinical importance. Sometimes, however, tuberculosis is primary in the kidneys, or at all events may be found post mortem to be as far advanced in these as in other organs ; and under such circumstances the renal affection is a material, possibly the chief, item of the patient's illness. When tubercles are abundant and far advanced in the kidneys, they are probably always present also in the mucous membrane of the urinary organs — pelves, ureters and bladder — and even in the vesiculse seminales and testes, or in the ureters and Fal- lopian tubes. Tubercles appear in the first instance as grey granulations scattered mainly in the cortex, but occurring also in the medulla. It is in this form that they are generally discovered. After a while they increase in number and in size, coalesce into larger masses, undergo caseous degeneration, soften, and perhaps suppurate. Under such circumstances the kidney may become considerably en- larged, riddled with cavities of various sizes containing cheesy matter, tubercular detritus, or pus, and studded in the intervals with unsoftened tubercles. The destructive process may proceed so far, indeed, that the whole of the secreting structure becomes converted into a series of large tubercular cavities, of which one corresponds to each cone and its asso- ciated portion of cortex. These cavities may either communicate by ulcer- ation with the pelvis of the kidney, or remain separated from it, in which case the contents change after a time into a creamy or mortary material like that already adverted to as due to the drying up of ordinary renal abscesses. Tubercles affect the mucous lining of the pelvis and ureter in precisely the same way that they affect other such surfaces : miliary granulations appear in scattered groups in the substance of the membrane, become caseous, and then disintegrate, producing shallow circular pits, the sur- faces of Avhicli generally present more or less tubercular detritus. The junction of neighbouring pits leads to a greater or less extent of superficial destruction, and the formation of an irregular, sinuous-edged ulcer. There is generally also thickening of the subjacent and surrounding tissues. The pelvis generally becomes dilated. The ureter, on the other hand, usually gets narrowed or even obliterated. Symptoms and progress. — In considering the symptoms of renal tuber- culosis it is almost impossible to separate them practically from those due to the associated affection of the urinary passages ; and it is not difficult to 842 DISEASES OF THE GENITO-UEINAEY OEGANS. surmise what the main symptoms of these united conditions must be. They are, indeed, essentially those of chronic pyehtis ; and comprise pain and tenderness in the loins, tumour possibly, irritability of bladder with perhaps pain or scalding in passing water, and the discharge of m'ine containing a greater or less abundance of mucus, but more generally pus, and occasion- ally it may be a little blood together with debris of tissue. The urine is said generally to be scanty, and not to contain renal casts ; but the dis- covery of casts must not be taken to disprove the presence of renal tubercle, nor is the scanty secretion of urine by any means constant. The reaction of the urine is for the most part slightly acid ; but, as in cases of non-spe- cific pyelitis and cystitis, is apt to become alkaline from decomposition. The course of renal tuberculosis is essentially unfavourable ; for, indepen- dently of the slow but sure destruction of the renal tissue, which must ultimately lead to a fatal result, the local disease sooner or later becomes associated with the development of tubercles in other organs. The symp- toms and progress of any case will necessarily vary according as the phe- nomena due to the urinary apparatus or those referrible to implication of other organs preponderate. It is important to bear in mind that the symptoms of renal tubercle and of tubercle of the urinary passages are not in any sense specific ; and that their diagnosis must rest mainly on the detection of similar disease in the lungs or elsewhere. Treatment. — The treatment of renal tubercle comprises that of tuber- culosis and that of chronic pyelitis. VIII. SYPHILITIC DISEASE OF THE KIDNEY. Lardaceous infiltration of the kidney is a common attendant on ad- vanced syphilitic cachexia ; but specific syphihtic affections of this organ are exceedingly rare. Very few cases of distmct gummatous tumours are recorded ; but occasionally, on examining the bodies of persons who have suffered from syphilis, and in whom gummata or their remains are visible in other organs, the surface of the kidney presents well-marked linear and stellate depressions correspondmg to localised induration and atrophy of tissue. These are most likely of syphilitic origin, but have probably never given any indication during life of their presence. As regards diagnosis, all that can be said is that when patients with advanced syphilis present symptoms indicative of renal disease, they are probably due to lardaceous infiltration, but may possibly result from the formation of gummata. IX. MOKBID GEOWTHS OF THE KIDNEY. Morbid anatomy. — Several varieties of tumour are met with in the kidney. Fibromata sometimes attain a large size, so large, in fact, as to be easily recognisable during life. But they do not, so far as we know, produce any inconvenience or symptoms beyond such as depend on their MOEBID GEOWTHS OF THE KIDNEY. 84a situation and bulk. The only tumours that have any practical interest are those possessing malignant properties. 1. Lijmphadenoma generally occurs in the kidney as a secondary or late event in the gradual generalisation of the disease. The renal growth occurs in patches which at the surface of the organ are circular, pale, and scarcely elevated, and are prolonged into its substance in a wedge-like form. Other patches are wholly imbedded in the substance of the organ. On microscopic examination the cells which constitute the growth are found to occupy the intertubular spaces only — the tubules and Malpighian bodies, which may remain healthy, being surrounded and separated from one another by them. 2. Sarcoma has occasionally been observed in young children. It is- probable, however, that many infantile renal tumours, which have been described as cancerous, were really examples of sarcoma. The disease seems to attack one kidney only, to cause enormous enlargement of the organ, and to be undistinguishable during life from cancer. 3. Carcinoma may be primary or secondary. When secondary it rarely attains large dimensions ; when primary it is generally limited to one kidney, and this soon forms an enormous tumour. Eenal carcinoma is, almost without exception, of the encephaloid variety, and usually highly vascular. It commences in the form of one or more isolated tumours, which gradually invade the adjacent renal structure until the greater part or the whole of the organ is involved. While this process is- going on the kidney enlarges, but still probably on section presents the outHnes of its original divisions. With the continuance of the growth, however, all traces of renal structure are obliterated, and the kidney is- converted into a simple carcinomatous mass, still probably presenting the form of the healthy organ, but attaining the size it may be of a cocoa-nut or large melon, and weighing several or many pounds. In the progress- of its growth it becomes adherent to surrounding tissues and organs which may then be involved by continuity ; and it develops nodular, papillary, or even villous outgrowths into the cavity of the pelvis and infundibula.. The carcinomatous kidney is of course liable to all those changes which generally characterise carcinoma ; it presents consequently, in addition to growing tissue, patches or networks of caseous and fatty degeneration,, hemorrhagic effusions, and tracts of liquefaction. The ureter is not un- frequently involved, and, even when not distinctly cancerous, is apt to- become thickened and occluded. Symptoms and i^rogress. — The recognition of secondary growths in the kidney, whether they be lymphoid, sarcomatous, or cancerous, is a matter of little importance ; and that of primary carcinoma is, until the disease is far advanced, often extremely difficult. The chief circum- stances to be taken into consideration in forming a diagnosis are : first, the very gradual development of symptoms ; second, the frequent discharge of blood in quantity with the urine ; third, the gradual formation of a tumour in the situation of the kidney ; fourth, the appearance of secondary cancerous growths ; and, fifth, the occurrence of progressive emaciation,. 844 DISEASES OF THE GEXITO-UEINAEY OEGANS. debility, and cachexia. The symptoms, iiifact, are mainly those common. to cancerous growths, together vrith such as depend on the situation of the tumour, and on the modification of the urinary secretion. Of these three symptomatic groups the latter Wo only call for fm-ther remark. The development of cancerous tumours is sometimes painless ; sometimes, on the other hand, the patient suffers from fi-equent paroxysms of the most intense agony ; and generally sooner or later there is manifest local tenderness. The tumour is characterised by originating deep in the lumbar region, and (as it grows and fills more and more of the abdominal cavity) by its position, its fixation, its general rounded form, and very importantly by the fact that it is almost always crossed lay the ascending or descending colon, the presence of which may sometimes be detected by the eye, and can generally be recognised by palpation or percussion. The veins in the abdominal walls on the affected side are often much dilated ; and not unfrequently from the pressure of secondarily affected glands, oedema of the corresponding lower extremity or of both lower extremities comes on. A cancerous kidney generally feels hard, but is sometimes yielding, and may be so soft as to give a deceptive sense of fluctuation. It often enlarges so greatly as to fill its own side of the abdomen, and occasionally not only fills this, but encroaches to a great extent on the opposite side. It has been pointed out that the urine often contains blood. Hemorrhages occur at h-regular intervals, and are some- times so profuse and frequent as to blanch the patient. It must not be forgotten, however, that in many cases no hemorrhage whatever takes place ; and that m many the urine from first to last is perfectly healthy. The latter circumstance is in great measure due to the fact that the ureter of the affected side often becomes impervious even at an early stage of the disease. Cancer-ceUs rarely if ever find then- way from the kidney mto the discharged urine, and, even if present there, would pro- bably be undistinguishable from the epithehal ceUs of the bladder. The affection with which renal cancer is most apt to be confounded is renal calculus associated with pyehtis and distension of the cavity of the kidney. The HabiHty to error is increased when gravel or smaU calcuK are, as is not uncommon, present in the pehis of the cancerous organ. In the early stages of cancer, indeed, it is often impossible to discriminate between it and calculous pyehtis. Later on its recognition is more easy, but then the diseased organ is apt to be mistaken for an ovarian, splenic, or hydatid tumour. Treatment. — In the treatment of renal cancer there is nothing to be done beyond endeavourmg to reheve the patient's symptoms. . Opiates are invaluable. X. PAEASITIC AFFECTIONS OF THE KIDNEY. Animal parasites seldom affect the m-inary organs, at any rate in temperate climates. The Strongylus gigas and Pentastoma deiiticulatum have been so rarely observed in the Iddney that no practical interest PAKASITIC AFFECTIONS OF THE KIDNEY, 845 attaches to them. Hydatids are much more frequently met with there, and the Bilharzia hcematobia is common in the vessels of the urinary organs in certain tropical countries. Of the Filaria sanguinis hominis in relation to the uruiary organs, we shall speak under the head of chyluria. A. Hydatid cysts of the kidney are far less common than hydatid cysts of the hver. Still many authentic cases are on record. The anatomical characters, progress, and consequences of renal hydatids present nothing distinctive beyond the facts that the enlarging cysts have the tisual situation and connections of renal tiunours, and that they not unfrequently rupture into the pehis of the kidney and discharge their contents with the urine. It must not be forgotten, however, that hydatid tumours may originate in the sub -peritoneal tissue in the neighbourhood of the kidney ; and that both these and hydatids occupying other situa- tions may open into the pehis of the kidney or into the bladder. If suppuration takes place in the cyst of a renal hydatid, the case becomes essentially one of abscess of the kidney. The treatment of renal hydatids is the same as that of hydatids of the liver. B. The Bilharzia hcematohia, one of the trematoda, is the cause of a form of hematuria, endemic in Egypt, at the Cape of Good Hope, and elsewhere. The parasite is of a worm-hke form, and three or fom' lines in length. The female is longer than the male and filiform ; the male is comparatively thick, and in the act of copulation encloses the female in a gynfecophoric canal. It is sup^Dosed to be swallowed with the food, and thus to gain entrance into the system by the stomach, but it specially inhabits the mesenteric veins and those of the large intestine, bladder, ureter, and peh-is of the kidney. Its presence in the small vems of the urinary organs gives rise to lenticular patches of inflammation in the mucous mem- brane, which yield mucus and sometimes blood, ulcerate, and discharge shreds of tissue charged with ova. The patient consequently sufi'ers from irritability of bladder, and passes m-ine containing these several ingredients. He often falls also into a state of anaemia and debihty. When the ureter or renal pelvis is afl^ected, obstruction to the flow of urine may arise, pyelitis and hydro -nephrosis may ensue, and the patient's sjnnptoms may hence as- sume a more serious character. The ova may form the nuclei of urmary concretions. The presence of these creatures in the mucous membrane of the large mtestine is apt to produce dysenteric symptoms, which, how- ever, are rarely severe. The recognition of the disease depends on the discovery of the ova and embryos m the urine. Fig. 80. BrLHAEziA H^nfatobia x 10 (KUchenmeister). (n) male ; (6) fe- male grasped in gynscophoric canal. 84:6 DISEASES OF THE GEXITO-UEINAEY OEGANS. Treatment. — It is doubtful if vermifuge medicines are of any efficacy in this afiectiou ; injections, liowever, into the urinary bladder may act beneficially on so much of the disease as involves that viscus. The forms of mjection which are beneficial in the treatment of thread-Tvorms naturally suggest themselves — namely, bitter infusions, or solution of perchloride of iron. Dr. J. Harley prefers solution Fig 81 (a) oviam x 100 °^ iodide of potassium. For general treatment, tonic (6) embrjo x 100. remedies are indicated. XL LAEDACEOUS DEGENEEATION OF THE KIDNEY. Causation. — The causes of lardaceous degeneration of the kidney are the same as those of lardaceous degeneration of the liver and other organs : and indeed the hver, kidneys, and spleen are generally con- currently affected. 2Iorbid anatomy. — The lardaceous kidney increases in size with the amomit of degeneration present, and may attain a weight of twelve omices or more. If the disease be Httle advanced it is apt to escape recognition by the naked eye ; when, however, it reaches a high degree, the organ is somewhat waxy, pale and homogeneous in texture, and presents a shght degree of translucency. The morbid change usually commences in the vessels of the Malpighian tufts, but very soon spreads from these to the -afferent and efferent vessels, the intertubular plexus, the interlobular arteries, and the vasa recta. The hyahne walls of the urmary tubes and Malpighian bodies also suffer, but for the most part somewhat later than the vessels. The degeneration here is always most advanced in the large collecting tubes, and diminishes in degree as one proceeds from these to the Malpighian capsules, which in fact generally remain unaffected. The epitheHal cells are rarely if ever involved, but are often granular, and even distinctly fatty. Lardaceous change is apt to be superadded in the course of ordinary fatty and granular degeneration of the Iddney, in which case the several morbid conditions are variously intermingled. Waxy casts may generally be detected in both the cortical and the medul- lary tubules. Symptoms and progress. — The presence of lardaceous change in the kidney does not necessarily give rise to any special symptoms until the disease is far advanced. The symptoms then, if not of themselves dis- tinctive, become distinctive when the history of the patient, the condition of his other viscera, and his general state are all taken into consideration. They are mainly as follow : the urine is increased in quantity, pale, of low specific gra^dty, and poor in urea ; it contains albumen, sometimes in large quantities, and casts which have not necessarily any special cha- racter, but are often waxy, yet rarely if ever lardaceous ; micturition is generally frequent ; there is often some degree of anasarca, but it is not usually abundant ; and the patient is anaemic. In these respects the S}Tnptoms are not milike those due to the granular kidney ; but the heart GKAVEL AND KENAL CALCULI. 847 •does not become hypertropliied ; there is absence of arterial tension ; there is httle tendency to ursemic poisoning ; and although patients often suffer from serous inflammations, inflammation of the lungs, diarrhoea, vomiting, and hemorrhages, these complications are not distinctly refer- rible to the kidney disease, but are due in part or wholly to the presence of associated visceral lesions. The treatment of lardaceous kidney is involved in the treatment of the affections to which it is secondary. Dropsy and other consequences, when they are sufficiently serious to demand separate attention, must be treated according to the principles already enunciated under the head of chronic Briffht's disease. XII. GEAVEL AND EENAL CALCULI. Causation and morhid anatomy. — The presence in the urine, or the ■deposition from it, of uric acid and urates, of oxalate of lime or of phos- phates, is occasionally observed in various morbid conditions of the system, and even in states of apparently good health. Such occurrences rarely if ever call for medical interference. Occasionally, however, the appearance in the urine of one or other of these, or of other rarer crystalline matters, persists for some time or becomes habitual. If under such circumstances symptoms of ill-health manifest themselves, medical treatment is obviously demanded ; and, indeed, even in the absence of symptoms, the danger of the formation of urinary calculi is so great that, if the peculiarity of the urine be recog- nised, it should, if possible, be counteracted. The amorphous urates are sometimes found deposited in the renal tubules, but this is probably a post-mortem phenomenon only. Urate of soda, in stellate masses of acicular crystals, is now and then discovered im- bedded in the substance of the kidney ; uric acid also, in solitary or clus- tered crystals, is occasionally detected within the tubules, and again, in the form of small calculi, is sometimes found loose in the cavity of the kidney or adherent to the mammillary processes. The same may be said in regard to the infinitely rarer xanthine and cystine concretions. Octahedra and dumb-bells of oxalate of lime, singly or in groups, may ,be met with in the urinary tubules, and occasionally also form small calculi, which lie loose or adlierent within the cavity of the kidney. The phosphates are rarely deposited, except in ammoniacal urine, and as a consequence of the decomposition of that fluid ; they are, therefore, seldom if ever detected in the kidney except as secondary deposits around nuclei of other matters. Carbonate of lime, however, though much less frequently forming a urinary deposit, is occasionally met with in the form of small laminated globular concretions, either imbedded in the substance of the kidney, or free in its pelvis. The minuter concretions above described are sometimes discharged with the urine in considerable abundance, constituting what is called ' gravel.' Small calculi, from the size of a pin's head to that of a horse- 848 DISEASES OF THE GENITO-UEINAEY OEGANS. bean, are also not unfrequently transmitted, with more or less delay,, along the ureter to the bladder, and thence into the chamber-pot. Some- times a solitary calculus is thus discharged, and there is never any re- currence ; sometimes large numbers of calculi are discharged at intervals. In other cases these bodies remain in the renal cavity, gradually grow there, and finally, perhaps, form a complete cast of the pelvis, infundibula and calyces ; or a considerable number of small calculi may become aggregated into that form. The presence of calculi in the kidney generally induces pyelitis, and probably at length abscess, hydro -nephrosis, or some other serious conse- quence. Symptoms and progress. — The symptoms of ' grave! ' are : pain of an aching or burnmg character in one or other lumbar region or side of the abdomen, probably shooting down to the testis or labium, and along the inner aspect of the thigh ; frequent desire to micturate ; soreness or cut- ting pain during micturition, especially at the end of the urethra in passing the last few drops ; and nausea and sickness. At the same time the urine generally is clear, though it may deposit a greater or less abundance of a sand-like sediment, or show microscopic aggregations of crystals, with epithelial scales. The pain may of course affect both sides ; and the patient's complaint may be limited to lumbar or abdominal pain or uneasiness. A renal calculus may never reveal its presence by symptoms, and may even lead to the disorganisation of the kidney without the least suspicion of disease ha^-ing ever been excited. The special indications of the pre- sence of a calculus are : first, the occasional occurrence of aching or burn- ing pain in the situation of the kidney, resembhng, but probably more severe than, that attending the passage of gravel ; second, the occasional discharge of bloody urine ; and, third, the facts that the nephralgia and htematuria are often induced by anything that jolts the body, such as riding, jumping, and other forms of exercise, and that the pain may occa- sionally be relieved by change of posture. This becomes much more intense when the calculus enters the ureter, and continues intense as long as the stone is passmg along that canal. The pain of renal or ureteric calculus may be traced along the ureter, shooting thence into the loin, radiating throughout the abdomen, and especially extending to the thigh and labium or testis, which last often becomes retracted ; it is attended with nausea and vomiting, and not unfi^equently with rigors and faintness. It is often increased by the patient's voluntary attempts to flex the thigh on the abdomen. Further, tenderness may exist in the loin and along the course of the ureter. The pain due to the transmission of a calculus begins suddenly, and ends suddenly in a few hours, or after intermissions in the course of a few days, m consequence of the stone becoming either arrested in its course or discharged into the bladder. It need scarcely be said- that the microscopic investigation of the lU'ine often throws important light on the diagnosis of cases which come under treatment ; and further that, when one kidney has already been destroyed or rendered useless, the GEAVEL AND EENAL CALCULI. 849 impaction of a stone in the opposite ureter may cause fatal suppression of urine. The symptoms of pyelitis, renal abscess, and liydro-nephrosis, which are frequent accompaniments or consequences of renal calculus, are elsewhere discussed. Treatment. — The treatment of gravel and of renal calculus is for the most part identical with that of pyelitis — a subject which has already been fully considered. The pain, however, in so-called ' nephritic colic ' is generally so much greater than in other forms of pyelitis that opium, rest, and local measures are all more urgently needed. Opium, especially, is our sheet-anchor. As valuable adjuvants we may enumerate purgatives, copious enemata, ice-bags, hot applications or cupping to the loins, and especially the hot bath. Belladonna is sometimes useful when opium fails ; and, when a calculus is descending, may be of special service in relaxing the spasmodic action of the ureter which takes place around it, and impedes its progress. The removal of renal calculi by operative measures can scarcely be attempted unless the proof of their presence be afforded by the abundant or persistent escape of blood or pus with the iirine, or there be a manifest tumour in the loin. The removal of renal calculi, however, and indeed the extirpation of the kidney, have been practised with success. In the intervals between the acute attacks, which, from their severity, call for special treatment, the question of the removal of the conditions on which the gravel or calculi depend presents itself for consideration. Our action here must be determined mainly by the nature of the sabulous matter which is habitually discharged. If uric acid crystals or gravel are passed, it is certain that the urine is abnormally acid, and the exhibition of alkalies is demanded. The car- bonate, acetate, and citrate of potash are probably the best for the purpose ; and they should be given in such quantities as to render the urine con- stantly alkaline. Dr. W. Eoberts has shown that the alkaline carbonates slowly dissolve uric acid calculi, and that the urine may be rendered and kept sufficiently charged with carbonate to produce this effect by adminis- tering to the adult forty or fifty grains of the acetate or citrate in 3 or 4 oz. of water every three hours. And hence he recommends that, if there be reason to believe that uric acid calculi are present in the kidney, the patient should be submitted to this alkaline treatment. Phosphate of soda also dissolves uric acid, and Dr. Golding Bird recommends its use in scruple or half-drachm doses. It is important at the same time to have regard to the patient's mode and habits of life and to any morbid conditions which may be present. Thus, valuable indications for treatment may be furnished by the fact that he is a hon vivant or of sedentary habits, or that he suffers from indigestion or gout. Cystine and xanthine deposits and calculi may be treated in the same manner as those of uric acid. Oxalate of lime, like uric acid, is generally precipitated in acid urine, and indeed they are not unfrequently associated. Its presence in small ■quantity is often dependent on the use of certain articles of diet ; when it is 3i 850 DISEASES OF THE GENITO-UKINAEY OEGANS. more abundant and persists, the patient frequently suffers from indigestion^ or presents symptoms of mental depression. The direct treatment of oxa- luria is not generally very efficacious. The patient's general health should be improved by tonic medicines and general tonic treatment, and by absti- nence, as far as possible, from vegetables containing oxalate of lime, and from sugar and other substances which are readily convertible into oxalic acid. Nitro-muriatic acid is often recommended; while, on the other band, alkalies seem sometimes to be efficacious. Persistent alkalinity of urine from the presence of the fixed alkalies is. rare and in itself not very important. It generally seems to be associated with some degree of ill-health and cachexia, and may be taken to indicate- the need of tonic treatment and of generous diet. Mineral acids, especially the nitro-muriatic, and perchloride of iron, are valuable remedies. Alkalinity from the presence of carbonate of ammonia is a much more serious matter. This always results from decomposition of the urine in the urinary channels, is indicative of cystitis or pyelitis, and necessarily leads to the deposition of crystalline phosphates. For the relief of this condition we must have recourse to the usual treatment of cystitis. XIII. HYDEO-NEPHEOSIS AND ATEOPHY OF THE KIDNEY.. Causation and morbid anatomy. — Whenever any permanent impedi- ment to the flow of urine occurs (whether it be in the urethra, bladder, or ureter ; whether it be due to a calculus or any other obstacle within,. or to some affection of the walls themselves, such as thickening and con- traction, valvular folds or paralysis, or to pressure from without, caused by ovarian, uterine, or other tumours) the cavities above the seat of obstruction dilate and their parietes thicken, and at the same time the kidney structure becomes expanded and attenuated. The condition known as hydro -nephrosis results. If complete obstruction take place, excretion of urine continues for a time ; but its accumulation causes more and more distension of the renal cavity, and more and more pressure on the renal structure, until at length the function of the organ ceases ab- solutely to be performed. In this case, equally with that in which pus accumulates, those portions of the renal ca\dty whose lining membrane is least resistant expand most ; and consequently, while the pelvis and in- fundibula alter comparatively little, the calyces dilate until they form a series of sub-globular cavities surrounded and separated from one another by atrophoid kidney structure, and communicating by separate and com- paratively small orifices with their respective infundibula. When the obstruction is partial, as well as during that period of total obstruction in which the renal elements are still excreting urine, this fluid changes in quality; it becomes less and less rich in solid constituents, pale, watery, and of low specific gravity, but remains for the most part devoid of albu- men. Subsequently to the cessation of the proper urinary discharge, the fluid in the cavity may still increase in quantity and still undergo HYDEO-NEPHEOSIS. MOVABLE KIDNEY. 851 changes. Thus m advanced hydro-nephrosis it is generally watery but still containing traces of the urinary solids ; often albuminous ; some- times charged with decomposing blood ; sometimes glairy and colloidal ; occasionally piu'ulent. After a kidney has become completely hydro- nephrotic and ceases to secrete m-ine, various consequences may ensue. In some cases it remains for a long while almost stationary. In some the contents are slowly absorbed and the atrophied tissues shrink and indiu'ate, mitil at length a small, hard lobulated cystic body, weighing perhaps h-om a drachm or two to half an ounce, remains. In other cases the dropsical kidney gradually enlarges mitil it forms a tumour several times the bulk of the healthy organ, and occasionally sufficiently large to fill at least one-half of the abdomen. Hydro-nephrosis from total or partial, and often vahailar, obstruction of the ureter is not mifrequently con- genital, and at the same time double ; and hence hydro-nephrotic tumours are not altogether uncommon in new-born babes and young children. Symptoms and progress. — As a rule the changes above described creep on (if no inflammation ensue i without producing symptoms, and without, therefore, calling for treatment. It is comparatively rare for the hydro- nephrotic kidney to become so large as to excite observation, still more rare for it to become so large as to exert by its pressure on surrounding organs any deleterious influence. But in these cases alone is diagnosis needed or indeed possible. The elements on which an accurate opuiion must be based are the history of the case, the situation and relations of the tumour, its characters as to form, resistance and fluctuation, and the constitutional symptoms which are associated with it. In addition tO' these there is a symptom of rare occurrence, but very characteristic when it does occur, and pecuhar to cases of incomplete obstruction— namely, the occasionally rapid but temporary subsidence of the tumour, attended with a sudden increase in the quantity of urine passed, and some change in its quaUty. In some cases the dilated organ suppurates, and a renal abscess with the usual symptoms of that condition supervenes. A hydro-nephrotic tumour is hable to be confounded ■v\ath carcinoma and hydatids of the kidney or neighbouring parts, and with ovarian cysts. It is rarely fatal, except in those cases in which it is double, or where it is associated with other maladies, or where, from its bulk and interference with other organs, or h'om suppuration, slow exhaustion ensues. Treatment. — The treatment is entu-ely surgical. If manipulation fail to drive the contents into the bladder, paracentesis may become neces- sary. To prevent danger from escape of fluid into the peritoneum this operation should be performed behind the line of colon which crosses the tumour. XIV. MISPLACED AND MOVABLE OR FLOATING KIDNEYS. Causation and morbid anatomy. — Misplacements of the kidneys are chiefly important in relation to the diagnosis of abdominal tumours. Sometimes as a congenital peculiai'ity one or both kidneys, instead of 3i2 So2 DISEASES OP THE GENITO-UEINAEY OEGANS. occupying tlieir usual site, lie upon the brim of the pelvis. Sometimes one or both of them, though otherwise normally placed, are attached to the lumbar region by a peritoneal duplicature or mesonephron analogous to the mesentery, or lie freely movable in the lax retro-peritoneal connec- tive tissue which surrounds them. Mobility of the kidney is said to be much more common in women than in men, and on the right than on the left side. Its cause is obscure. It may perhaps in some cases be a con- genital defect ; but it seems also occasionally to follow upon parturition, and possibly then to be connected with that general laxity of the ab- dominal parietes which parturition causes. There is still considerable doubt on the part of many with respect to the occurrence of floating Iddney. The question has, however, been set at rest affirmatively by an enquiry made a few years ago for the Patholo- gical Society, ' and by numerous more recent clinical and anatomical enquiries. Symjotoms. — The floating kidney projects more than natural, generally assuming an oblique position with the upper end pointing forwards and. inwards, and is freely movable within narrow limits under the abdominal parietes. Sometimes it forms a perceptible tumour only when the patient stands up or reclines towards the opposite side, falling into its place and becommg no more distinguishable when he lies on his back. It may usually be perceived somewhere in the hypochondriac or umbilical region, between the navel and the cartilages of the ribs, but may even be found lying upon the vertebrae. If on the right side it is apt to make its appear- ance just below the liver and to be mistaken for an hepatic tumour. If it be grasped, as it sometimes can be, a sickening sensation is produced, simi- lar to that which results from squeezing the opposite loin ; and sometimes, it is stated, a distinct falling in of the corresponding lumbar region with increase of resonance may be clearly recognised. It is generally attended with a painful dragging sensation in the loin ; and from its prominent and pendulous condition is unduly exposed to pressure or injury, and con- sequently apt to become painful, tender and swollen. It may even suppurate. Treatment. — When a movable kidney is painful, rest, local applications, and the internal use of sedatives may be requisite. To protect it from injury, and at the same time to replace it to some extent, an abdominal belt may be worn with a concave pad beneath it adjusted to the form and position of the kidney. XV. CHYLUEIA. (Chylous Urine.) Causation and symptoms. — This affection was first recognised and described by Dr. Prout, but since his time has been pretty frequently met with and investigated by other observers. It is characterised for the most part by the occasional or constant discharge of urine which is milky Tvhen passed, coagulates on standing into a tremulous mass resembling ' 'Path. Trans.,' vol. xxvii. p. 467. CHYLUEIA. 85S l)lanc-mange, and then, becoming again liquid, furnishes a creamy scum and a pinkish or brownish sediment. The urine has, in fact, exactly those characters which would result from the admixture in varying proportions of normal urine and normal chyle. It presents the ordinary urinary con- stituents, but in diminished proportion to the whole bulk of fluid. And it also contains fibrine, the presence of which explains its spontaneous coagu- lability ; albumen, as may be shown by the usual tests ; fat in a molecu- lar form, like the fat of chyle, the presence of which accounts for the milky character of the fluid when passed, and for the creamy scum ; leucocytes ; and occasionally red corpuscles, to which the coloured sediment is partly attributable. No casts, however, are ever detected in it ; nor indeed is there any other evidence that the chylous material comes from the kidney. Further, it often happens in these cases that the urine which is passed is not milky, although probably presenting in all other respects the pecu- liarities which have been enumerated. It is, in fact, lymphous, and not chylous ; there is no fat, and the coagulum is transparent like ordinary calves-foot jelly. The presence of fat is, in some instances, observed mamly in the morning's yield ; more commonly it characterises the urine passed shortly after meals. Chyluria appears to be more common in tropical than in temperate climates, more frequent in adults than m children, and m females than in the opposite sex. It manifests itself, for the most part, suddenly, is liable to intermissions, and occasionally, after lasting some time, disappears for years or even for life. It is attended with no special symptoms, exceptmg such as may result from the continuous drain of nutrient fluid, and those directly connected with the condition of the urine and urinary organs ; and its presence is compatible with apparent good health, and even with long life. The characters which the urine presents have afready been described. It may be added that chylous urine not unfrequently coagulates in the bladder, causing more or less discomfort and the discharge of coagulated material. Pathology. — Dr. Prout attributed the disorder to a combination of two circumstances ; — one a defect of assimilation which permits chyle to mingle with the blood without bemg converted mto blood, the other some renal default, in consequence of which unchanged chyle is allowed to sweat from the kidneys. But the blood has been examined in cases of chyluria without the detection of any abnormal chemical constituent in it ; and not only, as has already been stated, is there no evidence during life to show that the kidneys themselves are diseased, but post-mortem examination equally fails to detect any structural change in them. Dr. W. Eoberts, basing his views partly on a case recorded by himself, and partly on one published by Dr. Vandyke Carter, suggested some years since an explanation of the phenomena of chyluria which, so far as it goes, seems to be correct for at least many cases. In these two examples there was chyluria, but there was also on the lower part of the abdomen and in the scrotum, enlargement of lymphatic vessels, with vesicular dilata- 854 DISEASES OF THE GENITO-UEINAEY OEGANS. tions, wliich yielded abundance of lymph or chyle — exactly the same kind of fluid as that which was passed with the urine. In Dr. Carter's patient, the discharge of chyle from the urinary organs and that from the skin alternated. Dr. Roberts contended that in these cases the chyle in the urine and that yielded by the skin were derived from a common source — namely, rupture of vesicular dilatations of lymphatic vessels situated on the one hand in the mucous membrane of the bladder, or that of some other part of the urinary tract, on the other hand at the cutaneous sur- face ; and he thence argued that chyluria generally depends on a similar lymphatic affection of the mucous membrane of the urinary tract. The disease, in fact, from this point of view, is identical with what has been described earlier in this volume under the name of elephantiasis lym- phangiectodes. Many other cases of this association have since been recorded. In a case of Dr. Stephen Mackenzie's ^ of combined chyluria and filarial disease, in which death resulted mainly from double pleurisy and empyema commg on (concurrently with a total disappearance of £lariffi from the blood) three months before that event, there were found acute cystitis and suppurative nephritis in an early stage. But also the thoracic duct was impervious, and lost in a mass of inflammatory material about the middle of its course ; the part below, together with the abdominal lymphatics and those connected with the kidneys, being enormously dilated. No filarife were discovered. But there was reason to believe that the parent worms had been lodged in the thoracic duct, had caused the mflammatory mischief and obstruction, and hence the general dilatation of lymphatics ; and that the chyluria was connected with the enlarged state of the lymph -channels in the substance of the kidneys. We have already discussed the interesting discovery by Dr. Lewis of the filaria sanguinis hominis in the urine, diseased tissues, and blood of patients suffering from chyluria and spurious elephantiasis in India ; and liave shown that there is good reason to beUeve that the parasite is (at any rate in many cases, possibly in all) the essential cause of these two affections ; the frequent association of which is thus plausibly explained. Treatment. — It is needless to enumerate all the remedies that have been employed in the treatment of chyluria ; nothing appears to have ever been really efficacious, and it is clear, if the explanation above given be correct, that nothing, except perhaps rest and astringents locally applied, is likely to be efficacious. Tonics may be needed m the anemia which is apt to come on in the course of chyluria. XVI. H/EMATUEIA. Causation and symptoms. — The presence of blood in the urine may be due to many different circmnstances, but these have already been discussed in sufficient detail, and Deed not be further considered now. It is not always possible to ascertain the source or the cause of hae- ' British Medical Journal, May 20, 1882. H^MATUEIA. PAROXYSMAL HEMATURIA. 855 maturia. It may, however, be observed that, if it take place from the sub- stance of the Iddiiey, it will almost always be attended with the presence •of blood-casts, and the m-me will generally be more or less smoky ; that, if it take place fi-om any of the urinary passages, no casts will be present ; and that, if it be derived from the bladder or urethra, pure mnnixed blood will probably be occasionally passed, either at the commencement or at the ■end of micturition, or at other times. Further, the more abundant the blood is, and the more it exhibits the ordhiary characters of blood and "tends to coagulate, the more likely is it to have been yielded by the urinary passages. The hemorrhage which attends simple congestion or inflam- mation of the kidneys or uruaary channels is generally scanty. The most profuse hemorrhages are usually due to villous or malignant growths of the bladder or kidney, or to the effects of renal or vesical calculi. Profuse hemorrhage is said also to occur vicariously of menstruation. We have p)reviously described the appearance which the urine presents when mixed with blood ; and we must refer the reader to other parts of this chapter for an account of the lesions of the urinary organs liable to be attended ^ith hemorrhage, and for the means by which their respective hemorrhages may be distinguished. Treatment. — When the discharge of blood with the urine is scanty and of temporary duration, the loss m itself is a matter of little importance, and no special anti-hemorrhagic treatment is needed. But persistent small hemorrhages, as well as occasional profuse hemorrhages, require if possible to be arrested. The patient should be placed in the recumbent position, and kept perfectly quiet and cool. He should have ice to suck, or be sup- phed with cold drinks in small quantities. In addition, it is advisable to give by the mouth astrmgent medicmes, such as turpentine, galhc acid, or other vegetable astringents, lead, perchloride of iron, or a mmeral acid. But probably more valuable than any of these is ergot or digitalis. If there be reason to believe that the bleeding is taking place from the ■kidneys, ice or cold compresses may be applied to the loins ; if from the bladder, similar applications may be made to the perineum or hypo- ■gastrium, and either cold water or solutions of perchloride of iron or tannic acid may be injected into the bladder. XVII. PAROXYSMAL HEMATURIA. [Paroxysmal Hamatinuria.) Definition. — This is a remarkable affection, which was first distinctly described a few years smce by Dr. G. Harley, and of which many cases have since been recorded. It is characterised by the sudden occurrence, at more or less irregular intervals, of severe rigors, followed by the ■discharge fr-om the kidneys of urine loaded with blood — the patient's health between successive attacks being apparently good, or at all events Tiot seriously impaired. Causation. — Paroxysmal hematuria has hitherto been observed almost exclusively in males and in such as are of adult age. A few of the sufferers have previously had ague ; but with this exception the patients 856 DISEASES OF THE GENITO-UEINAEY OKGANS. have, apart from tlieir renal affection, enjoyed good health, and have been apparently free from malarious taint. In all cases the onset of the disease is sudden, and almost without [exception distinctly traceable to exposure to cold or draughts. Symptoms and progress. — The patient, immediately after exposure, or even in the course of it, begins to complain of chilliness and uneasiness across the loms — the latter condition speedily passing into severe achmg, the former into an extreme sense of general cold, attended with pallor or duskiness of surface, shrmkuig of skin, and severe rigors ; together with which symptoms there may be weakness, stiffness or aching in the limbs, yawning, nausea and vomiting, and retraction of the testicles. During this time the temperature is lowered, and often by as much as two or three degrees. After the patient has been in this condition for half an hour, or it may be an hour or two, he is astonished to find on passing water that this fluid is exceedingly dark-coloured and turbid, not unfrequently re- sembling porter. The general symptoms now speedily abate, and the patient, after a little reactionary rise of temperature, but no sweating stage, appears at the end of a few hours to be perfectly well. The urine gradually loses its specific characters, and a little later perhaps than the patient's apparent restoration to health resumes its normal condition. The porter-like urine, which is generally famtly acid and of variable density, deposits an ahundant grumous sediment, and contains a large quantity of albumen, together -with granular and hyaline casts and probably crystals of oxalate of lime, but in place of blood corpuscles (which are detected rarely and in small numbers) presents abmidant brownish granular matter, which is supposed to be due to the disintegration of these bodies. The onset of subsequent attacks is equally stidden with that of the first ; and the succession of events is repeated exactly in them. Moreover, the later attacks, like the first, are generally distinctly traceable to the influence of cold : the slightest draught or the slightest chill being in many cases com- petent to evoke them. In some instances the paroxysms recur with almost ague-like periodicity ; more generally they come on at irregular intervals. Sometimes patients sufl'er from them once or twice a day, sometimes once or twice a week, sometimes at longer intervals, and they often lose their liability to them durmg warm weather, With such variations the disease may last for years, generally too without inducing any serious consequences as respects either the condition of the kidneys or the general health. The patient, however, often becomes anemic, languid, and weak. Pathology. — The pathology of paroxysmal hsematuria is somewhat obscure. It has been supposed to have some relation with ague, with oxaluria, and with rheumatism. It has been regarded, on the one hand, as an affection of the kidney, on the other as a disease of the blood. But, whatever view be ultimately adopted, there are certain facts which stand out clearly : namely, first, the dependence of the paroxysm on a cutaneous chill ; second, the intense congestion of the kidney which attends the paroxysm ; third, the relief of both congestion and paroxysm by a copious discharge of blood ; and fourth, the independence of all these conditions DIABETES. 857 of any structural disease of the Idclney. The phenomena of the disease, mdeed, are probably due to an influence transmitted fL'om the skin to the vaso-motor nerves of the kidney, in virtue of which temporary congestion takes place. Treatment. — Many remedies have been employed, but none with any strildng success : quinine and arsenic on the ground of the periodicity which the disease presents ; iron because of the patient's anaemic state ; perchloride of iron, gallic acid, and lead for their styptic properties ; and digitalis and ergot of rye on account of their influence in contracting the arterioles. The most important treatment, however, is the prophylactic. During the paroxysm the patient should be placed in bed and kept warm ; and at other times he should be cased in flannel and otherwise warmly clad, his feet and loins especially should be protected, and he should carefully avoid all exposure to draughts, all loitering in the cold, and riding in cold weather in an open vehicle. XVIII. DIABETES. {Diabetes Mellitus. Ghjcosuria.) Definition. — The most striking phenomenon of this disease is the excretion of urine containing a greater or less amount of glucose or grape- sugar. It is not, however, every one whose urine contains glucose who can be said to suffer from diabetes. For it has been shoT^ai that this sub- stance may be present in the urine temporarily or in small quantities in many affections involving hepatic congestion, such as injuries or organic lesions of the liver, and obstructive cardiac and pulmonary complaints, m certain affections of the central nervous organs, and also under the in- fluence of particular articles of diet ; while none of the other special phenomena of diabetes are either present or tend to become developed. Causation. — The cause of diabetes is not Imown. It is certainly here- ditary in some cases ; it occurs at all ages, from infancy to old age, and in both sexes, though about twice as frequently in the male as in the female. It has been attributed to exposure, habits of life, injuries of various kinds, and mental disturbance. In most cases, however, no cause whatever can be assigned or suggested. Symptoms and 'progress. — Diabetes, for the most part, comes on insi- diously. The patient perhaps observes, almost by accident, that day by day his urine is getting more and more abundant, his thirst is increasing, his appetite is getting voracious, and yet that he is losing flesh and strength. Occasionally he is also, and possibly first, struck by some peculiarities in his urine, dependent on the presence of sugar in it. He finds that when drops of it fall upon his trousers or boots, a whitish powdery film is left after evaporation, or that flies, bees, or other insects are attracted to the contents of his chamber-pot, or to surfaces on or against which he has emptied his bladder. The prominent features of the disease are comprised in this brief sketch : they are, the excretion of an excessive quantity of urine loaded with glucose, intense thirst,. 858 DISEASES OF THE GENITO-UEINAEY OKGANS. voracious appetite, together with progressive emaciation and debility, followed after a longer or shorter time by death. These symptoms, however, present a good deal of variety, and many others of more or less importance are generally associated with them. We will discuss them seriatim. The quantity of urine discharged is generally much larger than natural ; so that the patient not only micturates frequently during the •day, but is compelled to rise from his bed several times in the night in order to relieve himself. Its quantity depends, of course, mainly upon the quantity of fluid which he drinks, and therefore varies largely. It is sometimes little more than normal, but generally averages between six and twelve pmts daily, and occasionally rises to twenty, thirty, or more. The urine is usually of a pale yellow colour, acid, clear and free from sediment, and has a peculiar odour which has been likened to that of new milk, apples, or hay. Its specific gravity, notwithstanding the large quantity passed, is always abnormally high. It is rarely below 1035, often rises to 1045 or 1050, occasionally reaches 1060, and is said to have exceeded 1070. The cause of this density is the presence of an abnormally large proportion of solid constituents. As a rule, considerably more urea is discharged daily by diabetic than by healthy persons ; but the amount of urea is usually small in proportion to the quantity of fluid in which it is dissolved. The increase of specific gravity, therefore, is not due to that ingredient. It depends, indeed, almost entirely upon sugar. This varies, of course, considerably in quantity ; but generally forms from eight to twelve per cent, of the urine, and ranges from fifteen to twenty-five ounces daily. Its amount may, however, be much less than this, and also much greater. It is greatest after meals, and is always largely increased after the ingestion of sugar or starchy food. Under opposite circumstances it diminishes ; and it may disappear absolutely if the diet be restricted to nitrogenous substances. Sometimes, under the influence of inflammatory aftections, and again towards the close of the disease, the urine dimmishes both in quantity and in specific gravity, and its sugar lessens or fails : sometimes it becomes albuminous, and hyaline casts may be found in it. Dependent m some degree on the irritant effects of the iTrine, the urethral orifice in the male, or the vulva in the female, be- comes red and irritable, and even excoriated or eczematous. The sexual appetite is sometimes augmented in the begmning ; but both that and virile power diminish before long, and then disappear. One of the most distressing symptoms of which diabetic patients com- plain is extreme thirst ; and it is one of the first symptoms to make its appearance. The appetite, too, is generally excessive, often ravenous. This, however, is subject to considerable variation. Sometimes it is no greater than natural, sometimes it is much impaired ; and there may even be nausea and absolute loathing of food. The latter conditions often come on towards the termination of the case. The mouth, fauces, and tongue are usually dry, clammy, and morbidly red. The gums are apt to retreat from the teeth, and these latter to become loose and fall out. The patient DIABETES. 859 'Often complains of uneasiness or sinking at the epigastrium. The bowels usually are constipated, the motions scanty and dry ; but occasionally, and not unfrequently ushering in the fatal event, dysenteric diarrhoea supervenes. The skin of diabetic patients is almost always dry and harsh, though •occasionally slight perspirations occur, and some patients perspire freely. There is often a tendency to itching ; and various eruptions, especially eczema, psoriasis, and boils, are said to be of common occurrence. The hair sometimes falls out. The skin, or rather perhaps the patient gene- rally, yields an unpleasant odour, like that characteristic of his urine. The symptoms referrible to the heart and lungs are merely such as usually attend wasting disease — namely, increasing feebleness and rapidity of pulse, and shortness of breath, especially on exertion. The blood of diabetic patients contains glucose, of which as much as S to "5 per cent. has been detected by analysis. Nervous phenomena of various kinds usually manifest themselves in the course of the disease. The patient becomes apathetic, morose, taci- turn, or irritable, and towards the close drowsy or comatose. Insanity sometimes supervenes ; and occasionally various forms of hypersesthesia, loss of motor power, and the Hke. Impairment of \*ision is also a common incident of the disease : in some cases the patient loses simply the power of adjustment for near vision — becomes prematurely presbyopic ; in some he suffers from amblyopia without obvious ocular lesion; while in some soft cataract forms in one or both eyes. But, besides the above phenomena, others come on which are referrible not so much to any one organ as to general impairment of nutrition and advancing debility. There is great susceptibility to external cold. A sort ■of hectic condition arises, occasionally attended with febrile elevation of temperature ; generally, however, the temperature remains normal or falls .a little below the normal. Emaciation is almost constant ; the fat disap- pears, the muscles shrink, the frame becomes attenuated, the skin appears tightly drawT^i over the forehead and other parts of the face, and is thrown into fine vTinkles when expressional and other movements of the facial muscles are executed. Occasionally, on the other hand, and more particu- larly in elderly persons, the tissues remain overloaded with fat to the end. Towards the close of the disease anasarca, generally limited to the lower extremities, is of common occurrence. And not unh-equently gangrene takes place in the fingers, toes, or more extensive portions of the extre- mities, in the genitals, nose, ears, or other parts. Another comphcation which is at least as common as any of the above, and on the whole of far more importance, is pulmonary phthisis. This attacks a large proportion of diabetic patients ; and indeed of patients who die of diabetes probably one-half suffer from it. The affection is rarely if ever in the form of miliary tuberculosis, but almost invariably in that of caseous consohdation, with tendency to disintegration and the formation • of canities. In some cases the progress of diabetes is exceedingly acute and rapid. 860 DISEASES OF THE GENITO-UEINAEY OEGANS. Death has resulted from it after an ilhiess of two or three weeks only. On the other hand, death may be delayed for ten years or more. For the most part, however, the patient succumbs in from one to three years. Eecovery is exceedingly rare. The cause of death usually is asthenia,, hastened in some cases by gangrene, dysentery, or phthisis ; but not un- frequently the patient dies comatose. Death from coma is one of the most interesting phenomena of diabetes. It occurs mostly in young-^ patients, and in cases of acute progress, and occasionally even before the other symptoms of diabetes have been recognised ; sometimes coming on suddenly, sometimes being preceded by premonitory symptoms which vary in details, but amongst the most important and common of which are ex- haustion, restlessness, dyspnoea, and severe pahi in the epigastrium or loins.. But besides these may be enumerated as occasionally present loss of appe- tite, nausea and sickness, diminution in the amount of urine and m the excretion of sugar, and mental excitement. The symptoms of the attack differ somewhat in different cases, but for the most part are those of collapse, on which profound coma presently supervenes. The patient becomes restless, but apathetic ; he breathes deeply and noisily, but there is no impediment to the entrance of air into the lungs or to its escape therefrom, and no abnormal auscultatory signs ; the heart's action becomes rapid and feeble ; the internal temperature falls, and the extremities become cold ; his apathy passes into somnolence, and this into profound coma. Death usually follows in from 10 to 48 hours. The occurrence of coma has been attributed to the development of acetone in the blood by fermentation ; to the breaking up of the blood-corpuscles due to the effects of acetone or some allied poison ; to accumulation of fatty matter in the blood and the formation of fat emboli ; and to various other causes. But there is considerable doubt as to the sufficiency of any of the hypo- theses which have hitherto been suggested in explanation of the phenomena of diabetic coma. It should be added, however, that diabetic patients bear fatigue, mental or bodily, very badly, and that it is, especially after such fatigue, that they are apt to fall into the state of collapse and coma above described. The preceding remarks apply to the usual form of the disease. But in elderly persons, and especially in such as are gouty, the urine not unfre- quently contains sugar, it may be in large quantities, and yet few or none of the other symptoms of diabetes are present. The glycosuria under such circumstances may persist for years, either uniformly or with remissions, the patient perhaps passing at times more water than natural, and suffering more or less from dyspepsia, yet presenting no emaciation and no serious impairment of strength, and ultimately recovering, or dymg not of diabetes or its ordinary complications but of some independent disease. Morbid anatomy and pathology. — Morbid anatomy reveals little as to the nature and processes of diabetes. Excluding dysenteric affection of the bowels, gangrene of various parts, pulmonary tuberculosis, and cataract (which are not present in all cases, and present no distinctive characters), but little remains for description. The kidneys generally are DIABETES. 861 enlarged and congested, and the epithelial lining of the tuhules is occa- sionally distinctly fatty. The liver and other chylo-poietic viscera, to which on theoretical grounds attention should he mainly directed, present no constant lesions. The former has occasionally been found cirrhotic ; the latter inflamed ; but far more commonly all appear healthy. The nervous system, again, has been examined with care, on account of the influence which certain parts of it have in causing glycosuria. Tuber- cular and other tumours have occasionally been discovered in the neigh- bourhood of the fourth ventricle ; and Dr. Dickinson has drawn attention to the existence of small cavities, sometimes visible to the naked eye, ori- ginating in softening and degeneration of the tissues around some of the smaller arteries, and containing, when fully formed, simply serous con- tents. He has found them in most parts of the central nervous organs, hut more particularly in the olivary bodies, the median plane of the medulla oblongata, and the grey matter in the floor of the fourth ventricle. If the pathology of diabetes has not been completely elucidated, it has at any rate had much light thrown upon it during the last few years by the labours of Bernard and other investigators. It has been proved that the Hver, besides manufacturing bile, is an organ for the conversion of albuminous and starchy matters (mainly if not entirely those obtained directly from food) into dextrine or glycogen — a starchy substance which exists in large quantities in the liver, and is readily convertible by fer- ments (and among others by a peculiar albuminous ferment existing in the blood but not yet separated from it) into glucose, or grape-sugar. It is probable that the healthy liver also converts sugar itself into glycogen, and that hence, amongst other duties, the liver opposes a barrier to the admixture of saccharine ingesta with the blood. What becomes of this glycogen, which is formed and accumulates in the liver, we need not stop to consider. It is certain, however, that in health neither it nor glucose is discovered in the blood. Further, experiments made by Bernard, Schiff, and others, have demonstrated the important influence which the nervous system exerts over the glycogenic function of the liver. It has been proved that by irritating various parts of the central nervous organs arti- ficial diabetes may be induced — irritation of the floor of the fourth ven- tricle, particularly of a spot in it midway between the origins of the audi- tory nerves and par vagum, being especially efficacious in this respect. There is reason to believe that this spot is either the origin of, or in rela- tion with, the tracts of sympathetic nerves which regulate the diameter of the hepatic vessels ; and that through the agency of these nerves the vessels of the liver become actively dilated, upon which phenomenon congestion and glycosuria supervene. Schiff, by dividing the anterior columns of the cervical cord through which the sympathetic tracts above referred to pass on their way to the liver, also produces glycosuria ; which, again, is probably dependent on dilatation of the hepatic vessels and hypertemia, but upon dilatation of paralytic origin, and which, like the diabetes it causes, is of comparatively long duration. Experiment would there- fore seem to show : that diabetes depends on_j^dilatation of the hepatic 862 DISEASES OF THE GENITO-UEINAEY OEGANS. vessels, with accumulation of blood in them and rapid flow of blood through them, and consequently on increased or rather modified func- tional activity of the liver ; and that this dilatation may be either active (the result of irritation of nerves) producing for the most part a temporary condition of diabetes, or passive (the result of paralytic dilata- tion) inducing as a rule a chronic form of glycosuria. The dependence of diabetes on hyperaemia of the liver has been demonstrated by other ex- periments in which hyperemia has been brought about without the inter- vention of the nervous system ; and is confirmed by the not unfrequent oc- currence of some degree of the affection in pathological congestion of the liver, arising from cardiac or pulmonary disease, from injuries to the liver and from mflammation of the organ. According to these views, which it may be remarked only partially explain the dependence of diabetes on hepatic derangement, the occasional and temporary impregnation of the urine with sugar would seem to have an irritative, the typical forms of diabetes a paralytic, origin. Treatment. — The treatment of diabetes is a subject of great interest, and has been regarded and conducted from all points of view with varying- degrees of success. As with most other diseases, some cases of it are so serious from the beginning and so rapidly fatal that all efforts to arrest their progress are futile ; while some cases are so slightly pronounced that the patients either remain in fair health in spite of their sugary urine, or appear to derive benefit from almost any treatment. Between these extremes lie the great majority of cases, which, if not admitting of cure, undoubtedly often admit of important alleviation by appropriate treatment. It may at once be stated that the use of blisters and other local applications to the head or to the liver has been advocated and prac- tised by various physicians, on the ground that one or other of these organs was at fault ; and beneficial results have been recorded. Further,, we may at once point out the general importance of promoting the func- tions of the skin by warm baths and warm clothing ; of maintaining the regular action of the bowels ; of alleviating, arresting, or curing dysentery and the other complications which so frequently attend the progress of dia- betes ; of preventing all unnecessary fatigue ; and of putting the patient under those external conditions which are commonly regarded as con- ducive to health. The most important point, perhaps, in the treatment of diabetes is the regulation of the patient's diet. It has long been proved that the abstention from sugar and from those other articles of food which are most readily convertible into sugar is always attended with a marked diminution in the quantity of sugar voided, in the specific gravity of the urine, and in the amount of that fluid secreted ; and that in a very large proportion of diabetic patients there is at the same time gain of flesh with manifest im- provement of health. For these reasons it is customary to debar 'the patient from certain alimentary matters, especially sugar in every form, and all vegetables or vegetable products whose nutritious qualities depend on sugar, starch, or related matters — among which may be enumerated bread, pota- toes, rice, sago, tapioca, peas, beans, turnips, parsnips, carrots, and most DIABETES INSIPIDUS. 863^ fruits. There is good reason also to believe that alcohol in all its forms is pernicious. Among permissible foods are : first, green vegetables ; second,. all sorts of animal food, including milk, eggs, cheese, and butter ; and, third, tea and coffee without sugar, but sweetened if need be with glycerine. It is found, however, in practice almost impossible to overcome the cravuig for bread or some equivalent for bread which soon arises under the use of a restricted diet. Various substitutes have been suggested and may be used temporarily ; the most important being gluten bread, bran cake, and almond biscuits or rusks, to which may be added (as being more palatable,, though more objectionable) toast miiformly and deeply browned. Dr. Donkin has advocated the administration of skim milk, to the exclusion of all other food. He gives from six to eight pints daily to an adult. And it is certain that many patients in a short time get fairly reconciled to it, that they often gain strength and flesh under its use, and that at the same time the urine diminishes in quantity, in density, and in the amount of sugar it contains. It has often been held important to restrain the patient from gratify- ing his intense craving for drink. It is cruel, however, to put such restraint upon him, and of very doubtful benefit. Acidulated drinks are said to be specially useful in assuaging his thirst, and, above all, dilute solutions of phosphoric acid. Of all drugs, opium seems to be the most efficacious. It has long been esteemed in the treatment of diabetes ; and especially Dr. Pavy has latterly extolled its virtues. Diabetic patients are said to be little suscep- tible to the influence of opium, and may therefore take it with safety in comparatively large quantities. It is best, however, to commence with small doses, say half a grain, of the powder, three times a day, and gradually to augment them, according to their effect, until each dose is increased to five or six grains. A fair number of cases have been re- corded in which great amelioration, if not absolute cure, has followed this treatment. Still more recently Dr. Pavy has employed, and apparently with considerable success, codeia, in doses commencing at about half a grain, three times a day, and gradually increasing to two or three grains. Again, alkahes (bicarbonates, acetates, citrates) have been regarded as valuable remedies ; as also has the hot vapour bath. Iron and other tonics are sometimes beneficial. As respects the treatment of the masked diabetes of elderly people, it is impossible to lay down definite rules. It is generally needless to carry out the plans recommended above, at any rate to carry them out strictly or continuously. XIX. DIABETES INSIPIDUS. {Diuresis.) Definition. — Under these titles are grouped a number of cases, which are linked together and characterised by the association of extreme thirst with the excretion of a large quantity of pale limpid urme, free from sugar, and of low specific gra^dty. Causation. — Diabetes insipidus is rare, but appears to occur at any 864 DISEASES OF THE GENITO-UEINAEY OEGANS. age and in either sex. The causes to which it has been attributed are various. Among them may be mentioned tuberculosis, diseases of the brain, drink, accident, and exposure. According to Trousseau and some others, it has a close relation to diabetes mellitus, not only in symptoms but in the facts that there is an hereditary connection between them, and ihat the former is occasionally a sequela of the latter. Bernard, more- over, has shown that diabetes insipidus, as well as glycosuria, may be produced by irritation of the floor of the fourth ventricle. Symptoms and progress. — This affection comes on sometimes insi- diously, sometimes suddenly. Its chief symptoms are the following : — First, the secretion of large quantities of urine : the quantity passed is often considerably larger than in saccharme diabetes ; it may be as much as 20, 30, or 40 pints daily, or even twice as much ; the urine, moreover, is pale, watery, of low specific gravity (often not above 1002, 1003, or 1004) and containing no sugar or other abnormal ingredient. Second, •extreme thirst : this is proportionate to the diuresis, the quantity of fluid drunk being equal or nearly so to the quantity eliminated. Other symptoms vary. In some cases the patient appears to be v/ell in all other respects, and, except for the continued presence of his in- firmity, enjoys life, probably attaining old age. In some cases he presents all the usual indications of diabetes mellitus : he has a voracious appetite, a parched mouth, and dry skin ; he becomes anemic, sallow, emaciated, and weak ; and after a longer or shorter time dies as ordinary diabetics die. In other cases, again, diabetes insipidus is from its commencement associated with the presence of tuberculosis or other lesions, and is thus a mere incident or complication of a more serious malady. Morbid anatomy. — In a few cases which have been collected by Dr. W. Koberts, the morbid anatomy of diabetes insipidus is illustrated. There is little, however, in the recorded post-mortem examinations to throw light on the nature of the affection. In several of the cases the Tddneys were atrophied, and in one hydronephrotic. There is some reason to suspect that in these the primary affection was renal. We have known in fact the excessive diuresis of contracted granular kidney to be mistaken for it. In others the kidneys were healthy, as also were they in a case which died under our own care. In this case, as in one of Dr. Eoberts's, the patient suffered from tuberculosis, which probably caused death. Here undoubtedly the diuresis was symptomatic only. We have met with the disease also associated with syphilitic disease of the brain. Treatment. — There is little to say about the treatment of diabetes insipidus. Various remedies, including tonics and regulation of diet, have been tried. Trousseau and Eayer strongly recommend valerian in large doses. The former commences with two or three drachms of the extract daily, and generally pushes the treatment until the daily portion reaches an ounce. Baths are sometimes beneficial. The constant galvanic cur- rent, passed between the loins and epigastrium, has recently been tried by Dr. M. Seidel. SUPPEESSION OF UEINE. 865 XX. SUPPEESSION OF UEINE. (Ischuria Benalis.) A. Functioned sivppression of urine. More or less complete suppression of the urinary secretion, lasting for a longer or shorter period, is not unfrequent in the course of many diffei'ent diseases or morbid conditions, among which maybe enumerated malignant cholera, certain of the infectious fevers, acute enteritis, inflammatory afl^ec- tions of the kidneys, collapse, and hysteria. In many such cases the sup- pression is symptomatic only, and probably scarcely affects the patient injuriously ; in others the retention of urea and other effete nitrogenous matters in the blood which attends the suppressioij induces or aggravates typhoid phenomena and thus hastens death. It is remarkable, however, how sometimes, and more especially in cases of hysteria, the urine con- tinues for many weeks at a time in almost complete abeyance (the patient going, perhaps, for two or three days at a time without secreting any, and then perhaps passing only an ounce or two in the course of the twenty- four hours) and yet she remains wholly h'ee from evidence of uraemic poisoning. These several varieties of suppression are considered elsewhere in connection with the diseases in which they occur, and need not further detain us now. Li sudden obstruction of the renal arteries, or of the aorta above the giving off of these vessels, the kidneys become congested, and the secretion of urine is, for a time at any rate, suppressed or greatly diminished. In the latter case the urine becomes albuminous, and may contain blood. If the patient survive, the urinary secretion may be re-established, perhaps at the end of a few hours, and may resume its healthy character. For the treatment of the above cases, simple diuretics, more especially copious bland fluids, the use of hot hip or other baths, and the application of counter-irritants to the lumbar region, comprise everything likely to be of real service. B. Suppression of urine from obstruction. Causation and morbid anatomy. — Another class of cases of so-called ' suppression ' is that in which the failure to discharge urine depends on the existence of some mechanical obstacle to the escape of imne, situated either in the pelvis of the kidney or, as is far more common, in some part of the ureter. The permanent obstruction of one ureter, its fellow remaining pervious, is, as we have already shown, a not uncommon accident ; and on the one hand results in the production of hydro-nephrosis with ultimate wasting of the corresponding kidney, on the other hand leads to increased functional activity of the opposite organ, which henceforth does the work of both. Obstruction of the ureter is most commonly due to the impaction of a calculus ; and hence it is not altogether remarkable that a person who has had one ureter blocked up and one kidney destroyed should be liable to the occurrence at some future time of the same accident on the opposite side. And indeed it is generally in cases of this sort that mechanical suppression occurs. 3k 866 DISEASES OF THE GENITO-UEINAEY OEGANS. Symptoms andj^rogress. — The suppression of urine under these circum- stances comes on suddenly. Sometimes it is, and remains, absolute ; perhaps more frequently a small quantity of urine of low specific gravity,, and containing little urea, is still passed at irregular and probably long intervals. It is very remarkable that in most cases of this kind, no matter how complete the suppression may be, the patient scarcely seems to suffer during the first seven or eight days. He may perhaps have a little nausea,, there maybe some degree of insomnia, and there may also be some failure of muscular strength ; and this is all. At the end of this time, however, manifest symptoms of the effects of the retained poisonous matters on the system arise. They consist m the first instance in muscular tremors- associated with distmct increase of muscular debility ; and in the next place in slow, panting respiration, and contraction of the pupils. These phenomena appear never to be absent ; and they become more and more marked with the progress of the case. But soon other symptoms are superadded. The patient complains of anorexia and thirst with dryness of the mouth and fauces ; he becomes drowsy, but sleeps only in snatches ; and he may present a little occasional delirium. Death, which is rarely preceded by coma, and still more rarely by convulsions, takes place mainly by asthenia at the end of two or three days from the first occurrence of toxaemic symptoms. Throughout the patient's illness there is no fever ; on the contrarj^ towards the close the temperature tends to fall, the pulse differs little m frequency from the normal, and the skin is often moist. The symptoms, indeed, are in many respects widely different from those ordinarily attributed to uraemia. Tlie diagnosis of cases of this kind is often facilitated by the combina- tion of a history of some long antecedent attack of renal colic on one side, with present symptoms of an acute attack of the same kind on the opposite side. The calculus soon, however, becomes impacted, and then probably all local pain and uneasiness disappear. Further, there is no necessary pain or uneasiness in the loin. Treatment. — For this affection we can do little or nothing. We may adopt such treatment as is recommended for renal colic, in the hope that the stone, if there be one, may be aided in reaching the bladder ; and we may endeavour, as Dr. W. Eoberts recommends, by kneading the abdomen, to empty the distended ureter and coincidently, it may be, to dislodge the- calculus. The feasibility of siu'gical interference might be worth con- sideration. Section II.— DISEASES OF THE PELVIC OEGANS. The diseases of the genito-urinary organs, situated within the pelvis, are of extreme interest and importance ; but they are claimed for so many de- partments of practice that it is difficult to determine to what extent they ought to be mcluded in a work on medicine. We propose to discuss very briefly, and mainly in reference to diagnosis, those among them which are important on account of their liability to be confounded with or to com- plicate the diseases, already considered, of the other abdominal viscera. DISEASES OF THE UEINAKY BLADDER. I. DISEASES OF THE URINAEY BLADDEE. 1. Inflammation arises under many different circumstances, which need not be enmnerated. It is characterised anatomically by congestion and thickening of the mucous membrane, with the secretion of mucus, which may be simply abundant or may acquire the characters of pus. Sometimes submucous extravasations of blood occur, sometimes blood escapes from the surface. Occasionally ulceration takes place, or membranous pellicles form, or the mucous membrane itself or large patches of it exfoliate and are dis- charged. Occasionally, also, abscesses are developed in the substance of the vesical waUs, or mflammation, commencing at the mucous surface, extends in depth until it involves the serous membrane. The syvijjtoms of mflammation of the bladder are mamly : pain and tenderness in the neighbourhood of the organ, therefore in the perinfeum and immediately above the pubes, extending probably to the penis, to the sacrum or loins, and to the contiguous parts of the thighs ; irritability of bladder, with constant desire to pass water ; and the discharge of lu'ine which, accordhig to circumstances, presents only a slight cloud of mucus, or more or less abundant thick ropy mucus, or mucus mingled "s^ith blood, or pus. Sometimes the urine contains shreds of tissue, and fi-ec[uently becomes alkaline and offensive. Cystitis may be acute or chronic, and varies greatly in its mtensity and danger in different cases. When acute the general febrile symptoms may be very severe. Cystitis often leads to pyelitis ; and further, the latter affection not only resembles cystitis in some of its sj-mptoms, but inflammation, commencmg in the pelvis of the kidney, is apt to travel along the ureter and thus to involve the bladder. For the treatment of cystitis we must refer to surgical works and to what has been previously said m reference to pyelitis. 2. Tubercle affects the bladder but rarely, and is then almost invariably associated with tubercle of the kidneys and ureters, or (which is yet more common ) with tubercle of the prostate and vesiculs seminales. It is of the miliary variety, and tends, as m the intestines and on other mucous surfaces^ to produce shallow circular ulcers, which, by coalescence, are apt to cause superficial destruction of some extent. The symptoms are in themselves undistmguishable from those of chronic cystitis. 3. Morbid groivths. — The most important of these are villous tumours and the several forms of malignant disease. The latter usually commence in the prostate or some neighbourmg part, and are rarely of primary origin, in the bladder. Tumom's are generally attended with pain referrible to the bladder, and more or less mterference with micturition. Moreover they are apt to be complicated, after a while, with sjanptoms of cystitis. Villous and malignant tumours are frequent sources of profuse hemorrhage. The latter are further characterised by sooner or later involving contiguous organs, and by inducing progressive cachexia. 4. Dilatation. — This condition depends on the accumulation of urine or 3 Jt 2 868 DISEASES OF THE GENITO-UEINAKY OEGANS. other matters within the cavity of the bladder. It may occm- in paraplegia and other paralytic conditions from paralysis of the vesical walls, and also in hysteria. It is common in the later stages of many of the specific fevers, and during the typhoid condition, from failure of the reflex influence on which the evacuation of the bladder depends ; and it is especially common as a consequence of obstructive disease, such as stricture of the urethra, enlarged prostate, or tumours of any kind involvmg or compressing the neck of the bladder. When the dilatation is chronic, and secondary to some impediment, the muscular walls become hypertrophied, and sacculi are developed. Under any circumstances the mucous surface is apt after a time to get inflamed ; and the dilatation and inflammation are both of them liable, sooner or later, to involve the ureters and the cavities of the kidneys. Symptoms. — In cases in which retention of urine is dependent on para- lysis, or connected with the presence of febrile disturbance or the typhoid condition, the bladder may become enormously distended without causmg any apparent suffering to the patient. Even in cases of chronic stricture and such-like conditions in which, although the dilatation of the bladder may be extreme, it has been slowly attained, the organ becomes remark- ably tolerant of its burden, and the patient suffers comparatively little. In other cases his sufferings are often extreme. He complains of general un- easiness, pain and tenderness over the hj^oogastric region, in the penis and in adjoining parts ; but the pain is subject to frequent exacerbations, depen- dent on the violent but futile spasmodic efl^orts of the bladder to void its contents. In many cases, if the obstruction be not complete, more or less urine either constantly dribbles away or is passed in small quantities during the spasmodic efl^orts. The distended bladder forms a tense, ovoid tumour, which rises out of the pelvis from behind the pubes, and may extend up- wards to the umbilicus or beyond. It occupies the middle part of the abdomen, and, unless it be largely sacculated, is symmetrical in form and position. The enlarged bladder can rarely fail of recognition if due atten- tion be paid to the position and form of the tumour, to the perfect dulness on percussion which it presents, and to the characteristic pain which so often attends it and is evoked by manipulation. Treatment.- — When the bladder becomes distended in the course of fever and paralytic affections, equally as when it becomes distended in consequence of surgical diseases, the urme should be drawn off; and, if necessary, should be drawn off periodically. Further, if the urine be ammoniacal, or there be discharge of ropy mucus or pus, it may be well not only to empty the bladder, but to wash it out either with pure water out. Its outer limit is represented by the smooth inner aspect of the dura mater ; its inner limit is formed by a delicate transparent membrane which lies loosely upon the surface of the central organs, never dipping into the sulci, and lying especially loosely upon the parts situated at the base of the 908 DISEASES OF THE NEKVOUS SYSTEM. brain, and upon the spinal cord. The inner and outer aspects become continuous by means of tubular prolongations wherever nerves or vessels pass from the protective organs without to the central nervous organs within. The ina mater is the vascular membrane which closely invests the outer surface of the brain and cord, following all its inequahties. It is continuous by its applied suirface with the connective web and vascular network which pervade the substance of the subjacent organs ; and the neurilemma of the nerves appears to be derived fi'om it. The pia mater within the skull is delicate and highly vascular, dips to the bottom of all sulci, and acciu'ately fits the comphcated arrangement of processes and depressions which exist at the base of the bram. It dips also into the great transverse fissure of the brain, and into the somewhat similar fissm^e existing behind between the medulla oblongata and the cerebellum — form- ing in either situation a reduplication, the fi'ee margins of which are wrinkled and folded, and constitute the bodies known as the choroid plexuses. The pia mater of the cord is much thicker, denser, and less vascular than that of the brain, forms in front a duplicatm'e which dips to the bottom of the anterior furrow, and behind a thin vertical septum which occupies the posterior furrow. The interval which exists between the pia mater and the visceral lamina of the arachnoid is known as the subarachnoid space ; it is crossed by numerous dehcate fibrous bands, and in the spinal canal on either side by the ligamentum denticulatum, and behind by an incomplete vertical septum. It is the seat of the subarachnoid iiuid, which constitutes the great bulk of the cerebro- spinal iiuid. 2. Ventricles of brain and cord. — The existence of the ventricles of the brain and cord (excepting the fifth) as distinct cavities is due in some sense to the failm-e abeady referred to of the pia mater at the great trans- verse fissure of the brain and at the posterior part of the fourth ventricle to follow the various diverticrda or involutions which take then- origin in these situations. The system of ventricles comprises : the lateral ven- tricles, which are continuous with one another and with the third ventricle in the interval (into which the velum interpositum extends ) between the fornix above and the optic thalami below ; the third ventricle, which commmiicates by means of the iter with the fourth ventricle ; the fourth ventricle ; and the central canal of the cord which commences above at the calamus scriptorius or posterior extremity of the fourth ventricle. The nervous boundaries of the ventricles are covered with a dehcate mem- brane which is contmuous with the neuroglia or connective web permeat- ing the substance of the subjacent organs, is identical in structm-e with it, and is furnished with an epithehum. The ventricles form a continuous system, and have no communication with other cavities or spaces, except- ing with the subarachnoid space through Majendie's opening at the lower extremity of the fourth ventricle, and two other small openings, one on either side, close to the points of emergence of the glosso-x^har^iigeal nerves. 3. Cerebral hemispheres.— TDiq cerebrum consists of two hemispheres,, ANATOMY AND PHYSIOLOGY. 909 •separated the one from the other above by the great longitudinal fissure, and united below mamly by means of the commissural fibres of the corpus ■callosum, by the fornix, and certain other structures which need not be specified. It is composed of white and grey matter, of which the one forms a comparatively thin lamina on the surface, while the other makes up the great bulk of its mass. The surface of the organ, and T\ith it of course the grey matter, is arranged in folds or convolutions, separated by fissures or sulci, the more important of both of which present a tolerably definite and regular arrangement. The superficial grey matter is doubt- less the seat of the intellectual and emotional functions, and the primary source of those various combined muscular actions which accompany and reveal their operation. The study of the convolutions is, therefore, a matter of interest, especially m connection with the localisation of func- tion, on which subject important light has been throT^ii by modern patho- logy and recent experimental inquiries. We proceed to describe so much of the topography of the cerebral surface as bears directly on this subject. a. Fissures. — Th^ fissure of Sylvius (Fig. 82 and 96 d) commences on the base of the brain at the locus perforatus anticus, and, separating the middle from the anterior cerebral lobe, passes directly outwards until it reaches the lateral aspect of the hemisphere. Here it di^ddes into two branches: an anterior short branch, which proceeds upwards and forwards, and a posterior long branch, which courses nearly horizontally backwards upon the outer surface, dividing the temporo-sphenoidal lobe below from the parietal lobe above. The fissure of Bolando, or sulcus centralis (Fig. 82 and 92 c), commencing above at the great longituduial fissure a Httle behind the vertex, runs downwards and forwards over the outer surface ■of the hemisphere to near the point of bifurcation of the Sylvian fissure, separatmg the fi-ontal lobe in front from the parietal lobe behind. The inter-parietal fissure (Fig. 82 and 92 e), originating in the angle contamed between the fissure of Eolando and the posterior Syhdan branch, passes irregularly backwards and towards the parieto-occipital fissure. The IKirallel or first temporo-sphenoidal fissure (Fig. 82 li), running parallel to but below the posterior Sylvian branch, turns up behind its posterior extremity, and there loses itself in a group of convolutions, which are limited above and behind by the posterior part of the inter-parietal fissure, and are known by the name of the gyrus angularis or pli courbe. On the inner aspect of each hemisphere there are four fissures which call for special notice :— the first is the fronto-parietal or calloso-riiarginal (Fig. 83/), which, commenchag in fi'ont, runs backwards parallel ^\dth the corpus callosum, forming the upper Hmit of the gyrus fornicatus, until ha\dng arrived near the posterior edge of the corpus callosum, it tmiis up to reach the upper margin of the hemisphere a little behind tlie upper termination of the fissure of Eolando; the second is the vertical, ox parieto- occipital (Fig. 83 g), which separates the occipital from the parietal lobe, and, commencing above on a level mth the posterior extremity of the parallel sulcus, runs downwards and forwards to unite at an acute ano-le with (third) the calcarine fissure (^Fig. 83 l), which is nearly horizontal in 910 DISEASES OF THE NEEVOUS SYSTEM. position, and corresponds to the hippocampus minor ; the lastf is the hippocampal fissure (Fig. 83 m), which runs round the crus cerebri, and indicates the course of the hippocampus major. Fig. 82. Lateral view of brain, sliowing principal convolutions and fissures. Fig. 83. Inner surface of liemisphere, sliowing principal convolutions and fissures, and Farrier's centres of touch (xni.), and of smell and taste (xrv.). The several letters in the above figures, and also in figures 91, 92. 94, 95, and 96, refer to the same parts. Fissures : — a, superior frontal ; 6, inferior frontal ; c, fissure of Rolando ; d, fissure of Sylvius ; e.iuter- parietal : /, fronto-parietal : g, parieto-occipital ; h. first temporo-sphenoidal ; i, second ditto ; j, third or inferior ditto ; Z-. occipito-temporal ; /, calcarine ; ??;, hippocampal. Convolutions : — A, superior or first frontal ; b. second ditto; c. third ditto ; D, ascending frontal, or anterior parietal; e, ascending parietal ; f, superior parietal ; Fj, prsecuneus ; G, snpra-marginal ; G,. g.vrus angularis, or pli coiirbe ; h, first temporo-sphenoidal ; I, second ditto ; J, third ditto ; k, fusiform lobule : l, lingual lobule ; M, gyrus fomicatus ; ii, , gyrus hippocampi : ir.,, uncus gyri fornicati, or subiculum cornu Ammonis ; x , cuneus. h. Convolutions. — In front of the fissure of Eolando, and foUowuig its course from below upwards, runs the ascending frontal, or anterior parietal convolution (Fig. 82 and 92 d); and from the anterior aspect of this are given off in succession from above downwards the first, second, and third frontal convolutions (Fig. 82 and 92 a b c ) . The first of these rmis parallel to the longitudinal fissure, and forms, indeed, the marginal convolution (Fig. 83 A) of that fissure ; the second follows the same course as the first, ANATOMY AND PHYSIOLOGY. 911 but lies external to it ; and the third, still more external, by its posterior part forms the upper and anterior boundary of the anterior branch of the fissure of Sylvius, and by its anterior part separates the second convolution above from the external orbital convolution below. The third frontal con- volution of the left side is also called Broca's convolution. The orbital convolutions occupy that portion of the under surface of the anterior cerebral lobe which lies upon the floor of the skull. Parallel to the ascending frontal convolution, and separated from it by the fissure of Eolando, courses the ascending iMrietal convohttion (Fig. 82 and 92 e b), from the posterior and outer margin of which two secondary convolutions, separated from one another by the inter-parietal sulcus, pass nearly directly backwards : the inner and upper one, the superior ijarietal con- volution (Fig. 82 and 92 p), forming the margin of the longitudinal fissure in this situation, and ending behind at the parieto-occipital fissure ; the outer and lower one, or gyrus supra-marginalis (Fig. 82 and 92 g), lying at its anterior extremity, mainly between the inter-parietal sulcus and the posterior branch of the fissure of Sylvius, and further back between the inter-parietal sulcus and the posterior extremities of the Sylvian and first temporo-sphenoidal fissures. In the latter part of its course it is con- siderably curved, and receives the name of gyrus angularis or pli courhe (Fig. 82 and 92 Gi). There are three temporo-sphenoidal convolutions passing nearly horizontally backwards from the anterior part of the tem- poro-sphenoidal lobe ; the first (Fig. 82 h) is situated between the posterior branch of the Sylvian fissure above and the first temporo-sphenoidal fis- sure below ; the second (Fig. 82 1) lies below the first temporo-sphenoidal fissure ; the third is lower down, but parallel to the others. At the bottom of the fissure of Sylvius, at its point of bifurcation, and concealed by the overlying convolutions, lies the island of Beil, the grey matter of which is in close anatomical relation in front with that of the posterior part of the third frontal convolution, behind with that of the first temporal. On the internal aspect of the hemisphere, amongst other convolutions, may be observed the gyrus fornicatus (Fig. 83 m), which, commencing in front beneath the genu of the corpus callosum, runs backwards over this body, between it and the calloso-marginal fissure, then turns round its posterior extremity, being continued downwards and forwards under the name of the gyrus hippocampi, or uncinate convolution (Fig. 83 and 96 Mi ), first between the hippocampal and calcarine fissures, and thence nearly horizontally forwards until it reaches the internal extremity of the fissure of Sylvius, where it forms the uncus gyri fornicati, or suhiculum cornu Ammonis (Fig. 83 and 96 Mj,). For an account of the remaining con- volutions, to some of which we nlay subsequently allude incidentally, we must refer to anatomical works. In connection with the subject of the convolutions it may be observed that M. Betz has shown that the surface of the cerebrum may be divided by microscopic peculiarities into two regions, of which the anterior, limited by and including the ascending parietal convolution, is characterised by containing, in greater or less abundance, giant-cells resembling those of 912 DISEASES OF THE NEKVOUS SYSTEM. the anterior cornua of the spinal cord, the posterior by an almost total absence of sucli cells. 4. Ganglia at base of brain. — Excepting the commissural fibres of the ■corpus callosum and fornix, and certain other commissures, which need not be enumerated, all the nerve-fibres from the grey matter of the convo- lutions converge to the group of ganglia situated at the base of the brain, namely, the corpora striata and the optic thalami, together with the cor- pora geniculata and corpora quadrigemina, and are thence continued (directly or indirectly) either through the superior cerebellar peduncles to the cerebellum or along the crura cerebri to the medulla oblongata. Each striated body comprises three nuclei, separated from one another by white fibres. The first of these is the caudate nucleus, and is that portion of the body which is visible in the lateral ventricle. The second is the lenticular nucleus, which is placed in part external to and below the caudate nucleus, in part external to and below the optic thalamus : being separated from these bodies by a layer of white fibres, which forms ihe internal capsule, and on the outer side from the grey matter of the island of Eeil by a similar white lamma, which is known as the external capsule. Imbedded in this last is the third or tceniceform nucleus or ■claustrum, which forms an exceedingly thm plate. The cerebral fibres which enter these nuclei and occupy the intervals between them come from aU parts of the cerebral surface, but mainly from the anterior half ; ;and those which emerge from them below pass mainly downwards and backwards to form the under portion or criost of the corresponding cerebral pedmicle, within which they become connected with an additional ganglion ■of the same system, namely the locus niger. The further destination of the crust is twofold : it sinks into the anterior and upper edge of the pons, -and there di\ides into two portions ; of which one, according to Meynert, crosses among the anterior fibres of the pons, and passes with these to the opposite half of the cerebellum, thus decussating with its fellow ; while the other emerges from the posterior border of the pons as the anterior pyramid, which also decussates with its fellow, and is prolonged mainly io form the lateral column of the opposite side of the cord. The optic thalami, corpora geniculata, and corpora quadrigemina also derive fibres fr'om nearly all parts of the cerebral surface, though mainly probably fr'om the posterior and lateral portions ; and, restmg by their imder sm-face upon the cerebral peduncles, are more or less dfrectly con- tinuous with their upper half or the tegmentum. This, which includes within it the red nucleus, divides like the crust into two portions. One of these continues backwards as the processus e cerebello ad testes .and valve of Vieussens to form the superior peduncles of the cerebellum ; and the fibres which constitute it for the most part decussate anteriorly to the posterior limit of the testes, and so reach the opposite sides of the cere- bellum. The other continues do^\■nwards in the substance of the pons and on the floor of the fourth ventricle, to become continuous mamly with the sensory tracts of the medulla oblongata and cord. 5. Cerebellum and its peduncles. — So little is known comparatively of ANATOMY AND PHYSIOLOGY. 913 Fig. 84. Aiit3rior Proutal Section . Fiot. 85. Posterior Frontal Section. Pig. 86. Anterior Parietal Section. Fig. 87. I'osterior Parietal Section. ' The Roman capitals in the above figures have the same meaning as those in figures 82 and 83. The several Greek letters in the above figures relate to identical parts. a. Island of Reil. /3. Corpus callosum. y. Caudate niicleus. S. Lenticular nucleus. €. Tfeniaaform nucleus, f. Optic tlialamus. t). Internal capsule. 6. External capsule. From the Thfese Inaugurale of M. Pitres, ' Eeeherches sur les lesions du centre ovale des hemispheres cerebraux, etudiees au point de vue des localisations ceriibrales.' Paris, 1877. 3 N 914 DISEASES OF THE NEKVOUS SYSTEM. tlie specific functions of different parts of the cerebellum that it is needless- to consider here either its general form and arrangement or the names which have been given to its separate lobes and lobules. It may, however,, be pomted out that, in addition to its superficial grey investment, it con- tains imbedded in its white medulla in the first place two ganglia (one on either side), the corpora dentata, and in the next place two other grey nuclei, the roof nuclei of Stilling, which lie below the central lobule of the superior vermiform process. The cerebellum presents three pairs of peduncles or groups of white fibres, of which one comes from the cerebrum, one from the medulla oblongata, and the other is mamly transversely commissural. The first pair or the superior p)eduncles come almost exclusively from the tegmentum of the cerebral peduncles, comprise the ijrocessus e cerehello ad ^es^es with the intermediate valve of Vieussens, and pass into the corpora dentata and thence to the convolutions. The second pair or the middle peduncles are constituted mainly by the transverse fibres which form the great bulk of the pons Varolii, but comprise the cerebellar fibres derived from the crust of the cerebral peduncles ; of these the more internal pass into the roof nuclei, but the outermost, accompanied by the restiform bodies, reach the sm'face of the cerebellum without the mtermediatiou of either of these ganglia. The third pair or the inferior peduncles are the restiform bodies. It will thus be seen that the most direct, if not the only, communica- tion between the hemispheres of the cerebrum and those of the cerebellum is effected by means of fibres which, takmg their origin in the cerebral ganglia, pass backwards and lose themselves probably in the gangha im- bedded in the white substance of the cerebellum ; that of these some are derived from the crust, some from the tegmentum of the crura cerebri ; and that all, accordmg to Meynert, decussate in the course of their passage. It will also be gathered that both the cerebrum and the cere- bellum send down strands of fibres to take part in the formation of the medulla oblongata. Those from the brain are continued from both layers of the crura cerebri ; those from the cerebellum are the restiform bodies. 6. Spinal cord. — Before speakhig further of the medulla oblongata it •s^oU be well to describe the spinal cord. This, which extends, in the adult, from the foramen magnum above to. the lower part of the first lumbar vertebra below, presents an anterior and a posterior median fissure, and on either side two lateral furrows, which correspond to the successive points of emergence of the anterior and posterior roots. It is thus divided superficially, on each side, into posterior, lateral, and anterior columns. But, in addition to these, a slender median column, most obvious m the upper part of the cord, may be observed, running along the edge of the posterior median fissm-e. On transverse section the grey matter of the cord mil be found to occupy its central part, the white its periphery. The grey matter is arranged in the form of two lateral crescents, placed back to back, and miited with one another in the middle by a transverse com- missure, which crosses the narrow interval between the bottoms of the anterior and posterior fissures, and contains within it the ventricle of the ANATOMY AND PHYSIOLOGY. 915 cord. The posterior limb of each crescent constitutes the posterior horn of grey matter, the anterior Hmb the anterior horn. In the latter are situated distinct groups of large multipolar cells, which appear to be the nuclei of origin of the anterior or motor nerves ; and from it the root of each nerve passes forwards through the substance of the white matter in several parallel bands. The posterior horn is tipped by the gelatinous substance of Eolando, from the whole transverse extent of which the fibres of each posterior root escape in wavy bands, some undulating through the substance of the adjoming posterior column, previous to their appearance at the surface of the cord. At the root of the posterior cornu^ on its outer side, is the group of cells which indicates the longitudinal tract to which Lockhart Clarke has given the name of tracfus interrnedio- lateralis ; and in almost the corresponding situation, on its inner side, Fii>. 88. Diagrammatic sections of tlie spinal cord x 2. A. At cen-ical enlargement ; B. At mid-dorsal region ; C. At lumbar enlargement. a. Posterior median fissure, b. Anterior median fissure. c. Posterior nerve root. d. Posterior grey horn. e. Anterior grej- horn. /. Anterior nerve root. g. Posterior median column or fasciculus of (roll. h. Posterior external column. i. Crossed pyramidal tract. j. Lamina of 'nhite matter from cerebellum (?). k. Direct pyramidal column or fasciculus of Tiirck. I. Presumed sensory tract in lateral column (Go^yers and Hadden). may be seen the sectional surface of the tract of cells which constitutes Claxke's posterior vesicular column. Less on anatomical than on physio- logical and pathological evidence, the white matter of the cord admits of di^-ision into several regions which are functionally distinct from one another. As regards the posterior columns, these, as has already been pointed out, may be divided into two parts, namely, the i^osterior median columns, or fasciculi of Groll, situated on either side of the posterior median fissure, and the posterior external columns lying between these and the posterior horns of grey matter, and nerves springing from them. Each lateral column presents on transverse section a wedge of white matter^ situated almost entirely behmd the ventricle and m close relation with the posterior grey horn. It represents the direct continuation downwards. of nearly the whole of the opposite anterior pyramid. These may be 3 N 2 916 DISEASES OF THE NEEVOUS SYSTEM. termed the crossed pyramidal tracts. Tliey are separated from the outer surface of the cord by a lamma of white matter supposed to be connected /with the cerebellum. On either side of the anterior median fissure is a thin tract of white matter which descends directly from the anterior pyramid of its own side. This is termed the fasciculus of Tiirch, or the direct pyramidal tract. And lastly, Dr. Gowers, in a case of cord crushed in its lower part, found symmetrical are^e of slight ascending degeneration in the anterior part of the lateral columns in front of the pyramidal tracts. These he could not trace far up the cord. But Dr. Hadden dis- covered in the upper part of the cervical cord, from a case of which the liistory was unknown, symmetrical tracts of degeneration occupying almost ■exactly the same relative positions as those of Dr. Gowers, but separated Jfrom the surface by a thin layer of healthy white matter. They are doubt- less parts of the same tracts, and there is good reason to believe, partly from the fact that in one case at any rate they were the seat of ascending degenerative changes, that they represent sensory routes. The grey matter varies in bulk in different parts of the cord, and is especially .abundant in the cervical and lumbar enlargements, but the superficial white matter increases absolutely in quantity from below upwards. 7. Medulla ohlongata. — At the upper part of the cord, where it merges in the medulla oblongata, considerable changes are presented in the dis- tribution of its parts. These changes become more and more remarkable as we proceed from the lower to the upper part of the medulla oblongata, and are complicated by the appearance of additional grey nuclei. The posterior fissure opens out and blends with the ventricle of the cord ; the posterior pyramids are divaricated, forming between them the calamus scriptorius ; and the remainder of the posterior columns, now constituting the restiform bodies, passes upwards and outwards to form the inferior pe- duncles of the cerebellum ; in front of these is gradually developed, on either side, a grey column, due to the altered position of the gelatinous substance of Kolando ; still further forwards we see the seeming blending of each lateral column with its olivary body, and in front the anterior columns, apparently continued upwards into the anterior pyramids. The arrange- ment of parts here is exceedingly complicated ; but it may be stated generally : that the bulk of each posterior column of the cord passes up- wards in the restiform body to the cerebellum ; and that, according to Meynert, it has in its passage upwards a direct connection with the olivary body, and that in this region decussation of the tracts of opposite sides takes place, so that the relation between the cord and cerebellum becomes crossed ; that the greater part of the white substance of each antero-lateral column decussates with the corresponding part of the opposite side at the lower extremity of the anterior pyramid ; and that each pyramid is hence constituted mainly by the continuation upwards of the medullary matter of the opposite side of the cord to that on which it is itself situated, and then, passing through the substance of the pons Varolii, forms in front of it the larger bulk of the crust of the corresponding cerebral peduncle ; and, lastly, that some portion of the fibres of the lateral columns, and most of the opened- out grey matter of the cord, pass upwards along the floor of ANATOMY AND PHYSIOLOGY. 917 the fourth ventricle and. back of the pons VaroHi, partly to form the tegmentum, partly to become associated with the grey matter of the iter and third ventricle. 8. Cerebro-sjnnal nerves . — The cerebro-spinal nerves, with only two ex- ceptions, originate in the grey matter of the spinal cord, or its continuations, in the medulla oblongata, along the floor of the fourth ventricle, and around the iter. They are of two kinds, motor and sensory. The motor spinal nerves have their immediate origin in the groups of large cells contained in the anterior cornua, and emerge at the surface of the cord in the furrows separating the anterior from the lateral columns ; the sensory nerves originate apparently in the posterior cornua, and make their appearance superficially in the groove which divides the lateral from the posterior columns. The cerebral nerves, in the main, arise according to their properties in the upward continuations of the motor and sensory tracts of the grey matter of the cord ; in other words, the motor nerves spring from the upward continuation of that portion of grey matter which is anterior to the spinal ventricle, the sensory nerves from the upward continuation of the portion behind it. But these tracts, as has been shown, become modified in their relative positions in the medulla oblongata and floor of the fourth ventricle : the motor tract gets superficial on either side of the median line in the course of the fasciculi teretes ; the sensory tract, on the other hand,. split into two halves, continues upwards on either side of the motor tract, occu- pying each lateral half of the floor of the ventricle, spreading out on either side along the inner aspect of the cerebellar peduncles towards the cerebellum, and at the anterior point of the fourth ventricle rising up and coalescing again, as in the cord, over the iter or tubular continuation of the ventricle. The motor nerves, in their order from behind forwards, are the spinal accessory and hypoglossal, the portio dura, the abducens or sixth, the motor branch of the fifth, the fourth, and the third. The upper part of the spinal accessory arises from a nucleus situated in the lower part of the medulla oblongata, a little outside the central canal, and concealed by the posterior pyramid ; and it becomes superficial as the lowermost member of the eighth nerve at the lateral aspect of the medulla below the level of the olivary body. The nucleus of the ninth, or hypoglossal nerve, com- mences below in front of the spinal canal, in contact with the spinal ac- cessory nucleus, and extends for a short distance along the floor of the fourth ventricle in the neighbourhood of the calamus scriptorius. Its superficial origin is between the olivary body and the anterior pyramid. The common nucleus of the portio dura of the seventh nerve and abducens ■is situated just in front of the hypoglossal nucleus. The former nerve becomes superficial at the posterior margin of the pons, between the middle and inferior peduncles of the cerebellum ; the latter in the groove between the anterior pyramid and the pons. The nucleus of the motor root of the fifth nerve is situated within the fasciculus teres, a little above, in front of, and external to that of the portio dura ; the nerve becomes superficial by penetrating the lateral portion of the pons. The third and fourth pairs 918 DISEASES OF THE NEEVOUS SYSTEM. arise in common from a pair of nuclei, situated side by side in the floor of the iter. The fourth nerves encircle the iter in their course, and then winding romid the outer side of the crura cerebri reach the base of the brain ; each third nerve penetrates the subjacent locus niger, and makes its appearance on the inner side of the crus. The sensory nerves, in their order from behmd forwards, are the vagus and glosso-pharyngeal, the auditory, and the sensory portion of the fifth ; to which may be added the optic and the olfactory. The nucleus of the vagus, connected with that of the spinal accessory below, appears on the floor of the fourth ventricle just above the calamus, and external to the hypoglossal nucleus. Above, it appears to sink beneath the auditory nucleus. The glosso-pharyngeal nucleus, which is partly continuous with that of the par vagum, but higher up, is wholly concealed by the auditory- nucleus, with which it is m some measure blended. These two nerves become superficial along the posterior border of the olive. The auditory nucleus is of large size ; it involves the upward continuation of the grey matter of Eolando, and, in part, the posterior pyi-amid and restiform body. It occupies the floor of the ventricle external to the fasciculus teres, and its outer part turns backwards with the restiform body to reach the cerebellum, some portion of it becoming connected with the dentate nucleus, some stretching across the roof of the ventricle to join its fellow. The nerve-fibres arising from this nucleus, taking various routes, combine to form the portio mollis, which has its superficial origin at the posterior margm of the pons, between the superior and middle cerebellar pedu.ncles. The nucleus of the sensory portion of the fifth is, like the auditory, largely developed out of the upward continuation of the grey tubercle of Eolando, and also from that of the root of the posterior horn. It is situated in advance of the nucleus of the portio mollis (with which, indeed, it is, to some extent, connected behind), and extendmg upwards to the fossa, where the fillet meets the anterior fibres of the pons, arches backwards with the rest of the continuation of the grey matter from the cord towards the side and roof of the anterior part of the fourth ventricle and of the adjoining part of the iter. The superficial origin of the nerve is to the anterior and outer part of the pons Varolii. The optic nerves interlace ui the chiasma, and thence each optic tract winds round the correspond- ing crus cerebri to reach the posterior portion of the optic thalamus, the corpora geniculata and the corpora quadrigemina, of the corresponduig side, which therefore may be regarded as its nuclei, or at all events as containing its nuclei ; but, further, the optic tract in its whole extent is intimately connected structurally with the crus cerebri, and the chiasma with the grey matter linmg the third ventricle. The olfactory nerve is really, as comparative anatomy has long shown, a lobe of nervous sub- stance. It is formed of grey and white matter, and contains, according to Meynert, a central ventricle continuous with those of the cerebrum, which, however, according to Struthers, is absent in the adult ; its so- called roots are connected respectively with the anterior and posterior extremities of the gyrus fornicatus, and some of the white fibres connected with it have been traced uito the anterior commissure. It is an important ANATOMY AND PHYSIOLOGY. 919 fact that the fibres of the anterior commissure are connected with the ■occipital and temporo- sphenoidal lobes only, and that hence the olfactory nerves, and it may be added, from their connection with the optic thalami and associated ganglia, the optic nerves, are both intimately connected with that portion of the brain with which, through the intermediation of the same ganglia, the rest of the sensory nerves are connected. 9. Besume of the relations of the different parts of the central nervous system. — The anterior portion of the surface of the brain (all that in front of the fissures of Eolando, together with the ascending parietal convolu- tions behind those fissures, and certain other convolutions connected therewith) appears on sufficiently good grounds to be regarded as the supreme organ of the cerebro-motor processes or impulses ; and, indeed, as will presently be pointed out, pathological and experimental investiga- tions have demonstrated that certain definite regions of this area are con- nected with certain special groups of combined movements. From all •this extent of surface radiating fibres converge to certain parts at the base of the brain, namely the caudate and lenticular nuclei of the corpora striata and the white matter (the internal capsules) which lies between these bodies and the optic thalami. Of these radiating fibres some pass without interruption throvTgh the internal capsules, while others enter the nuclei of the corpora striata. Below these nuclei, the fibres passing un- interruptedly through the internal capsules, together with others given off from the under surface of the corpora striata, form the crustse of the crura cerebri, which, continued downwards through the pons Varolii, emerge from its posterior and lower border in the form of the anterior pyramids of the medulla oblongata. Hitherto the fibres derived from each cerebral hemisphere have travelled downwards and backwards on the corresponding side of the body ; at the lower part of the anterior pyramids, however, decussation takes place, and the fibres of the anterior pyramid of one side are continued downwards, mainly along the anterior and lateral white columns of the opposite side of the cord. But, in addition to the corpora striata, with which bodies all the fibres passing from the cerebro-motor region of the brain have, in their passage down- wards, a more or less intimate connection, there are, imbedded as it were in each lateral motor tract, a series of subordinate motor centres or nuclei, succeeding one another in close succession from the floor of the iter above to the termination of the cord below, each one of which gives origin to a motor nerve or to a certain number of fibres going to the constitution of a motor nerve. It follows generally from the above account that complex motor impulses, originating in the hemispheres of the brain, are conveyed along the radiating fibres to the corpora striata, through the agency of which bodies, resolved as it were into their simplest elements, they are trans- mitted to the several subordinate cerebral and spinal nuclei which imme- diately govern the movements of those muscles, which in combination effect intended results. It follows generally also that impulses originating .in one cerebral hemisphere act through the corpus striatum of the same .side upon the spinal nuclei of the opposite side of the body, and hence 920 DISEASES OF THE NEEVOUS SYSTEM. upon tlie muscles of the opposite side of the body. The same holds: good of those motor nerves whose origins are situated above the decus- sation of the pyramids. There are, however, certam exceptions to these statements, due doubtless to the fact of the intimate connection by means of commissural fibres between the two hemispheres of the brain^ and especially to the similar connection which subsists between the cor- responding motor nuclei of opposite sides along the motor tracts. These exceptions are presented especially by the motor nerves of the eyes, and by the nerves con- cerned in pho- nation, respira- tion, and other acts in which the corresponding muscles of oppo- site sides of the body habitually act in unison or concert. Further, it must not be forgotten that, every subordinate motor centre has independent mo- tor powers, which,, if it retain its con- nection with its correlated afferent centre, are capable of being brought into action by re- flex stimulation : that, if the cere- brum be removed, or its functions in abeyance, com- bined movements, to all appearance voluntary, may be effected through the immediate agency of the cor- pora striata ; that if the spinal cen- tres be cut off' from their con- nection with the higher centres, these also are capable of inducing reflex: Fig. 89. FIG- 90. Pig. 89. Diagram to show decussation of motor tracts in medulla oblongata, relations of motor tracts, and of their nuclei, both above and below decussation, to corpora striata ; and close union by commissural fibres ot nuclei of opposite sides ^'hose actions cannot be dissociated by voluntary effort. «,«!. Corpora striata, ^. Oculo-motor nerves. 6 6,. Motor tracts of cord. e. Lingual motor nerves. c. Decussation of motor tracts in /, A. Motor nerves of legs and arms, medulla oblongata. g. Motor nei-ves of trunk. i, i. Commissural fibres. Fig. 90. Diagi-am to show relations of sensory spinal nerves to sensory tracts and optic thalami. a, n,. Optic thalami. &, 6,. Sensory tracts of cord, c c c c, CifiCiC,. Spinal sensory nerves. ANATOMY AND PHYSIOLOGY. 921 movements ; and that under various conditions of health and disease the- independent action of these various subordinate centres is a fact of more or less importance. The afferent or sensory nerves, which near their entrance into the spinal marrow are furnished vidth ganglia, penetrate into the posterior cornua, and thus become connected with that portion of grey matter lying behind the central canal which constitutes the sensory region of the spmal cord. This sensory region occupies the whole length of the cord, and at the medulla oblongata becomes split longitudinally from before backwards, both halves passing upwards, one on either side of the now superficial motor nuclei of the medulla oblongata, to form the tegmenta and to become connected with the optic thalami, corpora geniculata, and corpora quadrigemina, and thus with the nuclei of origin of the optic nerves. From these ganglia radiating fibres proceed mainly to the grey cortex of the posterior portions of the cerebrum or to the true sensorium. Thus it appears that the posterior part of the cerebral surface has some sucli relation with the sensory fimctions as the anterior has with the motor functions, and the optic thalami and ganglia behind them some such connection with the same system as the corpora striata have with the motorial. And further, it seems probable (judging at all events by the analogies afforded by the organs of seeing and hearing) that complicated- external impressions become analysed or disentangled, as it were, or reduced to their simplest elements by the organs which first receive them ; to become again blended into a whole, so to speak, in their onward pro- gress to the sensorium. Both experiment and pathology have shown conclusively that the sensory tracts decussate equally with the motor ; and that the cerebral hemisphere and optic thalamus of one side are in direct relation with the sensory tract and nerves of the opposite half of the medulla oblongata and spinal cord. The decussation does not, how- ever, take place in the pyramids or at any one spot ; but each sensory nerve immediately after its entry into the grey matter of the cord decus- sates with its fellow of the opposite side, and its fibres of communication with the optic thalamus continue thenceforward to pass upwards on the same side as that body. The relations of the cerebellum with the motor and sensory tracts as- they traverse the base of the encephalon, and which are such that (con- trary to what obtains in the cerebrum) each lateral lobe is functionally connected with its o\m side of the body, have already been considered^ and its connection with the posterior columns of the cord through the intervention of the restiform bodies has also been pointed out. It is further established that the posterior columns of the cord are in no sense the conductors of ordinary sensory impressions, as fi'om their position was formerly supposed, but that whether afferent or merely commissural they are mainly subservient to the co-ordinating functions. It is important to bear in mind : that at the base of the brain, and especially m the situation of the pons Varolii and medulla oblongata, the sensory and motor tracts of both sides become to some extent intermingled. ■922 DISEASES OF THE NEEVOUS SYSTEM. .tliat the nuclei of origin of many nerves of the highest interest and import- ance are crowded together into a very small space, and that hence disease affecting these parts is Hable to be attended with complex, aggravated, and it may be added striking features ; and that as regards the cord the sensory tracts, although probably in part occupying the lateral white columns, are mainly imbedded in its interior, while nearly all the white matter which forms its peripheral portion as well as the anterior cornua belong to the motor system, and that hence the sensory columns are specially protected from the influence of pressure or other injurious influences operating fr'om without. 10. Localisation of function. — a. Pathological observation and recent experimental researches have combined to prove : that certaui definite arese of the grey surface of the cerebral hemispheres are the seats of special endowments ; and that their stimulation is attended with certain specific consequences, for the most part revealed by definite groups of movements, their destruction by equally specific consequences of an opposite or paralytic kind. It need scarcely be said that experimental investigation has been conducted almost exclusively on the lower animals, and that hence the determination of the arere above referred to in relation to the human brain ■can only be regarded as approximative. The positions assigned to these arese or centres by Dr. Ferrier are shown in Figs. 91, 92, and 83.^ It will there be seen : that the centre (v.) for movements of the lips and tongue occupies the posterior part of the third frontal and the lower part of the as- cending fr'ontal convolutions; and that in im- mediate relation with this are the centres, (vi.) for the depression of the angle of the mouth, (vii.) for its elevation (both seated in the ascending frontal), and (ix.) for its re- traction with contraction of the platysma Fig. 91. Lateral vie'n- of brain, showing Ferrier's centres of movements. The Roman numbers in the above figure, and in Figs. 92 and 83, refer to •Perrier's centres. L lateral movements of head and ej'es, with elevation of eyelids and dilatation ■of pupils ; ii., extension of arm and hand ; iii., complex movements of arm and leg, as in climbing, swimming. &c. ; iv., movements of leg and foot, as in loco- , . ,■■ motion ; v., movements of lips and tongue, as in articulation ; vi., depression of (^OCCUpyUlg tJie angle of mouth ; vii., elevation of angle of mouth ; viii., supination of hand and lp,.njp.,> -nart nf the ■flexion of forearm ; ix., centre of platysma— retraction of angle of mouth ; x., -lO vvei pdjl L Ui lub movements of hand and wrist : xi.. centre of vision ; xii., centre of hearing ; ascendilio' T)a- xiii., centre of touch ; xiv.. centre of smell and taste. ^ " rietal). At the upper part of the ascending frontal, encroachmg, however, on the neigh- bouring ascendmg parietal and on the first frontal, is situated the centre ' For much of what follows see Dr. Ferrier on the 'Functions of the Brain,' 1876. ANATOMY AND PHYSIOLOGY, 923 (iii.) for complex moYements of the arm and leg, as iu climbing, swimming, and tlie like ; immediately in front, upon the first fi'ontal, the centre (ii.) for extension of the hand and arm ; just behind it, and occupying partly the upper extremity of the ascending parietal, and partly the superior parietal, the centre (iv. ) for movements of the leg and foot, as in locomotion; and adjoining it, at the upper part of the ascenduig frontal, the centre (viii.) for supmation of the hand and flexion of the forearm. The centres marked (x.), occupying the greater part of the ascending pari- etal, are connected ■with move- mients of the hand and -^T-'ist ; and that marked (i.), seated in the first and second frontal convolutions, is correlated with lateral movements of the head and eyes to the opposite -side, elevation of eyehds, dila- tation of pupils, and generally the look of surprise. It will be observed that all the above ■■centres are included in that area of the surface of the brain which is in special relation through the corpus striatum with the motor tract, and which, according to M. Betz, contains giant-cells resem- bling those of the anterior •comua of the cord. Below and behind the in- terparietal and Syhdan fis- sures is a series of centres which, though associated like the others with more or less definite movements, are really sensory centres ; the movements due to their stimulation bemg excited reflectoriaUy through the motor centres, and their destruction being unattended with loss of muscular power. The first of these (represented by a gi'oup of circles numbered xi.), which occupies the whole extent of the supra- marginal convolution and ph courbe, is the centre of vision. Its de- struction causes temporary blindness of the opposite eye ; the destruction of both causes permanent and absolute blindness of both eyes. Its irritation appears to evoke subjective visual phenomena m the opposite eye with tmiiing of the eyeballs, and frequently of the head, towards ihat side, and contraction of the pupils. The second of these (xii. ) corre- sponds to nearly the whole of the first temporo- sphenoidal convolution. It has a similar relation to hearing that the last has to seeing. Destruction of this part involves absolute loss of hearing on the opposite side ; irritation causes sudden pricking of the opposite ear, and tm-iung of the head and -eyes m the same direction, A^-ith opening of the eyes and dilatation of the ■PlG. 92. Upper aspect of brain, showing principal convo- lutions and fissures ; and on tlie left side Ferrier's centres of movements, and on the right ihe arterial arese. 924 DISEASES OF THE NEEVOUS SYSTEM. pupils. The third (Fig. 83, xiii.), situated in the hippocampal region^ appears to be the centre for tactile sensation. Its destruction is attended with hemiansesthesia ; its irritation with moTements indicative of pain or uneasmess in the opposite side of the body. The last (Fig. 83, xiv.) is the centre of smell ; intimately associated with which, though as yet impossible of exact localisation, is the centre of taste. Irritation of the centre of smell induces torsion of the upper Kp and partial closure of the nostril on the same side as the centre ; its destruction abolishes the sense of smell in the same nostril. IiTitation of the part of the surface of the brain concerned, in taste provokes movements of the lips, tongue, and cheeks; its destruction involves the abolition of the gustatory sense in the opposite side of the mouth. These sensory centres occupy that part of the brain which is in special relation with the sensory tract, and which, as M. Betz shows, presents an almost total absence of giant-cells. There are certain parts of the cerebral surface the effects of irritation of which are negative. These are especially, the internal aspect of each hemi- sphere including the gyrus fornicafcus, the islands of Eeil, the occipital lobes, 'and the anterior parts of the frontal lobes mcluding the parts which overlie the orbits. But nevertheless Dr. Ferrier adduces plausible arguments: for believing that the occipital lobes have some definite relation to visceral sen- sation, and that their destruction is attended with abolition of appetite for food, associated with depression and apathy, and, in general, speedy death ;. and for regarding the anterior parts of the frontal lobes as being specially connected with the intellectual functions, their destruction being attended with apathy, dulness, disposition to sleep, and loss of the faculty of attentive and intelhgent observation. It should be added to the above summary that Drs. Dupuy and Burdon Sanderson have shown that the specific motor powers above considered (so far as they can be tested experimentally) do not reside absolutely in the grey matter of the convolutions ; but that in most cases similar motor effects may be produced by exciting, after successive removals, each succes- sive surface of that wedge of brain- substance of which the base corresponds to the particular superficial motor area, and the apex to a point in the corpus striatum. Dr. Sanderson, uideed, says that the movements are produced most distinctly when the irritation is effected dh-ectly upon the corpus striatum. Finally, in reference to the surface of the brain, it must be pointed out that the posterior extremity of the third frontal convolution of the left side, or Broca's convolution, is, judging fi-om pathological evidence, the centre of the faculty of articulate language. With this conclusion Ferrier' s experi- mental results are reasonably accordant. h. As might naturally be supposed, from its relations to the hemisphere above and to the medulla oblongata and cord below, destruction of the corpus striatum is attended with paralysis of voluntary motion of the oppo- site side of the body, excepting in so far as this is obviated by the intimate connections subsisting between those collateral spmal nuclei supplying op- posite muscles which habituallv act in lanison. Irritation of this ganglion ANATOMY AND PHYSIOLOGY. 925 -causes spasmodic contraction of the muscles on the opposite side of the body, c. It seems clear that the optic thalamus has the same relation to sen- sation, including tactile sensation, sight, hearing, and taste (but probably not to smell), that the corpus striatum has to motion. It is stated that irritation of this body is unattended with motor manifestations, while its destruction involves hemianfesthesia of the opposite side of the body, in- cluding loss or impairment of taste and hearing, impairment of smell, due to anaesthesia in the domain of the fifth nerve, and blindness. Yet in one case, in which there was partial destruction of both thalami, the main symptoms were paresis with tremors, followed by rigidity. Dr. Hughlings -Jackson records a case of destruction of the optic thalamus by disease, in which, together with the phenomena above enumerated, there was loss of sight in the half of each retina on the same side as the lesion. It has been maintained by many physiologists that the optic thalamus has not the connection with sensation here assigned to it, but that the posterior part of the internal capsule is the direct channel for the transmission of peripheral sensory impressions to the surface of the brain. There is no ■doubt that this is so far true that destruction of this part causes, Hke de- struction of the thalamus, opposite hemianjesthesia ; but this is due to the fact that the mternal capsule is the medium of communication between the bram and thalamus. d. Whatever other functions may belong to the cerebellum, at any rate this portion of the encephalon appears beyond aU doubt to be the supreme centre for the regulation of ' the various muscular adjustments necessary to maintain the equihbrium of the body.' But the maintenance of equilibrium demands, not only a central organ, but a sensory or afferent mechanism by which the central organ may be kept informed of the condition of the body in relation to equilibrium, and an efferent or motor mechanism by means of which muscular adjustments may be effected. The former of these are the organs of common sensation, the eyes, and more important than all the semi-circular canals T\ath their afferent nerves ; the latter are the motor nerves and voluntary muscles. Experimental lesions of the cerebellum always induce disorders of equilibrium, but never impairment of sensation, or actual loss of voluntary muscular power. "Without entering into any physiological explanation of the phenomena, we may briefly state that experimental evidence proves that destructive lesions of the anterior part of the middle lobe cause a tendency to fall forwards, of the posterior part of the middle lobe a tendency to fall backwards, of the right lobe a tendency to turn to the left (in the case of one of the lower animals, therefore, or of a person lying down, to roll from left to right, or towards the injured side), and of the left lobe a tendency to turn to the right ; and that precisely converse tendencies result from irritation of the same parts. Attending these movements there is spasmodic contraction of the muscles of that side of the body towards which twisting occurs ; and when the lateral lobes are affected the twist com- mences with spasmodic torsion of the head and neck. Usuallv also there 926 DISEASES OF THE NEEVOUS SYSTEM. is conjugate deviation of the eyes to the right, left, upwards or downwards,, in accordance with the direction of the general bodily movements, or more or less nystagmus. Lesions of the structures connected with the cerebellum are also attended with disturbance of equilibrium : division or- destruction of the middle pedmicle of the cerebellum on either side causing- the same symptoms as destructive lesions of the corresponding cerebellar lobe ; and irritation and injury of the corpora quadrigemma equally in- ducmg inco-ordination of movement. Affections of the semi-circular- canals produce the same consequences as regards equilibrium as affections of the cerebellum : affections of the superior vertical canals being equiva- lent to affections of the anterior part of the middle lobe ; affections of the- posterior vertical canals to those of the posterior part of the middle lobe ; and affections of the horizontal canals to those of the corresponding lateral lobes. e. The corpora quadrigemina are through the corpora geniculata brought into immediate relation with the optic tracts, arid, indeed, there is no doubt that these bodies are the subordinate centres of vision, and have reflex connections with the motor nerves of the eyes. In the lower animals destruction of one optic lobe causes blindness of the opposite eye and more or less immobility of the pupil ; irritation induces sudden starting backwards of the animal as if in alarm, tu.rning of the eyes and head to the opposite side, dilatation of the pupils, and spasmodic con- traction of the facial muscles with trismus and opisthotonos. It is im- portant to note that the pupils are completely paralysed only when the destruction of these bodies is bilateral ; and that when irritation causes dilatation of the opposite pupil, dilatation of the pupil of the sound side speedily follows. In man destruction of one of the anterior tubercles of the corpora quadrigemina appears to cause hemianesthesia in both eyes on the same side as the lesion. There are good reasons for believmg that the testes are particularly connected with some forms of emotional expression. We have already referred to the relation of the corpora quadrigemina to equilibrium. In one case under our care, m which these- bodies appeared to be wholly destroyed by a tumour arising in their sub- stance, there was paresis of all the ocular muscles with ptosis and exophthalmos, and tremulous movements of the head and arms ; but no affection of the internal muscles of the eyes ; and the patient could see. /. From the anatomical facts which have been detailed it is ob\'ious that the medulla oblongata, including all that region from which the cerebral nerves arise, is the chief centre of many important functions which are more or less essential to the maintenance of life. It is clearly established, indeed, that even in warm-blooded animals all the centres above the medulla oblongata may be removed without destroying life ; and that with the medulla oblongata remaining respiration and deglutition are still capable of performance. The medulla is in fact the co-ordinat- ing centre of the respiratory acts, of phonation, of articulation, of facial expression, and of the acts of sucking and deglutition. Moreover, it is ANATOMY AND PHYSIOLOGY, 927 tlie centre of inhibition and acceleration of the action of the heart, and the centre of innervation of the blood-vessels. The co-ordinating- centre of respiration is placed by Flourens m the angle of the calamus- script orius. (J. As regards the cord all that we need add to statements already made _ is : that like the medulla it is a centre, though subordinate centre, of reflex action ; that cut off from its connection Tvith the parts above it is still capable through its afferent and efferent connections of producing- co-ordinated movements ; that under such cncumstances irritation of the ends of sensory nerves generally causes reflex movements of the part -vvith which the irritated nerves are in relation ; that if the irritation be extreme or the cord unnaturally irritable the influence instead of remainmg limited becomes diffused horizontally and perpendicularly throughout the cord, so that reflex phenomena, instead of bemg confined to a particular district, become more or less widely distributed ; that the tone of muscles, and consequently the action of the sphincters, is due to re- flex action in constant automatic operation ; and, lastly, that the nutrition of muscles and probably of other tissues, and secretions, are largely in- fluenced directly or mdirectly by the spinal cord. h. We only deem it necessary to remark in conclusion upon the olfactory and the optic nerves. There is reason to believe, partly on anatomical, but mainly on pathological, grounds, that the olfactory nerves, unlike all others, do not decussate, or at any rate that the olfactory nerve of each side is connected chiefly "n^ith the supreme centre of smell of the same side. The arrangement and course of the optic nerves are peculiar. But experiment and clinical observation demonstrate facts in relation to them which anatomy alone does not teach us. We have shown that destruction of the supreme centre of sight on one (say the left) side causes total blhidness of the right eye, a result which equally follows destruc- tion of the right optic nerve ; whereas , ^ ,. „ ,, J. . J L E and R E. left and right eyes ; C, cliiasina7 destruction OI the optic tract, corpora l g and e &, left and nght geniculate bodies : 1 i 1 • • J? Q. corpora qiiadrisreniLaa ; L H and R H, left ami gemCUlata, or corpora quadrigemma of Sght centres of vision : 6 and a. nei^e-fibres- miP qirip paimpc; hA-mim-tin of hnth pvpq fi-om left and right sides respectively of left one SlCie causes nemiopia OI DOin &J^^- Qy^.^i^^-a_^„^coT:res^onimzf^'ov&iixom.risht A reasonable explanation of these pheno- ey«- mena is offered in the accompanying diagram, for which we are indebted to Prof. Charcot. 11. Sympa.tlietic system. — The sympathetic system of nerves appears to have its supreme centre in the medulla oblongata, or rather on the floor of the fourth ventricle ; but it is ultimately interwoven with the spinal system, and, as is well known, each spinal nerve receives branches fi'om. RC Scheme of decussation of optic tracts. •928 DISEASES OF THE NEEVOUS SYSTEM. and transmits brandies to, a neighbouring sympathetic ganghon. We need not consider the anatomical details of this system ; it is sufficient to point out that it presides over the shortening and lengthening of the organic muscular fibres wheresoever situated, that it determines the dilata- tion and contraction of the blood-vessels, and therefore the amount of blood supplied to various parts, and in some degree the rapidity of its flow through them, and that it thus regulates to some extent the nutritive and other functions of the different parts of the organism, and their tempera- ture. There is reason also to believe that special branches are supplied to the secreting cells of some, if not all, of the glandular organs, and that hence a direct influence is ex- erted by it over the physiologi- cal processes which go on in these organs. 12. Arteries of brain. — The meningeal arte- ries are derived mainly from branches of the external caro- tids ; but a mi- nute branch is furnished also by each vertebral immediately after its entrance into the skull. They have no connection with the arteries which supply the brain and its vascular mem- brane, the pia mater. The proper arteries of the brain are derived from the internal carotids and the vertebrals, which, after entering the skull and giving off certain branches, to some of which we shall presently again refer, form between them that remarkable anastomosis known as the circle of Willis. Each internal carotid artery having first given off the ophthalmic and Pig. 94. Lateral view of brain, sliowing arterial arese. Fig. 95. Inner surface of cerebral hemisphere, showing arterial are£e. In the above figures, and also in flgs. 92 and 96, the dotted surfaces corre- spond to the anterior cerebral artery ; the clear surfaces to the middle cerebral ; the shaded surfaces to the posterior cerebral. The subdivisions of these surfaces made by dotted lines indicate the areas supplied by the principal branches of the above arteries, and the Arabic numbers attached to them the order of the branches from before backwards. ANATOMY AND PHYSIOLOGY. 929 then tlie posterior communicating artery, divides into two branches, namely, the anterior and the middle cerebral. The anterior cerebral (Figs. 92, 94, 95, 96), which is the smaller of the two, anastomoses after a short course with its fellow by the anterior communicating artery. Its trunk then turns round the anterior edge of the corpus callosum, and runs backwards along the upper surface of that body. It divides into three principal branches, of which the first is distributed superficially to the orbital convolutions below, and to a small portion of the inner aspect of the hemisphere in the neighbourhood ; the second is distributed to the first frontal convolution, to the greater part of the second, to the upper extremity of the ascending frontal, and to all that part of the inner aspect of the hemisphere which lies between the area of distribution of the first branch and the ascending limb of the fronto- parietal fissure, including the anterior two-thirds of the corpus callo- sum ; the third branch supplies that area of the inner surface of the hemisphere which lies between the ascending limb of the fronto-parietal and the parieto-.occipital fissure, and also the posterior part of the corpus callosum. The middle cerebral artery (Figs. 92, 94, 95, and 96) di^ddes in the fissure of Sylvius into four branches, which radiating in conformity mth the convolutions of the island of Eeil, and supplying them mth vessels, emerge on to the outer surface of the brain, and are thus distributed : — the anterior or first branch ramifies over the third frontal convolution exclu- sively ; the second is distri- buted to a portion of the second frontal convolution and to almost the whole of the ascending frontal ; the third supplies mainly the ascending parietal and supe- rior parietal convolutions, the posterior and lower limit of its distribution being indi- cated partly by the inter- parietal fissure, and partly by a horizontal line drawn from this to a point on the upper margin of the hemi- sphere midway between the fronto-parietal and parieto- occipital fissures ; the fourth ■or posterior branch is distri- buted to the first and second temporal convolutions, and to the gyrus angularis, its posterior limit being deter- mined by a line drawn from tlie posterior extremity of the second temporal 3 o Pig. 96. Under surface of brain, showing principal convolutions and fissures and the arterial arete. 930 DISEASES OF THE NEEVOUS SYSTEM. sulcus to the parieto-occipital. The posterior cerebral arteries (Figs. 92, 94, 95, and 96) result from the division of the basilar ; each sends branches into the brain-substance of the locus perforatus posticus, is then joined by the posterior communicating artery of the same side, and finally gives off three principal branches, which are distributed to all those parts of the cerebral surface which have been hitherto unaccomited for : tlie anterior to the uncinate convolution ; the middle to the third temporal and the fusiform or lateral occipito-temporal convolutions, and to the hinder part •of the gyrus fornicatus; and the posterior to the median occipito-temporal convolution, to the cuneus, and to the occipital lobe. The distribution of the arteries to the ganglia at the base of the brain is not less important than that upon the surface of the organ. All three pairs of cerebral arteries for the most part take a share in supplying these bodies. The anterior cerebral gives small branches to the anterior ex- tremity only of the caudate nucleus, and not unfrequently none at all. The middle cerebral, on the other hand, has a comparatively wide and a very important distribution. It gives off many branches of somewhat large size, which, entering at the locus perforatus anticus at right angles, or nearly so, to the trunk, supply the whole of the lenticular nucleus of the corpus striatum, the whole or greater part of the caudate nucleus, the internal capsule, and the anterior and outer part of the optic thalamus. They may be divided into two groups : an internal group, consisting of comparatively small vessels, which are distributed to the internal portions of the lenticular nucleus, and to the adjoining portions of the internal capsule ; and an outer group of vessels of considerably larger size, which course mainly over the outer aspect of the lenticular nucleus, and supply the outer part of that body, and also, according to their position, the caudate nucleus or the optic thalamus. One of these branches, called by Charcot 'the artery of cerebral hemorrhage,' is pre-eminently large, and, after penetrating the outer part of the lenticular nucleus, and traversing the mternal capsule, enters the substance of the caudate nucleus, and passes from behind forwards m it to its most anterior part. The posterior cerebral arteries give branches to the choroid plexuses and ventricular walls, and supply also the tegmentum, the corpora quadrigemina, and the posterior and inner parts of the optic thalami. The branches which they give to the last-named bodies may be divided into internal and ex- ternal. The former supply the inner aspects of the thalami, and their rupture is apt to be followed by the profuse escape of blood into the ventricular cavities ; the latter supply the outer parts of the thalami, and, since before they enter them they pass through the cerebral peduncles, their rupture is apt to be attended with effusion of blood into the sub- stance of these bodies. The vertebral arteries unite to form the basilar, which divides in front into the two posterior cerebrals. The vertebrals, besides supplying menin- geal and spinal branches, give off on either side a posterior inferior cere- bellar artery, which is distributed to the hinder portion of the lower aspect of the cerebellum and to the choroid plexuses of the fourth ventricle. ANATOMY AND PHYSIOLOGY. 931 The basilar, in addition to sending a branch to each internal ear and other branches to the substance of the pons, gives off also a right and a left anterior inferior cerebellar artery to the anterior part of the under surface of the cerebellum, and a right and a left superior cerebellar artery, which are distributed over the whole of the superior surface of the cerebellum, and supply the valve of Vieussens and partly the velum interpositum. It is necessary to bear in mind (for, indeed, it is this fact which makes an accurate acquaintance with the details of the cerebral circula- tion important) that, save at the circle of Willis, little or no communica- tion takes place between the branches of the cerebral arteries even down to their finest ramifications, excepting by means of capillary vessels ; and that hence, if any artery become obstructed, the region to which it leads almost necessarily suffers in its whole extent. Thus, if the middle cere- bral be blocked, the nutrition of the whole region to which it is dis- tributed becomes impaired ; if one of its primary branches be obstructed, the limitation of morbid change is equally definite ; and if a secondary or even smaller vessel be alone involved, secondary changes will be Limited to correspondingly minute districts. It is further important, in reference to this point, to know that the arteries on the surface of the convolutions give off' long and short branches, which are quite distinct from one another ; and of which the short are distributed to the cortical grey mat- ter, the long enter the white substance, and are limited in their distribution to it. The ultimate arteries supplying the ganglia are distinct from both. It is a matter of no slight practical importance that the ophthalmic artery arises from the same trunk as that which gives off the anterior and middle cerebral arteries ; and that it suppHes not only the eyeball itself, but the contents of the orbit including the lacrymal gland, and gives off' branches to the eyelids and contiguous parts of the forehead and nose, and to the ethmoidal cells. The arteries of the internal ear again are mainly derived from one of the intra-cranial arteries, namely, the basilar. 13. Veijis of brain. — The veins distributed over the surface of the cerebrum and cerebellum open into the several sinuses to which they are respectively contiguous. Those situated within the lateral ventricles con- verge to the venffi Galeni, by means of which they empty themselves into the straight sinus. It is needless to enumerate or trace the several sinuses. There are, however, two or three points in connection with the venous cir- culation of the brain, which are important. These are : — first, that the cerebral and cerebellar veins all converge, directly or indirectly, to the lateral sinuses, and that hence all or nearly aU the blood from these parts is returned by the internal jugular veins ; second, that the ophthalmic vein which has almost exactly the same distribution as the ophthalmic artery, empties itself into the cavernous sinus on the one hand, and on the other anastomoses with the branches of the facial and other veins • and, third, that the longitudinal sinus commmiicates with the veins on the exterior of the skull through the parietal foramen, and the lateral sinuses with those of the head and neck through the mastoid foramina. 3 2 932 DISEASES OF THE NERVOUS SYSTEM. B. Pathology. Most diseases of the nervous system may affect any part of that system ; and hence, although m many cases producmg symptoms mdicative of theh^ specific nature, they tend also to evoke symptoms referrible to the parti- cular regions of the nervous organism which they involve, and to the de- gree and mamrer in which they involve them. As regards the last poiiat it is obvious that here as elsewhere the functions of parts may be impaired, exalted, or perverted. And, as regards locality, it is clear that disease may involve some portion of the motor tract, some portion of the co-ordi- nating tract, or some portion of the sensory tract ; that it may be seated, either in the peripheral nerves, in the cord, or m the intra-cranial centres ; and that the symptoms will vary accordingly. Further, if the supreme centres be involved, there will be not only pathological sensory or motor phenomena, but also phenomena referrible to the intellectual and emotional functions. We proceed to discuss some of the more important phenomena, which are dependent on the situation of the parts affected, and on the degree and manner of their involvement. 1. Motor Paralysis. Paresis. By paralysis is meant the impairment or loss of that power which the different motor centres should exert over the movements of the muscles.. The term ' paresis ' is often used of the slighter forms of this condition. Paralysis of the voluntary muscles, to which alone we now confine our at- tention, may vary from the slightest degree of impairment of voluntary power over them to that condition in which every trace of such power has disappeared, and the part affected is absolutely motionless and incapable of motion. The quality, also, of this paralysis varies in different cases. In some, as in general paralysis of the insane and disseminated sclerosis, the enfeebled muscles become tremulous under the attempt to use them"; more commonly, as in most cases of ordinary hemiplegia, their movements are slow, weak, and halting, but uniform. In some mstances the paralysed muscles retain their normal bulk, in some they waste. Sometimes they are flaccid, sometimes they preserve their natural tonicity, sometimes they are rigid and perhaps contracted. In some cases, again, they more or less completely lose the power of reacting to faradism or other forms of irritation ; while occasionally their contractility remains unimpaired or even increases. And, lastly, in different cases the electro -sensibility of the affected muscles becomes weakened or exalted, or remains unaffected. a. Cerebral paralysis — i. General paralysis seldom occurs excepting in association with iiisanity, and is then due, as might be supposed, to some general impairment of the surface of the brain. It is for the most part slight in degree, and indicated by feebleness, not only of the muscles of the limbs, but of those of the trunk, head, and neck, and of those of expression, mastication, and deglutition. Further, as has already been pointed out, the muscles are usually slightly tremulous when put into action. MOTOE PAEALYSIS. HEMIPLEGIA. 933 ii. Hemiplegia, or paralysis limited to the distribution of the motor nerves of one side of the body, is due as a rule to disease of the opposite cerebral hemisphere, corpus striatum, or crus. Its most common cause probably is disease implicating the corpus striatum or the white matter immediately external to it ; and it is in such cases that hemiplegia pre- sents its typical characters. The paralysis, as has been observed, is limited to the opposite side of the body ; but it does not affect the whole side uni- formly ; for while some nerves are almost always affected in a greater or less degree, others almost invariably escape or suffer very slightly. Those which escape are such as act in association with corresponding nerves of the opposite side, whose combined actions we camiot voluntarily restrain, and' whose nuclei are probably (as Dr. Broadbent suggests) more intimately connected with one another than are the nuclei of other symmetrically placed nerves, and are hence influenced in a greater degree than these by motor impulses which descend from the other side of the brain. The third, fourth, and sixth nerves seldom if ever suffer, so that the motions of the eyeball on the affected side continue, for the most part, perfect. Again, the motor root of the fifth nerve suffers, as a rule, but little. The portio dura, on the other hand, generally is distinctly though slightly and un- equally involved ; hence the face is usually more or less blank on the affected side, the muscular wrinkles more or less effaced, the mouth drawn to the opposite side, the eye a little more open than its fellow, and wink- ing somewhat laggingly performed ; nevertheless the eye can generally be perfectly closed, and some power of movement remains in the whole of the side of the face, but more especially in its upper half. The hypoglossal is almost invariably markedly involved, and the tongue consequently is pro- truded with its tip pointing towards the paralysed side, while, on being drawn in again and often when it lies quiescent on the floor of the mouth, its median furrow is concave towards the unparalysed side, and its tip looks in the same direction. The motor fibres of the par vagum, and the motor roots of the spinal nerves going to the muscles of the head and neck and trunk, suffer but little ; and hence the patient as a rule has no diffi- culty in deglutition, in phonation, in maintaining the due position of his head, in respiration, or in acts needing the employment of the muscles of the abdomen or back. The nerves of the arm and leg are always chiefly affected. If the case be severe both limbs are alike motionless ; but it is a curious fact that if there be a difference between them it is generally that the leg retains a greater degree of motor power than the arm, that it is the last to fail, the first to recover. But the distribution of paralysis is liable to variation, and occasionally the leg escapes wholly, occasionally it is affected in a higher degree than the arm. Disease situated in the substance of the hemisphere is also generally attended with hemiplegia ; especially disease occupying the frontal or parietal lobe. And it is in such cases that our diagnosis of the seat of mis- chief and the cause of mischief may be aided by the facts which have already been discussed, with regard to the localisation of function in the ^grey matter of the convolutions, and the arete of distribution of the cere- 934 DISEASES OF THE NERVOUS SYSTEM. bral arteries. K the hemiplegia be attended with aphasia we may assume that either the posterior part of the third frontal convolution, or else the wedge of white matter extending thence to the corpus striatum, is involved. When the lesion is situated in the crus cerebri, together with hemi- plegia of the opposite side of the body, there will probably be paralysis oi the thh'd nerve of the same side. b. Bulhar ixiralysis. — When paralysis arises h'om disease of the medulla oblongata or pons Varolii, it is obvious, fi-om the abundance and close proximity of important nerves and nerve-nuclei m these organs, and fi'om the fact that the sensory and motor strands from both cerebral hemispheres here meet and blend, that such one-sided limitation of paralysis as occurs in hemiplegia is scarcely likely to be present, and that if there be general paralysis it must differ largely in its details and in its danger to life from that which has before been adverted to. It is mainly in such cases that what is called cross paralysis is met with — paralysis, that is to say, of one side of the body and of the opposite side of the face. It is in such cases, again, that we sometimes find paralysis of both arms and legs, or of one arm and both legs, or the converse. And, moreover, it frequently happens ^ for obvious reasons, that there is paralysis of the muscles of one or other or both eyeballs, or of one or other or both facial nerves ; or that there is. difficulty of articulation, phonation, mastication, deglutition, or respiration, or of control over the rectum and bladder ; or that a greater or less number of these paralyses occur in combination. It must be recollected, in refer- ence to these cases, and equally in reference to diseases invohing the under sm'face of the brain, that, together with the opposite or hemiplegic paralysis due to involvement of nerve-tissue above the nerve-nuclei, we are always apt to have paralysis, generally of the same side, due to the direct implication of nerve-nuclei, or of nerves after their emergence fi'om their nuclei. It is by this cu'cumstance that cross paralysis is to be explained. The great danger to life which, as is well known, attends disease of the j)arts- now under consideration is due mainly to paralysis of the nerves supplied to the organs of deglutition, respiration, or circulation, which is almost always present in a greater or less degree. c. Spinal jxiraly sis. Paraplegia. — When paralysis is due to disease of the spinal cord, it generally goes by the name of paraplegia, and is specially characterised by the fact that the paralysis involves only the muscles supphed by those nerves which are given off from the cord at and below the seat of disease. The symptoms will of course vary, both with the situation and with the extent of the lesion. Thus if it involve the whole thickness of the cord high up in the neck above the origin of the phrenic nerves, there will be complete motor paralysis of all parts seated below — of the arms and legs, as also of the diaphragm and other resph-atory muscles. If it be situated at or above the cervical enlargement, the move- ments of the diaphragm will be unaffected, but the arms and legs T\-ill be paralysed as in the former case. If the dorsal region of the spine suffer, the arms will necessarily escape, and the paralysis will be limited to the PAEAPLEGIA. 935 lower extremities and to just so much of the lower part of the trunk as is supplied by nerves given off below the seat of mischief. In all such cases there is interference with the functions of micturition and defaecation. For the most part if the disease is situated above the lumbar centres for causing contraction of the bladder and rectum, and those which regulate the sphincters, the bladder and rectum contract upon their contents when they become distended by them, the sphincters yield, and the evacuations are discharged involuntarily. If the disease be low down and involve the lumbar centres themselves, the urine escapes continuously and there is a tendency to the same thing as respects the faeces. The bowels are usually constipated in paraplegia. It need scarcely be added that in complete paralysis sensation as well as motion is annulled. But paralysis below the seat of lesion is not necessarily complete. In many cases where it is due to pressure, or to disease of the surface of the cord, or of the structures which surround it, sensation remains perfect, or nearly so, while motorial power is wholly lost. In many cases, again, the paralysis, though involving all parts below equally, involves them only to the extent of impairing their power of motion. Further, many cases are met with in which the disease implicates unsymmetrically certain defined tracts only of the cord. The consequences are often very remarkable. If one lateral half be diseased in its whole horizontal extent, but to a limited extent vertically, complete paralysis necessarily involves all the motor nerves given off from the cord on the same side as the lesion, but below it, in consequence of the lesion having cut off all direct connection between them and the brain above. But, inasmuch as the decussation of the sensory nerves takes place m the cord itself immediately after their entry into the cord, it follows that the sensory nerves associated with the paralysed region remain unaffected, while those of the corresponding region of the opposite side of the body share the fate of the motor nerves of the diseased side. Hence arise : paralysis, with retention of normal sensation on the one side ; anaesthesia, with perfect power of motion, on the other side ; and in some cases a more or less distinct line of ansesthesia formmg, on the side of the lesion, the upper limit of the region of motor paralysis. Perfect unilateral limitation of disease is of course rare ; it is more usual to find one side involved in a portion only of its horizontal extent, or both sides involved more or less, and in unequal degrees ; mider which circumstances the resulting paralytic phenomena are of course less typical, and irregularly distributed. It is a curious fact, which will hereafter be more fully considered, that certain forms of disease have a remarkable tendency to involve particular regions or strands of the cord, and to be limited to them. The parts to which particular reference is here made are the posterior columns, the lateral columns, and the groups of large or motor cells in the anterior cornua. AVhen disease affects the posterior columns only, or, as Charcot points out, the outer bands of these columns which abut directly on the imier aspects of the posterior cornua and roots of the sensory nerves, the condition known as locomotor ataxy, or, in other words, loss of co- 936 DISEASES OF THE NEKVOUS SYSTEM. ordinating power, and not ordinary motor paralysis, involves the volun- tary muscles of all those parts which are below the seat of disease. In a large proportion of cases the legs alone suffer, but the arms and even parts above the arms are all liable to become implicated. Inco-ordina- tion is shown : partly by loss of the muscular sense, in virtue of which the patient is unable to judge of the amount of force needed to accom- plish definite results, and unable therefore (especially if his eyes be closed) to determine the position of his affected limbs in relation to other parts of his person or to surrounding objects; and partly by want of control over his voluntary movements, which are consequently more or less violent than necessary, and involve a larger or smaller number of muscles than are suitable for their execution. There is not, however, any neces- sary loss of muscular strength, and the affected limbs sometimes retam extraordinary power. When the lateral columns only are the seat of disease, or more particularly the white matter which lies behind the horizontal line drawn laterally through the median canal, motor paralysis ensues in all those parts which are situated below the seat of lesion ; but under these circumstances, according to Charcot, the muscles of the affected limbs tend to get, not only paralysed, but at first tremulous, and ultiinately rigid and contracted. If the groups of large cells in the anterior cornua are diseased, then only the nerves which take their origin in them, and the muscles which these nerves supply, suffer : the muscles become paralysed, and in a large number of cases speedily lose their faradic contractility, and waste. d. Nerve ijaralysis. — In the foregoing account we have considered more especially those forms of paralysis which are due to disease occurring above the nuclei of origin of the paralysed nerves. We have, however, referred here and there to the fact that paralysis may be caused by disease involving either these nuclei, or the nerves after their emergence from them. We have, indeed, in considering paralysis due to disease originat- ing within the brain or cord, been almost compelled to advert to the fact that, when certain parts, more especially the pons, medulla oblongata, base of the brain, and spinal cord, are affected, the paralysis which ensues is necessarily apt to be compounded of paralysis due to the cutting off of the connection between nerve- nuclei and the higher centres, and of that dependent on direct implication of nerve-nuclei or nerves. Paralysis from destruction of a nerve or of its nucleus of origin, is necessarily of very limited distribution ; it affects a single muscle or a group of muscles, as for example the external rectus of one eye, or the superior oblique, or the other muscles of the eyeball together with the levator palpebrse, or the muscles of expression of one side of the face, or certam muscles of the head and neck, trunk, or extremities. It also tends soon to become absolute. It is not, of course, denied that other varieties of paralysis are often absolute ; but, as we have pointed out, in ordinary well-marked hemiplegia certain nerves appear to escape implication, and certain others, such as the portio dura, become involved only to a slight extent. In primary paralysis, however, of the portio dura, the paralysis of the muscles CONDITION OF MUSCLES IN MOTOE PAEALYSIS. 937 which it suppHes is for the most part general and complete. Further, the paralysed muscles usually rapidly lose the power of responding to the faradic stimulus, and at the same time grow flaccid, and waste. e. Disease of the cerebellum. — Diseases of this part are, no doubt, often attended with loss of sight, and with hemiplegia ; but these phenomena are accidental accompaniments of cerebellar lesions, and due either to the direct implication of some neighbouring part, or to pressure exerted by the diseased cerebellum on the adjoining quadrigeminal bodies or subjacent medulla oblongata. The usual and natural result of cerebellar disease is a staggering gait like that of a drunken man, or in extreme cases a total inability to stand or walk : in consequence, not of muscular debility, or of mere inco- ordination of the movements of the lower extremities as in tabes dorsalis, but of a general impairment or loss of the power of main- taining equilibrium. Nystagmus and parallel deviation of the optic axes are liable to occur in affections of the cerebellum ; as also the tremulous movements of the head and neck and arms, like those of disseminated sclerosis, when their mviscles are put into action. /. Condition of muscles in motor paralysis, i. To7ie. — In some cases of paralysis the muscles retain their normal tonicity ; in some they get limp and flaccid ; in some they become rigid and contracted. The normal tonicity is preserved in a large number of cases of both cerebral and spinal paralysis. It is essential, indeed, for its conservation that the connection between the muscles and the cord remain intact. Limpness of muscles not unfrequently attends those cases of paralysis of the same centres in which the affection which causes paralysis is sudden in its onset and extensive ; it generally also soon becomes developed in those muscles whose nerve-nuclei are directly implicated, and in those whose connection with these nuclei is interrupted. Eigidity or contraction of the muscles in cerebral or spinal disease is often the consequence of some irritation, inflammatory or other, going on at the seat of disease. It is then to be regarded as an acute condition, and generally comes on early. B.ut rigidity, with contraction, mainly of the flexor muscles, is apt to ensue gradually in cases of old paralysis : sometimes, in the case of atrophied muscles, from their gradual and slow longitiidinal contraction ; more fre- quently perhaps, in consequence of secondary degenerative changes going on in the lateral columns of the cord. ii. Electric contractility and irritability will be specially discussed later on, under the head of ' Electricity in nervous diseases.' iii. Nutrition. — In a considerable number of cases paralysed muscles retain their bulk and texture, or at most become slightly impaired in these respects, as even non-paralysed muscles are apt to do, from mere disuse, and hence remain in a condition to take on active duty so soon as the cause of paralysis disappears. This is generally the case when the cause of paralysis lies above the nuclei of origin of the paralysed nerves. In these cases, also, the muscles generally retain their tone and faradic con- tractility little or not at all impaired. When, however, the motor nuclei, or nerves emanating from them, are the seat of disease, rapid muscular 938 DISEASES OF THE NEKVOUS SYSTEM. emaciation usually takes place concurrently with loss of faradic contrac- tility. To this subject we shall subsequently recur. iv. Beflex action. — The involuntary movement of paralysed muscles in obedience to irritation of sensory surfaces is a phenomenon of common occurrence. Eefiex muscular action occurs of course constantly in health, and when met with in cases in which voluntary power over muscles is impaired or lost necessarily implies that the afferent nerves which convey impressions from the seat of irritation to the cord, the motor nerves passing from the cord to the muscles which are called into action, and the part of the cord with which these several nerves are connected, retain m a greater or less degree their normal powers. Eefiex excitability, therefore, may be impaired or annulled by disease or injury of any part of this nervous mechanism, and it may be increased in consequence either of the simple removal of the restrammg power exerted by the higher centres over that, of the cord, or by morbid irritability of the dynamical elements of the cord. Two varieties of reflex action are recognised : one dependent on im- pressions conveyed by the ordinary afferent or sensory nerves, mainly those of the skin ; the other evoked by any sudden impulse or blow applied either directly to a stretched muscle or to the tendon or fascia belonging to such a muscle. The former variety, or the superficial reflex, for the most part undergoes diminution on the paralysed side in cases of hemiplegia. On the other hand, it becomes markedly augmented in the paralysed regions in para- plegia due to disease simply interrupting the continuity between the upper- and lower parts of the cord. In such cases, sometimes under the influence of deffecation or micturition, sometimes from the irritation of bed-clothes, but more strikingly from touching or tickling the soles, the paralysed limbs perform movements which were formerly regarded as volmitary. When one sole is irritated the correspondmg limb may be made by successive efforts to become powerfully flexed at the hip, knee, and ankle joints, while the toes are widely separated and extended. In most cases the reflex movements are limited to the irritated member ; but in some instances both limbs become involved, and occasionally the muscular contractions are still more widely distributed. The presence of this reflex phenomenon implies that the nerves of the sacral plexus and the corresponding part of the cord are still capable of performmg their special functions. Other reflex phenomena tendmg to throw light on the condition of different regions of the spinal cord, and of the sensory and motor nerves connected with them, have received, and on diagnostic grounds deserve, attention. Thus : irritation of the skin of the buttock causes reflex contraction of the glutei muscles through the agency of the fourth and fifth lumbar nerves ; irritation of the imier aspect of the^ thigh causes retraction of the testicle through the agency of the first and second lumbar nerves ; irritation of the skin of the abdomen from the ribs downwards causes, by means of the dorsal nerves (eighth to twelfth in- clusive), contraction of the abdominal muscles ; irritation of the skin of the thorax between the fifth and seventh ribs leads to muscular contraction KEFLEX ACTION. 939 in the epigastrium, due to tlie agency of the fourth and the three lower dorsal nerves ; irritation of the skm in the inter-scapular region excites, by means of the last two or three cervical and first two or three dorsal nerves^ contraction of some of the scapular muscles ; and irritation of the palm through the instrumentality of the same nerves causes reflex phenomena in the arm. It may be added to the list that irritation of the conjunctiva, causes reflex closure of the eye ; and that in cases of hemiplegic paralysis a paralysed limb or group of muscles occasionally executes sudden move- ments under the influence of emotional excitement. The so-called ' reflex ' phenomena, which are developed when sudden tension is applied to muscles, are of much clinical interest and importance. By Erb, who first drew special attention to them, they were regarded as strictly reflex phenomena ; but by Westphal, who also early investigated the subject, they were considered to be due to the immediate contraction by their own inherent power of the suddenly stretched muscles. Many arguments are adducible, and have been brought forward, in favour of the former ^iew ; but that the latter is the true one seems to be established by the fact that the tendon reflex phenomena are evoked in much less time than true reflex phenomena are, and indeed in less time than (according to our present knowledge) it is possible for nerve influence to be conveyed from the sensory starting-pomt to the cord, and thence back to the muscles- which contract. The interval which elapses between the primary irrita- tion and the muscular response in the case of the tendon reflex appears to be about one-third of that observed in true reflex action. It is to Dr. Augustus "Waller that the experimental determination of this important, point is due ; and his conclusions have been confirmed by the later m- quiries of Dr. Gowers, Dr. de Watte-ville, and others. At the same time there is ample proof that there is an intimate relation between the tendon reflexes and true reflex action ; for tendon reflexes cannot be obtained when the conditions necessary for the development of ordinary reflex phe- nomena are absent, and their development is e^adently dependent on the presence of muscular tone, which itself is due to the fact that the aflerent and efl'erent nerves concerned and the intervening nervous matter of the cord discharge their normal functions. The tendon reflexes can only be- evoked from muscles which are the subject of passive tension. The phenomena here referred to are doubtless of general distribution.. But there are two or three which have been particularly studied, and are of special clinical importance. The first of these is the 'patellar tendon reflex,' the pathological relations of which were first investigated by Erb and Westphal. This is- the sudden contraction of the quadriceps extensor femoris and jerking forwards of the foot, which may generally be caused in health by strikmg sharply the patellar tendon when the leg is allowed to hang pendulous either over the edge of a bed or chair or by crossing the one limb over its fellow, so as to put the extensor muscles slightly on the stretch. In. order to elicit the phenomenon the limb should be allowed to hang loosely^ and the patient should be taken unawares ; for it mav often be counter- 940 DISEASES OF THE NEEVOUS SYSTEM. acted by voluntary effort or expectant rigidity of muscles. In cases in which the reflex is feeble it is necessary to strike the patellar tendon sharply with some heavy instrument, such as a percussion hammer ; but in cases in which it is aggravated or even well-marked a mere fillip with the finger-nail is often sufficient to excite it ; and it may often then be developed by striking the patella itself. Another phenomenon of the same kind may be produced in the foot when, after having slightly extended the muscles of the calf, the Achilles tendon is struck ; another in the forearm when, under similar circum- . stances, a sharp blow is inflicted on the tendinous attachment of the extensor muscles of the upper arm to the olecranon process ; and another in the hand by striking the tendons at the wrist. A further phenomenon of the same class is that known as the ' ankle -clonus.' If in certain cases (mostly paralytic) the patient's foot be grasped in the hand and then suddenly flexed so as to put the muscles of the calf on the stretch, a sudden contraction of these muscles takes place, attended with a corresponding extension of the foot. So far the result seems identical with those which have been above described ; but if in such cases the pressure be continued a series of alternate contractions and relaxations generally occurs, which are rhythmical and, according to Dr. Gowers, at the rate of from six to ten in the second, and persist as long as the pressure is maintained or until the muscles become tired. In order to elicit the clonus it is desirable that the leg be not fully extended on the thigh ; and in some cases its development is promoted by sharply tapping the Achilles tendon. Occasionally the tremors extend from the muscles of the leg to those of the thigh, and even to the opposite extremity. And further, in cases in which the clonus is present, similar tremulous movements are excited when, in attempting to walk, the patient presses his weight on his toes. It is apparently also of the same nature as the phenomenon which, when arising under other circumstances, is sometimes termed spinal epilepsy. Occasionally, owing to the action of the peronei, the oscillations of the foot are lateral. Other cloni may be obtained: one at the patella by suddenly and forcibly pushing this bone downwards towards the leg, and maintaining this pressure ; one in the hand by grasping the tips of the fingers and forcibly pressing the hand backwards ; and one in the great toe by means of a similar movement. If, in" certain cases, the extensor muscles of the leg be put on the stretch by passive flexion of the foot, and then the muscles of the front of the leg be tapped, the calf muscles contract and momentarily extend the foot exactly as they do when the tendo Acliillis is stretched. This is Dr. Tu-n l-nr PlTov^rvf +lio+ onnli -*^- Liniited to posterior external columns: B. Including SnOWn Dy UnaiCOl, inat SUCn ^.^^^^ ^^ posterior colnnms, and extending also to the lateral an amount of disorganisation columns. is unnecessary for the production of the characteristic symptoms of the disease ; that in some cases the posterior median columns, or fascicuH of Goll, remain perfectly healthy ; and that, m fact, the tracts whose lesions uiduce ataxic symptoms, are two narrow bands of white matter, lying one on each side, between the umer and posterior aspect of the posterior comu and nerve-roots on the one hand, and the posterior median column on the other. The sclerotic change occurring in these parts calls for no specific naked-eye or microscopic description ; the affected columns be- come indurated, grey, and translucent, in the early stage a little swollen, but at a later period notably diminished in bulk. The disease, how- ■ever, rarely remams strictly limited to the tracts which are its primary seat ; in a large number of cases (as has already been indicated) the posterior median columns become mvolved ; and generally the internal radicular fibres of the posterior roots of the nerves, and more or less of the adjoining parts of the posterior comua, get implicated to some extent. Occasionally, also, the disease invades the lateral columns, and occasion- ally even reaches the anterior cornua ; not, however, Charcot thinks, by gradual uivolvement of aU the intermediate tissue, but by extension along the internal radicular fasciculi. Symptoms and progress. — The invasion of locomotor ataxy is some- times quite sudden ; in other words, impairment of co-ordinating power 1020 DISEASES OF THE NEEVOUS SYSTEM. is the first symptom to declare itself. In tlie great majority of cases, however, the specific characters of the disease are only revealed after the patient has suffered for an indefinite time, sometimes many years, from premonitory symptoms. These are very various, but many of them are full of significance, and most belong equally to the fully declared disease. The more important of them are as follows : — First, Pains. These are of various kinds and are referrible to different parts. The most common are momentary sharp shooting pains, following the course of certain nerves, for the most part connected with the trunk or lower extremities, but occasionally implicating the branches of the fifth pair, or the great occipital. An erythematous or vesicular eruption sometimes appears in the arese of distribution of the affected nerves. Another variety of pain is of a boring or stabbing character, and is generally limited to certain definite regions in the neighbourhood of the joints or along the back ; and its occurrence is usually associated with hypersesthesia of the same parts. A further variety is of a constrictive character ; it mostly affects the trunk, constituting the so-called ' girdle pain,' but may involve the limbs or any part of them. These various forms of pain are often asso- ciated. The last of them is more or less persistent. But the others occur in momentary twinges, and their continuance is usually effected by a more or less rapid succession of such twinges. Sometimes they come on at irregular and long intervals, and then not unfrequently continue by successive paroxysms for several hours or several days ; sometimes they recur many times daily; sometimes they are constant, and wear the patient out by their unceasing severity. They are generally worse at night-time. Pains referrible to the viscera are also not unfrequent^ Among them may be included pain in the bladder attended with the frequent desire to make water, pain in the urethra excited by the act of micturition, and pain in the rectum as if the bowel were being distended, associated with violent tenesmus. The most important and characteristic of them, however, are attacks of gastralgia (crises gastriqiies) of extreme intensity, usually attended with vomiting, faintness, deranged action of the heart, and an extreme sense of illness. These may continue for several days, or even weeks, at a time ; separated from one another by intervals of entire freedom of variable duration. Occasionally the gas- tralgia is persistent, though hable to exacerbations. The pains in the stomach shoot to the back, about the abdomen, and in various other directions. Second, Paralyses of motor and sensory nerves. These are sometimes temporary, and apt to recur at intervals, sometimes permanent. Among the least common of them are hemixDlegia, facial paralysis, diffi- culty of swallowing, and anaesthesia in the area of distribution of the fifth pair ; among the most common, paralysis of the external rectus or of the other muscles of the eyeball, and ptosis. Third, Affections of the eye and ear. We have already referred to the fact that the patient may have an internal or external squint, or ptosis. It may be added that extreme contraction of the pupil is a marked feature of the disease ; that the pupils are sometimes unequal ; and that the contracted pupil is apt TABES DOESALIS. 1021 to dilate under the influence of the attacks of pain to which the patient is subject. But besides these conditions, which are obvious to casual observers, there are others of yet greater significance and importance. The patient's eyesight in many cases becomes defective : he sees double ; or his vision gets dim or indistinct, and he caiuiot distinguish smaU objects or the contours of objects so clearly as he formerly did; or his field of vision becomes contracted, limited perhaps to one side ; or there is some failure in the power of distinguishing colours, he recognises yellow and blue, but fails to distinguish red and green, and the secondary tmts in the production of which these colours are concerned ; or these various condi- tions are associated in a greater or less degree. These affections of the •eyesight tend to increase slowly, and at length culminate in absolute blindness. They are due to progressive grey atrophy of the optic discs, revealed ophthalmoscopically by chalkiness and opacity, with absence of the marginal rosiness of tint, and by mability to trace the trunk-vessels of the retinae as they sink into the substance of the optic nerves — they seem to terminate abruptly. The atrophy, according to Charcot, is due to a change occm-ruig in the optic discs (identical with that which goes on in the posterior columns of the cord), and gradually extending backu^ards along the optic tracts, as far at least as the corpora geniculata. Further, the pupils cease to act to the stimulus of Hght, while still varyuig hi size with efforts at accommodation (the Argyll-Rohertson jplieitomenon) . Headache referred to the back of the head and forehead, and neuralgic paias ui the course of the branches of the fifth pair, and in the eyeball, frequently attend the above visual lesions. Deafness in one or both ears is not uncommon. Fourth, Affections of the joints. These are of occa- sional occurrence ; they are observed mainly in the knees and hips, some- times in the shoulders. They consist in rapid effusion into the joints and tissues which surround them, taking place with little or no pain or fever, and usually followed at the end of some weeks or months by restoration to health. Occasionally they end in erosion of the ends of the bones, or disorganisation of the joints, followed after a time by dislocation. In association with joint-disease atrophy and brittleness of bones have often been observed ; and there is some reason for belie\'ing that these constitute the primary affection. Fifth, in almost all cases, not only when the disease is fully developed, but at its very earliest stage, and even before its true nature has been revealed, there is a total absence of patellar and other tendon reflexes. It is curious, however, that there is no relation between the absence of this phenomenon and the condition of the super- ficial reflex excitability. The latter, although occasionally impaired or even exalted, remains for the most part normal. Lastly, among other occasional precursory symptoms may be enumerated: nocturnal incontm- ence of urine ; spermatorrhoea, sometimes attended with erection and voluptuous sensations, sometimes occurring independently of erection or of orgasm ; a peculiar aptitude for repeating the sexual act many times within a short period ; and a permanent acceleration of pulse, attended, according to M. Eulenberg, with habitual dicrotism. 1022 DISEASES OF THE NEEVOUS SYSTEM. The explanation of the phenomena just enumerated is for the most part obvious. They are dependent on the progress and distribution of the morbid process which is going on m the nervous centres, but which has not yet destroyed, sufficiently to cause obvious mco-ordination, those portions of the cord which minister to the co-ordinate actions of the lower extremities. Thus, the various forms of neuralgic pain and cutaneous eruption are due to implication of the intra-rhachidian portions of the sensory nerve-roots ; the aifections of the eyes and ears are referrible to involvement of the ophthalmic and auditory nerves, or their nuclei ; and there are good grounds for believing that the lesions of the joints are the consequence of implication of the anterior cornua, and that various phe- nomena, such as those presented by the pupils and those connected with the action of heart and character of the pulse, are of sympathetic origin. The so-called ' premonitory ' symptoms are in truth an integral part of the disease, and if recognised may be taken as sure evidence of the insidious progress of those central organic lesions which ultimately induce the proper ataxic phenomena. Some one or more of these premonitory symptoms may continue for years before the occurrence of obvious ataxia ; the disease may even stop short with them ; but in many cases those which first made their appearance undergo gradual aggravation, others become super- added to them, and presently the ataxic phenomena supervene and become mingled, as it were, with them. In other cases, again, want of co-ordina- tion in the movements of the lower extremities is the very first mdication of nervous disease, and various of the phenomena hitherto spoken of as prodromal appear as complications only during its later progress. The earliest of the special phenomena of locomotor ataxy is the gradual supervention of a certain difficulty in walking, frequently associated with numbness and tinglmg of the toes and feet. The difficulty is pecuHar in its character ; it does not consist in any loss of muscular power or any inabihty to take long walks without discomfort or fatigue, but in a certam clumsiness or micertainty which manifests itself especially when the patient first rises from his seat, or when he is endeavouring to avoid obstacles, or when he attempts to turn suddenly on his heels, or to go upstairs. It becomes especially obvious in the dusk; and, indeed, the very first indication of disease is sometunes the difficulty which the patient experiences in walking in the dark. Under all these circumstances, his movements become more or less tumultuous, and there is an obvious difficulty in the maintenance of his equihbrium. This difficulty becomes evident in the most marked manner, even in the very earhest stage of the disease, when the patient is made to stand blindfold with his feet together. At once he begins to totter and to sway, and, unless he opens his eyes or is supported by others, soon falls to the ground. With the progress of the disease the movements aU become more tumultuous, and the difficulty of progression increases proportionately ; the patient now perhaps experiences considerable difficulty in assuming the erect posture ; in endeavourmg to attain it his legs jerk here and there, apparently urged by an uncontroll- able impulse, and he has to resort to a stick, or the arm of his chair, or TABES DOESALIS. 1028 to a friendly band to aid him in liis efforts. When once he is on his legs, he pauses for a while to balance himself, and then starts off with his body bent forwards and his legs apart. Every movement of his legs is now tumultuoiTS ; the leg with which he steps out is Kfted from the groimd and thrown forwards and upwards with needless suddenness and ^dolence, and is then brought down with equally unnecessary force, and even when on the ground still presents a tendency to jerk, which may be continued even while the other leg is in its turn executing its series of awkward progressional movements. The patient continues to walk in this manner either without assistance, or with the aid of a stick or chair, or between a couple of friends, according to the stage which his loss of co-ordinating power has reached. But if he be able to walk alone or with a stick, his movements usually become a little less wild after he has taken a few steps ; and he may contmue to walk, with excessive violence of movement, no doubt, and with short hurried steps and the body thrown forwards, but nevertheless with considerable power and efficiency. A patient in this state will sometimes walk ten, a dozen, or twenty miles at a stretch, with comparatively little fatigue ; but in some cases the mere violence of his muscular movements involves such rapid esliaustion of power that the sufferer can scarcely do more than walk across the room. A time, how- ever, comes sooner or later in which his want of control over the move- ments of his lower extremities becomes so extreme that it is absolutely impossible for him to make a step or two consecutively or even to stand. His legs, when he attempts to use them, move, as Trousseau observes, like those of a puppet or marionette. Thenceforward he is confined to his chair or bed. It is a remarkable fact, for the due appreciation of which we are indebted to Duchenne, that the muscles of the affected limbs retam, as a rule, their bulk, then- tonicity, their electrical contrac- tility, and their strength, little if at all impaired, not only so long as the patient can walk or stand, but long after his limbs have become absolutely helpless. And often, at a time when the patient camiot rise from his chair or stand, he can freely execute movements of extension and flexion as he sits or lies, and successfully resist all manual efforts on the part of his physician to extend or flex his legs. The numbness and tinghng to which reference has already been made generally persist, and for the most part increase in degree and extent, and always from below upwards. There is sometimes total abolition of cutaneous sensibihty in the feet, and there may be some impairment of it extending even to the abdomen. Occasionally it is absent. This impairment of sensibility gives to the patient the impression that his feet are swollen and soft, or that they are enveloped in some thick soft covering, and when he stands or walks that he treads on sponge or wool, or some other yielding and elastic material, or even that he treads on air. However great the loss of tactile sensibility, that which takes cognisance of differences of temperature usually survives to the last. The symptoms of ataxy do not generally remain limited to the lower extremities. In most cases, sooner or later, numbness, at first perhaps 1024 DISEASES OF THE NEKVOUS SYSTEM. occasional, but after a while permanent, is complained of intlie tips of one or two of the fingers — generally the little and ring fingers ; and the numb- ness may remain thus limited, or may gradually involve more and more of the hand and arm, always, however, continuing most highly developed in the parts which were first attacked. In association with this, clumsiness in the movements of the fingers, and probably of the hands and arms, may be observed. The patient experiences considerable difficulty in per- formmg all delicate manipulations ; he cannot pick up a pin lying upon a hard smooth surface ; he cannot button or unbutton his clothes or tie a bow, especially if he be unable to direct the operation with his eyes ; in grasping a pen or any other similar object which is offered to him he first opens his hand wide and then closes it with violence upon it, entirely fail- ing to execute those delicate combined movements which are necessary to the precision of his performance, and which impart such grace to the natural movements of the hand. The same clumsiness is observable in his efforts to transfer the object from one hand to the other, and, if it be a pen, in acquiring that hold of it which is proper for writing. Further (and this is a defect belonging equally to the lower extremities, but less readily recognised in their case), the patient is unable without the assistance of his eyes to judge of the position of his hands, or so to adjust the action of his muscles as to determine accurately the direction or extent of the movements of his arms. Hence, if his eyes be closed, he cannot if he wishes to clasp his hands bring them together with any certainty : they are brought towards one another at different elevations, or one in front of the other, and it is only after several failures have been made that they finally meet. Similarly, if he tries to touch his nose with his finger, he probably strikes his eye or his forehead or his mouth. The voluntary motions of the arms are occasionally effected by successions of jerky move- ments. But notwithstanding the widespread affection of his volmitary muscles, he probably during the whole duration of his illness retains perfect control over the rectum and bladder, and has no tendency to bed- sores. Various other phenomena, due mostly to extension or multiplication of the nervous lesion, are apt to supervene in the course of the disease. In some cases the muscles of the trunk and of the head and neck become im- plicated in the same way as the muscles of the extremities, and the patient executes slight oscillatory movements when he sits up unsupported. In some cases difficulty of articulation comes on ; the patient is slow, yet somewhat jerky and indistinct in utterance ; he can pronounce every letter perfectly, but fails to pronounce them accurately in combination and slurs over his syllables. There is often, too, a manifest over-exertion of the muscles of the mouth and tongue in the effort to speak, and fatigue is soon experienced. In some cases (if such phenomena have not appeared earlier in the disease) paralysis of the third, fourth, sixth, portio dura, hypoglossal, or vagus of one or other side, comes on ; or double vision, impairment of vision, or amaurosis supervenes; or the patient grows absolutely deaf; or he becomes subject to the various forms of pain which have already been TABES DOESALIS. 1025 described ; while, on the other hand, if these have previously existed, they may disappear. The patient may also suffer h-om perforating ulcer of the foot, or even (though much more rarely) of the hand. Further, he may be liable to severe and continuous aching pains in the forehead and back of the head, along the spine, and in the trunk and extremities, ua connection with which, as with the earher neuralgic pains, cutaneous eruptions may appear temporarily ; or he may, late in the disease, suffer from retention or mcontinence of urine, and equivalent conditions affect- ing the rectum ; and generally he loses sooner or later all sexual desire and power. Occasionally, in the far-advanced stages of the disease, rigidity, contraction, and wasting of muscles come on— complications which are obviously due to the extension of disease from the posterior columns to the lateral columns and anterior cornua. In most cases the cerebral functions are unaffected from first to last. But in some instances patients become low-spirited and incapable of appHcation ; in some, manifest symptoms of insanity arise ; in some, general paralysis of the insane supervenes ; and occasionally (as also m this last affection and in disseminated sclerosis) epileptiform or apoplectic attacks occur. For the most part these phenomena come on late. But they may appear at any period, and may even constitute a part of the prodromal stage. Locomotor ataxy does not always involve the opposite limbs sym- metrically ; it often commences earlier in one leg than the other, and invades one arm in advance of its fellow ; and in the subsequent progress of the disease the legs or arms may continue to be unequaUy affected. The course, too, of the disease is very various. Sometimes the symptoms arise and succeed one another so rapidly that the patient becomes bed- ridden at the end of a few months. But much more commonly the suc- cessive phenomena are slowly and n-regularly evolved; periods of apparent amendment from time to time intervene ; and ten, twenty, or thirty years may elapse before the disease attains its full development. It is more than doubtful if absolute restoration to health ever takes place when the clinical phenomena are so fully declared as to render diagnosis clear. It is not, however, doubtful that many persons do experience great ame- lioration of their symptoms, and that such amelioration is sometimes of long duration. Occasionally, indeed, the course of the disease appears to be permanently arrested. In the vast majority of cases, however, the pro- gress of the patient, excepting for occasional interruptions, is miiformly from bad to worse, until death ends the scene. The causes of death are various. Generally it is due to some intercurrent malady ; but it may be referrible to implication of the muscles of deglutition and re- spiration, to secondary bladder and renal mischief, or to the formation of bed-sores. Treatment. — When temporary improvement has occurred mider our o\n\ observation, it has always seemed due simply to avoidance of over- exertion, rest, protection from cold and wet and other such adverse m- fluences, judicious dieting, and good hours— in fact, to careful attention to 3 u 1026 DISEASES OF THE NEEVOUS SYSTEM. the general well-being of the bodily health. It is not clear that any remedy exerts any, even the slightest, direct influence over the course of the disease. Nitrate of silver has been strongly recommended, iodide of potassium has been employed, iron and other so-called nervine tonics are often called into requisition. For the relief of pain, sedatives, such as opium or belladonna, or local applications, such as counter-irri- tants, frictions, and galvanism, may prove serviceable ; and indeed it may be said generally that all complications and all discomforts arising in the course of the disease should if possible be relieved. Bathing and shampooing seem sometimes to be beneficial. As regards electricity, Duchenne observes that faradism, and galvanism with intermittent current, are either of them often serviceable both in relieving pain and in restor- ing voluntary power to the affected muscles in the earliest stage of the disease. But, while not forbidding their employment at a later period, he is evidently not sanguine as to the results which are then likely to be obtained. This is in accordance with general experience. Galvanism is doubtless preferable to faradism. Stretching of nerves has been practised with reputed success. H. Glosso-lahio-laryngeal Palsy. {Bulbar Paralysis.) Definition. — This name has been given by Duchenne to a paralytic dis- order due to an affection of the medulla oblongata (whence also it has been termed paralysie bulbaire] involving mainly the seventh, ninth, and spinal accessory nerves, and revealing itself during life by paralysis of the lips, tongue, soft palate, and larynx. Causation. — Its causes are as obscure as those of other afi'ections of the same class. It has been referred to the effects of cold and moisture, and it has appeared to follow upon strong moral emotions. It has also been referred to syphilis. It seems to be a disease of adult life, and to affect women more largely than men. Morbid anatomy. — The essential lesions of this disease are identical, so far as regards their nature, with those of locomotor ataxy, lateral sclerosis, and the like. They affect, however, a different region. Post-mortem ex- aminations conducted on patients dead of this affection have revealed sclerosis, with more or less atrophy, of the roots of the spinal accessory, hypoglossal, and facial nerves, and sometimes similar changes in the roots of the vagi, in the motor roots of the fifth pair, and in the anterior roots oi several of the upper cervical nerves ; but they have also revealed (which is of still greater importance) that these changes in the nerves are secondary to pigmental atrophy of the large cells contained in the nerve- nuclei situated in the medulla oblongata, associated with more or less circumambient sclerosis. Certain phenomena in the chnical history of these cases, and the fact of the frequent supervention of the symptoms of glosso-labio-laryngeal palsy in the course of lateral sclerosis, render it probable that the disease, when occurring in the uncomplicated form, is often due less to a primary lesion of the nerve-nuclei than to their second- GLOSSO-LABIO-LAEYNGEAL PALSY. 1027 ■&VJ implication in the course of some sclerotic change occupying the anterior pyramids. Symptoms and progress.- — Li most uncomplicated cases of glosso-labio- laryngeal palsy the symptoms of the disease come on gradually. The tongue usually suffers first. The patient experiences some difficulty in "the articulation of words, especially of those which need the special em- plojmient of the tip of the tongue, and presently also more or less diffi- culty in mastication and deglutition ; and he suffers from the accumula- tion of saliva in his mouth. The paralytic condition of the tongue gradually increases ; he has difficulty in protruding it and in drawing it in again, and ere long it lies motionless or nearly so on the floor of the mouth, with its tip behind the anterior incisors and its edge pressed and indented against the arch of the lower teeth. It is sometimes reduced in isize and wrinkled; sometimes it feels large to the patient, and either retains its normal dimensions or exceeds them. Whilst the lingual paralysis is in progress, the muscles of the soft palate and arch of the :fauces become implicated, the patient's voice acquires a nasal quality, the difficulty of swallowing becomes aggravated, and his food is apt to pass into the posterior nares. The arches of the palate may occasionally be seen to be unequal, with the uvula pointing to one side ; but it is remark- able that even when the paralysis, so far as deglutition and enunciation :are concerned, is complete, the velum often can still be excited by local irritation to violent action. The lips also are early involved : the orbicu- laris becomes enfeebled, the hps get large, the lower one pendulous, and it is soon difficult or unpossible for the patient to close his mouth, to prevent the flow of saliva from it, to utter the labial consonants, to whistle or blow out a candle, or to perform any function requirmg the use of the lips. According to Duchenne, it often happens that the quadratus menti and triangularis oris of each side become implicated, so that the angles of the mouth cannot be drawn down and extended ; but he says that the buccinators rarely suffer, and that the muscles of expression of the upper part of the face remain unaffected, and by their tonic con- traction so act on the angles of the mouth as to cause the transverse elongation of the orifice, and at the same time so deepen and modify the direction of the naso-labial sulci as to impart to the patient's physiognomy the appearance of crying. Not mifrequently, when a patient in this con- dition is made to laugh or cry, his mouth becomes widely opened, and re- mains open until the upper lip is restored to its original position by hand. The muscles by which the upward and downward movements of the lower jaw are effected for the most part retain their normal force, so that the patient can bite powerfully up to the last. Nevertheless, difficulty of mastication, already extreme in consequence of the paralytic condition of the tongue, is enhanced by paralysis of the pterygoid muscles, which renders the movements necessary for trituration impossible. Sooner or later the muscles of the pharynx, and even those of the larynx, share m the general paralytic affection, and hence the difficulty of deglutition becomes further aggravated. 3 u2 1028 DISEASES OF THE NEEVOUS SYSTEM. Ill tlie later stages of the disease the patient ceases to utter any- articulate sound, although a laryngeal grunt, indicative of the due action of the vocal cords, may attend each effort to speak. The saliva which is constantly dripping from his lips accumulates in his mouth, becomes sticky from long retention, and on opening his jaws hangs m ropes and festoons between the opposite surfaces. His food collects ui the buccal pouches, or faUs out through the open lips, and can only be made to reach the fauces either by thro-viing the head backwards or by pushuig the food onwards with the fingers. The pharyngeal stage of deglutition is equally difficult. Pultaceous matters are swallowed best; but these have to be passed to the back of the mouth in small quantities and with great care ; . and even then constantly cause choking — either finding their way hito the wmdpipe or into the nose, or being ejected by the spasmodic action of the pharjmgeal muscles. The entrance of food into the larynx is due mainly to the failure of the tongue and epiglottis to descend over the superior laryngeal orifice during the act of swallowing ; for it is only in rare cases that suppression of the lar}Tigeal voice, indicative of paralysis of the laryngeal muscles, is obser^'ed. Sooner or later, however, the pneumogastric nerves become imphcated, and then symptoms referrible to the respiratory and circulatory organs are superadded. Attacks of difficulty of breathing, not due to the entrance of food or saliva into the mndpipe, are now of frequent occurrence. They come on by day or night, and are often provoked by exertion. They do not appear to be connected necessarily either with pulmonary disease or with any paralytic condition of the ordinary respiratory muscles. Du- chenne refers them to paralysis of the bronchial muscles. There is no doubt, however, that catarrhal affections of the bronchial tubes are now exceedingly apt to arise, and that these, however slight they may be,, greatly aggravate, if they do not induce, dyspnoeal attacks. Eemarkable feebleness of circulation also supervenes at this period ; and especially the patient is hable to syncopic attacks, which sometimes accompany the fits of dyspnoea, and are attended with precordial anxiety, fear of death, and extreme feebleness, irregularity, and generally quickening, of the pulse. The phenomena above described are all unattended with febrile dis- turbance, loss of sensation, pain, giddiness, or any form of mental defect ; the appetite contmues good, the corporeal functions generally are well performed, and the system at large for the most part retains its powers, excepting in so far as they may become impaired by the starvation which the difficulty of swallowing gradually induces. Hence some patients who are far advanced m the disease will continue to go about the house and even to take long walks. In many cases, however, towards the close of life, they are confined to the chair or to bed. The com-se of glosso-labio-laryngeal palsy is generally rapid, and its and is invariably death, which may come on within six months of its onset, and is very seldom delayed beyond three years. The causes of death are : starvation from mability to take nourishment ; asphyxia, from the impaction of a lump of solid food at the back of the throat, or from OPHTHALMOPLEGIA. 1029 tlie repeated entrance of portions of food or saliva into the larynx ; an attack of dyspnoea or syncope ; and lastly, pulmonary complications (bronchitis and the like) which are especially dangerous when involve- ment of the respiratory muscles renders the discharge of bronchial accumulation difficult or impossible. Although glosso-labio-laryngeal palsy conforms in a large number of cases to the description which has just been given, it is not unfrequently • a fragment, as it were, of some more widely diffused nervous disease. Thus, as is subsequently pointed out, it often forms one of the complica- tions of disseminated sclerosis ; its supervention constitutes, almost with- out exception, the last stage of lateral sclerosis ; and, further, it is not un- commonly associated with progressive muscular atrophy, generally coming on late, but sometimes manifestuig itself at an early period. The most important cases of the last group are those (and they are not rare) in which the respiratory muscles also waste. Again, it is important to recollect that groups of symptoms closely resembling those of glosso- labio-laryngeal palsy may be caused by effusion of blood into the pons or medulla oblongata, or by syphilitic or other disease of the same parts ; and may even arise in connection with the descending lesions which follow chronic forms of cerebral disease. Treatment. — Nothing that we are acquainted with is capable of arrest- ing the course of this formidable malady. In the early stages electricity may be applied to the enfeebled muscles, and possibly with slight tempo- rary apparent benefit. In the later stages we must endeavour to relieve symptoms ; and it may then be of service to feed the patient either by the .aid of the stomach-pump, or per anum. I. Oplithalmoplegia Interna and Externa. Definition. — The above names have been applied by Mr. Hutchinson^ to two groups of cases, the one of which is characterised by progressive and more or less symmetrical paralysis of the internal muscles of the eyes, the other by progressive and more or less symmetrical paralysis of the muscles which move the eyeballs and raise the eyelids. Cases of the latter affection had previously been described by Von Grafe. Causation and morbid anatomtj. — The causes and morbid anatomy of these disorders have not been satisfactorily determined. They occur in both males and females, and in large proportion in early adult life. Mr. Hutchinson states that in most of his cases there was a history of syphilis, and is inclmed to attribute the ophthalmoplegia to this affection. No post-mortem evidence, however, of the presence of gummata in any of them has yet been adduced ; and he acknowledges that antisyphilitic remedies have had but little influence over their course. Some of the recorded cases have no doubt been attended with other phenomena strongly pointing to the presence of cerebral tumours, which may of -.com'se have been syphilitic. But in many the ocular affection has ' Medico-Cliirurgical Transactions, vols. Ixi. and Ixii. 1030 DISEASES OF THE NEEVOUS SYSTEM. been associated with symptoms pointing to the presence of more or less extensive sclerosis of other parts of the nerve-centres ; and there is good reason, therefore, to believe that ophthalmoplegia is, in many instances at any rate, a consequence of chronic inflammatory or degenerative lesions, and has intimate relations with other such affections. The two forms of ophthalmoplegia, though apt to occur independently of one another, are not unfrequently combined ; and there is reason, there- fore, to believe that the lesions producing them severally occupy neigh- bouring, though not identical, parts of the nervous system. Direct symmetrical implication of the nuclei of the third, fourth, and sixth pairs of nerves in degenerative or other processes might well explain their con- currence ; it might even explain (supposing definite parts of the several nuclei to be concerned in movements of the eyeballs, and other definite parts to be concerned in movements of the intra-ocular muscles) the separate occurrence of each.^ There is some reason, however, to suspect that the parts involved in these affections may be (at any rate in some cases), not so much the nerve-nuclei themselves, as certain higher centres, not far removed from them, which co-ordinate the several forms of bin- ocular movements. It has been shown by Henson and Voelcker that in the hinder part of the floor of the third ventricle there are three such centres \ of which the one in front controls the action of the ciliary muscles, and so regulates accommodation, while the middle one regulates contraction, and the posterior one dilatation, of the pupils. Again, it has been shown by Adamuk that irritation of certain spots in the corpora quadrigemina produces severally elevation and depression of the eyeballs, and conjugate movements to the right and left. Now, affection of the former groups of nuclei would readily explain the occurrence of symmetrical paralyses of the internal muscles of the eye ; affection of the latter group would readily explain symmetrical paralyses of the muscles of the eyeballs ; and from the near proximity of the two regions extension of disease from one to the other might readily take place and the symptoms referrible to each thus become combined. In the only case of Mr. Hutchinson's which proved fatal, the symptoms had been going on for years ; and there were in combination, not only external and internal ophthalmoplegia, but blindness and other progressive symptoms pointing either to locomotor ataxy, to lateral sclerosis, or to progressive muscular atrophy ; and Dr. Gowers, who examined the nervous organs post mortem, discovered atrophy and degeneration of the optic nerves, and of the third, fourth, and sixth pairs with their nuclei, resembling the lesions found in progressive muscular atrophy. In a case under Dr.. , Buzzard's ^ care in which the symptoms of tabes were present in an extreme degree, and in which also ophthalmoplegia externa and immobility of pupils were present, the lesions indicative of locomotor ataxy were found far advanced in the cord, the nuclei of the sixth pair of nerves were found degenerated, apparently secondarily to vascular disease ; and in the course ' See Discussion, and Dr. Sturge, Oplithalinological Transactions, vol. i. 2 Buzzard, Diseases of the Nervous System, 1882. OPHTHALMOPLEGIA. 1031 of the nerves through the medulla were detected obstructed vessels and miliary clots. The other ocular nerves were not examined. Symptovis and progress. — 1. Ophthalmoplegia interna, in its most extreme and typical condition, is characterised by the presence of absolute immobility of both irides, and of total loss of the power of visual adjust- ment. The pupils undergo no change under the influence of either light or accommodation ; and sight, which has become adapted to distant vision only, is wholly incapable of adjustment for near objects. The disease is slow in progress, begins sometimes in one eye sometimes in both, and always in the first instance with paralysis of the irides. At this stage the patient is probably unaware that anything is the matter with his eyes, for mere immobility of the pupils scarcely affects the general perfection of eyesight. The loss of power of accommodation also for the most part comes on gradually, and often in one eye before the other. But occasionally it is almost sudden in its incidence. The failure of vision for near objects, and its increasing suitability for distant objects only, naturally attract the notice of the patient, especially if he be young ; and now probably for the first time he consults a medical man. 2. Ophthalmoplegia externa also occasionally occurs independently of all other ocular disease, and indeed of all other disease. Li such a case the first specific incident is usually partial ptosis affecting either both eyelids at the same time, or one in rapid succession to the other. With ptosis there is usually associated paralysis of the superior recti ; and then, gradually following, but in no special order, paralysis of corresponding- ocular muscles, until at length the paralysis becomes more or less general and complete. In a typical and extreme, but uncomplicated, case we find : the upper eyelids drooping over the eyeballs, with little or no power of voluntary elevation — imparting a sleepy aspect to the patient ; the eyes almost absolutely motionless and looking directly forwards, or haply presenting an internal or external squint ; and more or less marked exophthalmos, due to the absence of tonic contractile power in the muscles of the eyeballs ; but withal integrity of the retinae, mobility of the pupils, power of accommodation, and for objects lying in the line of vision perfect sight. The immobility of the eyes necessitates incessant bird-like movements of the head in exercising the function of sight. The paralysis, however, is rarely so complete as is represented in the above picture. In most cases there is still some slight mobility of one or both eyeballs ; or the disease, though affecting both sides, is more advanced on one than on the other. The progress of these cases, like that of ophthal- moplegia interna, is generally slow, and often extends over many years. But in some cases it is rapid ; and the paralysis may become extreme in the course of a few months. Pain in the eyes and head are often complained of. 3. Not unfrequently, in both forms of ophthalmoplegia, the patient becomes blind, with white atrophy of the optic discs ; and not unfrequently also, as we have already pointed out, both forms of the disease are combined in the same patient. 1032 DISEASES OF THE NEEVOUS SYSTEM. The association of ophthalmoplegia with other nervous phenomena is extremely interesting. And abundant clinical evidence has now accrued to show : not only that the symptoms of these affections are apt to follow on such diseases as locomotor ataxy, disseminated sclerosis, bulbar paralysis, lateral sclerosis, and progressive muscular atrophy ; but that they may be among the earlier symptoms, possibly the first recognised symptoms, of these well-known diseases, and may foretell their coming on. Paralysis of the fifth, seventh, eighth, and ninth nerves may severally also become developed during the progress of ophthalmoplegia ; and in a case under our own care hemianaesthesia, with colour-blindness of the correspondmg eye, and loss of smell and taste on the same side, appeared in the course of the patient's illness. Treatment. — Some of Mr. Hutchinson's cases, especially those of ophthalmoplegia interna, seem to have been benefited by antisyphilitic remedies, a point of some importance in connection with the frequent presence of a syphilitic history. For the most part, however, treatment has proved of little ser\dce ; and the affection, even if it has not developed into something worse, has either remained stationary or undergone gradual aggravation. J. Disseminated Sclerosis. {Multiple Sclerosis.) Definition. — ' Sclerose en plaques disseminees ' is the name which Charcot (to whom we are mainly mdebted for its recognition and descrip- tion) has given to the affection which we here term disseminated sclerosis. Dr. Moxon calls it msular sclerosis. It is characterised, post mortem, by the presence of a number of small roundish patches of sclerosis, scattered irregularly throughout the nervous centres ; clmically, by a variety of symp- toms, among the most characteristic of which are trembhngs of the head, neck, trmik, and limbs, coming on only when the muscles are being exerted, difficulty of speech, oscillation of the eyeballs, gradually supervening para- lysis, with contraction, chiefly of the lower extremities, and some impair- m.ent of the mental functions. Causation. — Disseminated sclerosis is mamly a disease of adult life, usually coming on between the ages of twenty and twenty-five, rarely after thirty, but sometimes at the period of puberty, and even in childhood. It is more common in women than in men. It has been attributed to the same causes as those to which other forms of sclerosis have been attri- buted — namely, moral influences and exposure to wet and cold. Its advent has sometimes been heralded by hysteria, neuralgia, or other nervous symptoms. Morbid anatomy. — Sclerotic patches may appear in the cerebrum, cere- bellum, pons, medulla and spinal cord, either collectively or separately ; but generally are distributed in several of these organs at the same time. In the cerebrum they occupy mainly the neighbourhood of the ventricles, and are found, therefore, in the corpus callosum, septum lucidum, corpora striata, and optic thalami ; they occur also in the centrum ovale, but seldom in the grey matter of the convolutions. In the cerebellum, their almost DISSEMINATED SCLEEOSIS. 1033 •exclusive seat is the corpus dentatum. As regards the pons and medulla oblongata, they may be either superficial or deep-seated. In the former they affect mainly the anterior and inferior aspect, extending thence to the ■cerebral peduncles and corpora albicantia ; in the medulla, they occupy all parts indifferently, inclusive of the region forming the floor of the fourth ventricle. In the cord, as in the medulla, all parts are liable to be impli- cated. The cerebral and spinal nerves sometimes emerge, unaffected, from diseased tracts ; in other cases they are studded with similar morbid patches or are mvolved generally. The cerebral nerves which chiefly thus suffer .are the first, second, and fifth pairs. The patches of sclerosis vary in size, but are for the most part well-defined, and of roundish form. They are dense, hard, slightly translucent, and of a greyish colour, closely resembling that of the healthy grey matter of the brain. They sometimes project a little above the general level, sometimes are depressed below it. Micro- scopically they present all the ordinary characters of sclerosis ; and usually, according to Charcot, may be divided into three zones, of which the outer- most represents the disease in its earliest phase, the innermost represents it in its most advanced condition. In the outermost zone, the neuroglia is increased in amount and its nuclei in number, and the nerve-tubules are diminished in diameter at the expense of the white substance of Schwann ; in the next zone, the neuroglia has still further increased and has become distinctly fibrillated, the nerves (more widely separated than they were) have become yet more reduced in size, and the white substance has almost wholly disappeared, while the axis cylinder has in many cases undergone enlargement ; in the central area, the overgrown neuroglia reigns para- mount, the nerve-cells and nerve-tubules have for the most part vanished, and those which stiU survive are far advanced in atrophy. It may be added : that the gradual disappearance of the white matter of Schwann involves the production of a large number of free oil-globules and granule- cells, which stud the outer two zones, and tend to accumulate withm the lymphatic sheaths of the vessels ; that the blood-vessels enlarge, and the nuclei in their walls increase in number ; that the nerve-cells undergo pigmental atrophy, shrink, and finally disappear ; and that corpora amy- lacea tend to develop in the course of the vessels. Symptoms and i^ogress. — The symptoms to which patches of sclerosis may give rise must depend partly on their size, partly on their situation, partly on their number. Thus it is obvious : that if a patch of sclerosis should interrupt the continuity of the posterior columns of the cord, symp- toms like those of locomotor ataxy would be developed; that if it should involve one of the lateral columns, the symptoms referrible to it would have some resemblance to those characteristic of lateral sclerosis ; that if the anterior cornua should be implicated, more or less rapid wasting of certain muscles might be expected to follow ; that if the medulla oblongata should be its seat, some of the symptoms of bulbar paralysis or of glosso-labio-laryn- geal palsy would necessarily arise ; and that, if seated in the cerebrum, hemiplegia, convulsions, impairment of intelligence, or other of the various consequences of brain-lesion would almost certainly follow. It is, further, 1034 DISEASES OF THE NEEVOUS SYSTEM. obyioiTS that if many sclerotic patches should be distributed throughout the- nervous centres, the consequences due severally to them would blend, as it were, into a common whole, producing collective symptoms of more or less complexity. It is, nevertheless, a fact that a large number of cases of dissemi- nated sclerosis, in which the nervous centres are generally implicated, are attended with groups of symptoms which collectively afford almost positive proof of the nature of the malady which is in progress. We "svill consider the more important of these symptoms, successively. 1. Rhythmical tremors. — These constitute one of the most distinctive features of the disease. They are absent when the patient is asleep, they are absent also when he lies at rest, with his limbs and head supported ; but they come on whenever he makes any muscular effort, and become more and more pronounced the greater and more sustained that effort is. When he raises his hand from the bed-clothes, convulsive movements seize his fingers, his hand, and his arm ; if he attempt to raise his hand to his lips, the tremulous movements increase ; and if, further, the muscular effort be rendered greater by his ha^nrig to lift some heavy body, or some- tliing which requires care and precision in handling, as, for instance, a glass of water, they are apt to become exceedmgly tumultuous, and to increase in tumultuousness as the task set him approaches completion.. Occasionally they are induced when the arm is apparently at rest by the nervous efforts of the patient to keep it still. If he sit up unsupported, similar movements affect his trrnik and his head and neck. If he endeavour- to stand or to walk, they become universal, and the legs, arms, trunk, and head are all \-iolently agitated. It is not pretended that these tremulous movements are present in all cases of disseminated sclerosis ; but they are present m the great majority of cases. Nor must it be assumed that, when present, they are always of general distribution ; they may (for a time at least) be limited to one arm, or to both arms, or when present in both may affect them unequally ; or the legs may chiefly suffer. Neither must it be supposed that they are present during the whole course of the malady. Ehythmical trembling is rarely one of the earliest symptoms of the disease ; but it usually comes on before long, and then invades the various parts slowly and irregularly ; and it disappears as the patient becomes more and more enfeebled, and especially when paralysis super- venes. The movements are peculiar ; they are rhythmical, and yet there is some degree of irregularity both in the extent of the successive vibra- tions and in the intervals which separate them. They have some resem- blance to those of paralysis agitans ; but in the latter the vibrations are more rapid and more regular, moreover they occur when the patient is at rest, and seldom, if ever, directly implicate the head and neck. They have a greater resemblance still to those of chorea, but they are less wanton, less violent, and altogether more rhythmical than these ; and further, the "sibrations in sclerosis for the most part take the direction of the general movement of the limb or part which is engaged in movement. It must not, however, be forgotten that tremulous movements, midistinguishable DISSEMINATED SCLEEOSIS. 1035 from those of sclerosis, may attend various other affections, and especially chronic mercmial poisoning, chronic cervical meningitis, and sclerosis of the lateral columns, 2. Affections of the eyes. — Double vision is a not uncommon symptom of the earlier stages of sclerosis, as it also is of locomotor ataxy, but is for the most part transitory and unimportant. Indistinctness of vision is a much more frequent phenomenon, and is generally permanent, but rarely ends in blindness. It is often present when no signs whatever of disease can be detected with the ophthalmoscope. But sometimes atrophy of the optic disc is present, which becomes complete m cases of total blindness. Nystagmus is a symptom of considerable importance, and is present in about half the total number of cases ; it consists in consensual small os- cillations of the eyeballs, which m slightly advanced cases maybe apparent only at the moment when the patient endeavours to fix his glance upon some fi-'esh object, or looks out of the corners of his eyes ; but they are generally constant, although aggravated by voluntary movements of the eyeballs. They cease when the patient is asleep, or when his eyes are shut in repose. Nystagmus is rarely present m locomotor ataxy. 3. Defect of speech. — This is nearly constant. Li well-marked cases the utterance is slow and drawling. The words (to use Charcot's expres- sion) are ' scanned,' as it were, there is a pause after each syllable, and the syllables themselves are slowly evolved. Moreover, the voice is weak and monotonous, and only two or three words probably are uttered on each breath, owing apparently to rapid loss of breath by expiration during the inter- syllabic pauses. Also the words are often imperfectly pronounced, certain letters or difficult combinations of letters being slurred, and some- times to such a degree that speech becomes unintelligible. Further, the lips and tongue are often tremulous : the lips tremble previous to the utterance of articulate sounds, and during the course of utterance ; and the tongue when it is protruded is m constant fibrillar movement. This tremulousness of the organs of speech adds to the difficulty of articulation, and unparts to it a peculiar tremulousness or uncertainty. A very similar defect of speech is apt to accompany locomotor ataxy, but m that case the tremulousness of the lips and tongue is absent, and (at least according to our observation) the muscular efforts to utter articulate sounds are umie- cessarily violent. 4. Vertigo is an early symptom in about three-fourths of the total number of cases. It is mostly gyratory, and generally comes on in par- oxysms of short duration, but is sometimes almost continuous. It often interferes seriously with locomotion. The presence of nystagmus is also a cause of vertiginous sensation, the oscillations which take place in the eyeballs being referred by the patient to the objects which are figured on his retinte. Vertigo is not common either in tabes or in paralysis agitans. 5. Paresis of the limbs, and more especially of the lower extremities, comes on at an early stage of the disease. It generally begms hi one leg. This feels weak and heavy, and drags in walkmg, but there are no move- 1036 DISEASES OP THE NEEVOUS SYSTEM. ments indicative of inco- ordination. Soon the other leg becomes affected; but even then (so different from what occurs in tabic patients) so long as he has sufficient strength to stand he is capable of maintainmg his equili- brium even when his eyes are shut. The weakness subsequently extends to the arms. This enfeeblement of the Hmbs gradually increases until it culminates in absolute motor paralysis ; the con^-ulsive oscillations of the earlier period undergoing proportionate diminution until they finally cease. The paralysis which commences in the lower limbs becomes as a rule com- plete in them while the arms are yet comparatively little involved. The patient not unfrequently complains of some degree of tinglmg and numb- ness, but there is rarely if ever any ob^dous impairment of cutaneous sensibility. Moreover, the muscular sense remains unaffected, so that he recognises exactly the position of objects and the amount of force necessary io accomplish various voluntary movements. There is no paralysis of the bladder or rectum ; the affected muscles retam their form, bulk, and tonicity ; and reflex and electrical contractility are for the most part mi- impaired ; but sometimes they are diminished. Frequently, on the other hand, and especially in those cases in which the affection of the lower extremities is of a paraplegic character, both ordinary reflex irritability and patellar reflex with other tendon reflexes of the lower extremities .are greatly exaggerated. The paretic condition of the limbs is hable to remissions. 6. Contraction of limbs. — At some period or other in the course of the paretic symptoms, the lower extremities, either spontaneously or under excitement, become suddenly stiffened in extension, and pressed one against the other. These attacks may last some hours, or even some days, and are at first separated from one another by comparatively long intervals. But by degrees the intervals shorten, and, at length ceasing, the rigidity of the muscles becomes permanent. At this period the thighs are ex- tended on the trunk, the legs on the thighs, the feet on the legs, and the members lie in close apposition, and cannot be separated. Sometimes the flexors overcome the extensors, and the limbs are flexed at all the joints. Occasionally, but at a later period, the arms become rigid and pressed against the sides of the body. At this time violent tremblings, lasting for a few minutes or even longer, are apt to arise in the stiffened Hmbs. These seem sometimes to come on spontaneously ; but they may be excited by exposure to cold, or by pricking, tickling, electricity, or other forms of irritation ; and they may extend fr'om the limb in which they were first induced to the opposite limb, and even cause general trembling of the body. They may be at once stopped, according to Brown- Sequard, by forcibly flexing the great toe. This stiffening of the limbs may be developed while their movements are still in some degree under the control of the patient, and does not therefore necessarily incapacitate him from walking with assistance. 7. Expression and mental condition. — During the course of the disease a marked change in the expression is apt to come on. The patient's glance is vague and uncertain, his lips pendulous and apart, his general aspect DISSEMINATED SCLEEOSIS. 1037 sad, weak, or fatuous. At the same time there is some change in his mental condition ; the memory fails, the conceptions are slow, and the intellectual and affective faculties generally impaired. He is stupidly indifferent to all that goes on about him, and is apt to laugh or cry without occasion. Sometimes he becomes maniacal or demented. One or more of the symptoms which have just been enumerated may fail in a greater or less degree in certain cases. But, on the other hand, additional phenomena are not unfrequently superadded. We have already suggested as possible complications certain phenomena which actually do not unfrequently present themselves in the course of the disease : — namely, inco-ordination of the movements of the lower extremities, and even of the hands and arms ; wasting of certain of the voluntary muscles ; and diffi- culties of deglutition, respiration, and circulation, indicative of mvolve- ment of the medulla oblongata. But, further, apoplectiform attacks are not unfrequent. These may come on without warning, or may be pre- ceded by rapid failure of the mental faculties. They recur as a rule several times at irregular and long intervals. They are often attended with convulsions, which are usually unilateral, or with hemiplegia, asso- ciated sometimes ^itli flaccidity, sometimes with rigidity of the paralysed muscles. In these attacks the pulse becomes greatly accelerated, and the temperature of the internal parts rises rapidly, so that probably in the course of the first few hours it momits to 102°, and within twenty-four hours to as much as 104°. If the case is about to prove fatal, the tem- perature may reach 108° or 109°. In these cases bed-sores also are apt to form with great rapidity upon the sacral region. These apoplecti- form attacks (which are not peculiar to disseminated sclerosis, but occur equally in cases of general paralysis and tumours of the brain, and in cases in which embolic softenings or apoplectic effusions have left chronic lesions behind themj are distinguishable from those due to hemorrhage by the fact of this sudden and rapid rise of temperature. Charcot divides the clinical history of cases of disseminated sclerosis into three periods. The first extends from the first appearance of symp- toms down to the supervention of rigidity of the limbs. The second includes all that time subsequent to the first appearance of rigidity during which the patient's symptoms undergo gradual aggravation, but during which the organic functions as yet maintain their integrity. The third commences with the failure of the nutritive functions. First period. — The mode of invasion is various. Sometimes the dis- ease commences with symptoms referrible to the brain, such as vertigo, or diplopia, soon followed by embarrassment of speech and nystagmus. More commonly the first symptoms are spinal, especially weakness of the lower extremities, which may contmue for months or even for years before it becomes complicated with other phenomena. This weakness is liable to remissions, and is usually miattended with pain, loss or impairment of sensation, or difficulty of micturition or defecation. It presents nothing distinctive. Barely the disease commences with symptoms like those which usher in locomotor ataxy. The early progress of the disease is 1038 DISEASES OF THE NEEVOUS SYSTEM. usually slow, but now and then the symptoms appear and follow one another with great rapidity. The contraction of the limbs, the supervention of which termmates this stage, does not usually show itself till after the lapse of two, four, or even six years. Second period. — This is usually of long duration. Dimng it all the characteristic symptoms of the disease are present and undergo gradual aggravation, until the patient becomes utterly helpless and confined to his chamber or his bed. The third jperiod comes on with progressive weakening of the organic functions. At the same time some of the symptoms proper to the disease come into special relief. Intelligence fails ; the patient becomes, perhaps, fatuous ; the sphincters cease to act, and the evacuations are all passed unconsciously ; the bladder inflames ; bed-sores form ; and appetite for food declines. At this time, also, various intercurrent maladies are apt to come on, such as pneumonia, dysentery or diarrhoea, or difficulty of deglu- tition with other signs of involvement of the medulla oblongata. The duration of the cerebro- spinal form of the disease usually varies between six and ten years ; but, if the cord only be affected, life may be prolonged for twenty years or more. The causes of death are numerous. Among the more important may be enumerated : apoplectic attacks, the consequences of affection of the medulla, pneumonia and other intercurrent disorders, inflammation of the bladder, bed-sores, and debility from failure of the nutritive powers. Treatment. — This appears always to have failed. Charcot observes that both strychnia and nitrate of silver have served for a time to check the trembling of the muscles, but have had no permanent good effect. Arsenic, belladonna, ergot of rye, and bromide of potassium have all been used at various times, but without obvious beneficial results. Little that is favourable can be said even of hydropathic treatment, or faradism, or the continuovTS current. VI. PAEALYSIS AGITANS. (Shaking Palsy.) Definition. — This is a disorder mainly of advanced life and of chronic progress, characterised especially by trembling of the limbs arising inde- pendently of voluntary movements, and for the most part sparing the head and neck. The patient in an advanced stage, without vertigo, is unable to maintain his equilibrium when walking. Causation. — The causes of paralysis agitans are various. It would seem to be not mifrequently brought on more or less suddenly by violent emotion, such as terror, grief, rage, and the like. It is often referred, and probably with truth, to long-continued exposure to cold and wet. And it is asserted that it is occasionally traceable to wounds or bruises involving peripheral nerves ; in favour of which statement is the fact that severe neuralgic pains referrible to such injuries have been succeeded by trembling of the parts involved, and subsequently by the general PAEALYSIS AGITANS. 1039 phenomena of paralysis agitans. There is little proof that the disease is hereditary. Neither does it belong to one sex more than the other. It is for the most part a malady of advanced life, usually first making its appearance after the age of forty. It may, however, occur at an earlier period, and cases are on record in which it commenced at twenty or even sixteen. Morbid anatomy. — Of the condition of the nervous system in this affection nothing definite is known. Previously to Charcot's investiga- tions paralysis agitans and disseminated sclerosis were usually confounded with one another, and the lesions of the latter disease were consequently regarded as having an important connection with the clinical phenomena of the malady now under consideration. In cases, however, of true paralysis agitans no constant lesions, sufficient at all events to explain the peculiarities of its symptoms, have yet been discovered. In some recent examinations of Charcot's there were found obliteration of the •central canal of the cord by increase of its epithelial lining, overgrowth of the nuclei which surround the ependyma, and marked pigmentation of the nerve-cells, chiefly those of Clarke's posterior vesicular columns. It must be observed, however, that post-mortem examinations in cases of this disease are almost necessarily made on persons far advanced in life, in whom, therefore, on other grounds, such changes as are here referred to are likely to be met with. Symptoms and progress. — The symptoms of paralysis agitans may come on gradually or suddenly. In the great majority of cases the onset -of the disease is insidious. The part attacked is the hand or foot, or the thumb. If the hand be affected, its different segments oscillate on one another in a manner which is almost distinctive. The thumb moves on the other fingers as in the act of twisting wool, rolling a pencil, or crumbling bread. If the affection involve also the rest of the upper extremity, these movements of the fingers are associated with similar rapid backward and forward movements of the hand as a whole on the forearm, and of the forearm on the upper arm. At this period of the ■disease the trembling is often transitory. It comes on occasionally only and maybe at long intervals. It comes on, moreover, when it is least expected — when the patient is at complete rest, mentally and bodily ; and it may be arrested by an effort of the will, and often ceases when he walks, or when he uses the affected limb for writing, lifting a weight, or other purposes. The trembling may be confined for an indefinite time to the part first attacked. But it generally spreads sooner or later : first, if a part only of a limb have been involved, to the rest of the limb, and subsequently, and often after longish intervals, to other limbs. It usually assumes in the first instance the hemiplegic form, affecting first the arm and then the leg of the same side, and extending later to the arm and leg of the opposite side. Sometimes it puts on the paraplegic character, spreading from one leg to the other, before the upper extremities get in- volved. It seldom extends from one arm to the other, leaving the leo-s unaffected, or from the arm of one side to the leg of the opposite side. 1040 DISEASES OF THE NEEVOUS SYSTEM. In some cases tremulousness is not the first symptom of which the patient complains. But its occurrence is preceded for a longer or shorter time either by a sense of profound fatigue, or by rheumatic or neuralgic pains referrible to the limb or part of a limb in which convulsive movements subsequently manifest themselves. In rare instances the affection comes on suddenly, with tremulousness either of a single limb or of all the limbs.. Under these circumstances it may subside at the end of a few days. But other similar attacks are liable to follow at decreasing intervals, until ulti- mately the disease becomes established. The duration of the initial stage- to which the above account refers varies from one to two or three years. "When paralysis agitans has attained its complete development the trembling not only involves several limbs, and probably all of them, but is also (at all events in severe cases) almost incessant. It is liable, however,, to remissions and exacerbations, the latter of which seem to be often in- duced by emotional disturbance or muscular exertion, yet not unfrequently come on without obvious cause. Natural sleep, or that induced by chloroform, is always attended with entire cessation from convulsive move- ments. It is at this period that the tremors put on their most distinctive- characters. They consist of involuntary rhythmical oscillations, which have little amplitude, follow one another rapidly, and present considerable- uniformity ; and which, when the hand is involved, give to its different segments the aspect of being collectively engaged in the performance of some delicate process or operation. The head and neck remain as a rule free from convulsion. So far indeed from being agitated, the muscles of the face are immovable, the look is fixed, and the features present a per- manent aspect of sadness or hebetude. The muscles of the jaw also generally are free from movement. Nevertheless, occasionally the head presents distinct rhythmical tremors, and the chin and lower lip even may be affected by independent tremors of their own, especially observable when the mouth is open. The tongue also, when protruded, not unfrequently presents well-marked tremulousness. Nystagmus, so common in dissemi- nated sclerosis, is absent here. There is no real failure of language, but speech is slow, hesitating, laborious, as though the enunciation of each syllable were attended with considerable effort. It may, however, become tremulous in consequence of the transmission of the tremulousness of the limbs to the head and neck. The voice, as Dr. Buzzard points out, is apt to assume a shrill piping character. Deglutition is performed without difficulty, but is perhaps somewhat slow ; and often in old cases saliva tends to accumulate in the mouth. Eespiration does not suffer. A striking phenomenon of the disease, to which Charcot has especially called attention, is rigidity of the muscles, which comes on for the most part late in the malady, though occasionally at its commencement. It affects the muscles of the extremities, trunk, and neck. The supervention of this rigidity is attended with cramps, followed by contraction, which is at first transitory, but after a time becomes persistent, though even then liable to exacerbations. The flexor muscles suffer in the chief degree. The rigidity and contraction becoming permanent give a peculiar aspect PAEALYSIS AGITANS. 1041 to the patient. The head is thrown strongly forwards and fixed in that position ; and the trunk, when the patient stands, is bent in the same direction. The elbows are separated a little from the trunk ; the forearms are slightly flexed on the upper arms ; and the hands, similarly flexed on the forearms, rest upon the waist. The hands, moreover, are more or less deformed ; usually the fingers are slightly flexed in mass at the metacarpo-phalangeal joints, with an inclination to the ulnar side of the arm, and with the thumb resting against the forefinger as in the ordinary position for writing ; but in some cases the fingers, though substantially occupying the same position, are flexed at the proximal and distal joints, while extended at the middle joints. The rigidity of the lower limbs is such as sometimes to give the appearance of paraplegia with contraction ; the feet are occasionally in the position of talipes equino-varus, and the toes bent into the form of a claw. The patient, however, retains the power of voluntary movement, and the muscles are never thrown into the tetanic spasms which are so common in many spinal diseases. The difficulty of movement which characterises patients suffering from shaking palsy is due no doubt in some degree to the muscular rigidity and contraction which have just been described. But it often manifests itself long before the rigidity has become particularly obvious. The same peculiarity attends speech. It would seem that unwonted efforts are needed for the transmission of the motor impulses ; and indeed the slightest movements are followed by extreme fatigue. This group of phenomena has been taken to imply the existence of true paralytic weak- ness. But it is not so, for on testing the strength of different limbs by the dynamometer, it has often been found, that (excepting in the case of patients m the last stage of the malady) muscular force is remarkably preserved. Sometimes, indeed, the muscles of the most tremulous and apparently weakest limb are really more powerful than those of its seem> ingly healthier fellow. The mode of walking in paralysis agitans is usually highly character- istic of the disease. The patient rises perhaps with difficulty from his seat, then steadies himself for a few seconds, and at length, with his head and trunk in advance, runs straight forwards in spite of himself with rapid steps. He appears to be losing his equilibrium, and rumiing forwards to re- gain it ; and not unfrequently he falls down. This difficulty of maintaining his balance in walking is not wholly due to the position which his body generally assumes, for it may occur while he is yet capable of retaining the erect posture ; and, further, in some cases the patient has a tendency to fall or run backwards even when his body is bent forwards. Neither is it connected with the presence of vertigo, for the patient does not as a rule suffer from this sensation. This latter tendency (or retropulsion as it is sometimes termed) may sometimes be evoked by slightly pulling the patient's dress from behind when he is standing or walking forwards. Various other symptoms besides those which have been enumerated complicate the course of shaking palsy. Patients usually complain of a sense of persistent tension or traction in the affected muscles, or of cramps ; 3x 1042 DISEASES OF THE NEEVOUS SYSTEM. they experience a feeling of prostration or utter fatigue which especially comes on after fits of tremblmg ; or they are the victims of an midefinable malaise or fidgetiness. They want incessantly to shift their position ; and if they be not assisted in their desire their sufferings become mien- durable. They suffer most in this respect at night and when in bed. Another cause of suffering is an habitual sensation of excessive heat, referred mamly to the epigastrium and back, but not limited to these situations. It varies in intensity, and is usually most severe after the occurrence of a paroxysm of trembling. It is not attended with any actual elevation of temperature. Cutaneous sensibility is in no degree affected. The patient retains his mental faculties and the power over his rectum and bladder. The final stage of the disease supervenes for the most part at the end of some years. It is indicated : by aggravation of the difficulty of move- ment, the patient being consequently compelled to keep his room or his bed; by failure of nutrition, in which the muscles chiefly suffer, occasion- ally becoming fatty ; by impairment of intelligence or of memory ; by general prostration; and by the formation of bed-sores. At this time the convulsive movements not unfrequently cease. Death results sometimes from gradual asthenia, more commonly from the supervention of some other disorder, especially pneumonia. The duration of the disease may extend to twenty or thirty years. Treatment. — All kinds of treatment have been employed, but for the most part with little success. Among the medicmes which have been recommended may be named iron, nitrate of silver, chloride of barium, arsenic, zmc, strychnia, ergot of rye, belladonna, opium, hyoscyamus, and Calabar bean. Of these iron is advocated by Elliotson, and has perhaps been instrumental in improving the general health of patients ; and strychnia has been lauded by Trousseau, but seems to have been found mjurious by Charcot. The only one of the sedative drugs which the latter authority thinks serviceable is hyoscyamus, and this effects no permanent improvement. Warm baths, cold baths, and shower baths are also soine- times of temporary service. Electricity has been largely employed, but the only form which seems to have been of real efficacy is the constant current. A few cases of recovery under its use have been recorded. It must not be forgotten, however, that cases which have not advanced beyond the early stage occasionally get well spontaneously. On the other hand, this fact justifies the hope of benefit from judicious treatment. Hygienic measures should never be neglected. VII. PSEUDO-HYPEETEOPHIC PAEALYSIS. Definition.— TuiB is a form of paralysis, first recognised and described by M. Duchenne, occurring in children, and attended with remarkable enlargement of some of the paralysed muscles. Causwtion.—li has hitherto been observed in childhood only, and PSEUDO-HYPEETEOPHIC PAEALYSIS. 1043 almost exclusively in boys. It has been met with also in several children of the same family. But beyond these facts nothing whatever is known in reference to its causation. Morbid anatomy. — The morbid process, so far as the muscles are con- cerned, appears to consist mainly in the gradual growth of connective tissue in the interstices between the ultimate fibres ; this becomes abundant and dense, and in some cases the seat also of the formation of fat. It is to this overgrowth that the apparent hypertrophy of the muscles is due. The muscular fibres appear to dwindle away mider the influence of the pressure to which they are subjected ; and, although retaining their transverse striation for a long period, at length undergo degenerative changes — the striaB becoming indistinct, or effaced, longitudinal markings perhaps un- usually apparent, and more or less abundant deposit of granular or fatty matter taking place. The condition of the muscles in the earliest stage of the disease has been less thoroughly investigated than their condition in the later periods. M. Duchenne believes that at that time there is an oedematous state of the tissue which itself causes a certain amount of increase of volume. Symptoms and progress. — The course of pseudo- hypertrophic paralysis has been divided by M. Duchenne into three periods. Of the first but httle is certainly known, for its symptoms are slight, and children are rarely at that time brought under medical treatment ; moreover the symptoms are in no degree distinctive of the disease, and are apt therefore to be misunderstood. The first symptoms appear to be due to gradual enfeeble- ment of the muscles of the lower extremities, and per- haps of those of the back. The child presents certain peculiarities of gait. He stands with his legs widely sepa- rated and his shoulders thrown back, probably beyond the buttocks, the concavity of the small of the back being correspondingly deepened ; he also walks with his legs apart, liftmg the knee of his advancing leg needlessly high, while the foot is extended, and the toes point downwards, and swaying his body from side to side m association with the peculiar position and movement of his lower extremities. This stage, according to M. Duchenne, usually varies in durations from a few months to a year. It may, however, be delayed, or it may so speedily merge in the second stage as to be unappreciable. The second stage is marked by the gradual extension of the disease and the enlargement of certain muscles. The paresis, which probably always commences symmetrically in the lower extremities, gradually mounts, involving successively the muscles of the back and of the trunk generally, the muscles of the arms, and in some cases those of the face — more especially the temporals and masseters. Possibly some fulness of the 3x2 Pig. 104. Portrait of a toy suffering from psendo-liypertrophic paralysis. 1044 DISEASES OF THE NEEVOUS SYSTEM. calves may already have been apparent in the first stage ; but now they augment rapidly and considerably in volume ; and by degrees various other groups of muscles become similarly affected. The degree of en- largement and its distribution differ in different cases. In some, only the calves become hypertrophied, while the muscles of the rest of the body either retain their normal bulk, or shrink ; m some the calves and buttocks are the chief seats of overgTowth ; in some the mcrease of bulk involves all the muscles of the lower extremities together with the posterior muscles of the spine ; in some again, the deltoids share in the widely diffused hypertrophy ; and occasionally all the muscles of the limbs and trunk become enormously increased in volume, and the child (though so feeble, perhaps, that he can scarcely move) acquires the appearance of an infant Hercules. This enlargement of the muscles, even if it be limited to the calves, is a very striking phenomenon ; especially when, as in these cases, it goes along with progressive loss of muscular power. During the progress of this stage the phenomena which have already been referred to as attending the acts of standing and walking become more pronoimced ; the legs are kept widely apart ; the shoulders are thrown far backwards ; and the peculiar swaying of the body from side to side, which iattends the efforts to raise and project the legs successively forwards, becomes con- siderably exaggerated. Moreover, the child has the greatest difficulty in rising from the ground on which he is sitting into the upright posture ; he gets on all-fours, then protrudes his buttocks like a dog in the act of stretching, and probably finds all his efforts fruitless unless he can manage to raise his head and shoulders hand over hand by means of a chair or bedstead. This stage attams its full development in a year or a year and a half, and may then continue with httle change for two or three years more. The third stage is characterised by extension of paralysis to the upper extremities, supposing these to have escaped hitherto ; by arrest of the progressive enlargement of the muscles ; and possibly even by their dimi- nution. The child grows more and more helpless ; the voluntary eleva- tion of the arms becomes difficult and at length impossible ; and he gradually loses all power in his lower extremities, and is hence con- demned to pass the rest of his existence on his chair or in bed. Since respiration, circulation, and digestion remain unaffected, Hfe may be sus- tained in this condition for a considerable period ; but sooner or later the vital powers of the patient become prostrated, and pneumonia or some other intercurrent affection carries him off. Death usually occurs during the period of adolescence. In order to complete the picture of the disease, two or three other facts in relation to these patients must be mentioned. No febrile symptoms manifest themselves at any period of the disease. The muscles in the early stage retain their electro-contractility almost unimpaired ; later, faradic contractihty undergoes diminution, while galvanic contractility either still remains unaffected or becomes increased. Tendon reflexes disappear in the second stage. It has been shown by Dr. Ord that the MOKBID GEOWTHS. 1045 temperature of the legs, in cases in wbicli the calves are hypertrophied, is three or four deg-rees higher than that of the thighs, a fact which he con- nects with the active growth of fibroid material taking place between the muscular fasciculi. It has often been observed that children afflicted with this disease are or become defective in their intelligence ; and that, if they be attacked before they have learned to speak, they are slow in learning to speak, and imperfect in their articulation. Lastly, there is no impair- ment of sensation, and no loss of control over the bladder or rectum. Pathology. — Notwithstanding the symmetrical character of pseudo- hypertrophic palsy, its tendency to become generalised, and its association with impaired intelligence, there is no sufficient reason to regard it as of nervous origm. For no lesions whatever have been detected in the nervous centres or m the nerves ; while the absence of rigidity, mco-ordination, and rapid wastmg, and the retention of sensation, control over the sphinc- ters and muscular contractihty, equally point to integrity of the spinal cord. On the other hand, in the muscles themselves progressive changes have been discovered which are ample to explain the main phenomena of the disease. Treatment. — According to M. Duchemie, pseudo-hypertrophic paralysis may sometimes be cured or arrested in its first stage by muscular faradism, aided by baths and kneading, or shampooing. When once, however, dis- tinct enlargement of muscles has taken place, no treatment that has yet been adopted avails to delay the fatal progress of the disease. Vm. MOEBID GEOWTHS. ANEUEYSMS. ENTOZOA. Various forms of adventitious growths affect the nervous centres or structm'es m relation with them. It is quite impossible, however, to distinguish them from one another during life by reference simply to the nervous symptoms which they induce. It is needless, therefore, for clinical purposes to discuss each variety separately ; and we shall content ourselves with first giving a brief sketch of some of the most striking pathological phenomena which the more important forms of growth present, and then discussmg the clmical history of such tumours as a whole. Morbid anatomy. — 1. Tubercle. Li a strictly scientific arrangement of disease we ought of course to include under this head miliary tubercles of the pia mater. We have considered these, however, elsewhere in asso- ciation with meningitis, which they generally induce, and mdependently of which they rarely if ever cause symptoms. The variety of tubercle which we have now specially to consider is that which originates within the nervous substance and forms tumours there, varymg from the size of (say) a phi's head to that of a fowl's egg. They are well-defined, rounded, or lobulated masses, opaque, of a yellowish or greenish tinge, with much of the consistence and aspect of cheese. They correspond pretty exactly to the description usually given of typical yellow or crude tubercle ; but 1046 DISEASES OF THE NEEVOUS SYSTEM. although they may disintegrate at points, they seldom, if ever, break down into cavities. They are made up of an aggregation of smaller masses, and differ in no important respect from the tubercular aggregates which in cases of tubercular meningitis are found along the vessels or in the depths of the sulci, and are the results of the coalescence of miliary tubercles. They may be solitary, or may exist ia large numbers, and they may occur in any part of the nervous centres, involving, however, by preference the grey matter, both of the brain and of the cord. No doubt, fL'om their large size, the cerebral lobes are pre-eminently liable to suffer. But tubercles have also a remarkable aptitude to form in the substance of the cerebellum ; and then (according to Andral) in the ascending order of frequency in the pons, medulla oblongata, spinal cord, peduncles of cerebrum and cere- bellum, optic thalami, and corpora striata. They are much more common in the upper part of the cord than in the lower part. Tubercular tumours of the brain appear to occur more frequently in boys than ghis, and are rarely met with either in adults or in children under two years of age. They occur most commonly between the ages of three and seven. Tuber- cle of the nervous centres is probably always associated with tubercle in other parts ; and, although ordinarily there is no coiniection between them, tubercular meningitis sometimes supervenes on the presence of tubercular masses of old date m the substance of the brain. 2. Syphilis. — The ordinary seat of intracranial syphihs is the dura mater. The disease may involve the outer aspect of that membrane, ia which case it is usually associated with disease of the bones of the skull , and affects the brain mainly by i)ressm-e. Or it may iavolve the substance of the membrane, or its inner aspect, leadhig to the development of hard, dense gummata, which may be solitary or multiple, localised or scattered over a considerable extent of surface, and may vary iadividually from the size of a hazel-nut downwards. These tend gradually to involve the con- tiguous structares. The visceral arachnoid becomes adherent to them, and not unfrequently similar growths then develop in the subarachnoid tissue and pia mater. Subsequently the subjacent brain suffers, becoming first indented, and then either softened or the seat of gummatous growths. The parts of the dura mater which are most commonly affected are those corresponding to the convexity of the hemispheres, and those in relation with the anterior and under surface of the brain, more especially in the neighbourhood of the sella turcica, whence the disease may sx^read to the surface of the petrous portions of the tem^^oral bones and to the tentorium cerebelli. Gummatous tumours originating in the pia mater or in the substance of the brain are much less common than the last, and as a rule are softer and more transparent and jelly-like ; they are usually of small size, but may attain the bulk of a hen's Qgg. Those which are developed primarily from the pia mater affect mainly the under aspect of the brain, more especially between the optic commissure in front and the pons behind, and in the course of the cerebellar peduncles. These, too, are the situations in which they attain their greatest bulk. Tumours of the substance of the brain arise MOEBID GEOWTHS. 1047 chiefly in the liemisplieres and the larger ganglionic masses, especially the optic thalami. After these parts they affect mainly the pons Varohi and the cerebral and cerebellar pedmicles. It is an important fact that s}'phihs, whether of the dura mater, pia mater, or nervous tissue, has a marked ten- dency to affect the parts at the base of the brain, and consequently to im- plicate the nerves there situated. Although there are good cHnical reasons for belie\ang that the cord and its membranes are not unfrequently the seat of this disease, there are but few published cases in which the diagTiosis has been verified by post-mortem exammation. It is not rare for the cerebral arteries in connection with syphilitic growths to become obstructed with thrombi ; but it also not unfrequently happens, in cases of secondary or tertiary syphilis, that, mdependently of the formation of gummata, the walls of certain of the arteries at the base of the brain become thickened, mdurated, and translucent, and the channels subsequently obstructed, partly from this thickening of the walls, partly from thrombosis. 3. With respect to other neoplastic formations, notwithstanding the im- portance and frequency of some of them, we need not, for many reasons, go into much detail. They are mainly the following : fibroma, psammoma, melanoma, and cholesteatoma (to which, on account of their rarity or of their insignificance in a chnical sense, we shall make no further reference), : and myxoma, ghoma, sarcoma, and cancer. a. Myxomatous tumours are not altogether unfrequent. They some- times origmate in the membranes of the brain or cord, sometimes in the cerebral substance. Their most common seat, however, is the cerebral hemispheres, where they form transparent gelatinous growths which often become cystic, and tend to acquire large dimensions. They may attain the size of a man's fist. h. Gliomatous tumours, also, are not unfrequent, and, indeed, are almost special to the nervous centres. They are greyish or pinkish m tint, translucent and highly vascular, infiltrate, as it were, the tissues in which they are found, and blend insensibly with them at their edges. Moreover, though varying somewhat in colour, transparency, and density, they have a considerable resemblance to the grey matter of the nervous centres. There are two forms of glioma, the one hard, the other soft. The former has a considerable anatomical resemblance to simply sclerosed tissue ; the latter, which is the more common, blends on the one hand with myxoma, on the other with small romid-celled sarcoma. Gliomatous tumours of minute size sometimes stud the ependyma of the ventricles. They are usually found, however, in the substance of the hemispheres, more especially in their posterior lobes and in their upper and lateral parts. But they may be met with elsewhere in the nervous centres, and even m the spinal cord. They are for the most part solitary, of slow growth, and apt to attain a large size, as that of the fist, or even of the foetal head. Owing to the great vascularity of the softer forms of tumour, they are liable to attacks of congestion, and to more or less abundant internal hemorrhage. 1048 DISEASES OF THE NEEVOUS SYSTEM. c. Sarcomatous tumours occur both in the dura mater of the brain and cord, and in the substance of these centres. They vary widely in their microscopical structure, and in their aspect and rapidity of growth. But they may be divided roughly into two forms — hard and soft. The former has some resemblance to fibroma, the latter is usually more or less translu- cent, white or grey, vascular, and, from its general resemblance to brain- substance, has been termed, in other organs than the brain, cerebriform. Sarcoma of the cerebral dura mater generally occurs at the base, in the neighbourhood of the sella turcica or petrous bones ; that of the theca verte- bralis affects no special seat. Sarcoma originating in the nervous tissue is usually of the soft form and solitary, and often grows to a large size. In the brain its usual seats are, not the hemispheres, but the optic thalami, corpora striata, corpora quadrigemina, pons, cerebral peduncles, and cere- bellum. It is only occasionally met with in the substance of the cord. Sar- coma originating in the nervous centres is seldom, if ever, malignant ; the solitary tumours, therefore, which have just been considered, are not asso- ciated with the presence of similar tumours in other part. On the other hand, it must not be forgotten that malignant sarcomas (melanotic and other) of other organs are apt to be attended with multiple secondary tumours in the substance of the brain. Primary sarcoma of the brain is mostly a disease of early childliood. d. Carcinoma of the nervous centres, and of the parts about them, was formerly believed to be of common occurrence ; but by all authors up to a recent date, sarcoma, glioma, and probably other forms of tumours, were all regarded as varieties of it. Carcinoma, in the restricted sense of the term, originates rarely if ever in the brain or cord, and not often m the bones and soft parts immediately surrounding them. Frequently, however, during the period of generalisation, it involves all these parts, and hence scirrhous, en- cephaloid, and melanotic tumours are not uncommon as secondary occur- rences in the brain or cord, and in the membranous and bony parietes of these organs. Cancerous tumours therefore are generally multiple, and seldom reach a large size. Carcinoma of the skull, vertebrae, or periosteum of these parts is apt in its progress to reach the surface of the brain or cord, and to involve these organs either by pressure or by direct extension ; it is especially apt, moreover, to constrict the bony channels by which the nerves escape, to implicate the nerves, and finally to destroy them. 4. JEntozoa.- — The only entozoa which infest the bram of man are the cysticercus cellulosse and the hydatid. a. Although a considerable number of cases of cysticerci of the nervous centres are on record, they are met with very rarely. The cysts, which are of the size of a pea or horse-bean, vary in number from one, or two to a hundred or more, and they occupy either the subarachnoid tissue, the choroid plexuses, or the nervous parenchyma. In the last case they are most common m the cerebral hemispheres ; but they have been met with in the cerebellum, medulla oblongata, and other parts. b. Hydatids of the brain are rare. They are generally solitary, but a couple or more have been found in the same case. They are almost always MOKBID GEOWTHS. 1049 "barren. Their size varies ; but they not unfrequently attain a couple of inches in diameter before they cause death, and may be much larger. They generally occur in the substance of the cerebral hemispheres, but have been found in the cerebellum, and elsewhere in the nervous paren- chyma. They also affect the meninges, and have been discovered in the lateral ventricles, and in the subarachnoid tissue of the cord. They seldom cause inflammatory changes in the surrounding parts, or other mischief than that arising from simple pressure. Neither do they appear ever to become the seat of suppuration. Hydatids of the brain are not unh-equently associated with hydatids of the liver or other organs. They are said to occur chiefly in persons between ten and twenty years of age. 5. Aneurysms of the arteries at the base of the brain. — We speak of these now only as tumours, and because from their bulk and situation they are exceedingly liable to interfere with the functions of important parts. They arise chiefly in the internal carotid arteries and their middle meningeal branches, and in the basilar ; but they may also be found in other vessels, such as the anterior and posterior cerebrals, the anterior and posterior communicating branches, and at the bifurcation of the basilar. An occasional seat is that portion of the internal carotid which lies within the cavernous sinus. They usually vary in size from that of a pea to that of a marble, but have been met with as large as a hen's egg. From their position they are liable to compress some of the nerves at the base of the brain, and to indent the surface of the brain itself. They usually occur in persons over forty, but they have been met with even at the age of puberty. Males are more liable to them than females. Sympt07ns and progress. — 1. Brain. The symptoms referrible to tumours involving the brain present the greatest variety — a statement which is not likely to be disputed when one takes into consideration the various circumstances under which tumours arise, the different proclivities of different tumours, and the wide range of functionally distinct parts of the surface or substance of the brain which they may implicate. It is impossible, indeed, to draw up any scheme of symptoms generally applic- able to cases of the kind ; and we propose, therefore, to consider seriatim the more important symptoms which the presence of cerebral tumours may induce. Vertigo is generally present at some period or other. Sometimes it is the first symptom of which the patient complains, and often it is the most constant. Headache is with rare exceptions a prominent symptom. In most instances it is, in association with vertigo and occasional vomiting, one of the earliest symptoms. It is often persistent, but liable to exacerba- tions ; sometimes only comes on at irregular intervals. It may be little complained of, or even wholly absent, but is usually severe, and often unbearable. It varies in character ; is sometimes a sense of constriction or pressure, sometimes a feeling as though the head would burst, some- times shooting, aching, or boring. It is referred to different parts in different cases ; sometimes affects the vertex, forehead, or occiput mainly ; 1050 DISEASES OF THE NEEVOUS SYSTEM. sometimes shoots through the ears or temples — in the latter case probablj involving the eyeballs, and associated with intolerance of light. The situation of the pam is no sure guide to the seat of disease ; nevertheless pain referred to the occiput and back of the neck is not unfrequently con- nected with disease in the posterior fossa of the skull ; and it is believed by some that percussion excites especial pain in that part of the skull beneath which a tumour lies. Vomiting is a common symptom of many cerebral diseases, and is often an early indication of the presence of cerebral tumours. Indeed, it is well known, especially in reference to the tubercular tumours of children, that unaccountable vomiting is often the first warning of the affection which is in progress. The sickness often comes on at h-regular intervals, without obvious cause, is not unfrequently attended with nausea or loss of appetite, and is generally associated with constipation. It may continue on and off during the whole of the patient's illness, but is mainly a symptom of the earlier stages. Sloioness of jnilse, with more or less irregularity, is of frequent occur- rence, more especially during the period of invasion ; subsequently also the same condition of pulse may prevail. But on the other hand it is then often of normal rate, or increased in frequency. Hemiplegia and HemiancBsthesia. — Hemiplegia is no doubt entirely absent in a large number of cases, and when present usually comes on insidiously durmg the later stages. There is, however, great variety as regards this symptom. In some instances almost the first indication of disease is an apoplectiform or epileptiform fit followed by hemiplegia. In some the attack of hemiplegia comes on suddenly in the course of other symptoms. And in either of these cases more or less complete recovery from the paralytic phenomena may ensue, to be followed by a relapse or by a series of recoveries and relapses. The hemiplegia generally follows the rule of ordinary hemiplegia in the fact that the arm is more affected than the leg, and the lower distribution of the seventh nerve than the other motor nerves of the face. But occasionally the paralysis is slight or limited, and reveals itself only in the face or arm. It may or may not be associated with niunbness, tingling, or anaesthesia of the paralysed parts, or with hypertesthesia, tenderness, or pain. Eigidity and con- traction of the affected limbs may supervene. Local iKtralyses are very common, sometimes in association with hemi- plegia, sometimes independently of it. They are generally due, not as hemiplegia or hemiansesthesia is, to disease involvuag the opposite corpus striatum, optic thalamus, or cerebral hemisphere, but to dnect implication by pressure or by involvement m the morbid process of the nuclei of origin of the affected nerves, or of the nerves themselves. If, therefore, they be due to the same mass that causes hemiplegia, they occur on the opposite side of the body to the hemiplegia. But more tumours than one are not unfrequently present, and tumours of the crura cerebri, pons, or medulla, or growths in the neighbourhood of the circle of WilHs, may readily involve directly several nerves of either side, even when causing at the same time MOEBID GKOWTHS. 1051 distinct liemiplegic plienomeua. In some cases there is paralysis of one or both external recti, leading to single or double internal squint ; in some, paralysis of the whole or a part of one of the third nerves, involving ptosis, with paralysis perhaps of the internal rectus and an outward squint ; in some the portio dura suffers, and Bell's paralysis is the consequence, pro- bably associated with paralysis of the corresponding arch of the fauces ; in some the h}^oglossal becomes implicated. It is important in reference to these local paralyses to bear in mmd that, contrary to what occurs in ordi- nary hemiplegia, the faradic contractihty of the affected muscles rapidly disappears, and acute wasting is apt to ensue. Implication of sensory nerves. — The fifth nerve occasionally suffers, either generally or in some of its branches ; in some instances intense burning or neuralgic pains arise, in some tinghng, numbness, or absolute anaesthesia. In the last case the surface of the eye, among other parts, becomes msensible, and consequently unconscious of h-ritation and Hable to inflame. Sometimes from impHcation of one or both olfactory nerves, or one or both gustatory nerves, the sense of smeU or taste is lost on one or both sides. As regards the ears, there is not unfrequently more or less deafness, "with buzzing, rushing, or singing noises ; and absolute deafness on one side may ensue. The most interesting and important comphcations, however, are those which involve the visual properties of the eye. We have alluded to the fact of the occasional occurrence of double vision and of intolerance of hght. But, besides these phenomena, we often meet with obscurity of vision, which may go on to complete blindness, in one or both eyes ; hemiopia, the field of vision being echpsed in the identical halves of both retinae ; the appearance of muscle ; and other visual derangements. The presence of cerebral tumours is, moreover, almost always associated with optic neuritis, which may after a time result in atrophy of the optic disc. The same rule appKes to paralyses of individual sensory nerves as to paralyses of individual motor nerves : they are usually due to du'ect impli- cation of the nerves or of thek nuclei, and are observed therefore on the same side of the face as the cerebral tumour which causes them. The question whether they be dependent on local causes or on disease of the nervous centres above their nuclei can, in doubtful cases, generally be determined by the fact that in the former case reflex phenomena cease, in the latter they may be readily excited (M. Jaccoud). If, for example, the disease causing blhidness be in the optic nerve, the pupil will be dilated, and will remain dilated when exposed to hght ; while, if it be situated above the corpora quadrigemina, the patient, though equally blind, will have free action of the pupil under the influence of the ordinary stimuh. These various local sensory and motor affections may come on at any period of the disease ; they are liable to appear and disappear before they become permanent ; and they tend to increase in degree and in number with the advance of the disease. Convulsions and spasms. — These, though not always present, constitute some of the most striking phenomena of cerebral tumours. They may be tonic or clonic, limited to the distribution of a single motor nerve, or impli- 1052 DISEASES OF THE NEEYOUS SYSTEM. eating a group of muscles, a limb, the liead and neck, or one side of tlie body. They may come on rarely and at distant intervals, or in frequent daily paroxysms, or may be almost continuous. And m either case they are apt to disappear wholly for a time, or to cease altogether. They are often distinctly epileptiform in character ; but, unhke true epilepsy, are often unattended with loss of consciousness ; or loss of consciousness comes on in the course of the attack instead of at the beginning. It is in cases of this kind, rather than in cases of simple paralysis, that, as Dr. Hughlings Jackson has shown, the seat and distribution of the peripheral phenomena point to the imphcation of definite cerebral arese. Intellectual and emotional disorders present great variety. In some cases one of the earliest indications of cerebral tumour is the occurrence of attacks, sometimes momentary, of incoherence, delirium, failure of speech, or loss of consciousness, associated or not with some partial convulsive movement or paralysis, or of attacks which may exactly simulate hysterical fits, or apoplectic seizures. On the other hand, these may be delayed until a late period of the disease, and may occur only as the immediate precursors -of death. Sometimes they come on at long and irregular intervals ; some- times they are very frequent, occurring many times a day, and even in long-continued sequences. In a large proportion of cases the patient suffers from gradually increasing failure of memory and hebetude ; he becomes aphasic or incoherent, or fatuous, and under such circumstances possibly loses, or fails to exert, control over his evacuations ; or he gets dehrious or maniacal ; and, associated with some of these mental derange- ments, we not unfr-equently find him either given to boisterous laughter, or low-sph'ited and apt to cry. Obstruction of venous sinuses. — Cerebral tumours occasionally cause obstruction either of the cavernous sinus or of the sinuses between this and the internal jugular vein ; and, as a consequence, the veins of the eyehds and of the correspondmg side of the forehead become more or less obviously distended. Similar dilatation of veins sometimes occurs in these cases, even when no obvious obstruction is present. Lastly, it may be pointed out that bed-sores are often developed sooner or later ; occasionally early, in connection with the occm-rence of irrita- tive or inflammatory processes ; more fr'equently late, when the patient is bedridden, paralysed, and demented. We repeat that the symptoms due to cerebral tumours display remark- able diversity ; nevertheless, careful attention to all the phenomena of the case will generally allow of a fairly accurate diagnosis being made. The onset of the disease may be gradual or sudden ; and the symptoms which attend it may be of the most varied kind. The subsequent progress of the case is equally tmcertain : sometimes the symptoms increase progressively and rapidly mitil death takes place ; sometimes, and mdeed in the great majority of cases, the patient is liable to remissions, or intervals of apparent restoration to health. But always such remissions become less and less marked with the advance of the disease, and at length continuous illness is established. The duration of Hfe fr'om the first development of MOKBID GEOWTHS. 1053 symptoms varies largely ; sometimes the patient sinks at the end of a few weeks ; sometimes death is delayed for several years. But the commence- ment of symptoms cannot always be determined — especially when the cerebral tumom's complicate other diseases. The causes of death are various. In some cases the patient sinks from innutrition and the for- mation of bed-sores; in some he is carried off in an attack of convulsions; in most, death is ushered in by coma. It is not always possible to distinguish the symptoms of cerebral tumours from those caused by other affections of the same parts. Nor is this surprising when we bear in mind : that many other diseases attack districts of the brain which tumours also affect, and that these as well as tumours are liable to be attended with swelling, mflammation, and soften- ing of surrounding parts, and to produce both general and local symptoms. Among the affections here referred to are apoplectic effusions, embolic softenings, abscesses of the brain, and chronic diseases of the dura mater. The determmation of the site of a tumour must rest upon a considera- tion of the various details of the paralytic and other phenomena which the patient presents ; and especially we may here be guided by our anatomical and physiological knowledge, and the ascertained facts of cerebral localisa- tion. In many cases we may come to a fairly accurate conclusion on these points. But it must not be forgotten that insuperable difficulties are often presented by the fact, either that tumours are multiple, or that they occupy some tract within the hemispheres, or at their surface, lesions of which are not necessarily attended with hemiplegia or any specific nerve- phenomena. Our recognition of the nature of a tumour must depend partly on our knowledge of the ch'cumstances under which different growths are apt to arise, partly on our knowledge of the parts of the brain which they are severally most prone to affect, and partly on the duration of the disease. Tubercle occurs chiefly in children ; the cerebral phenomena due to its presence are often remarkably slow in their evolution ; and the disease is generally associated with tubercular disease elsewhere. The cerebellum often suffers. Moreover, symptoms of tubercular meningitis are apt to supervene. Syphilitic tumours occur in adults who have usually either a distinct history of having contracted a chancre, or ob^dous traces of con- stitutional syphilis. They have, moreover, a remarkable tendency to affect the under part of the brain, and to involve the nerves there situated ; to cause cephalalgia, defect or loss of smell, hemiopia, paralysis of oculo- motor nerves, deafness, paralysis of the portio dura, bulbar palsy, and above all, perhaps, trigeminal neuralgia or paralysis, and, in connection with these, the nutritive lesions, which have already been described. Further, it must not be forgotten that syphilitic patients are (even in the secondary period) liable to have sudden thrombotic occlusion of cerebral arteries, and symptoms identical with those attendmg embolism. Secondary malignant growths would be suspected if the patient were suffering also from a mediastinal tumour, or some form of malignant disease involving the skin, bones, mamma, uterus, or other organs. The presence of 1054 DISEASES OF THE NEEVOUS SYSTEM. hydatids might be surmised if there were a total absence of all constitu- tional symptoms or taint and of all indications of local inflammation or softening, if moreover the patient were young, and especially if an hydatid tumour were detected in the liver or some other accessible organ. The symptoms due to aneurysms are generally much more obscure than from the position of the tumours might be supposed. Indeed, their presence is often not suspected until their rupture causes apoplectic phenomena and death. 2. Spinal cord. — Tumours involving the spinal cord, its membranes, or the nerves which spring from the cord, cause symptoms due partly to the compression or destruction which they effect upon the substance of the cord, partly to involvement of the nerves, partly to local conditions of inflammation and the like. a. Those which originate m the substance of the cord are attended with much the same symptoms as compression of the cord connected with vertebral caries. They cause more or less complete paraplegia in the parts which derive their innervation from the portion of cord below ; and the distribution and character of the paralysis will necessarily vary according as the tumour is situated higher or lower in the cord, and ac- cording to the tract which it primarily involves, and its horizontal ex- tension. There are some points, however, in regard to these tumours which it is well to remember : their presence is rarely, if ever, attended with either central or peripheral pam ; they originate mainly in the grey matter, and hence both sensation and motion are as a rule early affected ; they commonly involve one side of the cord, or some other limited portion of the cord, in the first instance, and hence induce irregular or cross para- lysis, so that during the earlier period of their development there is very likely to be motor paralysis on the side of the lesion, and anaesthesia on the opposite side ; and the progress of the paraplegic symptoms is liable to remarkable remissions. It may be added : that, owing to certain peculiarities as to their primary site, it is possible that their first symptoms may simulate those of locomotor ataxy or those due to lateral sclerosis ; that they tend ultimately to produce absolute paraplegia; and that, wheresoever originating, they are liable to be followed by ascending and descending degenerative changes, and by spasms and contractions of the affected muscles, with more or less rapid wasting of some of them. h. Tumours taking their origin in the meninges of the cord are apt at a very early period to implicate the sensory or motor roots of the nerves which are in relation with them. Hence arise (and sometimes before any paraplegic symptoms are developed) twitchings of certain muscles, followed by paresis, paralysis, and rapid wasting, and burning or quasi-neuralgic pains referred to the peripheral distribution of certain nerves (it may be in the first instance to a single spot) — pauis which are subject to great varia- tions, are often exceedingly intense, and are occasionally attended by cutaneous eruptions. The paraplegic symptoms of such cases are usually Tuidistinguishable from those accompanying vertebral caries, and are (at all events in the first instance) due to compression of the cord alone. It MOEBID GEOWTHS. 1055 is obvious that the distribution of the paralytic phenomena, and the order of their sequence, must depend largely on the position of the tumour and the direction in which pressure on the cord is applied. c. Tumours which are primarily developed in the tissues external to the membranes, more especially therefore aneurysms and malignant growths, usually involve the sensory and motor nerves in the neighbour- hood of their origin long before they involve the cord itself. These, far more even than tumours originating in the meninges, are thus apt to induce severe sensory and motor troubles of limited distribution. The pain which they provoke is burning, wrenching, or crushing, constant, but liable to frequent exacerbations, which are often quite beyond endur- ance, and during which the patient grinds his teeth, groans, or actually shrieks. It is often attended with hyperesthesia of the affected surfaces, and probably followed after a while by circumscribed anaesthesia, and by bullous or erythematous eruptions. The motor troubles are mainly paresis, and rapid wasting and contraction, of certain groups of muscles, "with abolition of the tendon reflexes. The above phenomena occur with special intensity in cases of carcinoma involving the bodies of the vertebra, owing partly to the tendency of the affected bodies to collapse, partly to the tendency to direct implication of the nerves. They are apt, moreover, not only to be exceedingly acute, but to have a comparatively wide dis- tribution. Symptoms due to compression of the cord come on (if they come on at all) at a later period. Assummgthe presence of a tumour, its nature can only be determined in certain rare cases. If tubercle be ascertained to exist in other organs, we have some reason to suspect that associated paraplegic symptoms (if not due to vertebral caries) are due to a tubercular mass in the substance of the cord. If paraplegic symptoms come on during the reign of consti- tutional syphilis, we may have in that association a clue to the nature of their cause. If they be preceded by agonising pain, such as has been above described, we have gromids to suspect the presence of some tumour involving the vertebrae ; and if they come on in the course of mammary or abdominal cancer, and especially if we find the spine presenting some localised obtuse bend in the neighbourhood of the point from which pain radiates and paraplegic symptoms begin, we have confirmatory evidence of the strongest kind. Treatment. — The treatment of tumours, whether of the brain or cord, must be for the most part simply palliative. We must endeavour to relieve sickness by some of the various methods which are usually had recourse to for that purpose ; to alleviate pain, either by the application of cooling lotions, ice, aconite, belladonna, or other sedatives, to the seat of pain, or by the internal exhibition of sedatives or narcotics, especially Indian hemp or opium ; to calm convulsions or mental excitement by suitable remedies ; to promote appetite ; to keep the bowels free, and the patient clean ; to prevent the formation of bed-sores ; and generally to relieve symptoms as they arise. There are certain cases, however, in which treatment is of real value, either in arresting the progress of a tumour or in causing its 1056 DISEASES OF THE NEEVOUS SYSTEM. removal. Tubercular masses are often of exceedingly slow growtii, and may, in fact, remain quiescent for months or years. If we have reason to suspect the existence of such tumours, it is of course important to have recourse to iron, cod-liver oil, and other drugs and modes of treatment serviceable in tuberculosis. Tumours of syphilitic origm may often, if attacked early, be so far uifluenced by treatment that the patient becomes practically restored to health ; and, even if complete restoration be not effected, great and permanent amendment may ensue. Iodide of potassium and mercury are the drugs specially indicated in these cases. IX. CEEEBEAL AND SPINAL HEMOEEHAGE. {Apoplexy.) Causation. — Excepting those forms of hemorrhage (which have little clinical interest) occurring in the course of purpura, small-pox, and other specific disorders, and due to an abnormal condition of the blood, all hemorrhages within the skull or spinal canal are consequent on the rup- ture of blood-vessels. Eupture due to violence, as for example to blows on the head or spine, or to fracture of these parts, may of course occur at any age. Idiopathic hemorrhage, however, although it occasionally arises below the age of twenty, becomes common only after forty ; from which time onwards its frequency in relation to the number of persons living at each successive lustrum rapidly increases. Old age, therefore, has great influence in its causation. But there are certain other conditions which are of more direct importance than even old age : these are the presence of chronic Bright's disease, and that of degenerative affections of the arterial system. It is more common in men than in women. Morbid anatomy. — Hemorrhage may occur either between the dura mater and the bone, within the cavity of the arachnoid, in the subarach- noid space, in the nervous substance, or, lastly, in the ventricles. 1. Meninges. — Effusion of blood between the cranium and dura mater is not imcommon m adults, especially as the consequence of blows on the head or fractures of the skull, and is usually immediately referrible to laceration of the middle meningeal artery. The extravasated blood separates the dura mater from the bone in some limited area, and forms a convex protuberance, which displaces the cerebral surface in relation with it. If the patient survive, the blood undergoes those changes which are common to all such extravasations, and, after a while, becomes absorbed. Hemorrhage external to the theca vertebralis is also mostly due to mechanical violence. It may, however, result from the rupture of an aortic aneurysm. Hemorrhagic accumulation in the cavity of the arachnoid is always referrible to escape of blood either from the dura mater or from the sub- arachnoid tissue. If the dura mater be its source, it may be either a direct consequence of mechanical violence, or derived from a patch of pachy- meningitis, with hemorrhage between its lamiaae. If the subarachnoid tissue be its source, it maybe due to anyone of the causes, to be presently CEEEBEAL AND SPINAL HEMOEEHAGE. 1057 discussed, of effusion of blood into that part. The arachnoidean cavity appears to be a frequent seat of effusion of blood in new-born children, probably from violence in the process of being born. Blood escaping into this cavity readily diffuses itself throughout its whole extent. Here, as in other cases, if the patient live, the blood for the most part undergoes gradual absorption ; occasionally, however, it gets converted after a time into a thin-walled cyst, full of Hmpid serous fluid, with little or no tendency to undergo further change. Hemorrhage into the subarachnoid tissue is frequently due to the rup- ture of an aneurysm of one of the arteries at the base of the brain. It is generally then very abundant, and distends primarily all the lax tissue which abounds in this locality ; encircling the vessels and nerves and con- cealing them from view, together with the surface of the crura cerebri, pons, and adjoining part of the medulla oblongata ; and extending thence into the laminae of the velum interpositum and the corresponduig dupKcatures comiected with the fourth ventricle, along the fissures of Sylvius, and, according to circumstances, over more or less of the surface of the cerebral hemispheres and lobes of the cerebellum. Sometimes the blood escapes by laceration from a hemorrhagic cavity in the substance of the bram either into the ventricles or on to the surface. This accident is not uncommon in cases of abundant extravasation into either the corpus striatum or the internal capsule ; it is apt also to occur when blood is effused into the pons or crus cerebri. Another cause of subarachnoid hemorrhage is punctiforrrt extravasation, or extravasation from injury to the surface of the bram, as- is caused by contre-coup. Subarachnoid hemorrhage is occasionally also observed in connection with the cord. 2. Brain. — Hemon:hage into the substance of the brain, especially if it- be into certain parts of the cortex, maybe due to laceration from violence ; occasionally it results from embolic softening ; but it is a far more common consequence of the rupture of diseased vessels, or of the mihary aneu- rysms which Charcot and Bouchard have shown to be frequently present, mainly in the optic thalami, corpora striata, cerebral convolutions and pia mater, in cases of cerebral hemorrhage and in old people. The vessels in which rupture takes place are usually the seat of either fatty degenera- tion, calcareous deposit, or chronic arteritis, with hyperplasia of the corpuscles of the outer wall and perivascular sheath. The mmute aneu- rysms which usually stud them vary, perhaps, from the size of a small pin's head downwards, but occasionally they are as large as a grain of wheat, or larger. The escape of blood in some instances, doubtless, is from a single aneurysm or vessel ; but much more frequently it takes place simultaneously from many lacerations occurring within a circum- scribed area. In some cases the hemorrhage is mainly from capillaries ; it is then apt to be spotty, and a careful examination will probably reveal in the centre of each spot a capillary vessel, with its lymphatic sheath dis- tended with blood — a capillary dissecting aneurysm, in fact. In other cases, and more especially in those in which the effusion is considerable, and in mass, the presence of miliary aneurysms, and even the ruptured aneurysms, 3 Y 1058 DISEASES OF THE NEEVOUS SYSTEM. can generally be easily recognised. But here also the rupture is first into the perivascular sheath, so that a dissecting aneurysm precedes the actual escape of blood into the surrounding nervous tissue. The quantity of blood which may be poured out into the brain-substance varies, roughly speak- ing, from a few minims to several ounces. , Groups of minute or capillary extravasations are occasionally alone present ; and generally, when a large hemorrhagic cavity exists, the tissues around are studded more or less abundantly -vv^th similar small hemorrhagic spots. The escaping blood necessarily tears up the brain- sub stance ; and thus, when its amount is large, a very irregular cavity is produced, the interior of which is occupied by blood mingled with the debris of the broken-down nervous tissue, while the margins are formed by the irregular interdigitation of the lacerated brain- substance and of the peripheral portions of the clot. The extravasated blood speedily coagulates, and, if the post-mortem examination be performed shortly after its effusion, will be found to pre- sent the ordinary characters of recent clot. If, however, the patient survive, changes gradually ensue in it and in the brain-substance around. The irregularities of the cavitj get smoothed away, its form becomes more rounded, and its margins denser and better defined. The clot contracts, grows drier and more friable, assumes a brownish or rusty tint, and gradually undergoes more or less complete absorption ; the final result bemg the formation either of a cicatrix (which can only happen if the effu- sion were very small), or, as far more commonly occiu's, of a cyst traversed by delicate processes of coimective tissue, occupied by a thin serous or milky fluid, and studded as to its parietes with pigmentary particles and crystals of haematoidine. The time reqmred for the total disappearance of a clot depends upon its size : a small one may be absorbed within a week or two, a large one within six weeks. The effects of clots on the surrounding brain-tissue must not be omitted. In the first place, they always cause displacement and pressure, and, if large, flattenmg of the convolutions, obliteration of the sulci, and displacement of subarachnoid fluid from a greater or less extent of the surface which overhes them. In the second place, the sm-roundhig tissue, for some Httle distance, always becomes yellow from imbibition of the colouring matter of the clot, oedematous, and softened. In the third place, they are very apt to set up inflammatory mischief in the parts which are in their immediate vicinity. And, lastly, at a later period, descend- ing atrophic changes, which have already been described, are liable to supervene. Hemorrhage may occur in any part of the brain ; but it takes place mainly in the corpus striatum, and is then generally due to laceration of some of the twigs of a particular branch of the internal carotid, to which Charcot calls special attention, and which we have aheady referred to. After the corpus striatum, the parts most likely to suffer are the optic thalamus and the white substance of the brain immediately external to these bodies. Hemorrhage occasionally also takes place in the crus cerebri, pons, or cerebellum, and, though much more rarely, in the CEEEBEAL AND SPINAL HEMOEKHAGE. 1059 medulla oblongata. Large effusions may implicate the optic thalamus and corpus striatum at the same time, and even destroy these bodies completely. More frequently, perhaps, they involve the corpus striatum and external capsule, and especially, as Dr. Broadbent asserts, the external capsule itself. They are very apt to rupture into the lateral ventricle, or, if they extend upward, through the cerebral parietes, into the subarachnoid tissue. In the latter case, more or less abundant effusion of blood takes place directly on to the surface of the brain ; in the former case, one or both lateral ventricles, or the whole system of ventricles, including the fom'th, becomes inmidated with blood and sometimes enormously dis- tended ; and, m consequence of laceration of the floor of the third ventricle, the effusion may extend over the base of the brain, along the fissures of Sylvius, and even diffuse itself generally throughout the subarachnoid tissue. Dr. Broadbent shows that laceration rarely takes place in the island of Eeil or in the course of the Sylvian fissure. Hemorrhage into the pons is not unfrequently continued thence by rupture either into the fourth ventricle or into the subarachnoid tissue below. It is not common for more than one extensive hemorrhage to take place in the brain at one time. But it is by no means uncommon to discover, after death, the re- mains of one or two or even more extravasations in addition to the recent one which has caused death. Hemorrhage into the ventricles is almost always secondary to hemor- rhage into the brain-substance or to rupture of aneurysms at the base. 3. Cord. — Effusion of blood into the substance of the cord is very rare. It depends no doubt in some cases on the laceration of diseased vessels ; but in the great majority of cases is probably (as Charcot suggests) secondary to inflammatory softening. It is said to be more common in youth and middle life, than in old age. Symptoms and iwogress. — 1. Brain. The term ' apoplexy ' is so com- monly used to imply cerebral hemorrhage, and is on the whole so mis- leading when thus used, even if its scope be limited by the prefix * sanguineous,' that it may be well to observe here that typical apoplexy (that condition in which the patient suddenly falls down in complete coma, with total abolition of motion and sensation and of sense, with full pulse, and slow stertorous breathing) is very seldom observed in cases of effusion of blood within the cavity of the cranium. Further, in most works, and especially in those of the older school, much stress is laid upon the type of body which is most liable to apoplexy, on the habits of life which predispose to it, and on the various symptoms which were supposed for weeks, months, or even years, to herald the approach of the actual seizure. It is certain, however, that although there was some amount of truth in the observations which led to these generalisations (a sort of rough connection between the collective antecedents above hinted at and the supervention at some period or other of death, ushered m with an apo- plectic seizure, or due to hemorrhagic effusion), there is little or no direct connection between them and the rupture of a blood-vessel in or on the brain. 3 y2 1060 DISEASES OF THE NEEVOUS SYSTEM. In a large number of cases of cerebral hemorrhage the attack comes on suddenly and unexpectedly, although it may be freely admitted that in no inconsiderable proijortion of them there has pre-existed, for a longer or shorter time, either chronic Bright's disease, or some distinct evidence that degenerative changes have been going on in the arterial system. In other cases there have been precursory symptoms, referrible to local dis- turbance of the cerebral circulation, caused either by partial obstruction of some artery or by the occurrence of capillary bleeding, or it may be by the actual formation of a hemorrhagic cavity which, either from its smallness or from its situation, is unattended with striking symptoms or permanent injury. Among the symptoms here adverted to may be enumerated headache, vertigo, confusion of thought, failure of memory, drowsiness, want of sleep, irritability of temper, and the like. Others are bleeding from the nose and retinal hemorrhage. But the most important are temporary paralytic phenomena, such as numbness or tingling on one side of the body or in the arm or leg, loss of power in the same parts, or in one half of the tongue or face, difficulty of articulation or deglutition, and double vision. It must not, however, be assumed that any of these symptoms necessarily points to the occurrence of hemorrhage. They may equally indicate the presence of a tumour, or other circumscribed lesion, or be connected with epilepsy or other purely functional affections of the brain. The symptoms which attend effusion of blood into the brain are very various both in kind and in severity. Sometimes the patient, while engaged in his ordinary avocations, suddenly finds that he has lost the use of his arm, and presently becomes hemiplegic ; sometimes while engaged in conversation, his articulation becomes thick, and he presently discovers that his mouth is drawn to one side, and that an arm and leg are limp and weak ; sometimes the first intimation that there is anything amiss is the accidental discovery by the patient that one side of his body is totally useless when he attempts to rise from his bed in the morning, or from a chair in which he has been sitting quietly or dozing. In other cases the appearance of paralysis is attended or preceded by sudden giddiness or confusion of thought, or by a pain or sensation in the head which makes the patient cry out. In some instances he talks and acts for a few seconds like a drunken man. In some he suddenly becomes faint and collapsed, with pallid face, cold damp skin, feeble irregular pulse, and vomiting — the affection is ushered in indeed with an attack of syncope, during which he may become insensible, but from which he often recovers, to lapse after a longer or shorter time, but gradually, into coma and paralysis. Here Dr. Broadbent believes that the hemorrhage begins in the external capsule. In exceptional cases only does the patient become at once comatose ; and then the attack is apt to commence with a convulsion. The last are for the most part cases in which blood is effused into the pons Varolii, or on to the surface of the brain from rupture of a large vessel or aneurysm. The further progress of the disease presents the greatest variety. In CEEEBEAL AND SPINAL HEMOEEHAGE. 1061 some instances the patient's symptoms stop short at that indistinctness of speech or that unilateral paresis with which he was seized ; and he remains in this condition for a few hom's, a few days, or a few weeks. In some instances these primary symptoms become aggravated up to the super- vention of absolute hemiplegia, with or without anaesthesia ; in which condition again the patient may remain for a variable time, sometimes recovering completely sooner or later, sometimes undergoing imperfect recovery, and remaining more or less feeble on the affected side, or in some degree inarticulate, for the remainder of his life. Not unfrequently headache, vertigo, impairment of intellect, or alteration of temper, not only is present during the continuance of the paralysis, but persists even after its amelioration or disappearance. Occasionally there is temporary deviation of the eyes, and even of the head and neck, towards the un- paralysed side. In many instances coma presently succeeds the symptoms of invasion. This may come on in the course of a few minutes, a few hours, or a few days, even in those cases in which the initial symptoms are of the mildest character. It generally supervenes before long in those whose first symptoms are those of shock : the patient recovers from his faint- ness, perhaps to find himself hemiplegic, not improbably to feel fairly well ; but by degrees drowsiness and stupor creep on and gradually deepen into profound coma. But, however the coma may come on, whether it be gradual in its in- vasion, whether it supervene in the course of symptoms already pointing to cerebral hemorrhage, or whether it become developed in all its intensity within a few minutes or a quarter of an hour of the first signs of illness, its symptoms do not on that account present any differences. The patient lies on his back insensible, with face flushed, skin moist, pulse slow, per- haps irregular, but full and hard, respirations slow and attended with stertor or snoring as he draws his breath in, and puffing of the cheeks as he exhales, and depression of temperature, which may continue for some hours. In the early condition of this, which is sometimes termed the apoplectic state, the patient is still perhaps capable of being roused ; when spoken to loudly he makes some incoherent response ; when pinched or pushed he indicates by some movement or gesture that he is not altogether without feeling. But soon he becomes utterly unconscious. In this con- dition many various symptoms cluster, as it were, around his unconscious- ness. In some cases he lies on his back quietly as if asleep, his expression placid, his limbs apparently miaffected assuming a natural attitude. But usually there is obvious muscular aflection : the limbs of one or both sides are flaccid — when raised falling back helplessly on the bed ; or they are rigid, and ofier more or less resistance to the attempts to move them ; or convulsive twitches or more powerful spasmodic movements occur from time to time either generally or on one side of the body. There may, in fact, be simply that failure of the muscles to move which stupor alone involves, or there may be general or unilateral paralysis with or without flaccidity, rigidity, or convulsive movements. In the face the same con- ditions may be observed ; sometimes the muscles are in repose ; sometimes 1062 DISEASES OF THE NEEVOUS SYSTEM. more or less obvious facial palsy is observed upon one side, sometimes twitching of the muscles. The eyelids are generally shut. The condition of the eyes varies ; frequently the pupils are dilated, especially towards the fatal close ; sometimes, and more especially in cases of hemorrhage into the pons, they are contracted ; often they are natiu'al ; they are some- times irregular, sometimes insensible to Hght. The last are symptoms of considerable significance. In the early stage the patient, though unable to masticate, is still able to swallow fluid or food placed in the back of his mouth ; when, however, the case is going on unfavourably, the power of deglutition fails absolutely. Respiration, as has been stated, is usually slow, but it is often irregular, and is Hable to cease completely for some seconds. Sometimes the patient breathes as quietly as a child. But when a fatal termination is impending, stertor (if it were not before present) comes on ; mucus and other fluids accumulate at the back of the throat and in the air-passages ; the breathing becomes attended with loud rattling sounds, and the respu-atory movements are often accelerated.^ The character of the pulse varies : at first probably it is slow, full, and hard, but it may be of natural rate, and present no deviation whatever from the normal ; but with the continuance of coma it is apt to increase in frequency, and may rise to 120, 140, or 160 in the minute. The face usually is flushed, the skin moist ; and towards the end of life profuse sweats generally if not always break out. The patient has retention of urine, and loss of con- trol over his ahine evacuations. Inability to swallow, accumulation of fluids in the fauces and air-passages, indifference of the pupils to light, failure of the eyehds to close when touched, extreme rapidity of pulse, and the occurrence of profuse perspirations are phenomena of the gravest omen. In some cases the stupor of coma passes in the com'se of a few minutes, a few hours, or a few days, into that of death. But in a considerable number of cases the patient, after a longer or shorter time, slowly emerges from it, regains his consciousness more or less completely, and probably is found to be paralysed on one side, and to present a greater or less number of other indications of cerebral mischief. From this point, sometimes, recovery is rapid and thorough ; sometimes hemiplegia continues for a considerable period, or, after more or less improvement, for life ; some- times he has hemianfesthesia as well as paralysis ; sometimes his speech remams indistinct or his voice feeble ; sometimes he has aphasia ; some- ' Dr. Bowles, who has given much attention to the subject of the stertor which attends apoplectic and other forms of coma, describes a nasal stertor due to iDaresis of the muscles of the external nares, a palatine stertor characterised by vibration of the soft palate, a pharyngeal stertor resulting from narrowing of the interval between the back of the tongue and posterior wall of the pharynx, and a stertor referrible to the larynx and air-passages below the larynx ; and he di-aws attention to the dangers which attend some of the forms of stertor, and points out how they are to be counter- acted. The most dangerous of them are pharyngeal stertor, which may generally be relieved by shifting the patient's position, and especially by laying him on his side ; and stertor referrible to the air-passages, attended with accumulation of mucus therein, which also may often be benefited by change of posture. CEEEBEAL AND SPINAL HEMOKEHAGE. 1063 times he complains of headache or giddiness ; sometimes he has loss of memory, failure of intelligence, or emotional perversion ; or he may be stupid or demented, and then not unfrequently fails to control his bowels or his bladder. It is obvious that the various conditions here described are in the main identical with those which are apt to follow hemiplegia coming on without msensibility ; aid that, in fact, but for the cncum- stances that the supervention of coma on the whole implies either a large effusion of blood, or effusion into some vital part, and that coma itself brings with it special dangers, there is no essential difference as regards their subsequent progress between those cases of cerebral hemorrhage which are attended with coma and those which are and have been free from coma. The character of the symptoms will be determined largely by the seat of lesion, by the size of the clot, and by the rapidity with which the blood is effused. When hemorrhage occurs in the corpus striatum, or in the white matter or convolutions of the brain in relation with the motor tract, or in the crus cerebri, motor hemiplegia will almost necessarily follow, and will probably be more complete according as the amount of brain-substance de- stroyed or compressed is larger. If, however, the effusion take place in the white matter of the hemisphere, paralysis is more likely to be absent than if it occur lower down ; if it take place in the crus, it is probable that the third or fourth or some other of the nerves on the same side as the clot will also be implicated. Aphasia generally attends right-sided paralysis. Hemiantesthesia alone is rarely if ever present ; but it is not unfrequently associated with hemiplegia, especially perhaps with hemiplegia of the left side; in which case the hemorrhage probably involves the optic thalamus, internal capsule, or crus. We have pre'ST.ously drawn attention to the fact that sudden but temporary loss of sight on the anaesthetic side is occasionally observed. If blood primarily effused into the corpus striatum or other neigh- bouring paints escape with sudden violence into the ventricular cavities and flood them, the pressure which is at once exerted on a large number of ganglia essential to life induces sudden profound coma with general paralysis and flaccidity of the limbs. Also, if the surface of the brain be suddenly deluged with blood, profomid coma almost immediately ensues, which is often at- tended with convulsions, but by no means necessarily with paralysis, and in some cases, especially if it be at the base, with inequality of pupils. When hemorrhage occurs in the pons, there are often convulsions, and usually sudden profoimd coma and general paralysis, attended at the commence- ment with contraction of pupils ; and the case is rapidly fatal. Sometimes, however, the effusion here is small in amount and misymmetrical in position, in which case the paralytic symptoms will probably be irregu- larly distributed ; there will perhaps be hemiplegia, with implication of various sensory and motor nerves, situated either on the side opposite to the hemiplegia, or irregularity on both sides ; there is apt also to be serious interference with the muscles of speech and deglutition — the usual symptoms, in fact, of bulbar paralysis. Hemorrhage into the cerebellum is often attended with severe occipital pain, vomitmg, and 1064 DISEASES OF THE NEEVOUS SYSTEM. especially vertigo. Paralysis is for the most part absent, but the patient, if able to walk, staggers like a tipsy man. We have already pointed out that a patient who has had cerebral hemor- rhage, whether he has had coma from which he has emerged, or whether he has had a simple attack of paralysis and has attained that stage at which all present fear of coma has passed away, may rapidly or slowly recover from all his symptoms, may recover imperfectly, or may remain without any improve- ment whatever. We have not, however, referred to the important fact that various complications may arise in the progress of the case. The principal of these may be briefly considered, a. The presence of a clot, and of the collateral oedema which always attends its presence, is very apt to induce at any time during the first few weeks after its formation some inflamma- tion in the surrounding brain-tissue — an occurrence which is often indi- cated by elevation of temperature, rapidity of pulse, return of paralysis, drowsiness, and impairment or loss of control over the emunctories, and may lead to coma and death, h. Bed-sores are apt to form. In some in- stances these come on when the patient is bedridden, or has continued for some length of time in a fatuous or semi-comatose condition, just as they may come on in any other persons who are confined to bed and of uncleanly habits. But they are also apt to appear, and then mainly upon the buttock of the paralysed side, from the second to the fourth day after the attack, apparently in consequence of some direct influence transmitted from the seat of lesion in the brain. The formation of these early bed-sores is always a bad sign, and almost without exception foretells an early fatal issue, c. In- flammation of internal organs, such as pneumonia, dysenteric ulceration, and the like, occasionally supervenes, cl. Not unfrequently, after the second or third week, or later, if the Hmbs remam paralysed, rigidity and contrac- tion gradually ensue, associated after a while, in some cases, with wasting of the muscles. This rigidity is not to be confounded with the temporary irritative rigidity sometimes observed at the commencement of paralysis, but is the consequence of secondary degenerative changes m the course of the lateral columns of the spinal cord, and is permanent. It is observed by Trousseau that m those rare cases of hemiplegia in which the arm recovers more rapidly than the leg, the prospects of the patient are very gloomy ; that the leg becomes stiff and painful ; that imbecility comes on, and the patient usually dies within the year. Whatever the explanation of the imbecility in these cases may be, it seems pretty certain that the arrested recovery of the leg is sometimes due to the fact that degenerative disease has already conimenced in the cord. e. All patients who have had one attack of cerebral hemorrhage are specially likely to have subsequent at- tacks ; and sometimes two or three of these occur at irregular intervals, previous to the fatal issue of the case, adding complexity to the patient's symptoms. . Lastly, partly from the effect of the primary lesion, partly from the associated diseased state of arteries, partly from pressure, oedema, inflammation, or degeneration of surroundmg parts, many additional symptoms are hable to come on — among others athetosis, choreic move- ments, epileptiform attacks, delirium, mania, and dementia. CEEEBEAL AND SPINAL HEMOEEHAGE. 1065 2. Cord. — Hemorrhage into the arachnoid cavity or subarachnoid tissue or into the substance of the cord is so rare, except as a consequence of injury or pre-existing disease which has ah-eady caused serious symptoms referrible to the cord, that it is scarcely necessary to discuss the symptomatology of these lesions. It is sufficient to say that hemorrhage around the cord will naturally cause the symptoms of pressure — namely, more or less loss of voluntary motor power, associated with little or no impairment of sensa- tion ; and that the effects will vary according to the seat of the effusion, its extent, and the degree of pressure exerted by it ; and that hemorrhage into the substance of the cord wiU be attended with precisely those symp- toms which occur in inflammatory softening involving the whole thick- ness of the cord, the main distinction being that hemorrhagic paraplegia is more sudden in its onset, and more immediately complete, than the para- plegia of inflammation. Its occurrence is often attended with severe pain. Treatment. — When a patient is seized with sudden paralytic symptoms due, as we suppose, to hemorrhage, there is little to be done save to keep him perfectly quiet, mentally and bodily, to make him lie down with his head somewhat elevated, in a room of equable but not elevated temperature, and to feed him sparingly with milk and farinaceous food. There is no harm, probably, even if there is no good, in giving him coohng drinks, and in administermg medicines which are supposed to check hemorrhage. A powerful purgative is often given, but it is questionable whether the strain- ing which attends its action is not more injurious to the patient than the retention of faecal matter in the bowels. If coma have come on, again, there is little to be done beyond leaving the patient at rest. Some bleed, but bleeding will not benefit those who have large effusions of blood in the pons or ventricles, or on the surface ; and those who have large hemorrhages else- where for the most part recover from their coma without any such assistance. Further, bleeding is probably quite incompetent to arrest cerebral hemor- rhage. Nevertheless, we are inclined to believe that the guarded removal of blood in these cases may sometimes prove beneficial, by diminishing pressure within the skuU, or, as Sir Thomas Watson suggests, by reHeving the congestion of the right side of the heart, which is often manifested by engorgement of the veins of the head and neck, and lividity of surface. At all events a single bleeding will probably have no injurious eft'ect whatever. It is customary to give powerful purgatives in these cases, such as a couple of drops of croton oil alone, or mixed with a little castor oil ; and on the whole the practice appears to be good ; purgation tends to derive (as the expression is) from the head ; and in cases of profound coma does not induce that powerful straining which is so great an objection to its employment when the patient is sensible. Other measures which may be adopted are the application of cold in the form of evaporatmg lotions or ice to the shaven head, or of counter-irritants, such as mustard plaisters, to the head, back of neck, and legs. During the further progress of paralysis following hemor- rhage, the chief things to do are still to keep the patient quiet, and fi-ee from either mental or bodily excitement, to regulate his hours and employments, to keep his bowels regular, if necessary by the use of opening medicines, to 1066 DISEASES OF THE NEEVOUS SYSTEM. relieve all discomforts and secondary affections under which he may happen to labour, to counteract, as far as possible, the effects of any renal or other organic disease of which he is the subject, and to attend very carefully to his diet. As a rule, all alcoholic beverages should be interdicted, or, if circumstances render their use necessary, should be allowed only in small quantities, and in a dilute form. The patient should be well nourished, but the amount of food given him should not exceed what is essential for his well-being. The food, moreover, should be wholesome and readily digestible. It is often recommended that the patient should be restricted to a vegetable diet and milk — a diet which is doubtless very appropriate if there be any chronic renal affection. But if his abdominal viscera be healthy, we do not see how such diet should have any superiority over a diet containing a fair proportion of animal food. As regards the affected limbs, friction and faradism are sometimes efficacious, when the acute symptoms have passed away, in promoting the restoration of the impaired motor powers ; and when late contraction is occurring it may be relieved or prevented by galvanising the contracting muscles and faradising their opponents. X. OBSTEUCTION OP CEEEBEAL AETEEIES. {Thrombosis. Embolism. Softening.) Causation and morbid anatomy. — We have drawn attention to the facts : that the group of arteries supplying the brain, although anastomos- ing freely in the circle of Willis, have no further comminiication with one another excepting by means of the capillary vessels situated at the peri- phery of their several areas of distribution ; that the same arrangement holds good with respect to every branch of these arteries, down to their smallest twigs ; and that hence any obstruction, however produced, whether in a primary or in a subordinate branch, no matter how small, puts a stop to the circulation of the blood in the district to which the obstructed vessel leads, and involves its degeneration and death. The same rule obviously does not apply with equal force when obstruction takes place in the basilar or either internal carotid artery below the anas- tomosis, since by means of that anastomosis blood for the most part finds its way readily from the pervious trmiks to the branches of the obstructed vessel. Nevertheless, such obstruction, or even obstruction of the common or internal carotid in the neck, occasionally influences seriously the nutrition of that portion of the brain with which the obstructed vessel is in relation. The arteries of the cord, on the other hand, are small, are derived or reinforced from many sources, and rarely, so far as we know, become obstructed, or if obstructed, instrumental in the production of degenerative changes in the substance of the cord. The causes of obstruction are various, a. In many cases the arteries at the base of the brain in persons advanced in life get rigid, thick-walled, and the seat of atheromatous or calcareous degeneration ; and as a conse- quence of the advance of these processes it sometimes happens that one OBSTEUCTION OF CEEEBEAL AETEEIES. 1067 of the diseased vessels becomes reduced in calibre or altogether impervious. &. In a considerable number of cases, again, one of the arteries at the base of the brain or one of the primary branches becomes obstructed in a greater or lesser portion of its length by a clot or thrombus, which fills it, adheres to its surface, and after a while undergoes degenerative changes, in which also the vascular parietes probably share. The causes of such thrombosis are not always obvious. Occasionally it is due to the fact that the affected vessel leads to some diseased tract in which the smaller vessels are involved and obstructed ; and the coagulation of blood in it is therefore secondary. Sometimes, possibly, it is due to the special ten- dency which the blood appears to have in some dyscrasic conditions to undergo spontaneous coagulation. Sometimes it is determined by dis- ease of the arterial walls, such as roughening from atheromatous or other chronic processes, inflammatory thickenmg, or syphilitic growth, c. But perhaps the most interesting cause of obstruction is the detachment of granulations from diseased valves on the left side of the heart, their con- veyance to the arteries of the brain, and their impaction, usually at the pomt of bifurcation of an artery, or at some other spot where the vessel is too small to allow of their further transmission. The embolus usually forms the nucleus for the development of a thrombus extending to a greater or less distance in either direction along the channel of the obstructed artery. Obstruction of the arteries at the base from atheromatous or earthy degeneration is observed mainly in persons advanced in life, and especially in those suffering from arterial disease elsewhere, or who are the subjects of chronic renal disease, or have led laborious or debauched lives. The obstruction usually occurs in one of the arteries forming the circle of Willis, or in one of the trunk- vessels below this anastomosis. Thrombosis is not uncommon in the vertebrals, the basilar, the in- ternal carotids, and their several primary branches ; and indeed not very mifrequently involves two or three of these vessels, one after the other, at irregular intervals. Obstruction from thrombosis connected with arterial degeneration is an affection of advanced life ; as a consequence of syphilis, it is mainly a phenomenon of early adult life and middle age. Embolism is in the great majority of cases the consequence of rheu- matic inflammation of the valves of the heart ; ' it may, however, follow degenerative lesions of the same parts and the detachment of masses of calcareous or atheromatous matter, or of fibrinous tubercles which have become developed on the degenerate surfaces. Embolism may occur at almost any period of life, yet is certainly most common from puberty up to the age of forty or fifty. It almost always affects the middle cerebral ' It is a curious fact that, within a few weeks of one another, two cases occurred to Dr. T. Barlow, and one to ourselves, in which children convalescent from scarlatinal nephritis with dropsy, who had not had rheumatism and had no signs of valve-disease, were attacked with hemiplegia, in one case associated with blindness of the eye on the non-paralysed side. There is little doubt that these were cases of embolism dependent on detachment of vegetations from the auricular aspect of the mitral valve. 1068 DISEASES OF THE NEEVOUS SYSTEM. artery in some part of its course, and usually the middle cerebral of the left side. The changes in the brain- substance which result fi-om arterial ob- struction are (excepting when this takes place below or in the circle of Willis) almost accurately limited to the district which the obstructed vessel suppKes. The affected region becomes opaque white, yellowish, or greenish, mottled with light red patches, or even minute extravasations of blood, and softened — often so soft as to break down readily into a pulp under the finger, or to admit of being washed away under the impulse of a stream of water. The microscopic characters which it presents depend on the appearance of granule-cells in greater or less abundance, on the degeneration of the nervous elements, more especially the white substance of Schwann, and its conversion into masses of refractive globules, and on the accumulation in the walls of the vessels and perivascular sheaths of numerous fatty granules. Patches of softening from obstruction, especially if of small size, may, like apoplectic clots, become absorbed, and leave behmd them a mere scar or a cavity containing serous or milky fluid. If of large size, they may undergo more or less diminution of bulk, and involve obvious shrinking of the mass of brain in which they are contained. Not unfrequently inflammatory changes go on in the brain-substance around them. Occasionally abundant hemorrhage, Hke that of ordinary sanguineous apoplexy, results from the softening consequent on arterial obstruction. Sympto7ns and progress. — The symptoms due to obstruction of one of the cerebral arteries so closely resemble those caused by hemorrhage that, if there be no appeal to other facts than those afforded by the cerebral symptoms which are present, it is utterly impossible in the great majority of cases to distinguish the one affection from the other. It is stated by Eecamier and by Todd, and their views are supported by Trousseau and many others, that whenever hemiplegia, complete and absolute, occurs suddenly without loss of consciousness, it is due to softening and not to hemorrhage. And in reference to this statement, we may point out that the mere sudden loss of function in a limited portion of brain-tissue (as occurs in softening) is likely to be attended with less general disturbance of the cerebral fmictions than the extravasation of blood into a similarly Kmited space, which not only destroys the tissues which it uifiltrates, but, fr'om its bulk, causes more or less serious pressure on surrounding parts. The rule may doubtless, within certain limits, be accepted as the expres- sion of a fact ; but it is a rule to which there are fr'equent exceptions ; for in many cases of softening from arterial obstruction, the hemiplegia, if sudden, is not complete, and in some the attack is ushered in by loss of consciousness ; while on the other hand, hemorrhagic hemiplegia, as we know, is in a large number of cases unattended with insensibility. Various prodromal symptoms of cerebral softening are often enimie- rated ; but it is clear that in most of the varieties of softening now under consideration no sj-mptoms of the kind are likely to be met with. They can attend neither embolism nor thrombosis. And any that may be OBSTEUCTION OF CEEEBEAL AETEKIES. 1069 referred to disease of the arterial walls are equally indicative of future hemorrhagic effusion. As a matter of fact the symptoms due to arterial obstruction are always sudden in their onset, and for the most part occur unexpectedly at a time when perhaps the patient seems to be in perfect health. The seizure comes on in various ways : sometimes the patient, who is walking or making some exertion, or perhaps even sitthig down quietly, is attacked with sudden vertigo and confusion of thought, and tumbles or throws himself forward on the ground ; sometimes he is seized with sudden pain in the head of such severity that he cries out ; sometimes he suddenly becomes faint, and occasionally this faintness is attended with a slight convulsion. But, however various these initial symptoms, it is almost always discovered so soon as the momentary attack has passed that hemiplegia is present. It is almost needless to say that the character of the symptoms which present themselves and their severity must depend largely upon the size of the vessel obstructed and the part to which it is distributed — m other words (as also in hemorrhage), on the amount of brain-substance which becomes incapacitated, and on its situation. Thus affections of the posterior cerebral lobes and of the cerebellum are always more obscure in their symptoms than those which involve the anterior parts of the brain, and more especially than those which involve its base. And hence obstructions arising in the course of the posterior cerebral and cerebellar arteries lead to less definite, if not less serious, con- sequences than obstructions in the course of the anterior and middle cerebrals. It is very important, however, for the purposes of diagnosis to refer to the exact distribution of the various intra-cranial vessels which has been given on a former page. And especially is it important to bear in mmd : that it is from the basilar artery that the pons mainly receives its vascular supply ; that the posterior cerebral artery is distributed not only to the posterior part of the cerebrum, but especially to the posterior part of the optic thalamus, and to the corpora geniculata and quadrige- mina ; and that in the great majority of cases, and certamly in almost all cases of embolism, the obstruction occurs in the middle cerebral artery or in one of its branches, and that the tract which then undergoes softenino- is the district to which this vessel is distributed, or some part of that district, which includes the greater portion of the corpus striatum, the internal capsule, the anterior half of the optic thalamus, and nearly the whole of the antero-lateral region of the brain, inclusive of the island of Keil and the convolutions which surround the fissure of Sylvius. It is hence obvious, in the case of embolism : that the mam symptom which the patient would be expected to present is more or less complete (gene- rally complete) hemiplegia, not improbably associated with some degree of anaesthesia, and impairment of intelligence ; and that if the disease occupy the left side of the brain, either marked aphasia, or total inabihty to utter articulate sounds, will be present. Other symptoms, however, which are not special to softening, are generally associated with these — namely, vertigo, headache, sickness, rigidity of the affected limbs, loss of control over the bladder and rectum, and the like. Occasionally the attack of 1070 DISEASES OF THE NEEVOUS SYSTEM. hemiplegia is attended witli sudden loss or impairment of sight on the same side as the cerebral lesion, a phenomenon apparently dependent on the concurrent plugging by embolism or thrombosis of the orbital artery or arteria centralis retinae and of the middle cerebral, or on common obstruction of the internal carotid and its branches. The subsequent progress of cases of obstructed cerebral arteries depends largely upon the extent of softenmg and its situation. If the patch be small (even if it be in the distribution of the middle cerebral) recovery as complete as occurs after some cases of effusion of blood may be expected. In most cases, however, recovery does not take place ; in some the patient improves up to a certain point ; in some he remains, so far as his mental and motor failures are concerned, much as he was immediately after his seizure. Occasionally, and especially if the case be one of thrombosis and not of embohsm, several of the cerebral arteries, and even the main trunks of these vessels, may be obliterated at successive intervals, each attack adding its own special symptoms to those which had resulted from previous lesions. It remains a fact, however : that the patient rarely recovers com- pletely from the effects of thrombotic or embolic softening ; that, if he has become aphasic, the aphasia continues in a greater or less degree ; that hemiplegia for the most part persists, and is followed ere long by that form of contraction which results from secondary lesion of one of the lateral columns of the cord ; and that occasionally arthritic effusion or inflammation ensues, or wasting of muscles. Further, the intellect, already probably impaired, is apt to fail, and the patient after a while to become bedridden and childish. Bed-sores occasionally form rapidly after softenmg, as they do after hemorrhage ; and inflammatory processes may go on around the softened patch and bring with them special symptoms. It follows on the whole that the prognosis m cases of softening is very misatisfactory, and that even if patients survive they are apt to survive in a more or less maimed or wrecked condition. Death may occur at any period. Some- times it comes on early, the patient dying from coma, bed-sores, or failure of nutrition, or from pneumonia, or some other such complication. Death at a later period may be consequent on the recurrence of apoplectic attacks or on the supervention of inflammation around the focus of disease ; or it may be due to asthenia or intercurrent disorders. There is for the most part extreme diiflculty in determinmg of any case which comes before us whether it be one of sanguineous effusion or one of softening from arterial obstruction. In many cases, indeed, there is nothing whatever to aid us in coming to a differential diagnosis. The chief points on which reliance must be placed are the following : — First, our knowledge of the relative seats of hemorrhage and of softening and of the different symptoms which they are hence likely to evoke. Second, the clinical history of the patient and the state of his various organs : thus the case is hkely to be one of embolism if there be heart-disease present, or if there be a history of his having had former cardiac mischief, or even if he have had an attack of acute rheumatism or scarlet fever ; it is not unlikely to be one of thrombosis if the patient have had a chancre, HYDKOCEPHALUS AND HYDEOEEHACHIS. 1071 or if lie be suffering, or present traces of having suffered, from the secondary or later symptoms of syphilis ; it is almost certain to be hemorrhagic if 'we discover the presence of albuminuria or chronic renal disease, arterial degeneration, or hemorrhage into the retinae. And, third, the age of the patient — cerebral hemorrhage being on the whole a disease of advanced hlfe, emboHsm occuring mdifferently at all ages from puberty upwards. We need scarcely repeat that the occurrence of sudden and complete hemiplegia ^\"ithout loss of consciousness and without premonitory symp- toms points strongly to arterial plugging, while the gradual development of symptoms culmmating in hemiplegia and coma is strikingly charac- teristic of cerebral hemorrhage. Treatment. — It is needless to lay down any specific rules of treatment. We cannot reopen an obstructed artery ; we cannot hope that the area to which it leads shall be fed by collateral channels. The softened part remains necrosed, and the best thing that can happen is that it shall shrink into an inert mass or undergo absorption. It may, however, during this process induce inflammatory mischief in the parts aromid. This contingency should be guarded againsb as much as possible. For which and various other reasons the patient should be kept quiet and cleanly, his bowels should not be allowed to become constipated, and his food should be nutritious, but easy of digestion, and not too abundant. But, indeed, the same general treatment is applicable to these cases as to cases of paralysis after hemorrhage and need not be more particularly considered. XI. HYDEOCEPHALUS AND HYDEOEEHACHIS. (Cerebral and Spinal Dropsy.) CaiLsation and morbid anatomy. — Dropsical accumulations in the cavities connected with the brain and cord are not uncommon, their chief seats being the subarachnoid space and the ventricles. A relative excess of subarachnoid fluid, which has been mistaken for dropsy, is generally observed in connection with the shrunken brains of old persons and of those who die demented or fatuous, or the ^dctims of certain other chronic forms of insanity. Whenever any portion of the brain, whether from congenital defect or as a consequence of disease, wastes, the space which it formerly filled becomes occupied either by an excess of subarachnoid fluid or by fluid accumulated in a local dilatation of one of the ventricles. Further, effusion of serum attends the progress of many morbid conditions, such as inflammation, morbid growth, and softening : thus, in some cases ' of menmgeal inflammation, inflammatory products with excess of fluid accumulate in the subarachnoid space ; in some cases the substance of the brain becomes wetter or more succulent than natural, or serous in- filtration (collateral oedema) occurs in the ^dcinity of foci of disease ; and in some cases (and these are the most frequent and important) the lateral ventricles, the third ventricle, or the fourth ventricle, or all of them to- gether, get largely distended with fluid. In the last series of cases the 1072 DISEASES OF THE NEEVOUS SYSTEM. accumulation of fluid in one situation is balanced by its removal from other situations ; and lience, as a rule, excess of fluid on the surface is attended with comparative absence of fluid from the ventricles : and dropsy of the ventricles or substance of the brain causes flattening of the convolutions, obliteration of the sulci, and dryness of the subarachnoid tissue. Dropsical effusion plays an important part in the production of symptoms in the cases which it complicates ; but by far the most impor- tant, in this respect, is the intra-ventricular dropsy, which is so commonly associated with the presence of tubercles or other tumours of the brain, or of meningeal inflammation, and which occasionally arises (both in children and in adults) as an independent malady. This is often referred either to compression or obstruction of the venae Galeni, or to closure of the natural communications existing between the ventricles and the subarachnoid tissue. The most important and strikmg forms of dropsy are congenital or come on without obvious cause shortly after birth, sometimes associated with malformation, sometimes independently of it. 1. Among the former of these classes must be included : in connec- tion with the brain, hydromeningocele and hydrencephalocele ; in connec- tion with the cord, spina bifida. a. In hydromeningocele and hydrencephalocele a congenital perfora- tion is present, either in the occipital bone (which is most common), or in some other part of the vault of the cranium ; through which protrudes, in the form of a tumour, either the membranes of the brain alone, with a circumscribed accumulation of serum (hydromeningocele), or a portion of brain nipped off, as it were, from the rest, and usually containing within it a dilated dropsical diverticulum from one of the ventricles (hydren- cephalocele). h. Spina bifida generally occurs in the sacral or lumbo-sacral region, but may be met with in the neck or any other part of the spine. It forms a rounded tumour, usually with a central dimple, and is due partly to the fact that the arches of the vertebrae in the situation of the tumour have remained ununited, and partly to the fact that the membranes of the cord are there expanded and distended with dropsical fluid, and protrude through the abnormal fissure. In some instances the membranes alone protrude, and we have then a condition which is equivalent to hydro- meningocele. But much more commonly (especially if the disease be at the lower end of the spinal canal) the cauda equina is prolonged into the cavity. The filum terminale is then attached to the centre of the con- cavity of the cyst, causing the dimple to which reference has been made ; and the nerves of the cauda equina accompanying this to the posterior aspect then arch forwards across the cavity — double upon themselves— to reach their several foramina. If (as sometimes happens in such cases) the central canal of the implicated portion of the spinal marrow be dilated into a cyst, we have a condition which is the exact counterpart of hydren- cephalocele. 2. Congenital or early developed dropsy (independent of malformation) HYDEOCEPHALUS AND HYDKOEEHAOHIS. 1073 probably always occupies the ventricles ; altbougli in some cases, apparently by accident, fluid becomes effused also into tlie cavity of the arachnoid. a. Chronic hydrocephalus (as it is generally called) sometimes com- mences during the later period of intra-uterine life, and the child is born already hydrocephalic. More frequently, however, the first manifesta- tion of the disease occurs between the time of birth and six months after that event. But it may come on at any time previous to the union of the cranial sutures ; and a few cases are recorded in which the supervention of dropsy shortly after this union has caused the bones again to separate. The fluid of hydrocephalus is of higher specific gravity than cerebro- spinal fluid, and contains albumen, chloride of sodium, and urea. It mostly occupies the lateral, third, and fourth ventricles ; and its gradual accumulation leads to their dilatation, to the flattening of the various pro- jecting ganglia, to the romiding of the several ca\'ities, and to the enlarge- ment of their orifices of communication. In this way the lateral ventricles may become enormously dilated, the lateral walls of the third ventricle may be opened outwards, until they become horizontal, and lost, as it were, m the common floor of the general ventricular cavity, and the fora- men of Monro and the fissure passing thence backwards beneath the fornix may be so much dilated as to form a free arch-like communication (of which the surface of the expanded third ventricle forms the floor) between the two lateral ventricles. The dilatation is not, however, always uniform or general. In some cases one lateral ventricle is much more enlarged than its fellow, or one part of a ventricle much more ex- panded than another part. In some cases, indeed, the posterior cornu becomes isolated from the rest of the cavity, and forms an independent cyst. Sometimes the third or fourth ventricle remains miaffected ; some- times the dropsy is confined to one of tliese cavities. The effect of the gradual distension of the lateral ventricles upon the cerebrum is remarkable. We have pomted out that the various elevations and depressions m the ventricular walls become effaced, and that the lateral ventricles tend to communicate freely with one another in conse- quence of the displacement upwards of the corpus callosum, septum lucidum, and fornix. Concurrently with these changes the convolutions on the surface of the organ become unfolded, until finally, in extreme cases, their grey matter forms a continuous smooth plain over the dilated hemispheres, which at the same time become reduced m thickness to a half or quarter of an inch, and, in some situations, probably to that of writing paper. Under these circumstances the dilated ventricles not unfrequently contain several pints of fluid ; indeed, cases are quoted by Trousseau in which 30, and even 50 lbs. were found in them. Occasionally, as in the weU-known case of the man Cardinal reported by Dr. Bright, rupture of the surface of the brain or of its meninges occurs in the course of the disease, so that the fluid originally contained m the ventricles accumu- lates in the cavity of the arachnoid, and the brain lies coUapsed and empty on the floor of the skull. The effects of hydrocephalus on the skull, on the nervous functions, and 3 z 1074 DISEASES OF THE NEEVOUS SYSTEM. on the development of the child, are very important. As the dropsy in- creases, the head gradually enlarges, mainly m its lateral and upper parts ; the two halves of the frontal bone, the parietal bones, and the occipital bone open (as Trousseau expresses it) hke the petals of a flower, and are thrown outwards, while the intervals between them become pro- portionately widened. Consequently the forehead, the sides of the skull, and the occipital region all protrude, while the head becomes somewhat flattened at the top. At the same time, some want of symmetry is usually apparent. The inordhiate size and strange shape of the skull impart to the comparatively small face below it a peculiar aspect, which is aggravated partly by the emaciation which is usually present, and partly by the influence of the enlarging skull on the eyelids and orbits. The upper walls of these cavities are displaced downwards by the pressure to which they are subjected from above, while the upper eyelids, with the eyebrows, are drawn upwards over the forehead by the tension of the stretched pericranial integuments. The eyes consequently become pro- minent, and present a peculiar starmg character, due to the fact that the sclerotic coat is habitually visible above the upper margin of the cornea. The integuments of the head become attenuated and tense, the super- ficial veins remarkably distinct, and the hair scanty and poor. The dis- placed bones also become thin, and the serrations of their edges irregular and straggling. Further, as the case progresses, nuclei of ossification appear irregularly in the tense membrane which intervenes between the separated bones, and these grow into irregular osseous plates, termed ossa triquetra. After a time, with the aid of these intercalated bones, the sutures and fontanelles may become entirely closed. This closure, how- ever, may not take place for twenty years or more. The patient almost always emaciates notwithstanding that his appetite may continue good ; the frame remains undeveloped, and the limbs are puny and shrunken. h. Internal hydrorrhachis, or dropsy of the central canal of the spinal cord, is probably, like hydrocephalus, an affection of congenital origm or of early infancy. As has already been stated, it is sometimes associated with spma bifida ; it is sometimes also an accompaniment of hydrocepha- lus. The canal may be dilated more or less irregularly in its whole length, or may present circumscribed dilatations only, and may vary from a quarter of an inch to an inch in diameter. As regards the etiology of chronic hydrocephalus and hydrorrhachis commencing m foetal Hfe or early infancy, we can only say that it is said to occur specially in rickety children, and in children of scrofulous or mihealthy parentage, and that its immediate cause is probably chronic inflammation or some condition allied to mflammation, involving the lining membrane of the affected cavities. Symptoms and progress. — 1. The symptoms of chronic hydrocephalus are to a large extent comprised in the pathological account of the disease which has already been given, or may be surmised from the anatomical facts in relation to it there considered. As regards the invasion, it may be observed that in some cases progressive enlargement of the head, and HYDEOCEPHALUS AND HYDROEEHACHIS. 1075 'the gradual supervention of the characteristic physiognomy of the disease, are the earhest indications of the presence of hydrocephalus ; while in some instances epileptiform convulsions, repeated fi-om time to time, or other symptoms indicative of hrain-disturbance, precede the appearance of any obvious change in the form or size of the skull. We may arrange the symptoms of the disease under three heads : namely, those dependent on the progressive enlargement of the skull ; those connected with the -general nutritive functions ; and those which depend on the involvement of the nervous centres, a. The general shape which the head acquires, and the peculiarities presented by the stretched integuments, the eyes, the eyelids, and the face, have already been sufficiently described. We may mention, however, that fluctuation can generally be easily perceived in the course of the open sutures, and that these parts may often be seen to col- lapse with inspiration and to dilate with expiration. Occasionally, as in the case of Cardinal, the dilated head, Hke a hydrocele, is more or less transparent. The increasmg size and weight of the head render it before long difficult for the child to support it, and tend, among other things, to •delay the acquisition of the power of walking. The young babe is apt to rest its head constantly on the pillow, or on the nurse's lap, rolling it about from tune to time ; and, even when the child can walk, it still has frequently to lay its head down, or to support it with its hands, and, under any circumstances, walks with a slow and cautious gait. The latter peculiarities may be continued throughout adult life. h. The general nutritive frmctions are almost always seriously impaired. The child probably takes food well — nay, greedily ; but notwithstanding this, it remains undersized and weak, and its face, trunk, and limbs become, as a Tule, emaciated and shrivelled. The bowels are often confined, c. Not only are epileptiform convulsions often among the earliest symptoms of hydrocephalus, but similar convulsions, or attacks of laryngismus stridulus are very apt to come on at a later period of the disease ; and, even if they have been absent before, they may supervene at the time of puberty, or later. These, however, are not the only nervous phenomena present. The child is generally fretful and dull, its sight becomes impaired and sometimes lost, and occasionally also deafness ensues ; the limbs are liable to spasmodic twitchings ; and not unfrequently the muscles, and more especially those of the lower extremities, become rigid; they may also undergo atrophy. With the advance of age, we generally find gradually increasing hebetude or dementia — loss of memory, incapability of mental exertion, or some special incapacity for learning ; we probably find, too, that the patient becomes irritable, passionate, or morose. Nevertheless he occasionally remains fairly bright and intelligent. The duration of life is various. Hydrocephalic foetuses not uncom- monly die in the act of birth. Death usually occurs, however, during the first or second year, fr-om either convulsions, coma, or intercurrent dis- orders. But Hfe may be prolonged for five or ten years, or longer. In two cases quoted by Trousseau, from Frank, the ages at death were seventy-two and seventy-eight respectively. The prospect of Hfe, no 3 z 2 1076 DISEASES OF THE NEEVOUS SYSTEM. doubt, depends to a considerable extent on the bulk to wbicli the skull and its contents have attained, and on whether the disease has becoine stationary or not. It not unfrequently, indeed, comes to a stand-still at a comparatively early stage, and the patient survives with a large head, a protruding forehead, and other more or less obvious indications of the affection which he laboured under in infancy. But the prospects of life do not depend wholly on these conditions, for the man Cardinal, who lived to the age of thirty, had an enormously large head, and the ossification of his skull was not completed until two years before his death. 2. The symptoms due to dropsy of the ventricles, coming on after consolidation of the skull, are necessarily obscure, and none the less so that the dropsy is almost without exception dependent on the presence of some other grave lesion which has already produced cerebral symptoms. The special symptoms to be expected are those which \70uld arise from pressure on the important ganglia situated on the floor of the ventricles ;, or, if the accumulation be acute and abundant, and in these respects re- sembling intra-ventricular hemorrhage, those of almost sudden and pro- found coma, with general paresis. There is probably always impairment of the mental functions, loss of memory, dulness and stupidity, attacks of unconsciousness or convulsions, want of control over the evacuations, and finally coma. But, besides these phenomena, there may be hemi- plegia, and not improbably some interference with the conductiveness of some of the cranial nerves, or some impairment of speech. 3. The symptoms referrible to internal hydrorrhachis are also exceed- ingly vague. In some cases there is nothing either in the history or in the symptoms to indicate the presence of any affection whatever of the cord. In a case of Sir W. Gull's, and in some others that have been recorded, dilatation of the canal in the neck induced paresis of the upper- extremities, with wasting of the muscles. It is natural, indeed, to assrnne that the symptoms of this affection should be those of pressure on the grey matter of the cord ; and the symptoms which have been presented by published cases accord in the main with this assumption. The clinical history of hydromeningocele, hydrencephalocele, and spina bifida, and the treatment of these affections, belong rather to surgery^ than to medicine, and need not further occupy our attention. Treatment. — The treatment of dropsy of the brain or cord is exceed- ingly unsatisfactory. If indeed the dropsy be in the adult, and secondary" to some organic lesion, the probability is that it will not be diagnosed. If it were diagnosed it would not lead us to adopt any specific treatment. In the chronic hydrocephalus of children, however, we so easily recognise the presence of the disease, there is such a field for treatment offered by the slowness of the case and the gradual evolution of its various symptoms,, that it is difficult to believe that everything we do must be unavailmg. Yet this is certainly true of the great majority of cases. The attempt has often been made to promote the absorption of the fluid by the application of counter-irritants to the surface of the skull, or by compression of the skull by bandages, or better by the use of long strips of adhesive plaister CHOEEA. 1077 applied uanformly over its surface. Trousseau states that in a case in which he adopted this treatment, sudden death was caused by the yielding of the bones of the base of the skull and the discharge of the dropsical fluid by the nose. It has been recommended to tap the distended ca\dties by means of a fine trocar and cannula. In using these, the puncture should be made vertically, at the edge of the anterior fontanelle, but avoiding the situation of the longitudinal sinus. A small quantity of fluid only should be removed at one time, and external pressure should be used to counter- act the diminished pressure within. The operation is not dangerous, and has often been performed vntli temporary benefit ; though no doubt there is risk that inflammation may follow, or that a vessel may be wounded. For internal use, iodide of potassium, iodide of iron, and mercurials have been employed. Sir Thomas Watson suggests, on the recommendation of an old apothecary of his acquaintance, the exliibition thrice daily of about ten grains of a pill made by mixing two parts of crude mercury with one part of fresh squiUs and four parts of conserve of roses. It is stated that persistence in this for several weeks has cured more than one case of the disease. It is nevertheless questionable whether any of the above plans of treatment are of real efficacy ; and whether any children, who would not otherwise have got well, have recovered under their influence. On the wholes it seems to us that it is best to aim at promotmg the child's general health by attention to his diet and to his secretions, and by the use of iron, cod-Hver oil, or other tonic medicmes calculated to fortify his vital powers. XII. CHOEEA. [St. Vitus' s Dance.) Definition. — Chorea is a peculiar convulsive disorder, for the most part •of early hfe, characterised by disorderly movements, which m the first in- stance are usually unilateral, but soon become general, and which tend, as a rule, to subside spontaneously after a few weeks' duration. Causation. — This affection occurs mainly among children between the ages of five and fifteen, or from the commencement of the second dentition to the end of puberty. It is not, however, very uncommon to meet with it in persons between fifteen and twenty-five ; and indeed it may occur, but occurs with extreme rarity, at any subsequent period of life. Dr. Graves records the case of a chemist who had chorea when he was seventy, and M. Henri Eoger that of a lady who was seized with it at the age of eighty-three. Chorea attacks females far more frequently than males. This preponderance in favour of the female sex is manifested even in early childliood, but it becomes more pronounced as life advances ; and of adults who are attacked very few are men. Other predisposing causes are hereditary influence, childbirth, and especially a previous attack of the disease. Trousseau draws attention to its frequent association with chlorosis ; but perhaps the most interesting fact in relation to the causa- tion of chorea is the intimate connection which it has with articular rheumatism and cardiac disease. Not only does chorea often come on in 1078 DISEASES OF THE NEEVOUS SYSTEM. tlie course of acute rheumatism, not only does acute rheumatism occasion- ally come on in the course of chorea, but a large proportion of those victims of chorea whose cases do not fall mto either of these categories have suf- fered from acute rheumatism at some period or other prior to the choreic attack. It has further been clearly ascertained : that by far the greater number of choreic patients present some cardiac defect ; that either the action of the heart is irregular, or there is what is supposed to be an anemic murmur at the base, or there is distinct evidence of endocarditis, pericarditis, or both; and that this cardiac defect (even if clearly of in- flammatory origin) is often met with in cases in which there is no history of rheumatism, or comes on during the choreic attack without any associated impHcation of the joints. Eheumatism, therefore, especially rheumatism, attended with pericarditis or endocarditis, must be regarded as at least one of the most efficient of the determining causes of chorea. Other causes,.. which operate apparently independently of heart-disease or rheumatism,, are overwork, anxiety, excitement, and, above all, sudden fright. Symptoms and progress. — Chorea generally comes on insidiously; and not unfrequently before any convulsive movements are recognised the child is observed to mope, to avoid its companions, to take no interest in its accustomed amusements or games, and to be incapable of fixing its atten- tion on its work, of committing lessons to memory, or even of readily recollecting. Indeed there is generally some real or apparent mental, deficiency, associated mth emotional disturbance, mdicated by a tendency" to caprice and fretfuhiess, to cry, and to be suspicious or timid. These phenomena may go along with general loss of health and impairment of the nutritive functions. The first indications of the special nature of the disease under which the patient is labouring are usually restlessness or fidgetiness, and a certain clumsiness in his movements : he camiot sit long in one place ; he is constantly shifting his position or the position of one or other of his limbs ; he stumbles unaccountably in moving about the room or m going up and down stairs ; and he has a tendency to spill his tea or coffee, or to drop, or to knock against somethmg else, whatever he essays to carry. The choreic movements are mostly first manifested upon one side, sometimes in the face, sometimes in the hand and arm, less com- monly in the leg ; but soon they involve the whole side in a greater or less degree ; and after a variable time, a few days or a few weeks, the affection probably extends to the opposite side of the body, and thus becomes mii- versal, although there often still remains preponderance of the symptoms on one side. But this mode of access, though the most frequent, is by no means invariable. In some cases, when the affection comes on m the course of an attack of rheumatism, no obvious prodromal symptoms are presented. And sometimes, especially when the disease is induced by violent emotion, its onset is sudden, and the symptoms may be general from the beginning. The phenomena of the fully- developed affection , although varymg largely in degree, differ but little in kind, and are for the most part exceedingly characteristic. The convulsions affect, m a greater or less degree, the CHOEEA. 1079 whole body. They are remarkable for their disorderly character ; they are not rhythmical, neither are they simple alternate flexions and exten- sions ; but they consist in sudden impulsive movements succeeding one another at irregular intervals, and involving now one group of muscles, now another, now one part of the body, now another, now several concurrently. The convulsions generally subside in some degree when the patient is sitting or lying down ; and (if they are not very violent) he is sometimes able to restrain them for a few moments ; but they become aggravated whenever he endeavours to execute voluntary movements, whenever any- thing occurs to excite him, whenever he feels that he is being observed. It hence happens that the medical attendant rarely sees him at his best. The choreic phenomena cease during sleep and under the influence of chloroform. The affection of the muscles of the face induces constant contortions of the features ; the eyebrows are at one time elevated and the forehead is thrown into transverse wrinkles ; at another time the brows are knit ; the eyes move suddenly and without purpose in various direc- tions ; the mouth is now opened, now closed, now drawn into various odd forms by the influence of the orbicularis and surrounding muscles. The face, moreover, wears a strangely vacant imbecile aspect. The tongue shares in these tmnultuous movements. If the patient be asked to put it out, he opens his mouth wide and protrudes it with a jerk, and then as suddenly withdraws it, the mouth and jaws closing upon it with sudden violence. If he endeavour to answer questions, the convulsive movements of the face and mouth become aggravated ; and he has extreme difficulty in articulating his words, which come out in dribblets as it were, slurred over, or uttered with a peculiar drawl, hesitation, or stammer. The difficulty of speech depends partly on the convulsive action of the lips and tongue ; but not unfrequently also on spasmodic affection of the larynx and respi- ratory muscles, which compels him to draw his breath suddenly through the laryngeal orifice with a strange sound. In some cases, even when no attempt at speech is being made, odd croaking or grmiting noises are thus from time to time produced. The actions of the muscles of the head and neck are probably as incoherent as those of the face, so that the head is sometimes jerked to one side, sometimes to the other, or thrown disorderly into various odd positions. No parts usually manifest choreic phenomena more strikingly than the upper extremity ; all its segments are involved in a greater or less degree ; the patient hitches his shoulder ; he moves his upper arm to and from his side ; his forearm becomes flexed, extended, supinated, pronated ; his hands and fingers execute the most grotesque and inco-ordinate movements. The general movements of the limb, when the patient uses it (when, for example, he endeavours to raise a glass of water to his lips) are curious to watch. By an effort of the will (if the case be not exceedmgly severe) the glass ultimately reaches its destination, but it reaches it probably after many failures ; its progress is not arrested by a series of undulatory, tremulous, or backward and forward movements of the limb, but the different segments are suddenly and violently plucked, as it were, by some iia visible power first in one direction then in another. 1080 DISEASES OF THE NEEVOUS SYSTEM. in the line of the intended movement, or in direct opposition to it, or at right angles with it. The primary movement is overlaid, as it were, dming its course with innumerable uncontrollable secondary movements, which retard it, aggravate it, and distract it. The lower extremities are affected similarly to the arms. They are moderately quiet when the patient is at rest, but as soon as he begins to use them, as soon as he begins to walk, their movements become inco- ordinate, jerky, tumultuous. To quote Sir Thomas Watson's words : ' When the patient intends to stand or sit still, her feet scrape and shuffle on the floor, or one of them is suddenly everted and then twisted inwards, or perhaps is thrown across the other ; and, if she endeavour to walk, her progress is indirect and uncertain ; she halts and drags her leg rather than lifts it up, and advances with a rushing or jumping motion by fits and starts.' The muscles of the trunk p^^rtake in the general convulsive movements, and the body is twitched and contorted with sudden violence into all kinds of odd and unaccountable positions. It must be added : that mastication and deglutition are often rendered difficult by the spasmodic movements of the muscles engaged in these operations ; that respiration is frequently interrupted and rendered irre- gular, jerky, and noisy, by involvement of the diaphragm ; and that some- times in severe cases the sphinctqrs of the rectum and bladder relax, and the evacuations escape involuntarily. In mild cases the patient is able to walk about, though with more or less difficulty or clumsiness, and it may be to feed and dress himself. In more severe cases locomotion is impos- sible, and he has to be confined to his bed ; he becomes, moreover, quite incapable of using his hands for any purpose. In the worst form of the disease the condition of the patient is miserable in the last degree, and pitiable to behold. His features and head and neck are in constant motion ; his arms are flung out first in this direction and then in that, his fingers and hands meanwhile executing the most varied and fantastic movements ; his lower extremities are probably little less violently con- vulsed than his arms ; and his trunk is constantly being twisted about in bed, now into the prone position, now into the supine, is now doubled up, now straightened out again, now caught by some strange contortion. The phenomena above described are not, however, the only nervous phenomena which attend chorea. There is always impairment of the strength of the affected muscles, some paresis — a fact especially easy of recognition in cases of unilateral chorea. In some cases, indeed, the con- vulsive phenomena may be replaced by hemiplegia or even paraplegia. Sometimes the hemiplegic or paraplegic symptoms precede the onset of the choreic movements. More frequently they come on in the course of the disease and supplant them. Impairment of sensation is also observable in many cases ; and its degree has more or less relation to the severity of the convulsions, or to the degree of paralysis present. Occasionally the ansesthesia is one-sided, and it may be almost absolute. The fatuous aspect of the patient in the early stage of chorea has already been referred to ; this aspect continues and even becomes aggravated during the continuance of the disease. No doubt it depends largely upon the various spasmodic CHOEEA. 1081 movements in wliicli the muscles of expression and those that move the eyeballs are implicated ; but there is good reason to believe it is to some extent governed by the fact that intelligence does actually fail to a greater or less extent during the presence of the malady. Emotional sensibility, on the other hand, is somewhat exalted. Sometimes the eyesight fails. Subordinate symptoms of more or less importance are apt to attend the progress of chorea. The patient's appetite is often bad, or capricious, or lost. His bowels are confined. His nutrition becomes impaired. He suffers from palpitation, and, as has already been pointed out, he is liable to functional or organic disease of the heart, either of which may super- vene in the course of his attack. There is a striking absence of febrile symptoms during the progress of the disease. The issue of chorea is in the vast majority of cases favourable. Some- times (if, for example, the choreic movements come on in the course of acute rheumatism and involve one arm only) the patient recovers in the course of a few days. More commonly the disease continues for a period varying between four or five weeks and three months. In some instances it is prolonged for two or three years or more. But in these cases it is usually continued by successive relapses, each coming on before the symptoms of the preceding attack have wholly disappeared. Indeed, patients who have had one attack of chorea are peculiarly liable to subsequent attacks, which come on at irregular periods, and under the slightest provocation. Very rarely, indeed, chorea lasts for many years or for a lifetime. When the •disease is fatal, it rapidly assumes aggravated proportions. The spasms are incessant ; their violence and continuance prevent sleep, or allow only of occasional short snatches of sleep ; they interfere seriously with the ingestion of food, and thus rapidly induce mental and bodily exhaustion. Further, the evacuations escape unconsciously, or at all events are un- controlled ; and partly on this account, partly in consequence of the constant friction to which the trunk and limbs are subjected by their never-ceasing movements, the skin becomes chafed in innumerable places, and bed-sores form over the various prominences, more especially over the elbows, hips, and sacrum. Often also the child bites its lips until they bleed ; and very frequently the red portions of both lips become split by numerous deep vertical fissures. Death, which may be preceded by delirium, is generally due to asthenia. But its immediate cause may be the supervention of erysipelas or the consequences of heart disease. The recovery from chorea (putting cardiac disease out of the question) is generally complete ; the patient regains his muscular strength, and his intelligence is restored to him unimpaired. But it is not always so. Occasionally he remains feeble-minded, or even becomes insane, or lapses into a fatuous condition. In some cases, too, the implicated muscles remain enfeebled ; and they may then midergo slow contraction, or atrophy, or both. In a chronic case which has been under our observation, and in which the general symptoms were undistinguishable from those of genuine chorea, the choreic movements of the lower extremities were .associated with marked rigidity of the muscles, some degree of flexion at 1082 DISEASES OF THE NEKVOUS SYSTEM. the hip and knee joints, with overlapping of the knees from the prepon- derant action of the adductors of the thighs, and a tendency to tahpes equino-varus — facts which seem to indicate that degenerative changes of the lateral columns of the cord had supervened. Morbid anatomy and ])atliology. — The pathology of chorea is con- fessedly obscure ; it is not known either what parts of the central nervous organs are the seat of disease, or what is the nature of the morbid process going on in the affected parts. The facts of its unilateral commencement and general unilateral tendency point, however, to disease, either of the corpus striatum and optic thalamus, or of the corresponding cerebral hemi- sphere. And doubtless one or other of these parts is the main seat of the lesions on which chorea depends. But there are many features of the disease, such as the occasional implication of the muscles of phonation, respiration, and deglutition, and the frequent occurrence of functional disturbances of the heart, which would seem to imply involvement of the medulla oblongata. And the resemblance of the choreic movements to those of locomotor ataxy is certainly suggestive of implication of the cord. Then as regards the nature of the disease, its frequent connection with rheumatism and cardiac disease has suggested at least two hypotheses. One, originating with Dr. Kirkes, and since ably supported by Dr. Hugh- lings Jackson, is to the effect that the symptoms are due to obstruction by minute emboli of the smaller branches of the arteries supplying the corpus striatum and contiguous parts, with consequent scattered minute patches of congestion and softening. The objections, however, to this view are obvious. Obstruction of the arterioles has been observed only in a very small number of cases, and it is doubtful if m these the obstructions were embolic or thrombotic. Besides which, it is not only difficult to beheve that showers of minute emboli should be distributed throughout the minute vessels supplied to one corpus striatum or one side of the brain only, and that at some later period there should be a similar limitation of such embolic patches to the region supplied by the middle cerebral artery of the other side, but it is difficult to understand why large emboli should not be occasionally intermingled with the smaller ones, and cause sudden hemiplegia by obstructing a large vessel, and why small emboli shed simultaneously should not become blended by fibrinous coagulation around them into one or two concrete masses. The other hypothesis is that the same disease that affects the valves of the heart or the joints in rheumatism attacks also the smaller cerebral vessels or the ultimate tissue of the central nervous organs, a view which might well explain the super- vention of cardiac disease in chorea, as well as the dependence of chorea on rheumatic fever. A main objection to this view is that it is conjectural, and as yet wholly unsupported by anatomical evidence. Moreover, it fails, as also does the embolic hypothesis, to explain those cases which are due to fright or other powerful emotions, and in which, so far as we know, the heart remains sound. It seems to us,- however, that the clinical phenomena of chorea cannot possibly be referred to affection of any circumscribed region of the nervous. CHOKEA. 1083 centres ; and that, whether the seat of disease be thus Hmited or not, the embolic hypothesis is altogether inadequate as an explanation of the nature of the morbid processes to which the clinical phenomena are Hnked. The symptoms are partly intellectual, partly emotional, and referrible partly to the functions of the voluntary muscles, partly to the cutaneous sensi- bility, and partly also to the bulbar nerves, which subserve articulation, deglutition, respiration, and the motor functions of the heart ; they would seem therefore to be comiected at the same time or successively, and in different degrees, with the cerebral convolutions, the ganglia at the base, the pons and medulla, and the spinal cord. The valuable paper read by Dr. Dickinson before the Medico- Chirurgical Society is strongly confirma- tory of this view. He shows, from the results of careful post-mortem examinations made on several fatal cases of chorea : that there is a general tendency to dilatation of the smaller vessels, more especially the arteries, throughout the substance of the brain and cord ; that this dilatation is attended with exudation into the tissues immediately surromiding the vessels, and occasionally with small hemorrhages indicated by the pre- sence of blood-crystals and the like, or patches of sclerosis ; that these changes are most advanced in the corpora striata, in the nervous matter in the neighbourhood of the trunks of the middle cerebral arteries, and in the posterior and lateral portions of the grey matter of the cord, mainly at the upper part ; and further, that in all these regions the morbid con- ditions tend to be symmetrically arranged. And on the basis of these facts, and admitting that chorea is associated generally with rheumatism, in the larger proportion of cases with heart-disease, and in some cases with no inflammatory or structural disease of any organ, he comes to the con- clusion (in which we are disposed to concur) that chorea depends ' on a widely spread hyperemia of the nervous centres, not due to any mechanical mischance, but produced by causes mainly of two kinds — one being the rheumatic condition, the other comprising various forms of irritation, mental and reflex, belonging especially to the nervous system.' The tendency which the vascular changes have (on Dr. Dickinson's showing) to induce sclerosis in the tissues which surround the vessels well explains the wasting of muscles, rigidity of limbs, and permanent paralysis, which occasionally complicate chorea or supervene upon it. Treatment. — For few diseases have so many specific remedies been vaunted as for chorea ; yet few diseases are really so little amenable to treatment. It must never be forgotten, m weighing the value of medi- cines in this affection, that the great majority of cases tend to get well spontaneously in the course of a few weeks. Sydenham recommended bleeding and tartrate of antimony, and ' cured ' his patients by these means ; and even Sir Thomas Watson advocates local bleeding, when there is a fixed pain in the head. Large doses of antimony, indeed, have been strongly recommended by many physicians. Iron is a favourite remedy ; so is arsenic ; and so also is sulphate of zinc, given in doses, to commence with, of a grain or two three times a day, which are slowly increased by successive increments, until from 20 to 40 grains are given 1084 DISEASES OF THE NEKVOUS SYSTEM. at a time. Iodide of potassium is lauded by some ; bromide of potassium by others ; phosphorus by others. Of medicines derived from vegetable sources we may name turpentme, strychnia, cannabis Indica, opium, belladonna, and various anti-spasmodics. Exercise, frictions, and cold baths, more especially shower-baths, have all their advocates. We must confess that in our own opinion few, if any, of the above remedies have any real influence over the course of the disease ; if, however, we have any bias, it is in favour of arsenic, given in small doses, and continued for some length of time. We believe, however, that real benefit accrues in a considerable number of cases from improvement of the general health ; that in this point of ^dew, tonics (among which iron holds an important place) are useful, as also are careful attention to hygienic measures, good wholesome diet, early hours, avoidance of excitement, gentle exercise, cold or tepid bathing, and change of scene and air. Again, our treatment may ■often be usefully directed by the nature of the malady (if any) with which the chorea is associated ; thus when rheumatism is present, or chorea is .a legacy left by rheumatism, anti-rheumatic treatment may be of great service. In those severe cases in which the convulsive movements are incessant, and the patient has little or no rest, and death consequently threatens, narcotics and stimulants would seem to be indicated. The inhalation of chloroform arrests the convulsive movements so long as the patient is under its influence ; opium, morphia, or chloral in large doses has the same effect. But it must be admitted that notwithstanding the temporary ease they give, the progress of the disease towards its fatal end is rarely, if ever, retarded by their use. The patient should then be supported by food and stimulants. Further, every precaution should be taken to prevent the patient from injuring himself in his contortions, and all sores that form upon the siu-face of the skin should be at once treated, and protected from further injury. It may be pointed out, in conclusion, that chorea is apt to spread among children, apparently by imitation ; that choreic patients are often .rendered worse by their association with patients of the same class ; and that hence precautionary measures directed against such accidents should be taken. XIII. EPILEPSY. ECLAMPSIA. INFANTILE CONVULSIONS. A. Epilepsy. {Morhtis comitialis vel sacer.) Definition.— li is difficult, if not impossible, so to define epilepsy as within the limits of a mere definition to include all the varieties of form which it assumes. Speaking generally, it is a functional disorder of the nervous centres, characterised by sudden seizures of temporary duration, and occurring at irregular intervals, m which the patient either loses consciousness or presents some other form of mental disturbance, or has tonic or clonic convulsions, or all of these phenomena in sequence. For a true conception of the disease, it must be miderstood that, however EPILEPSY. 1085 mild tlie attacks may be, all the phenomena whicli liave been enmnerated are potentially present in them, and may be expected to occm- in com- bination dm'ing the progress of the disease. Causation. — The causes of epilepsy are very obscm-e. The disease has been attributed to all sorts of circmnstances which have probably little or no influence in its production. Among those to which most importance has been attached may be mentioned sudden fright, the witnessing of an attack of epilepsy, long-continued anxiety, overwork, drink, abuse of absinthe, and venereal excesses, especially masturbation. But their importance as exciting causes has been greatly over-estimated. It is considered by Trousseau that the real share of each one of them (except- ing fright) in the production of the disease is yet to be proved ; and Piussell Eeynolds remarks of excessive venery and masturbation, that far too much importance has been attached to them. Hereditary predisposi- tion, on the other hand, exerts a remarkable influence over the develop- ment of epilepsy. It is to be observed, however, that it is not so much epilepsy itself which is hereditary (although no doubt it is so in a high degree), as that epilepsy becomes hereditary in families, among the members of which neuroses, such as epilepsy, insanity, hysteria, and the like, prevail. It is not uncommon to find in such families that several of the children are epileptic, or that one is epileptic, one suffers from chorea, one is an idiot, and so on. But the predisposition to epilepsy may be acquired : for it is certain that many of those persons who subsequently become epileptic have suffered in infancy from convulsions, which were in- duced by teething or other accidental circumstances. Epilepsy occurs pretty equally in both sexes. The first attack may come on at any period of life — in early childhood or extreme old age ; but it occurs far more frequently bej}ween the ages of ten and twenty (more precisely, perhaps, during the time of puberty) than it does at any other period of life. Dr. Eeynolds points out that there is comparative immunity between the ages of twenty-five and thirty-five ; but that the outbreak of the disease becomes comparatively frequent again about the age of forty. After this time its primary appear- ance is extremely rare. Symptoms and progress. — The phenomena of epileptic attacks are so various, they differ so widely from one another in different cases, both in their characters and in their grouping, that it is impossible to give a com- prehensive, and at the same time graphic, account of them, exeeptmg by the aid of illustrative cases. Our space forbids the adoption of this course. We shall, therefore, begin with the description of a typical attack of the disease, and then discuss the variations to which attacks are liable. The epileptic fit is not unfrequently preceded by a well-marked pro- dromal period, lasting in different cases from a day or two to a few seconds.. But, under any circumstances, the fit itself comes on suddenly; the patient probably utters a cry, loses consciousness, and, if standing, falls down as if shot on his face or on the back of his head ; his muscles become rigid, especially, perhaps, those of one side, and at the same time slowly contract ; and respiration ceases. After these phenomena, which constitute the first. 1086 DISEASES OF THE NEEVOUS SYSTEM. stage of the attack, have lasted for a few seconds, the second stage super- venes. This is characterised mainly by return of respiration, Hvidity of surface, distension of the veins of the head and neck, clonic spasms, which are mostly unilateral, bitmg of the tongue, and continuance of unconscious- ness. At the end of a minute or two this stage also comes to a conclusion, the lividity disappears and the convulsions cease, but the patient probably still continues insensible ; presently, however, consciousness returns in some degree, and he either rapidly recovers, or remains confused or maniacal, or in a state of stupor, for some hours, or it may be a day or two, before complete recovery takes place. The prodromal period is present probably in about haK the total number of cases, and if present in one attack is most hkely present m other attacks occurring in the same patient. Moreover, under such cir- cumstances the premonitory symptoms continue probably, at any rate for a time, of the same kind. Those which precede the attack by some hours or a day or two are the least common, and although perhaps apparent enough to the patient or his friends, are on the whole slight in degree and vague. They consist, for the most part, in some modification of the patient's intelligence, feelings, or habits ; he gets dull and incapable of mental exertion or of attention to business, sullen or low-spirited ; or his manner and conversation become sparkling and Hvely, and his spirits unaccountably buoyant and jovial — he may even be furiously maniacal ; or there is simply something in his look (a wildness in his eye, or a dul- ness and heaviness of expression) which is not natural to him. The more characteristic premonitory symptoms are those which precede the fit by a few minutes or a few seconds only. They are remarkably various. In some cases they consist in the spasmodic contraction of certain muscles : the expressional muscles of one side of the face twitch ; or the hand and arm are convulsed, and gradually carried upwards towards the face ; or the lower extremity is equivalently affected ; or the muscles of one side of the head and neck contract and carry the face over the opposite shoulder ; or the muscles of several or of all these regions are simul- taneously involved. Sometimes the epileptic fit is preceded by vertigo, or sickness, or by severe pain or some undefinable sensation referred to the head, throat, chest, abdomen, or some other part. Not unfrequently the premonition is furnished by what has been termed the epileptic aura (a sense of coldness, heat, or pain, starting from some point, say the finger or toe, the abdomen or chest, or it may be from the seat of some former injury), which seems gradually to ascend until it reaches, as the case may be, the epigastrium, the prsecordial region, or the head, when insensibility suddenly supervenes. In some cases the attack is ushered in by some hallucination of the senses : the patient perceives some peculiar smell ; or he hears strange sounds, and, it may be, voices ; or he sees definite forms before his eyes — animals, departed friends, witches, devils. Not unfrequently, again, the premonitory symptoms consist in some odd mental disturbance : the patient experiences a sudden horror or trouble, or he finds himseK engaged in some special train of thought or perplexed EPILEPSY. 1087 hj some problem or the plot of some story or strange combination of cir- cumstances. It is curious that these mental perplexities which seize upon the patient are often entirely forgotten after the occurrence of the fit, yet that the same perplexity is repeated (exactly as the drawing up of the arm or the occurrence of an aura is repeated in other cases) before every epileptic attack. The most constant feature of the first stage of the fit is the sudden onset of absolute unconsciousness. This may be momentary only, or may be prolonged throughout the whole of the first and second stages, and for two or three minutes or more. As we shall afterwards show, it is sometimes absent. This unconsciousness while it lasts is profound ; the patient neither sees, nor hears, nor feels, nor can be roused by any means at our command. The convulsions which attend this stage are tonic ; they consist in the supervention in the affected muscles of great rigidity, attended in the first instance with fibrillar movements, and a tendency for certain muscles gradually to overcome their antagonists. They are rarely general, or if general they affect one side more powerfully than the other ; they are, in fact, almost always unilateral, and sometimes limited to the side of the face or head and neck, or to the arm. The face becomes hideously distorted, and the tongue probably thrust between the teeth ; the head, from contraction of the sterno-mastoid and other muscles, drawn down obhquely on one side, the face being thrust over the opposite shoulder ; the trunk contorted ; and the arm or leg flexed or extended. At the same time the respiratory and laryngeal muscles become fixed, and the acts *of respiration cease entirely. These spasms are sometimes whoUy absent. The epileptic cry which ushers in the attack occurs only in a hmited number of cases. It varies in character, is sometimes a loud shriek, sometimes a hoarse groan, and is usually very distressing to hear. It occurs (as Dr. Eeynolds points out) once only, but it may be prolonged throughout the whole period of insensibility. The pupils are dilated and insensible to light. If the patient be closely observed at the onset of his attack, his face will usually be seen to be suddenly overspread with a death-like pallor, which persists for a few seconds, but gradually, duriao- the progress of the first stage, becomes replaced by redness and turgidity. In some instances no change whatever of colour can be discovered. In association with the phenomena here enumerated there is usually extreme feebleness of pulse. Although the patient generally falls with sudden violence, he sometimes slips down quietly, almost as if by design ; and if the loss of consciousness be momentary only, he sometimes remauas motion- less, standing or sitting, or merely staggers. The first stage usually lasts from ten to thirty or forty seconds. The second stage is attended with continuance of unconsciousness. The face has usually by the time of its commencement become li\id and bloated, and the veins of the head and neck distended ; but this lividity and over-distension of the vessels slowly subside during its continuance. The tonic spasms cease, to be replaced by clonic spasms. These, which consist in alternate powerful contractions of flexors and extensors or 1088 DISEASES OF THE NEEVOUS SYSTEM. other groups of antagonistic muscles, may be general ; but tbey are more commonly one-sided and limited to those parts which had previously been the seat of tonic contraction. The pupils oscillate, the eyelids and muscles of expression work, the mouth is alternately opened and closed with violence, and the protruded tongue, caught between the teeth, is apt to get severely bitten, the muscles of the head and neck, and those of the trunk, are convulsed, and the arm and leg execute powerful movements of extension and flexion. At the same time probably the faeces and urine are discharged involuntarily. The respiratory acts are resumed at the commencement of this stage, and during its course are violent, jerky, noisy, and laboured. The skin is cold ; profuse sweats break out ; the pulse is full ; the heart beats violently. Mucus accumulates in the mouth and fauces, and, mingled with the blood yielded by the bitten tongue, escapes from the lips. The symptoms of this stage, violent in the beginning, gradually subside ; and at the end of a few seconds, a minute, or at most two or three minutes, the patient draws a deep sigh, and the second stage is completed. The condition of the patient in the third stage varies. Sometimes he recovers almost instantaneously, and appears at once in his normal health ; but more commonly he lies for some minutes or for half an hour in a con- dition of profound coma, from which it is impossible to rouse him. Sooner or later, however, consciousness slowly returns ; he opens his eyes and gazes stupidly or wildly about him ; he tries to speak, but mumbles unin- telligibly or incoherently, or fails to produce any articulate sound ; he tries perhaps to get up, and his movements and demeanour resemble those of a drunken man ; sometimes he becomes wildly maniacal, sometimes falls into a state of trance or ecstasy. "We have met with one case in which the patient always recovered laughing. It not unfrequently happens that the patient lapses into a profound sleep, interrupted it may be from time to time by slight convulsive twitchings. Muscular weariness, a sense of general bruising, headache, vertigo, restlessness, severe mental or emo- tional disturbance, are apt to remain for some hours or even for a few days after the fit. After the attack, the patient often passes a large quantity of limpid urine ; and, owing to the extreme distension of the vessels of the head and neck and upper part of the trunk, minute extravasations of blood are apt to occur durmg the fit, and the surface of these parts to become thickly studded with persistent hemorrhagic points, or peteehise. The above account applies to those.fits, typical in their severity and in the sequence of their phenomena, to which the names epilepsia gravior and hatit mal have been given. But in a large number of cases either the fit does not pass beyond the prodromal stage ; or various of the stages are absent, or so rapidly completed, or so blended with one another, that they escape observation ; or some of the features of the malady are aggravated ; or new features are superadded. Most of these attacks come under the denomination of epilepsia mitior, petit mal, or epileptic vertigo. In some cases the patient is affected with an occasional sudden spasm of one side of the face, or of one sterno-mastoid ; or his hand closes, and EPILEPSY. 1089 the arm is gradually drawn up or flexed ; or he experiences some one of those sensory hallucmations which have been previously enumerated ; or he has an aura, or a sudden attack of headache, giddiness, sickness, or faintness. Li other words, he is attacked with some one of the prodromal symptoms which are known to usher m epilepsy. Now it does not at all necessarily follow that the sudden occurrence of such phenomena, or even their occasional repetition, proves that the patient is epileptic ; but it is certain that, of those persons who suffer from them, some become epi- leptic sooner or later ; and that those epileptics, whose fits are preceded by warning symptoms, not unfrequently have such warnings without fits following them. There can be no doubt that such attacks must, under these chcumstances, be regarded as epileptic. They are, in fact, abortive epileptic fits. In some instances the patient's seizures consist in little more than a momentary mterruption to the continuity of his thoughts. He is engaged m talking, and suddenly for a second or two becomes quiet, and then resumes the thread of his conversation as if nothing had oc- curred ; or instead of ceasing to speak he may utter some incoherent sornids, or words and expressions utterly alien to the subject in which he was engaged. If he be closely observed at this moment, his pupils will probably be seen to dilate, his face to become momentarily pale, and then perhaps with returning consciousness a little more congested than natural. During the momentary attack the patient may become absolutely uncon- scious, and his mind may be a blank ; or, although unconscious to every- thmg about him, he may be the subject of a sudden trouble, perplexity of mind, or horror — some momentary nightmare, as it were. Sometimes he utters a shriek and reels or staggers, or performs a rotatory movement, and then without falling to the ground recovers. Sometimes he is seized with unconsciousness lasting for a few seconds, or for a minute or more, and remains sitting or standing, or in whatever other position the fit surprised him in, his features meanwhile being perfectly passive or pre- senting convulsive twitchings. In most cases the wholly unconscious patient will go on during his miconsciousness with the work in which he was engaged at the time of seizure ; if walking he will continue to walk, if running he will go on running. Trousseau mentions the case of a young amateur violinist who, during attacks of short duration, would go on playing with perfect accuracy as if he were still in his ordinary senses. There are other cases, again, m which the patient, during his attack of unconsciousness, performs strange actions, which have nevertheless an aspect of purposiveness about them, but of which he has no recollection whatever when consciousness returns. They seem, in fact, like the trans- lation into action of the fragment of a dream. Thus, sometimes, while walking, perhaps in the street, he all at once begins to run rapidly, avoid- ing all obstacles, and then coming to discovers himself unaccountably far from his destmation or from the place at which he lost his senses. Trousseau cites the case of a magistrate who, in such an attack, suddenly left the court over which he was presiding, went into the council-chamber, made water in a corner of the room, and returned to the court entirely 4 A 1090 DISEASES OF THE NEEVOUS SYSTEM. ignorant of the strange act lie had committed. Sometimes tlie ]3atient wUl dance or sing, or peer about in various directions as if in search of something which he had lost or mislaid. But perhaps the most important, if not the most remarkable, of these aberrant forms of epilepsy are those in which the patient is seized with sudden and unaccountable fury, tears his clothes, or destroys anything that is near him, belabom'S the friend or the servant that is with him, or rushes out of the house and attacks the first stranger that he meets, or jumps from the window, or m some other way maims or kills himself, and moreover not unfi-equently accom- pHshes such acts with apparent definiteness of purpose. Thus a husband, apparently waking out of sleep, will beat or strangle his wife with the ut- most ferocity ; a man walMng along the street will, at the moment when the impulse is upon him, make an unprovoked and violent onslaught on whoever chances to come near. Now it must be borne in mmd that in all the varieties of seizure, in all the different forms of epileptic vertigo, which we have been considering, the only appreciable part of the attack may be the temporary unconsciousness or delirium, together with the various specific motor phenomena which have been enumerated, and utter uncon- sciousness or forgetfulness of what has passed in the attack. There may be no premonitory s}Tnptoms, no tonic or clonic convulsions, no change of colour, no succeeding bodily or mental suflering. On the other hand, careful observation will often reveal the presence in a modified form of some of the more ordinary features of the typical epileptic fit. There may be shght premonitory s}miptoms ; there is generally a sudden pallor or ghastliness at the commencement of the attack, soon followed by red- ness or lividity, and in connection therewith dilatation of pupils, rolling of the eyes, or twitching or more \'iolent convulsive movements of the muscles of the face or one of the lunbs ; and, further, vertigo, confusion of mind, or other such conditions may remain for a longer or shorter time after the subsidence of the fit. The first epileptic fit may also be the last ; but m the great majority of cases it forms the prelude to subsequent attacks, which may come on at various intervals for months or years or during the whole subsequent life- time of the patient. Sometimes the fits recur with more or less irregu- larity at mtervals of a week, a month, two or three months, or a year, or more. There may then be a single fit at each recurring period, or there may be two or three, or a dozen, or more, succeeding one another during a period of twelve or twenty-four hours. In some instances frequent fits occur habitually day and night. It occasionally happens that, as the general health improves or age advances, the fits become less and less frequent, and at length recur at irregular intervals of years, or disappear altogether. It must be borne in mind, however, that those who have once been epileptic,- even if five, ten, or a dozen years have passed since the last attack, are still not unhkely to have a relapse ; and, again, that patients, whose fits have hitherto occurred only at long intervals, not xmfrequently suffer from aggravation of the disease — the fits rapidly increasing in frequency, and recurring in large numbers day and night EPILEPSY. 1091 for weeks together. Sometimes, when the attacks follow oiie another very rapidly, the patient falls into the status einlepticiLS — a condition in which he remains insensible for many hours, sometimes for a day or two, and which has often been referred to the persistence of a smgle fit ; it is made up, however, of a succession of fits, linked together by persistent epileptic coma. Convulsive fits recur as a rule much less frequently than attacks of epileptic vertigo ; yet when they recur at long intervals they are very liable to be repeated several times within a limited period. Epileptic vertigo may come on habitually twenty, thirty, or forty times, or even as many as a hundred times in the day. According to Dr. Eeynolds, cases of the haut mal are nearly twice as common as cases of the j^&tit mal ; there can be little doubt, however, that the petit mal is much more frequent than is generally supposed, and that many persons accounted healthy, and who never consult a doctor, are Hable to occasional slight seizures. Attacks of the haut mal not unfrequently, however, alternate with those of epileptic vertigo ; and still oftener patients who are subject to the former have abortive seizures represented by the aura only. On the other hand, although epileptic vertigo often constitutes the only form of seizure from which patients suffer, attacks of a severer kind are in such cases always liable to supervene. The circumstances which determine the epileptic fit in those who are liable to fits are not generally discoverable. They often, at all events w hen they first appear, come on only in the night, either, it is said, at the moment of going to sleep or at the moment of waking ; and, even when they take place both day and night, they often occur mamly at night-time. It is not uncommon for them to attack women at the monthly periods ; yet it stiU more frequently happens that epileptic women do not suffer specially at the time of menstruation ; and they escape as a rule during parturition, a time at which eclampsia has a special tendency to supervene. ■ In some cases the fit seems to be induced by severe mental labour, by emotion, by a debauch. It has occurred during the act of coitus. Sometimes, when the attack is preceded by an aura starthig from some accessible point, it may be induced by irritation of that pohit. Thus we knew one case in which it was invariably excited by compression of a certain tender spot on the abdominal wall ; and we have met with another in which for many weeks fits were brought on day and night whenever the patient's legs were moved voluntarily or involuntarily, whether he was awake or asleep. The condition of epileptic patients in the intervals between their seizures is very various. In a large proportion of cases they appear to be m the enjoyment of perfect mental and bodily health. Not mih'equently, however, some peculiarities reveal themselves sooner or later in connec- tion with their nervous organism. They become low-spirited or taciturn, or querulous, fidgety, or excitable ; or there may be a httle failure of memory, or some slowness of apprehension, or difficulty of application. The most remarkable mental phenomena, however, are those which are 4 A 2 1092 DISEASES OF THE NEEVOUS SYSTEM. included in the term 'epileptic mania.' The attacks of mania resemble those which have already been referred to as constituting a part of the epileptic paroxysm ; but they may occur independently of the epileptic fit, and may last from a few hours, or two or three days, to a week or two or more. They are remarkable, as a rule, for the suddenness of their inva- sion and the suddenness of their subsidence. They present two varieties, which by Dr. Falret are termed respectively ^e^^i mal and haut mat. The latter is furious, attended with sudden attacks of uncontrollable violence and ideas and hallucinations of a terrifying character ; the language of the patient is less incoherent than that of many other lunatics, and it is remarkable that each successive maniacal attack repeats the main features, in almost every detail, of the attacks that have gone before. In the petit mal the patient is morose and despondent, and mistrusts and fears those who are about him ; he is impelled, as it were, by some superior power, in obedience to which he performs acts that he would not otherwise do ; he leaves his home and occupation, wanders about, and is liable to sudden out- breaks of passion, in which he will attack, destroy, or kill whatever comes in his way, or commit suicide. Li both forms of mania the comparative co- herence of the patient might lead one to suspect that he was either malin- gering, or under the dommance of simple revenge or passion. Yet his memory of what has occurred in his attacks is exceedingly defective : sometimes he recollects nothing ; more often he recollects fragments of what has happened, as of a dream ; but he can rarely call to mind all that has taken place, and perhaps forgets the main incidents entirely. In some cases of epilepsy the patient's mind undergoes gradual deteri- oration, and he becomes imbecile or idiotic. It is said to be principally in the case of the ^jef ii mal that this result ensues. Epilepsy does not tend immediately to shorten the duration of life ; nevertheless it materially increases the risks to life. The epileptic patient is liable to incur serious accidents : to fall into the fire ; to tumble into the water ; to be drowned while bathing ; or to fall from his horse, or from a scaffolding, or over a precipice ; he may also be choked when eating, or asphyxiated as he lies in bed. Very rarely the fit itself proves fatal without extraneous aid ; when it does, the patient dies from asphyxia during its first stage, or from exliaustion or coma during the status epilepticus. From the multiform characters which epilepsy presents, its diagnosis is often a matter of extreme difiiculty. When occurring only at night- time, it not unfrequently happens that the patient is ignorant of the nature of his malady, or even that he has anything the matter with him. Yet, even in cases of this kind, a hint, or an admission, or the statement of some special occurrence, may awaken the suspicions of the medical man. Thus the patient on waking up feels weary, sore and bruised ; or he is uneasy, with giddiness, headache, or confusion of mind, from which he slowly recovers ; or he finds that his tongue is sore, and that there is blood upon his pillow ; or he notices petechial spots or ecchymoses upon his face, neck, and chest, or in the conjunctivae ; or he finds that he has EPILEPSY. 1093 passed his evacuations into the bed, or that he has dislocated his shoulder or otherwise injured himself. Now any of these accidents may occm' independently of epilepsy; but if they recur from' time to time, and especially if two or three be associated, the evidence in favour of epilepsy becomes very strong. The actual epileptic attack may be confomided with apoplexy or with hysteria. The true apoplectic attack, in which the patient falls down sud- denly comatose, is now generally allowed to be epileptic or epileptiform. The pomt, therefore, to determine in such cases is not whether it be apo- plectic or epileptic, but what is the pathological condition on which the loss of consciousness depends. The distinctions between hysterical and epileptic fits are generally well-marked, and little doubt usually remains when the history of the case is obtained. Still the affections appear to run mto one another, and the condition termed hysterical epilepsy forms the link between them. The main pomts to bear in mind in forming a diagnosis are (apart from the patient's history) the usually much greater violence and much longer continuance of the paroxysm of hysteria, the more general distribution of the convulsive movements, and the generally great and persistent noisiness of the patient. The hysterical patient, moreover, is seldom unconscious, can generally be roused without much difficulty, rarely bites her tongue, passes her evacuations into the bed, or injures herself; the skin, too, is hot, and the pupils act under the influence of light. Few diseases are so frequently feigned as epilepsy. The coarser fea- tures of the haut mal are so striking that few persons can fail, with a little study, to imitate them fairly well. There are various points, how- ever, about the real attack which the actor does not observe, or cannot copy. Thus he neither bites his tongue, nor passes his evacuations into his trousers ; his pupils are probably not dilated, and certainly not insen- sible to light ; and his skin becomes hot and perspirmg with his violent muscular exertions. Further, when he falls he takes care not to hurt himself ; he over-acts the convulsive part of the attack, but probably fails in details ; moreover, he is alive to what is going on aroimd him, takes furtive glances at the bystanders, and gives distmct evidence that he feels if he be hurt, or if a jugful of cold water be thrown over him. Still there may be real difficulty ; and it behoves the physician not to commit the error of assuming that a real epileptic is malmgering. The stage which succeeds the period of insensibility is one not likely to be copied by a cheat ; yet it is a stage in which it is often not difficult to persuade oneself that a patient is shammmg. Morbid anatomy and pathology. — There are few diseases about the pathology of which we are so entirely ignorant as we are about that of epilepsy. It has been referred to anaemia of the nervous centres ; it has been referred to hyperfemia ; it has been assumed that the cerebral convolutions, the ganglia at the base, or the pons and medulla oblongata are mainly at fault ; and the disease has been regarded as one involving the nervous centres as a whole. Morbid anatomy scarcely helps us ; for in the rare 1094 DISEASES OF THE NEEVOUS SYSTEM. cases in whicli death lias occurred in a fit, little or nothing more than hyper^emia has been detected, "svith in some cases hemorrhage into the perivascular sheaths of the smaller vessels ; and when chronic epileptics have been examined post mortem., either the brain has looked healthy, or it has appeared to have shrunk somewhat, or there has been some indura- tion of the white matter, or some thickening of the walls of the minute vessels with traces of pre'^dous hemorrhage in their "sdcmity. These lesions, however, have been mainly recognised in the brains of those whose epilepsy was associated with chronic insanity or dementia. Experiment has clearly shown that ansemia of the brain, suddenly produced, causes epileptiform convulsions ; but, on the other hand, extreme congestion of the brain, as occurs during the prolonged paroxysmal cough of pertussis, is also followed by uisensibility associated with convulsive twitchings. There is every reason on clinical grounds to beheve that in the epileptic paroxysm the brain is successively ansemic and congested. The extreme pallor which overspreads the surface at the commencement of the attack, and which has been observed, we beheve, by Dr. Jackson to pervade the retinal vessels as well, may be taken as a clear indication that the brain itself is anaemic at that time. And the great venous and capillary conges- tion which almost immediately afterwards replaces that pallor, coupled with the presence of post-mortem congestion and capillary hemorrhages in the brain in fatal cases of epilepsy, shows clearly that the early anaemic condition of the brain is soon succeeded by notable congestion. But, even if it be allowed that anaemia of the brain is the cause of the earhest epileptic phenomena, mcluding the tonic spasms, it is obvious that it is not the cause of the clonic spasms which come on with congestion. Dr. Marshall Hall, who clearly recognised this sequence, referred the clonic spasms to the congestion which followed upon the cessation of the respi- ratory acts, and recommended the performance of tracheotomy with the object of preventing their supervention, and so of robbing the disease of its chief horrors. But if the epileptic phenomena depend on mere congestion or ansemia, this must obviously originate in some functional disturbance at the source of the vasomotor nerves which are distributed to the cerebral vessels. The medulla oblongata and upper part of the cord are regarded by Dr. EejTiolds as the primary seat of epilepsy. And MM. Luys and Viosin, as the result of careful post-mortem investigations, conclude that the parts which mainly suffer in this affection are the medulla oblongata, corpora striata, cerebellum, and other parts at the base of the brain. On the other hand, it has been shown by Brown- Sequard that epUeptic convulsions may be artificially induced in guinea-pigs as a consequence of section of one of the lateral columns of the cord anywhere between the medulla and tenth dorsal vertebra. It must be admitted, indeed, that both tonic and clonic con\ailsions may be of spuial origin, and that in epileptic convulsions the motor tract of the cord must necessarily be largely concerned ; at the same time, from the special imphcation of the nerves at the base of the brain, there can be no doubt that the motor nuclei in the medulla oblongata and EPILEPSY. 1095 on the floor of the fourth ventricle and iter must he at least equally affected ; further, from the general unilateral tendency of the spasms or predommant action of the muscles of one side when both sides are in- volved, there is great reason to suspect that, however much the various nuclei of the motor tract are involved, they are dominated by the corpus striatum. Still, when we look to the cluneal facts of epilepsy, and recollect that convidsion is by no means the most frequent or the most important element of the attack, and that when it occurs it is usually preceded by some am-a, sensation, spasm, or hallucination, and is attended fi'om the beginning either with absolute loss of consciousness or with a dreamy con- dition in which there is often a total insensibility to external impressions, it is impossible not to acknowledge that, however seriously the cord, medulla, and gangha at the base of the brain may be implicated subse- quently, the earhest phenomenon must be connected with some hmited spot in the nervous centres, which, though different for different cases, is probably always the same for the same case ; that the pain, sensation, gidduaess, or hallucination is probably of central origin ; and that from this primarily affected spot a sudden influence is discharged over the sen- sorium and the sensori-motor regions of the cerebrum, which as regards the sensorium either annuls consciousness wholly or in part, or perverts it, and, as regards the motorial system, either excites it to unwonted or perverted action, or arrests its operations. There is reason, therefore, to believe that the epileptic fit commences before the brain becomes anemic, and room, therefore, to question whether this anemic state of the brain is the cause or the consequence of the symptoms which accompany it. There is equal reason, we thmk, to doubt whether the congestion which follows the anaemia is the cause of the clonic contractions and of the various phenomena which attend their occurrence ; and whether, finally, the after-symptoms are to be referred fas some suppose) to carbonic acid poisoning. The pathology of the affection is, we repeat, obscure, and we do not attempt to elucidate it. Treatment. — Durmg the epileptic attack there is usually little to be done beyond preventing the patient from injuring himself, and removing all sources of pressure fr'om his neck. It is often well to prevent him from biting his tongue by insertmg a pad between his teeth. Convulsions may often be allayed by the inhalation of chloroform ; and it may be advisable, when the congestion of the face is extreme and long-continued, to remove blood from the distended vessels of the neck. Not unfrequently, when the attack is preceded by a warning of sufficient duration, it may by proper management be averted. Among measures which have been successfially adopted for this pm'pose are : the inhalation of chloroform or ammonia, the administration of a dose of sal- volatile or ether, the apphcation of a ligature above the point from which the am-a springs, or the forcible pre- vention of the closing of the fingers or the flexion of the arm, when such movements constitute the premonitory symptoms. Latterly Dr. Crichton Brown has for the same purpose had recourse, with success, to the in- halation of nitrite of amyl. 1096 DISEASES OF THE NEEVOUS SYSTEM. The measures which have been employed to cure epilepsy are innu- merable. Many drugs have been administered with more or less success, among which may be enumerated the sulphate and oxide of zinc, arsenic, copper, iron, nitrate and oxide of silver, and the bromides of potassium and ammonium ; belladonna, digitalis, strychnia, opium, and Indian hemp ; as also musk, valerian, and assafoetida. The list might easily be extended. Of the above, those which have perhaps enjoyed the widest reputation are the salts of zinc, silver, and arsenic, belladonna, and the bromides of potassium and ammonium. Belladonna has been strongly advocated by Trousseau, who recommends that it be given in the form of a pill contain- ing -1- grain each of the extract and powdered leaves ; or that in its place the -j-^-g- of a grain of the sulphate of atropia be administered. He recom- mends that during the first month one of the pills be given daily, and that a pill per month be added, until the daily allowance of pills amounts to from five to twenty. He strongly urges that the pills be given either night or morning, according as the fits are nocturnal or by day, and in- variably at the same hour in the same case. Bromide of potassium has been the favourite remedy of late years, and there is no doubt that its use is often highly beneficial and sometimes curative. The dose should vary from 10 to 30 grains three times a day, and it should be given for a con- siderable length of time. But probably more important than medicine is careful attention to hygiene ; the patient's habits should be ascertained, and, if in fault, corrected ; masturbation and excessive venereal indulgence should be checked; over- eating, and especially over-drinking, late and irregular hours, and excitement of all sorts should be avoided. He should live quietly, keep good hours, take nourishing wholesome food, eschew alcohol as far as possible, attend to the condition of his evacuations, and, if need be, have change of air and scene. It is often a question whether the patient should give up work : whether, if a man, he should cease to engage in his ordinary business pursuits ; if a child, give up learning. The answer to such questions must depend on the special circumstances of the case. No doubt, when the fits are severe and frequent, it may be well to cease, at least for a while, from all mental labour and sense of responsibility ; but in the great majority of cases there is every reason to beheve that a certain amount of mental occupation, and it may be added of bodily exercise, is beneficial to the patient, and that, on the other hand, entire cessation from work is injurious. As a rule, therefore, the child should pursue his studies, the adult his usual avocations ; but neither should be allowed to push his work to excess. Lastly, counter-irritation, setons and issues behind the neck, shower-baths, cold baths, and ice along the spine, and even the removal of the clitoris or of the testicles have each had their special advocates. There are no sufficient grounds, how- ever, for believing any one of these measures to be really beneficial. ECLAMPSIA. 1097 B. Eclampsia. Definition and causation. — This is the name now commonly applied to all those varieties of epileptiform convulsions which occur accidentally, so to speak, in dependence on some specific lesion or the presence of some special pathological or physiological process. Eclampsia may be one of the phenomena consequent on h-acture of the skull, efiiision of blood into the brain, or obstruction of a cerebral artery ; it may be developed in connection with the growth of an uitracranial tumour, whether this be tubercular, syphihtic, carcmomatous, hydatid, aneurysmal, or other ; it is liable to occur when there has been sudden and copious loss of blood, when the brain is deeply congested, or when certain poisons circulate with the blood — it thus attends poisoning by hydrocyanic acid or absmthe, the retention of effete matters m the blood from renal disease, and in yomig children is often one of the earliest indications of the operation of the scarlatinal poison or that of other infectious disorders ; fm-ther, it is often induced by reflex action, and thus sometimes occurs during parturition, and in childi-en is a frequent consequence of teething, gastro-intestinal disturbance, and many slight local conditions which in older persons would cause httle or no inconvenience. Symptoms and progress. — The fits of eclampsia are not distinguishable from those of true epilepsy. They may be exceedingly slight, they may be robbed, as it were, of one or more of the recognised stages, or they may present m a typical form all the sequence of events characteristic of the hatit mat. But they are often less sudden in their invasion ; the patients are less liable to lose consciousness absolutely than true epileptics are ; the fits much more frequently have a fatal issue, either from coma or from exhaustion ; and they are much more irregular in their occurrence — probably, however, becommg more and more frequent and severe if the affection on which they depend is a progressive one, or ceasing permanently if their cause is removed. Further, with the exception that children who have eclampsia sometimes become epileptic in after life, these accidental fits seldom or never merge mto true epilepsy. The diagnosis of these cases must depend less on the phenomena of the attack than on their history and the circumstances which attend them — such as the presence of constitutional syphilis, the existence of renal disease, the fact that symptoms of cerebral disorder have been gradually creeping on before the convulsions attacked the patient, the evidences of abundant loss of blood, the progi'ess of parturition, and the like. Treatment. — The treatment of eclampsia will depend mainly on the diagnosis at which we arrive : thus, syphilitic eclampsia will need to be treated with iodide of potassium and mercury ; renal eclampsia will pro- bably demand the use of powerful drastic purgatives ; anemic eclampsia will call for tonics, nourishment, and stimulants ; eclampsia arismg from ac cidental causes of irritation will require the removal of these causes ; while that variety which is connected with progressive cerebral disease can only be treated by palliative measures. 1098 DISEASES OF THE NEEYOUS SYSTEM. C. Infantile Convulsions. Definition and causation. — These are seldom epileptic in the true sense of the term, and come therefore properly under the head of eclampsia. There are reasons, however, for giving a separate brief consideration to them. Convulsions arise in young children, especially during the time of teething, i^^th remarkable readiness and fi'equency ; and indeed Dr. West obser-ves that convulsions in children seem often to take the place of delirium, or rigors, in adults. It is certain that they are often developed in the course of diarrhoea and other disorders of the gastro-intestiiial tract ; that they occur in btonchitis and other affections of the resph-atory apparatus ; that they come on not only at the period of invasion of scarlet fever and other hke diseases, but that they may be induced in the com'se of these disorders by various accidental circumstances ; that they often depend on mere innutrition or anEemia ; that they are common in rickety children ; and that they are peculiarly liable to occur in connection with the irritation of teething. Children are, of course, hable, as adults are, to convulsions in the course of the development of tumom'S or other diseases of the brain or its meninges. Symptoms and ])rogress. — The convulsive attacks of childi'en do not differ essentially h'om those of adults. They may be equally numerous, equally violent, and the ' status epilepticus ' may equally be developed. They vary also in thek intensity between the widest extremes. They do not, therefore, need any special description. Shght fits or threatenings of fits are very often indicated, either when the child is awake or when he is asleep, by sudden spasm of one or both hands with tm-ning inwards of the thumb upon the palm, or by a momentary fixedness in the child's look, attended probably with pallor, dilatation of pupils, squinting, or some convulsive twitches of the face or limbs. It not unfrequently happens m children that the incidents of the fit are mainly connected with spasmodic contraction of the glottis and respiratory muscles. Respiration suddenly ceases, the face becomes Uvid and bloated, the veins swell, there is some roUing of the eyes, some convulsive movements of the muscles of the face ; then the head falls upon the chest, and the hmbs become flaccid, the pulse gets feeble, quick, and perhaps imperceptible, bloody sputum issues h'om the mouth, copious sweats break out, and if respu'ation be not speedily restored death ensues. In some instances such attacks are ushered in with a kind of crowing insph'ation (laryn- gismus stridulus) ; in many they are perfectly silent. They are sometimes brought on during the continuous holding of the breath, or continuous expiration, which occurs when the child begins to cry, or when he is coughing or about to cough, and especially in connection with the paroxysmal attacks of hooping-cough. The number of fits which children suffer from and the fi-equency of then recurrence vary greatly. Sometimes the child has a single fit and never anv more ; sometimes the fits recm- INFANTILE CONVULSIONS. HYSTEEIA. 1099 many times a day, and the child may experience many hmidreds of them in the course of a year. Not unfrequently, as before stated, he may pass into the status epilepticus and remain in that condition for some hours, or even a day or two. Infantile convulsions are always, and on good grounds, a matter for serious alarm ; it is astonishing, however, how children will suffer from almost innumerable fits occurring off and on for months and years, and yet recover perfectly. On the other hand, they are often fatal. The most dangerous are those which chiefly implicate the respiratory organs, and those which by their rapid succession render the child comatose for a long period. The immediate cause of death is either suddenly or slowly induced asphyxia, asthenia, or coma. Fits often repeated have in some instances similar results to those occurring in adults : they are sometimes followed by hemiplegia or some other form of paralysis, or by failure of intelligence or idiocy. Stammering, squinting, and other such defects are sometimes attributed to fits in early life. Treatment. — The child's general health must be carefully maintained or improved; all affections, all causes of irritation which are present must be removed. Bronchitis must be cured, diarrhoea checked, irri- tability of the stomach assuaged ; if the gums are congested and swollen and the child is evidently suffering in consequence, they should be freely lanced, and the operation should be repeated whenever the indications of irritation return ; if the child has been having unwholesome or insufficient food, or if he has been over-fed, these conditions must be obviated. The various specific modes of treatment are as applicable in the case of young children as in that of adults ; and hence belladonna, bromide of potassium, antispasmodics, and other remedies have all been recommended, and in certain cases have been found serviceable. In the fit itself, there seems no reason to object to the ordinary practice of putting the child into a hot bath, and applying cold water, or a sponge dipped in cold water, to his head or face. Chloroform inhalations may also be had recourse to. Fits may sometimes be averted by applying ammonia to the nose, or cold water to the face, at the moment of their commencement, or when pre- monitory symptoms are heralding their approach. XIV. HYSTEEIA. Definition. — It is difficult to describe, still more difficult to define, hysteria. It may, however, in general terms be said to be a functional disorder of the nervous system, occurrhag mainly in females from the age of puberty upwards, in which the will, the intellect, the emotions, sensation, motion, and the various functions which are under the influence of the nervous system, are involved, or apt to be mvolved, in a greater or less degree. Causation. — As has already been stated in the definition of the disease, hysteria prmcipally affects females and usually makes its appearance in them for the first time between the age of commencing puberty and that 1100 DISEASES OP THE NEEVOUS SYSTEM. of five-and-twenty. It may come on, however, previous to puberty, and at any age after twenty-five ; but in the latter case more especially about the time of the cessation of the menses. Males occasionally become dis- tinctly hysterical ; but there does not appear to be the same tendency in them as in women for the disease to come on in early life. The causes of hysteria, like those of so many other functional nervous disorders, are very obscure. There are two or three, however, which seem to have a very important influence, direct or indirect, in its causation ; these are emotional disturbance, sexual conditions, and occupation. Nothing is more certain than that hysterical phenomena and the hys- terical fit itself are frequently induced by circumstances which affect the emotions powerfully, such as sudden fright or horror, powerful religious impressions, disappointed love or hope deferred, grief, jealousy, and the like. And indeed in those who are strongly predisposed to the afi:'ection the most trivial disturbances of this kind are liable to provoke violent outbreaks. Hysteria, like chorea and epilepsy, is often contagious. The name hysteria was given to the disease under consideration in the belief that the womb was its seat. The fact that it occurs amongst men shows that that view of its origin cannot, at least in all case's, be correct. As regards females, however, there can be no doubt that the reproductive functions or organs do exercise a greater or less influence over its pro- duction. It comes on usually about the period of puberty or that of the climacteric change. Though not by any means occurring only in un- married women, and those who are unhappily married, it occurs in them much more frequently than in such as become the happy mothers of families. And again in no inconsiderable number of cases there is distinct evidence of involvement of one or both ovaries in the facts that they are painful to pressure and that characteristic hysterical symptoms may be induced by applying strong pressure to them. There is, however, no necessary connection between the condition of the catamenial flow and hysteria, although it must be admitted that the catamenia are often at fault in hysterical women, and that occasionally their restoration to the normal condition is attended with the restoration of the patient's general health. Nor is there sufficient ground for believing that the mere default of sexual congress either in the male or in the female has, as a rule, any important influence in its causation ; excepting perhaps in so far as it may be connected with the yearning for love, the sense of neglect, jealousy, and other such feelings. Sexual excesses, and especially mas- turbation, have been assigned as causes. There can be little doubt that occupation and position in life have something to do with the production of hysteria : for it is a disease which affects the higher classes in a disproportionate degree ; but if these con- ditions are concerned in its causation, it is owing to the accidental fact that wealth brings with it the needlessness for work and the capability of indulgence in frivolous amusements and idleness, with consequent neglect of the healthy exercise and discipline of the mind. Other causes which have been assigned for hysteria are hereditary predisposition, overwork, HYSTERIA. 1101 anaemia, debility, and other forms of failure of health ; but any influence they may exert is at best remote. Symi^toms and progress. — Li describing the clmical phenomena of hysteria we will first discuss the mental characteristics of those who suffer from it, and then consider seriatim the various motor, sensory, and sympathetic disturbances which are apt to be associated with them. The mental conditions of hysterical patients present the greatest variety, and yet there are gradations between the extreme conditions which prove their relationship. In many cases women who are liable to hysterical attacks under occasional states of ill-health or excitement are in the intervals between their attacks as healthy in body and mind, and as free from all caprice or peculiarities of temper, as we could wish to see them. They will often acknowledge, however, that at the moment when hysterical feelings come upon them, they feel compelled to yield to them, and indisposed to make any effort to restrain them ; and that yet if any- thing occurs to incite them to use self-control, they are able to resist them successfully. In other cases the patient is nervous and excitable, with little control over either her emotions or her actions, apt to laugh or cry on the slightest provocation and incongruously, and apt also to suffer from time to time from the various complications of hysteria. But in a very large proportion of cases the whole moral character of the patient is profoundly altered. She is apathetic and neglectful of her duties, or exacting, selfish, and suspicious, exaggerating all her trivial annoyances and discomforts or disorders, resenting all healthy advice or reasonable attempts to promote her welfare, and quarrelling, therefore, it may be, with her husband or dearest friend, but pouring out profuse affection on all those acquaintances, however new they may be, who affect to pity her condition, make the most of her ailments, and adapt themselves to all her changmg moods and caprices. Under such circumstances it is as- tonishing to see women, well-nourished, and apparently in the best of general bodily health, remain for months and years useless members of society, suffering from paralysis and other maladies which they profess to look upon with the utmost alarm (and which they declare perhaps to be family complaints) not only with quiet complacency, but with a studied resistance to all plans of treatment likely to be of service to them. They are probably only too willing, however, to put themselves into the hands of some fashionable charlatan, or to do anything else which will render their misfortunes in any degree notorious. It is but a step from hugging her ailments and exaggerating them to malingering. And although we cannot fairly accuse the great majority of hysterical patients of shammmg, shamming is by no means uncommon. The cravmg for pity and notoriety increases by bemg fed ; the greater the commiseration she excites, the more does she endeavour to be worthy of it, and the more serious become the ailments from which she is suffering ; and soon perhaps new phenomena develop. It is an interesting and important fact that the nature of these phenomena is not unfrequently determined by the direction which the interest and solicitude of the doctor or friends happen to take. If they 1102 DISEASES OF THE NERVOUS SYSTEM. pity her failing appetite, she soon perhaps affects to hve without food ; if it be observed that her urine and motions are scanty, she finds before long that they cease altogether ; if it be a matter of wonder or speculation what becomes of her evacuations, she will be found perhaps to vomit urine or fffices, or blood. It is by such persons, though not by these alone, that various other singular forms of malingering are practised. Thus at one time a patient will bring on hard oedema or spurious elephantiasis of the arm or leg by the constant application of a ligature round the upper part of the limb, and wiU even submit to its amputation ; at one time she wiU, by the constant application of some irritant substance, fret her skin into ulcers, and thus even cause perforation of the stomach ; at one time she will place lumps of coal up her vagina and pretend that she is suffering from vesical calculus : at one time she will affect to have communion with the Virgin Mary, to have the marks of the stigmata on herTiands and feet and side, and at the same time, probably, to live devoid of all those natural appetites and wants which are mherent m humanity. Hysterical patients sometimes suffer from a form of insanity known as hysterical mania ; and occasionally after the lapse of years pass into a state of dementia. We will now proceed to describe the various phenomena which are so apt to go along with the mental states which have just been considered, and which form, as a rule, the more striking phenomena of hysteria. 1. Convulsions and siMsms. — Hysterical convulsions vary in their severity and duration, and have a more or less general resemblance to those of epilepsy, from which, however, it is important to distinguish them. The patient is rarely att acked without warning. She has probably, for some little time previously, been suffering from hysterical symptoms ; she has been laughing, crying, or sobbing, or talkmg wildly or gesticulating violently, or she has complamed of a sense of constriction or of a ball in the throat, or has manifested, in a marked way, some of the mental or emotional phenomena which are characteristic of hysteria. Then suddenly, perhaps, she utters a loud scream, and falls upon the sofa or the ground violently convulsed. The fit may last for a few moments, or be prolonged for a quarter of an hour, or continued by successive attacks for many hours, interrupted from time to time by cries, and sobs, and laughter. Such phenomena generally also attend the subsidence of the attack ; or, if the patient be worn out with her long-continued exertions, she falls into a sound sleep. The main features by which the hysterical fit may be dis- tinguished from the epileptic are the following : — the hysterical patient, no matter how severe her attack may be, is very seldom totally uncon- scious ; she can generally be aroused either by the voice of authority, or a douche of cold water ; she is noisy— the epileptic utters a single cry, or none at all, while the hysterical patient probably screams and cries and laughs and groans, or talks volubly and mcoherently off and on during the whole of her attack ; her convulsions are much more general and ex- tensive than those of the epileptic— she throws her arms and legs about in all directions, she twists her body into the most grotesque attitudes, she suddenly raises herself to the sitting posture, and then throws her- HYSTEEIA. 1103 self violently down again ; but with all this violence and excess of muscular effort she rarely, if ever, injures herself; the convulsions are seldom tonic at any period of the attack ; they are rarely, if ever, unilateral, and the face (excepting when the patient is crying out) is free from the hideous distortion of epilepsy ; she does not bite her tongue ; the eyelids are closed and tremulous, but the pupils respond to light, and there is no tendency to squmt ; respiration never ceases, but is from the beginning noisy and irregular, and consequently, although the sldn may become hot and per- spiring, the patient never presents that lividity of countenance which attends the true epileptic attack ; she does not discharge the contents of her rectum and bladder ; and lastly, if we investigate the history of the patient, we never find that she suffers fi'om attacks of the petit mal or epileptic vertigo. Yet, though the distinction between epilepsy and hysteria is for the most part easy, instances are sometimes met with in confirmed and severe cases {hystero-epilepsy), in which the hysterical attack puts on some of the features of epilepsy. It is then attended with sudden and total unconsciousness, and it may be with tonic spasm, tem- porary arrest of respiration, lividity of face, and biting of the tongue ; but even here the antecedent presence of the globus hystericus and other indi- cations of hysteria, and the ultimate conversion of the attack into one of obvious hysteria, are generally sufficient to render diagnosis easy. Charcot points out as a further distinction between these attacks and those of true epilepsy, that they never lead to impairment of the intelligence or dementia ; he further points out as an important distinction between the status epilepticus and the corresponding condition in hysteria, that in the former case the temperature rises to 103° or 104° or more, while in hysteria it rarely exceeds the normal by more than one or two degrees. But, besides these general convulsive attacks, hysterical patients are liable to permanent or tonic contractions of groups of muscles or limbs. These, as will presently appear, are not unfrequently associated with paralysis. Among them may be mentioned spasmodic closure of the hands, trismus, and spasmodic contractions at the knee or other joints. 2. Hyperesthesia is exceedingly common among hysterical women. It may be general, or hemiplegia, or paraplegic, or it may affect a limb or a joint, the mamma or the ovary, the spine, or indeed any part of the surface, or any organ. Pain varies in its severity, is sometimes induced only by pressure, but often occurs independently of all external sources of irritation. It is a cmious and suggestive, but not invariable, character- istic of it, that the patient will shrink from the slightest touch when she is expecting it, and yet will allow the painful part to be compressed and handled violently when her attention is directed to other matters. A common pam of which hysterical women complain is that which is termed clavus ; it is generally referred to the forehead just above the eyebrow, and is likened to the effect of a nail driven into the skull. The most interesting variety of hyperesthesia, however, is that of which the globus hystericus forms a part. The globus hystericus is a sensation as of a ball rising into the throat and impeding respiration ; it is of frequent occur- 1104 DISEASES OP THE NEEVOUS SYSTEM. rence in hysterical patients, and is commonly present before and during paroxysmal attacks. It often seems to spring from the iliac fossa. The patient then complains of pain or tenderness on pressure in this situation, whence from time to time the hysterical aura, as it may be termed, seems to spread : first to the epigastrium, causing nausea and vomitmg ; then to the chest, provoking violent action of the heart and palpitation ; then to the neck, constituting the globus hystericus, which is often associated with sobbing, choking, and other such symptoms ; and thence finally, according to M. Charcot, to the head, when it induces noises in the ear, dimness of vision, and clavus, all on that side of the body from which the aura started. These phenomena constantly precede the occurrence of the hysterical fit, and, accordmg to the older writers, with whom M. Charcot is completely in accord on this point, are referrible to some peculiar condition of one or other ovary, generally the left. He states : that in a large number of hysterical women there is a tender point which may be discovered on deep pressure made directly backwards at the point of mtersection of the horizontal line drawn between the two antero-superior ihac spines, and the contmuation downwards of the vertical line which marks the lateral boundary of the epigastrium ; that this point represents the ovary, which may in fact, when the abdominal walls are flaccid, be often distinctly felt in this situation ; and that continued pressure upon it will induce all the phenomena above described of the hysterical aura. This iliac or hypogastric pain varies in severity ; in many cases it can only be discovered by hunting for it ; but in many extreme pain and tenderness, so great as to forbid the slightest x^ressure, occupy not only the ovary but the superposed muscles and sHn ; and occasionally these phenomena become so widely diffused as to simulate the local symptoms of peritonitis. Intolerance of light, intolerance of sound, and intolerance of certain sapid or odorous substances, often associated with extreme acuteness of the special senses, are very common in hysterical women. But here again the phenomena generally present that marked character- istic of hysteria, namely, that the patient will complain bitterly of the slightest impression when her mind is directed towards it, but will endure the most discordant sound or the brightest light when her attention is distracted by other objects. 3. Ancssthesia is frequent among hysterical persons. It may occur in various parts of the body, and be limited to the distribution of a single nerve ; it may affect the sense of smeU, or taste, or may implicate the eye, causmg dimness of vision or difficulty m recognisuag colours. The most remarkable cases, however, are those of hemian^esthesia, with or without eo-existmg loss of motor power. In this variety the loss of sensation as a rule involves uniformly the whole of one side of the body — leg, trunk, arm, and head and neck — ceasing abruptly at the median hne ; and it involves not merely the skin, but the mucous membrane of the mouth and the organs of sense, so that taste and smell are lost upon the affected side, and hearing and eyesight probably fail. As regards eyesight the patient loses in a greater or less degree the power of distinguishing colours HYSTERIA. 1105 or recognising the forms of objects. Sometimes she perceives only a white mist. Sometimes the field of vision is contracted. Fiu-ther, the anaesthesia usually implicates the deeper-seated tissues as well, namely, the muscles, bones, and joints. It may be complete and profound, or it may be merely insensibility to pain, ^\dth or without insensibility to varia- tions of temperature. The anaesthetic parts are usually pale, and their temperature more or less considerably reduced, and when pricked they bleed less readily than healthy parts. Hemianaesthesia is apt to come and go, and occasionally shifts to the opposite side of the body. Some- times the anaesthesia becomes bilateral. 4. Paralytic conditions are probably the most common of the com- plications of hysteria. Like anaesthesia, paralysis may affect any part ; it may involve the hand, the forearm, the entire upper extremity ; it may affect the leg or some part of it ; in some cases it assumes the form of paraplegia, in some that of hemiplegia ; or it may be irregularly distributed, or general. It seldom implicates the muscles of expression or the tongue. The paralysis may be complete or incomplete. The affected Hmb or Hmbs may be flaccid or rigid. The muscles usually do not waste, but they may of course waste from disuse. In the majority of cases hysterical paralysis may be distinguished from other forms of paralysis with tolerable readi- ness, but not always. If the paralysis be hemiplegic, it comes on probably after an hysterical fit ; it involves the arm and leg, but neither the tongue nor the face ; the affected- Hmbs are probably rigid — the arm bent, the hand firmly closed ; while the lower extremity, on the other hand, is extended — the toes pointed, and the limb and pelvis moveable only in mass ; it may be that the arm is flaccid while the leg is contracted, or conversely ; the paralysis is probably associated with hemianaesthesia. It may be remarked that the hemiplegia of organic brain-disease is only occasionally associated with complete hemianaBsthesia ; that it is never attended ^dth persistent rigidity from the beginning ; and that if in tliis case there be any difference between the arm and leg in this respect, it is the arm and not the leg which becomes rigid. If the paralysis be para- plegic, the limbs are usually rigid and in a condition of extension ; and the paralysis with rigidity is probably, as in the other case, suddenly developed. Whether the paralysis be hemiplegic or paraplegic, or limited to a Hmb, or part of a limb, it is apt to come and go, and to shift from limb to limb, or to involve more or less suddenly other limbs besides those first affected ; and, above all, it is generally associated with other pheno- mena indicative of the presence of hysteria. It is important, however, to recollect : that, although hysterical paralysis generally presents variations in degree, in character, and in site, it is (especially in its hemiplegic or para- plegic form) liable to continue for years or for life ; and that although as a rule the muscles remain unaffected as regards their bulk and con- tractility, they may, in cases of long standing, undergo degenerative changes from disuse, in connection with which secondary lesions may also take place in the cord. 5. Affections of the larynx and air-ijassages. — Aphonia is very com- 4b 1106 DISEASES OF THE NEEVOUS SYSTEM. nion ; the patient loses lier voice completely and speaks only in the feeblest whisper ; she probably, however, has no soreness in the throat, no difficulty or pain in swallowing, no evidence whatever of local disease. The voice, moreover, is generally feeblest when the patient is asked to display her powers ; a;nd sometimes reappears with sudden force under the influence of momentary excitement or it may be of forgetfulness. In some cases there is actual dyspnoea, which becomes so extreme as to demand operative procedure. Attacks simulating those of ordinary asthma are occasionally observed. Not unfrequently a peculiar cough, which Sir Thomas Watson describes as 'loud, harsh, dry, more like a bark, or a hoarse bleat, than a cough,' is one of the special phenomena of hysteria ; it is apt to come on in paroxysms, which may continue for hours without cessation, and may come on daily or nightly for weeks or months. In some cases, without apparent cause, and with a pulse but little exceeding the normal rate, the respirations suddenly rise to 40, 50, or even 70 or 80 in the minute, and continue thus for some minutes, or on and off for hours, and yet without other evidence of dyspnoea or distress. 6. Affections of the alimentary canal. — In some instances patients suffer from well-marked trismus, which interferes seriously with both speaking and eating ; occasionally they complain of difficulty of degluti- tion ; and distension of the stomach, with rumbling and eructations, is of common occurrence. Hysterical patients often suffer from vomiting, and in some cases this constitutes the most serious part of their malady ; the vomiting is apt to come on after every meal, or it may be at some parti- cular time of day, and to be continued day after day for months or years. This sickness is frequently associated with good or even voracious appetite ; but the bulk of matters vomited often seems in excess of the ingesta, and after a time extreme emaciation and debility probably ensue. In some instances the symptoms almost accurately resemble those due to ulcer of the stomach. In a case of hysteria recently under care, occurring in a girl fifteen years of age, who had had hysterical hip-joint for three years, her other symptoms got complicated with vomiting after everything she took, and she became reduced to a skeleton. She was treated successively with milk in dessert-spoonful doses, then in tea-spoonful doses, and sub- sequently with pulp of raw beef in small quantities ; but still she was sick, and from a few minutes to a quarter of an hour after deglutition vomited whatever she had taken. She was then fed only by enemata for some days ; after which the feeding with milk in small quantities was resumed, but with the same result. It struck us at length that possibly the food never entered the stomach, but was retained in the oesophagus in conse- quence of spasmodic contraction of its lower part. We determined there- fore to pass a tube, and to inject milk direct into the stomach. Three or four ounces were thus introduced, and they were retained. From that time forwards she swallowed without difficulty and was no more sick. The bowels are usually constipated, and there may be pain in defaB- .cation. 7. Affections of the urinary organs. — Retention of urine often occurs. HYSTEEIA. 1107 Doubtless it sometimes depends on paralysis of the bladder, contraction of the sphincter, or pain in the act of micturition ; but not unfrequently, like most other hysterical conditions, it is more or less within the control of the patient, who makes no attempt to relieve herself voluntarily so long as she can enjoy the morbid pleasure of having the catheter passed for her. But more mteresting than this are the phenomena connected with the secretion of urine. It usually happens, after an hysterical fit, or after other paroxysmal nervous disorders, that the patient excretes large quan- tities of pale limpid urine. And such profuse discharges are not unfre- quent at other times. But the opposite condition may be present. The patient consecutively for many days does not pass more than a few ounces of urine. In a remarkable case published by M. Charcot, the sufferer, a woman, forty years old, for more than a couple of weeks passed every other day only five grammes of urine, and none on the intervening days, and for a continuous period of ten days secreted no urine whatever. During one month her average daily yield was only three grammes, and during another month only two grammes and a half. In this case the diminution and suppression of urine were unconnected with renal disease, but were associated with constant vomiting, the quantity of fluid vomited havmg some supplementary relation to the quantity of urine voided. Further, the vomit contained urea, yet the urea secreted daily hy the kidneys and stomach together was very far indeed below the normal. For a period of twelve days it amounted from both these sources to only five grammes daily. M. Charcot remarks, in reference to such cases, that the escape of even a small quantity of urea in calculous obstruc- tion of the ureters often serves to ward off dangerous symptoms, and that doubtless the same rule applies here ; but he further observes that there is probably in hysterical ischuria an impairment of the functions of assimi- lation which diminishes the total amount of urea and extractives to be discharged from the body. 8. Of ajfections of the reproductive system little remains to say beyond what has already been said. Amenorrhoea, menorrhagia, and other men- strual disorders are no doubt frequent accompaniments of hysteria ; but many hysterical women are quite free from them. Again, the hyper^es- thesia which is so common in various parts of the body in hysteria may affect the vulva or vagina and render the act of coition intolerable ; whilst on the other hand, lascivious feelings are occasionally strongly developed, and either induce in the patient a demeanour, probably towards certain individuals, which far transgresses the bounds of womanly self-respect, or give a motive for feigning disease of the sexual organs. It is not surpris- ing that the mental obliquity of such patients should occasionally incline in this direction. 9. Other ajfections which hysterical patients are apt to mimic are those of the spine, of the joints, and of the mamma. These have already been adverted to under the head of hyperesthesia. It need only be added that they often closely simulate inflammatory disorders of the same organs, and are apt to be mistaken for them ; and that we must not hastily assume 4 B 2 1108 DISEASES OF THE NEEVOUS SYSTEMT. that a suspected hysterical affection of these parts is not hysterical because we discover swelhng in addition to pain and tenderness. 10. Spinal irritation is the name given to a group of hysterical pheno- mena which have been particularly described by Mr, Teale and the Messrs. Griffin, and is still by many regarded as a distinct affection. It is charac- terised by the presence of tenderness at some spot in the course of the spine, or more rarely generally throughout its whole length, and .by pain or other nervous phenomena referred to those parts of the body whose sensory nerves are in relation with the tender spot, or to certain of the viscera. Moreover, pressure upon the tender spot aggravates, or it may be actually induces, the phenomena in question. If the tenderness occupy the upper part of the cervical spine, the neuralgic pain associated with it. affects the occipital region, or it may be even the distribution of the trifacial ; if it be a Httle lower down, the neck suffers ; if it occupy the situation of the cervical enlargement the pain is experienced mainly in the arms ; if it be present in the dorsal region then the parietes of the chest or abdomen suffer ; if it imphcate the lumbar enlargement, the pelvis and the lower extremities are the chief seats of pain. Further, the sensation of a lump in the throat, palpitation, dyspnoea, spasmodic cough, gastralgia, nausea and vomiting, irritability of the bladder, or suppression of urine are all apt to attend the spinal tenderness ; but the particular group of these complications appears to be determined, like the neuralgic pains, by the situation of this tenderness. In all respects besides those which have been enumerated, the symptoms which the patients present are identical with those of other forms of hysteria, and indeed the pheno- mena of these affections are, if not common to both, inextricably inter- woven. The course of the disease, moreover, is identical m all respects with that of hysteria. The diagyiosis of hysteria is not always easy ; and yet if the patient be carefully watched from day to day it is difficult to remain very long in doubt. It is not, however, an unnecessary caution to remind the reader that not only does hysteria ape many diseases so as to be readily mistaken for them, but that other diseases often simulate the phenomena of hysteria and may be easily taken for it. There is always a great temptation to assume that nervous disorders which we do not understand, and obscure visceral affections, in females are hysterical. Among diseases which may thus be mistaken for hysteria should especially be named chronic inflam- matory conditions of the brain and cord, and tumours of the brain. In forming a diagnosis we must carefully consider all the features which the special affection from which the patient suffers presents, and how far and in what respects they differ fi-om those of lesions of the same parts which are not of hysterical origin. We must also look carefully to the various complications which attend the main affection, or which supervene from time to time, or alternate with it ; for it rarely happens that a patient, suffering from an hysterical joint or from hysterical hemiplegia or para- plegia, does not also at one time or another have an attack of aphonia, or retention of urine, or a bout of intermingled laughmg and crymg, or a HYSTEKIA. 1109 distinct hysterical fit, or that the original affection does not undergo some striking change, or shift to some other part. We shall oftenlbe importantly aided in coming to a decision by careful observation of the demeanour and conduct of the patient, and of her general tone of thought and feeling. It may be added that in hysterical paralysis the reaction of the muscles to faradism and galvanism either remains normal, or shows general slight diminution only ; and in the latter case generally becomes normal after a brief application of electricity. The reactions of degeneration are never observed. Electrical sensibiUty of the muscles is generally lost in these cases. The tendon reflexes are probably always retained ; and even, according to Buzzard, ankle clonus is sometimes present. The superficial reflexes, especially the plantar reflex, are often absent. Hysteria is very common ; and varies from a slight affection of little importance to one of such gravity that it renders the patient a lifelong invalid, and her existence a burden and a misery to herself and those about her. Fortunately the milder cases are by far the most common ; and in many of these complete recovery takes place, while in many recovery is so far complete that there only remains^a liability to the •outbreak of slight hysterical phenomena under special circumstances of ill-health or excitement. Not unfrequently, however, patients sufler from hysterical vomiting, alternating it may be or associated with other hys- terical symptoms, for years ; or they remain hemiplegic or^paraplegic and bedridden for one, two, ten, or twenty years ; or they suffer from urinary .disorders, or aphonia, or joint -affections for an equally indefinite period ; or they are the victims of constantly recurring violent fits. In some cases patients continue thus for life. It may be said generally that the longer the phenomena have persisted, the less likely is ultimate recovery to take place ; but it must never be forgotten thatj(unless any organic complication has arisen) there is always a possibility that the patient will get well, and not only get well, but get well suddenly. The patient who has been confined to her bed paralytic for years will perhaps, mider the influence of some sudden impulse or mental or emotional excitement, recover the complete use of her limbs ; the patient who appeared doomed .to lifelong voicelessness will suddenly speak aloud in her natural tone. Pathology. — We do not pretend to give any account of the morbid ;anatomy of hysteria or of its pathology. On these heads little or nothing ^of any importance is Imown, and we do not care to speculate. It is, so far as we know, a purely functional disorder. Treatment. — The treatment of aggravated hysteria is exceedingly diffi- cult, and all the more difficult that the patient's condition^^excites in those about her that sympathy which she craves ; and that consequently that judicious firmness of management which the medical man should exercise is apt to be resented not only by herself but by her friends. Nothing, indeed, is more injurious to such patients than the pity and attention they receive ; they live for them, they lay their plans to attract them, and their moral and bodily conditions deteriorate under tlieir influence. On ,the other hand, the exercise of a judicious firmness is essential for their 1110 DISEASES OF THE NEEVOUS SYSTEM. successful treatment ; and this it is impossible for the medical man to accomplish unless he acquires the confidence, if not of the patient, at all- events of those under whose control she is. For this purpose it is not necessary to be harsh, indeed harshness is likely to defeat its object ; but the respect, and if possible the trust, of the patient should be acquired by the cultivation of kindliness and friendliness of manner with firmness of purpose. There should be on the part of the doctor a judicious blending- of the ' suaviter in modo ' with the ' fortiter in re.' No doubt hysterical patients are extremely disposed to exaggerate their symptoms. No doubt they do occasionally wilfully and grossly deceive those about them. But it must not be assumed that there is generally intentional exaggeration, still less that there is imposition. They do, as a rule, really suffer that of which they complain, and suffer more when their attention is directed to the ailing part. It is impossible in a brief space to lay down any rules with regard to the general treatment of these cases. No doubt it is important to improve the general health, to relieve dyspeptic symptoms, to cure anaemia, to regulate the catamenia, to see that the bowels act properly, to insist on regular hours, good wholesome diet, and daily exercise, and it may be to order change of air and scene ; especially it is important to make the patient take an interest and pleasure in some useful occupation or some intellectual recreation or study. But it must never be forgotten that, to use Sir Thomas Watson's words, ' behind the moody, reserved, and tricky beha\dour there often lies some mental or emotional cause — some hope deferred or disappointed — which being ascer- tained, and capable of satisfaction and satisfied, the patient may h& restored to her customary health.' Dr. Weir Mitchell has proposed, and practised with success in severe cases, and especially m cases characterised by loss of appetite, refusal of food, and emaciation, a plan of treatment which combines moral influence and physical measures : the most im- portant factors being the enforcement of absolute rest of mind and body,, regulated passive exercise of the muscles, and abundant feeding. To carry out the plan effectually the patient should be wholly separated from her friends and home and placed under the sole charge of a competent nurse ; her muscles should be well shampooed by a skilled rubber for two or three hours daily, and also well faradised once or twice a day for ten, fifteen, or twenty minutes at a time, and her diet should rapidly be increased in amount until she takes perhaps two or three times as much food as a healthy person would do. The course of over-feedmg is usually preceded, by several days of under-feeding. A few weeks are generally needed to effect a cure. Among the drugs which have been employed with more or less success,. or want of success, may be especially mentioned iron, zinc, vegetable tonics, assafcEtida and other fetid gum-resins, and stimulants. Alcohol in various forms is often recommended by the medical attendant or had recourse to by the patient ; but alcoholic beverages, chloral, opium, and other narcotic medicines, should be given or allowed Tvith extreme caution,, for the temporary relief which they give is very apt to lead to their habitual HYSTEEIA. 1111 use and ultimate abuse. In the hysterical paroxysm very often nothing more is needed than to lay the patient down and unfasten her dress or anything tight about her neck ; it may, however, frequently be cut short or prevented by the free use of cold water — by dashing it in quantity over the neck and face — or, as Dr. Hare points out, by firmly closing the patient's nose and mouth for a time, or until her dyspnoea is such that she is compelled to draw a long breath. Less valuable than these mea- sures, though not altogether to be despised, are the inhalation of sal-vola- tile or smelling salts, and the exhibition of ammonia, assafoetida, or ether. M. Charcot, besides pointing out the readiness with which hysterical paroxysms may be induced by pressure made in the region of one of the ovaries, shows that in the same cases powerful, regulated, and sustained pressure is generally efficacious in arresting the paroxysm, however violent it may be. The removal or relief of the various local phenomena of hysteria fre- quently demands special forms of treatment ; aphonia may generally be cured by faradism of the throat, effected either by placing one pole of the instrument within the throat and the other external to it, or by placing the poles on either side externally. Paralytic affections are largely benefited by the same treatment, or by the frequent use of the cold douche. Dr. Eeynolds especially recommends the application of narrow strips of blister round the affected limbs. Anassthesia also is sometimes remediable by faradism. But for this, especially if there be at the same time coldness of surface and imperfect circulation, as also for the cure of hysterical contractions, galvanism is probably preferable. It is mainly in cases of hysterical anaesthesia that Dr. Burq's ' metallo- therapeutic treatment has come into vogue. This consists in the local application of some metal to which, by experiment, the patient is found to be sensitive. The metals employed are gold, silver, iron, copper, and zinc. To ascertain which of these is appropriate, discs of each must be applied in succession for two or three minutes each to the region about to be operated upon. This point having been determined, bands or groups of discs of the selected metal must be kept for a quarter of an hour or so in close contact with the affected surface by a bandage or other means. It would appear that the result is that the affected part (whether it be the skin or organ of special sense) gradually recovers its sensibility, and that associated with this there is a return of warmth and circulation, and of muscular power. But it would also appear : that whatever improvement there is on the one side of the body is at the expense of the opposite side, which becomes antesthetic in proportion as the other recovers ; and, moreover, that tl>e recovery is only temporary. The sudden cure of hysteria in any of its forms is almost always possible under the. influence of powerful emotional excitement. Thus a sudden alarm that the house is on fire will sometimes cause a woman who has been paraplegic for years to rush from her bed with the full use 1 See report by MM. Charcot, Luys, and DumontiDallier, quoted in the British Medi- cal Jotirnal, May 19, 1877. 1112 DISEASES OF THE NEEVOUS SYSTEM. of lier limbs ; the unexpected infliction of sudden and severe pain gene- rally suffices to make the dumb cry out at the top of her natural voice ; the promise that if a long-closed hand opens by a certain day it shall have a valuable trinket placed in it generally calls for fulfilment. XV. CATALEPSY, ECSTASY, AND OTHEE CONDITIONS ALLIED TO HYSTEEIA. A large number of curious nervous phenomena — motor, sensory, emo- tional, and intellectual — occur, which are difficult to describe save by the help of illustrative cases, difficult to classify, and difficult to attach to specific lesions or specific conditions of the nervous system. In a large proportion of cases they originate in powerful mental excitement, and more especially in such as is connected with rehgious fervour ; they some- times also arise from imitation or moral contagion. Young persons, from the period of commencmg puberty to the termination of adolescence, and more particularly females, or males of emotional temperament, chiefly suffer. The patients are often distinctly hysterical ; and not unfrequently hysterical paroxysms and some of the various other phenomena which have been considered mider the head of hysteria complicate some of the conditions we are now about to describe, or alternate with them. Indeed, if we look to the exciting causes, to the class of persons who are most commonly affected, to the character of the symptoms, and to their frequent association with hysterical phenomena, we can scarcely avoid regarding the affections under consideration as varieties of hysteria. We believe that they generally are so. In some cases, however, they seem to be related rather to chorea, epilepsy, or insanity. 1. Bhythmical and other methodical movements. — These present innu- merable varieties of character. In some cases the patient performs un- ceasing oscillatory, undulatory, or rotatory movements of the head and neck, or of the entire trunk. In some she is seized with an uncontrollable impulse to run forwards or backwards. In some she is impelled from time to time to leap into the air. To the same class must be referred the violent rhythmical movements which attended the ' dancing mania ' of the Middle Ages. 2. Catalepsy. — By this term is meant an attack of loss of sensation and of consciousness, attended with remarkable stiffening of the muscles. The patient for the most part is attacked suddenly, after mental or emotional disturbance ; she becomes pale and corpse-like, the respirations being slow and tranquil, the pulse soft. She cannot be roused, and is entirely insen- sible to pain. But the most striking phenomenon is the stiffness of the muscles, which is such that the limbs, head and neck, or featm-es, when forcibly put into any position, however constrained and umiatural it may be, or however difficult to be supported by the healthy muscles, retain that position for some length of time. But although the patient appears to be unconscious of external impressions, and to remember nothhig of CATALEPSY AND ECSTASY. 1113 what happens during the attack, she will sometimes smg or talk whilst it is upon her, or indicate by her expressions the presence of pleasing or painful impressions. A cataleptic condition may also occur in patients who still retain full consciousness. Cataleptic attacks may last from a few minutes to several days ; there may be a single attack only ; or they may recur with more or less frequency. 8. Ecstasy is a condition in which the patient is absorbed in some all- engrossing fancy or delusion. It is the condition to which weak-minded persons are wrought under the influence of re\TiYalist preachers, and in which they are sometimes impelled to plead frantically for pardon for imaginary misdeeds, are sometimes in a delirium of complacency and joy ■ at their supposed enrolment among the saved. It is the condition into which those persons fall who believe that they see visions of Christ, of the Virgin Mary, of saints, or of angels, or who hold familiar intercourse with them, or who receive divine messages. It is the condition mto which the medium is not mifi'equently brought under the mesmeric influence. It represents also the mental condition of the dancing maniacs of the Middle Ages. The nature of the fancies or delusions under which such patients labour may, therefore, present the widest range of variety, and their effects on the mind all degrees of intensity. Their influence over the actions of the patient, moreover, is very various. Thus, while one will gesticulate violently and roar or scream his prayers or denunciations ; another will dance or sing or utter pious ejaculations ; another will sit apart with an air of self-satisfaction or quiet happiness ; and yet another will be transfixed or stuimed, as it were, with intense anxiety or horror. In some of these cases the patient remains motionless and apparently insensible to every external impression for days together. But gene- rally they are not wholly insensible ; and although the mind may not be capable of being diverted from its engrossing thoughts, the pupils con- tract and the eyehds close under the influence of a strong light ; sneezing and watering of the eyes may be induced by the application of ammonia or snuff ; and the respiratory muscles may be made to act powerfully under the shock of a jugful of cold water. 4. Double-consciousness. — A cm'ious condition, allied to the last, is sometimes witnessed, in which the patient appears to live, as it were, a double hfe — the one her normal state of existence, in which she is fairly sensible, and knows and understands, and perhaps takes an interest m, everything that goes on about her ; the other a condition of ecstasy or somnambulism in which her mind is under the dominance of delusions, and in which the same hues of thought and feeling and the same delu- ,sions are continued through the successive ecstatic paroxysms; and in neither of which has she any recollection or knowledge of what occurs in her alternative condition. Occasionally these strange phenomena may be prolonged for years, the one state passing into the other almost suddenly several times a day. The waking condition, indeed, may form but a small portion of her existence, and may itself be attended with curious jmotor, sensory, or mental phenomena. 1114 DISEASES OF THE NEEVOUS SYSTEM. Treatment. — In treating the various cases whicli have just been con- sidered it is important not to lose sight of the fact of their intimate rela- tions with certain other nervous diseases, more especially epilepsy, hysteria, and insanity, of which indeed, in the great majority of cases, they may be regarded as mere varieties. Their treatment, therefore, resolves itself mainly into the treatment of these affections. Everything calculated to improve the general health of the body is indicated ; but if a cure is to be effected it is rather by judicious management than by medicines. XVI. TETANUS. {Trismus. Lochjcm.) Definition. — Tetanus is an acute and generally fatal disorder, charac- terised by painful tonic spasms of the voluntary muscles, and usually traceable to some local injury. Causation. — Traumatic tetanus may originate in a simple bruise, a trivial graze of the skin, the wound inflicted by a mere splinter, or a clean cut. But it is far more commonly due to compomid fractures or other injuries attended with laceration or crushing. It is generally believed that injuries of the extremities are much more liable to be followed by it than injuries of the head and neck or trunk ; but, as Mr. Poland justly remarks, the limbs are far more prone to accidents than other parts, and it is pro- bably on this accomit alone that their wounds are credited with a dispro- portionate proclivity to tetanus. But climatic conditions also are largely concerned in the production of tetanus ; for the disease is much more common in hot than in cold or temperate climates ; and although it so often supervenes on womids received in battle, it occurs much more fre- quently when the womided are exposed to cold and wet than under oppo- site circumstances. Indeed the .idiopathic form of the disease, which is somewhat unfrequent, is usually referred, and probably with reason, to the influence of these latter agencies — agencies which also induce rheu- matism, pneumonia, and other internal inflammations. Tetanus may occur in either sex, and at any age. In the West Indies it is very common in new-born children, in whom it is supposed by some to be due to the division of the umbilical cord ; and it occasionally happens in women after parturition. It has been attributed to intestinal irritation provoked by worms or other like causes. The supervention of traumatic tetanus appears to be wholly uninfluenced by the character of the changes going on in the injured parts. Symi^toms and -pt'ogress. — Tetanus comes on after mjury at periods varying between a few hours and three or four weeks — most commonly,, according to Sir T. Watson, between the fourth and fourteenth day.. When the disease is due to exposure, it always supervenes very quickly — occasionally in the course of a few hours. The first symptoms of which the patient complains are usually pain and stiffness of the muscles of the jaws and neck — symptoms which he TETANUS. 1115 probably refers to cold, and describes as sore-tliroat and stiff-neck. He has difficulty in opening liis month, in masticating, and in moving his head, which is soon followed by dysphagia, and by spasmodic attacks of pain and aggravation of his difficulties, provoked especially by every attempt to use the affected muscles. By degrees the stiffness and ten- dency to pamful spasm extend to the other voluntary muscles : to those of the back, which by their action on the trmik tend to curve the body backwards ; to the inspiratory muscles, especially the diaphragm, the implication of which involves difficulty of respiration, and occasional attacks of more severe dyspnoea, attended with acute pain striking through from the ensiform cartilage to the interscapular region ; to the muscles of the abdomen, which get rigid and knotted ; to those of the extremities, which become difficult of flexion, and from time to time powerfully and violently extended ; and to those of expression, which by their tonic con- traction impress upon the patient's features a fixed painful look (the risus sardonicus), which becomes intensified during each recurring spasm. The muscles of the tongue and eyeballs, and those which move the hands and feet, usually escape or are involved late and to a slight extent only. As the disease progresses all the implicated muscles become stiff', and the stiffness gradually increases. But from the begimiing the patient is liable to paroxysmal attacks, during which all his symptoms are enormously aggravated, and which come on at irregular but diminishing intervals : sometimes every quarter of an hour, sometimes every ten or every five minutes, and last individually from a few seconds to several minutes. These occur for the most part spontaneously, but are readily induced by any muscular effort, by moving the patient, or even by the slamming of a door and other such-hke trivial causes. In the fully developed disease the patient, during the inter-paroxysmal periods, probably lies stiff* in bed upon his back. The muscles of the trunk, limbs, and neck are hard and rigid ; the jaws cannot be opened at all, or admit of being separated only to the extent of a few lines ; the face wears a painful expression, the brows being knit and at the same time transversely wrinkled, the eyes somewhat closed, the angles of the mouth drawn outwards and upwards, the lips apart, and the grooves extending from the al£e of the nose towards the angles of the mouth deepened ; the mouth and fauces are clogged with saHva, which he has difficulty in swallowing ; the voice is feeble, possibly reduced to a whisper ; and the resphations are rapid and shallow. Further, he probably complains of general pain or soreness, and especially of pain extendmg from the scro- biculus to the back. During the paroxysms his sufferings become ex- tremely aggravated, and hightful to witness. His arms and legs (espe- cially his legs) become more powerfully extended, and at the same time widely separated ; the extensor muscles of the spine arch the trmik and head and neck powerfully backwards, so that not unfrequently the patient rests only on his head and heels ; the respiratory muscles get more or less fired, respiration difficult, and the face pale, livid, or ghastly ; the distor- tion of the features, moreover, is now extreme — the forehead corrugated 1116 DISEASES OF THE NEEVOUS SYSTEM. by the combined action of the frontales and corrugators, the eyeballs fixed and staring, the eyelids rigid and partly closed, the nostrils dilated, and the angles of the mouth drawn outwards and upwards so as to impart that peculiar appearance of grimaing which has been referred to. The lips moreover are retracted, exposing the clenched teeth ; between which bloody saliva occasionally flows in consequence of the accidental wounding of cheek or tongue by their sudden closure at the commencement of the paroxysm. The paroxysms are said frequently to come on with increase of the diaphragmatic pain ; and during their continuance cramp-like pains of the most agonising character pervade the contracted muscles. Certain other phenomena to which it is desirable to draw attention present themselves in the course of tetanus. The pulse is for the most part rapid and feeble, and its rapidity and feebleness increase with the progress of the case, and are especially observable during the paroxysms. At such times also the skin, which is generally moist or perspiring, breaks out mto profuse sweats. The urine is for the most part scanty, and the bowels are constipated ; but the patient has entire control over bladder and rectum. According to Dr. Senator, there is no increase of excretion of the urinary sohds. In the great majority of cases the patient retains his senses unimpaired throughout his illness, and is conscious up to the moment of death. He seldom sleeps, or he sleeps only by snatches. Sometimes the spasms cease entirely during sleep. The temperature in ietanus is generally somewhat above the normal, and liable to irregular diurnal variations. It does not usually exceed 100° or 101°, but may rise from time to time, even in cases which ultimately do well, to 102°, 103°, or more. Nevertheless, when the temperature reaches or exceeds 103°, the symptom must be regarded as of serious import. Occasionally, with the approach of death, the temperature rises rapidly, and it may then attain an elevation of 110° or even 112°. Sometimes in the course of tetanus the temperature becomes sub-normal. When the tetanic spasms affect only or principally the muscles of the jaw, the affection is often termed trismus or lockjaio. When, as usually happens, the body during the tetanic spasms is arched backwards, the condition is termed opisthotonos. In those rare cases in which, owing to the predominant action of other muscles, the body is curved forwards or to one side, the condition of emprosthotonos or pleurostliotonos, as the case may be, is present. The prognosis of tetanus is very gloomy ; almost all traumatic cases, and the great majority of idiopathic cases, die. According to Mr. Poland, taking all forms together, the mortahty is at the rate of about 88 per cent. The most rapid cases, according to the same writer, die in fom- or five hours. But death has been delayed until the thirty-ninth day. More than half the total number of fatal cases perish during the first five days. Death is usually caused either by asthenia, by asphyxia, or by a combina- tion of these conditions. It not unfrequently occurs suddenly in one of the spasmodic attacks, and is then probably due immediately to spasm of the respiratory muscles, and possibly to those of the glottis. TETANUS. HIT Tetanus may be simulated by hysteria, by inflammatory affections of the spinal cord, and especially by the effects of strychnia and other allied drugs. As regards the first two classes of disease, there can seldom be any real difficulty in distinguishing between them and tetanus, in conse- quence in the one case of the supervention of paralysis or other signs of organic lesion of the cord, in the other case of the association of various- hysterical phenomena with the spasmodic muscular rigidity. Strychnia- poisoning, on the other hand, may be readily confounded with tetanus.. The chief distinction between them lies (to quote Dr. Christison's words) in the fact that ' the fits of natural tetanus are almost always slow in. being formed, while nux vomica brings on perfect fits in an hour or less.' Further, tetanus rarely, if ever,' proves so quickly fatal as the rapid cases of poisoning with nux vomica.' It need scarcely be added that the history and aetiology of all cases in which tetanic spasms are present should be investigated with minute care. Morbid anatomy. — Various lesions have been discovered m the nervous .system. In tramnatic tetanus the nerves proceeding from the injured region have been found swollen, hypergemic, and inflamed, either in part or in their whole length. In many cases, however, no such lesions have been perceived. It was formerly believed that the spmal cord was healthy ; but recent investigations, and more especially those of Drs. Lockhart Clarke and Dickinson, have demonstrated the presence, in some cases at least, of considerable dilatation of the small vessels (particularly the arteries and veins) with accumulation of blood within them and around them, together with more or less abundant translucent or finely granular exudation, infiltrating the tissues, and tending to accumulate here and there, especially in the fissures, and occasionally on the surface of the cord. With these changes are associated sometimes disintegration of the proper nervous elements, sometimes local effusions of blood. In trismus neonatorum congestion of the spinal arachnoid is described, with effusion of serum and even extravasation of blood into the subarachnoid tissue. It can scarcely be admitted, however, that these lesions are proved to be invariably present in tetanus. That the motor nuclei of the spinal cord and medulla oblongata are generally in a state of polarity or abnormal irritability, or that they are generally under the influence of some abnormal condition which excites them to miwonted action, is clear enough. But whether this excited action is due to some peculiar change in the nerve-cells themselves, or to the influence exerted upon them by the congestion and effusion which surround them, or to the presence m the blood of some endopathic poison (as is suggested by Sir T, Watson and by Dr. Eichardson) resembling strychnia in its effects, are points upon which as yet we can only speculate. It is uncertain, therefore, at present, whether the lesions which have been discovered in the spinal cord are in any degree the cause of the tetanic spasms, or whether they are merely secondary to them. Euptures of muscular fibres are frequently seen after death from tetanus. They are common in the muscles of the back, but, sometimes occur in the abdominal muscles and those of the extremities. 1118 DISEASES OF THE NEEVOUS SYSTEM. Treatment. — No treatment, so far as we know, has any curative influ- ence over tetanus. A certain number of cases get well under tlie most unfavourable circumstances ; the great majority die in spite of the most strenuous efforts to save them. Innumerable drugs have been employed, and, according to their several advocates, with more or less success. Among those which have acquired the greatest reputation are opium, mercury, wourara. Calabar bean, and chloroform. Many other medicines, for the most part sedatives, have also been recommended, especially, perhaps, aconite, belladonna, digitalis, tobacco, hydrocyanic acid, chloral, and turpentine. By some authorities, drastic purgatives have been lauded, by some, profuse stimulation by means of ether or alcohol. It is important to know that tetanic patients can take large doses of the most powerful sedative medicines, and drink large quantities of alcoholic bever- ages without being brought under the influence of these agents. Warm baths, cold baths, ice to the spine, bleeding, division of the nerves leading to the injured spot, and even amputation of the limb or part on which the injury was inflicted, are measures which have each in turn been adopted and abandoned. As regards general rules of treatment we cannot do better than quote Sir T. Watson's words. He says : — ' Since any, the smallest, movement or impression made upon the surface, or upon the senses, will bring on the severer degrees of spasm, it is of primary importance to protect the patient against those sources of trouble, so sure to aggravate his sufferings, and so likely to augment his danger. Hence, if blood-letting should be thought advisable, it should be done early, sufficiently, and once for all.' ' The same remark applies to the frequent use of purgatives. The bowels should be well cleared in the onset, and then let alone. The patient should lie in a darkened room, from which noise also should, as much as possible, be excluded. He should not be surrounded by a multitude of friends or attendants. He should be enjoined to speak, to move, to swallow, as seldom as he can. In the severe traumatic cases, the nerve, in my judgment, should be promptly divided, and as high up in its course as may be practicable ; and in all cases, there being no special indications to the contrary, I should be more inclined to administer wine m large doses, and nutriment, than any particular drug. If the tendency to mortal asthenia can be staved off, the disturbance of the excito-motory apparatus may perchance subside or pass away,' The patient's sufferings may often be alleviated by the use of opium, or chloroform inhalation. XVII. TETANY. Definition. — By tetany is meant a peculiar affection characterised mainly by tonic, painful contractions of certain groups of muscles : primarily of the hands and forearms, but involving also not unfrequently the muscles of the lower extremities, and occasionally those of other parts TETANY. 1119 ■of the body. The contractions are of variable duration, often intermittent, and bilateral. Causation. — Tetany occurs mainly between the ages of fifteen or six- teen and thirty. It is by no means uncommon, however, ui early childhood. In women it is particularly Hable to come on during pregnancy and lacta- tion ; and in young children, as Dr. Abercrombie ^ shows, it has a clear association with rickets. Cold and damp, diarrhoea, and emotional ex- citement are severally recognised as important exciting causes. M. J. Simon records an outbreak of tetany in 1876 in a gu'ls' school at Gentilly. Four- or five-and-twenty cases occurred in the course of a month or five weeks. The first few were attributed to the influence of cold, the re- mainder to involuntary imitation. Si/mptoms ami progress. — The early symptoms of tetany are usually imcomfortable sensations or actual pain in the hands and forearms, and stif&iess or contraction of one or more fingers, mainly induced by the attempt to use them. The disease develops rapidly. When at its height the thumbs are strongly adducted, while their termmal joints are extended ; the palms of the hands are hollowed in consequence of the approximation of their borders ; the fingers are shghtly flexed at the metacarpo-phalangeal joints, but otherwise extended, and brought together in the form of a cone. Occasionally, the fingers instead of being pressed against one another are separated ; and in rare instances the thumbs are adducted and the fingers flexed over them. Besides the affection of the fingers above described, the hands are generally somewhat flexed, and tilted towards the ulnar side ; and in some cases the forearms are semi-flexed, the upper arms are adducted, and the hands thus become crossed upon the abdomen. When the lower extremities are involved, the toes are strongly flexed, the great toes occasionally being extended, while the feet are extended on the legs and the legs on the thighs. In severe cases the spasms may extend to the muscles of the back of the neck, to those of the trunk, to the diaphragm, and even to the muscles of expression, speech, and mastication. The aflected muscles are rigid and painful, and resist j)assive extension, which also is attended with aggravation of pain. They resume their contracted form as soon as extension has been discontinued. The attacks of spasm are generally described as intermittent, lasting severally from a few mhiutes to half an hour or more at a time, seldom longer than twelve hours, and separated by mtervals of variable dm-ation, sometimes of a few days or even a few weeks. Not unfrequently, however, and certamly in children, the spasms, though presenting remissions, are contmuous and last during the whole time of illness. Occasionally fibrillar tremblings of the affected muscles are observed. It is said by Trousseau that the spasms relax under the influence of chloroform. This, however, was not so in the cases described by Dr. Abercrombie. They continue (and this is a point of diagnostic importance) dm^ing sleep. Trousseau calls attention to the fact that during the intermissions of spasm these ' On Tetany in Young Children. A Thesis for the degree of ]M.D. in the Univer- sity of Cambridge. 1880. 1120 DISEASES OF THE NEEVOUS SYSTEM. . may be reiiiduced in the arms and sometimes in the legs by compression of the trunk arteries or nerves of the limbs. Another interesting pheno- menon, which he terms ' facial irritability,' was observed in the tetany of children by Dr. Abercrombie. If the finger be drawn across the facial nerve, the orbicularis palpebrarum of the same side contracts, and in some cases there may also be contraction of the levator muscle of the corner of the mouth and of the ala of the nose. The phenomenon is often more marked on one side than the other. Another remarkable feature of the disease is the occurrence of oedema, redness, and pain on the backs of the hands and feet. This does not appear to be by any means general ; but at any rate, in a greater or less degree, it is a common incident of the disease in children. Eheumatio inflammation of joints is said to arise occasionally. In children again,, as Dr. Abercrombie points out, laryngismus is very frequently associated with tetany. Other symptoms attendmg tetany are by no means characteristic. Fever is seldom present. According to Erb there is increase of electric excitability in the peripheral nerves to both constant and induced currents, but not in the facial nerves — a point of some interest and obscurity taken in connectionvwith Dr. Abercrombie's observation with regard to ' facial irritability.' The course of tetany presents considerable variety. In some cases it- lasts only a few days ; much more frequently it continues for weeks or months. But in the last case its continuance is usually due to the occur- rence of relapses. A few fatal cases have been recorded : mainly cases in which the affection was greatly prolonged, or in which symptoms pointing to implication of the medulla oblongata had supervened. The prognosis, however, on the whole, is decidedly favourable. Morbid anatoviy and patliology. — No distinctive or definite lesions have hitherto been discovered after death, to which the symptoms of tetany can be referred. Nothing in fact is known definitely in regard to the nature of the disease. That it does not depend on any coarse lesion of the central nervous system is certain. There is reason, however, to regard it as a so-called ' functional ' disturbance of these parts (more par- ticularly, no doubt, of the spinal cord), attended with increased irritabihty. Treatment. — The most important point in the treatment of tetany is to attend to the patient's general health. Thus we have a hint as to treatment if the disease occurs m a rickety child, a woman who is suck- ling, a person who has been exposed to cold, a child in whom there is gastric irritation, or a girl who is hysterical or has experienced some power- ful emotional disturbance. In many cases tonics are indicated. Bromide of potassium, chloral, and opium have severally been strongly recom- mended. Cold and warm baths have been employed with trivial success^ Electricity in its various forms has not hitherto been very efficacious.- The constant current is to be preferred. CONGESTION AND ANEMIA. 1121 XVni. CONGESTION. ANEMIA. SUNSTKOKE. A. Congestion and Ancemia. Symptoms. — So many nervous phenomena are commonly referred to congestion or anaemia of the nervous centres, that we can scarcely presume to pass these conditions over in silence. And indeed, although we are disposed to assert that the great majority of cases in which symptoms are referred to them m practice are not true examples of anythmg of the kind, it must be freely admitted that congestion and anemia of the brain and cord do really play an important part in the phenomena of disease in these organs. Whenever inflammation or other processes of prohferation are in progress, congestion is necessarily present. We see the evidences of former congestion in the condition of the blood-vessels and of the parts immediately bounding them in chorea, epilepsy, tetanus, and chronic insanity. In heart-disease, in chronic bronchitis, in cases in which tumours press upon the large veins at the root of the neck, during violent muscular efforts, in the attacks of hooping-cough, the brain also becomes congested. Anaemia may be the consequence of abundant losses of blood ; it may be due also to obstruction of the common or internal carotid, or of one of the arteries distributed to the bram. But in the majority of the above cases, either the symptoms which the patient presents are not those commonly attributed to congestion or anaemia, or the symptoms referrible to these conditions are mtermingled and confused with others dependent upon causes of a different kind. We shall not discuss the various symptoms, which on theoretical grounds might be attributed to cerebral and spinal congestion. It will be sufficient for our purpose to pomt out : that they must necessarily differ materially according as the congestion is acute or chronic, and according as it involves certain regions of these organs or pervades them generally ; and that abnormal congestion, if it be not excessive is likely to be attended with exaltation of function, if it be excessive is pretty certam to induce perversion or abeyance of function — vertigo, headache, delirium, convul- sions, coma, paralysis, muscae and dimness of sight, noises in the ears, and duLness of hearing. The effects of temporary congestion are sometimes well seen in attacks of spasmodic cough, such as attend pertussis, and the presence of thoracic aneurysms. The patient becomes livid in the face, suffers from vertigo, headache, muscae, and noises in the ears, and pre- sently becomes momentarily insensible, with probably some convulsive twitchings or spasms of the muscles of the eyeballs and of those of expression. The symptoms referrible to anaBmia, equally with those due to con- gestion, vary according as the anaemia is general or partial, acute or chronic, slight or extreme. Moreover, they are very much of the same kind as those which attend congestion. Thus, in cases in which the supply of blood to the brain is suddenly mterrupted either by obstruction of one or more of the arteries supplying it, or by temporary arrest of the 4 c 1122 DISEASES OF THE NEEVOUS SYSTEM. heart's action, or by copious loss of blood, insensibility and convulsions frequently ensue ; and again, upon ansemia more slowly produced, it is not uncommon for delirium resembling that of chronic alcoholism, or for acute mania, or for apoplectic symptoms to supervene. In many of the cases in which cerebral ansemia or congestion has been diagnosed during life, the condition of the brain appears post mortem to have been perfectly healthy ; and in some there has been found, from no obvious cause, accumulation of fluid in the ventricles or subarachnoid tissue. Hence it is possible that, at any rate in some cases, the symptoms referred to congestion or anaemia may really have been immediately due to the presence of serous effusion. It is possible, also, that in some cases they may have been due to the effects of undetected poisonous matters in the blood. Without venturing to decide upon what conditions of the brain each of them depends, we shall proceed very briefly to discuss two or three so-called functional disorders of this organ, which appear to belong to the group of affections we are now considering. 1. Delirium tremens. — We have already (page 604) fully described this affection as it occurs in drunkards ; but it occurs also, though much less frequently, independently of alcoholism, and indeed in persons of abste- mious habits, sometimes as a consequence of severe injury [delirium trau- tnaticum), sometimes as a result of long-continued mental anxiety. The symptoms and progress of the disease are identical in all these cases, and need not again be detailed. 2. Insanity. — Various forms of insanity, especially perhaps mania, me- lancholia, and dementia, are apt to come on during convalescence from acute febrile diseases, and after profuse hemorrhages. Their symptoms are in no way distinguishable from those of the same forms of insanity occurring under other conditions. They generally, however, end in recovery. 3. Eclampsia. — The convulsive attacks which may attend these con- ditions vary from mere momentary spasms of the muscles of the eyeballs or face, or some other limited part of the body, attended with momentary loss of consciousness, to epileptiform seizures of the most violent kind. And, indeed, there is nothing in the attacks themselves by which they are distinguishable from those of true epilepsy. The differential diagnosis must rest upon the associated phenomena of the case, and upon its history and progress. 4. Apoplexy and paralysis. — The apoplectic attacks which appear to be due to merely functional disturbance of the brain have in many respects a close resemblance to those which are the result of hemorrhage. Their onset is sometimes sudden ; but it is more commonly gradual, the patient becoming drowsy, then semi-comatose, and finally, perhaps after remis- SK)ns, passing into a state of complete stupor. When the apoplectic condition is fully established, the patient is absolutely insensible ; his pupils are probably dilated and inactive to light ; he has lost the power of deglutition in a greater or less degree ; his breathing is probably explosive or stertorous ; his arms and legs are motionless and flaccid ; he has no control over his emunctories ; and his urine is retained. The phenomena SUNSTEOKE. 1123 may, liowever, be as varied as tliose due to sanguineous effusion ; and scarcely any of the symptoms which have been enumerated may not fail in certain cases, or be replaced by others. Especially it must be recol- lected : that partial or general convulsions may occur ; that the limbs, instead of being flaccid, may be rigid ; and, indeed, that there may be distinct hemiplegia. The main distinctions between functional apoplexy and that from effusion of blood reside in their usually different modes of onset ; in the paralysis, which in functional apoplexy is mostly general and attended with flaccidity ; in the pulse, which is usually accelerated in the affection now under consideration ; and in the temperature, which here generally rises from the commencement of the attack, whereas in cerebral hemorrhage, for some hours at least, it usually falls. These comatose attacks are not limited to elderly persons ; they are consequences of lateral and disseminated sclerosis, and especially of general paralysis of the insane ; and affections not clearly distinguishable from them are occasionally observed in young children, in whom they simulate the phenomena of meningitis. In connection with the apoplectic attacks, and occasionally indepen- dently of them, hemiplegic and other paralyses may occur. Affections of the sensory nerves also may supervene ; and the patient may have dimness or loss of vision, or analogous conditions involving the sense of hearing. It need scarcely, perhaps, be said : that in each of the above cases the progress of the affection may closely simulate that of the malady which in its symptomatic phenomena it most closely resembles ; that in many m- stances complete recovery takes place within a shorter or longer time ; that in some instances relapses occur after such recovery ; that in some per- manent mental defect or paralysis follows ; and that not unfrequently death ensues. Treatment. — It is impossible to lay down any definite rules for the treatment of these various functional disturbances. In the majority of cases the treatment should no doubt be the same as that for the affections which they resemble. It is important, however, to bear in mind that if they be traceable in any degree to loss of blood, to want of food, or to anemia, Tiowever produced, it becomes essential to support the patient's strength by foojl and tonics. B. Stmstroke. {Coup de Soleil. Calenture. Insolatio.) Definition. — By the term ' sunstroke ' is usually impHed a more or less sudden attack of unconsciousness, occurrmg in persons exposed, under ad- verse conditions, to high temperature. It seems probable, however, that more than one affection is included under this name. Causation. — Sunstroke appears to result from prolonged exposm-e to intense heat, especially if the atmosphere be at the same time damp and impure, and the patient exhausted by long-continued over-exertion, and the wearing of clothes and accoutrements which impede the free action of his respiratory muscles. It often occurs, especially in tropical climates, from exposure to the direct rays of the sun ; but it is common also even 4 c2 1124 DISEASES OF THE NEEVOUS SYSTEM. in tlie night-time among persons who are subjected to intense lieat in. close, over-crowded, and ill -ventilated barracks, houses, or ships. Soldiers engaged in long and toilsome marches under the glare of a tropical sun are especially liable to suffer. Symptoms and progress. — Sunstroke is sometimes sudden in its onset,, but is more frequently preceded by premonitory symptoms. In the former case, the patient, who is probably engaged m some laborious occupation and exposed to the sun, suddenly falls down insensible and collapsed, with pale, cold, moist skui, gaspuig respiration and extreme feebleness and rapidity of pulse. There is no doubt that, in these cases, equally with those next to be considered, the internal temperature at the time of the attack is above the normal. Death mider these circumstances not unfre- quently takes place with great rapidity, or even quite suddenly. The premonitory or early symptoms of the other variety of the affection- comprise, in a large proportion of cases, great sense of weariness and pros- tration, vertigo, nausea, dryness and heat of skin, tendency to frequent micturition or even incontinence of urine, and restlessness or sleepless- ness. The actual attack is sometimes ushered in with drowsiness and the patient lays himself down to rest or sleep ; in other cases he is seized with momentary delirium or mania, more rarely with convulsions. Under any circumstances the patient rapidly becomes comatose or apoplectic^ and then presents most of the ordinary phenomena of this condition. He lies perfectly msensible ; his pupils are contracted and unaffected by light, - his conjunctiva injected ; he breathes rapidly, noisily, and sometimes stertorously ; his pulse is frequent, small, weak, and often irregular ; his face is pallid ; and his skin mtensely hot. In some instances the patient remains quiet during his comatose condition ; m others he is attacked with local or general convulsions. If death take place it is rarely delayed beyond twenty-four or forty-eight hours. The mortality from sunstroke is very heavy, exceeding 40 per cent. Eecovery is sometimes sudden and complete ; but it is more commonly slow, and attended for some few days by feebleness of the heart's action and oppressed breathing, and is then not unfrequently followed by consequences of more or less importance, such as headache, chorea-like affections of the muscles, epilepsy, and some degree of mental imbecility. These sequelse may be permanent. Morhid anatomy and pathology. — In most cases of fatal sunstroke the blood is found to have remained uncoagulated ; the lungs are intensely con- gested, and the right side of the heart is loaded with blood ; further, there is generally engorgement of the vessels of the brain. The proximate cause of the disease is uncertain. By some it is considered that the symptoms are due to the circulation of poisonous matters in the blood. It is suggested by Dr. G. Johnson that the intense heat of the body is attended with dilatation of the pulmonary capillaries, engorgement of the lungs, and asphyxia, upon which the other phenomena of the disease presently super- vene. The first symptoms, however, in many cases, are those of uncon- sciousness, and in all coma rapidly comes on with involvement of those MEGEIM. 1125 •organs, especially, which are in relation with the i^neumogastric nerves. The symptoms differ indeed little, if at all, from those of the typical apoplectic state ; and it is difficult therefore to believe that they are not primarily cerebral. Treatment. — Indian practitioners are mianimous as to the danger of bleeding in these cases, and are equally unanimous with respect to the value of the cold douche, or of cold applied in other forms. Especially it seems advisable to apply cold to the head. Subsequently, if consciousness do not return, the head may be shaven, and counter-irritants used. The bowels should be made to act, but not violently purged. Generally, ■also, it is better to give nourishment and diffusible stimulants than to -deplete. XIX. MEGEIM. [Migraine. Heviicrania. Sic Jc -head ache.) Definition. — A form of headache, for the most part circumscribed, coming on in paroxysms, and frequently attended with sickness, affection of sight, and other nervous phenomena. Causation. — Megrim appears in a large number of cases to be an hereditary disease ; and, when of distinctly hereditary origin, not unfre- quently commences during the period of the second dentition, from which age up to thirty it usually first declares itself. It rarely commences after thirty, and generally, even ua those who are liable to it, subsides with advance of years. Patients do not often suffer from it after fifty. Females are somewhat more prone to it than males. The determining causes of the attack are very various. Amongst the most common of them are, dis- turbance of the digestive organs, such as may arise fi-om over-feeding or prolonged abstmence, uterine disorders and the catamenial period, sus- tained mental labour or excitement, emotional disturbance, bodily fatigue or want of exercise, insufficient or over-abundant sleep, overcrowded rooms, foul air, and meteorological conditions ; and, besides these, impressions upon the senses, such as are produced by glaring lights, rapid successions of objects presented to the eye, loud or discordant noises, strong odours, a,nd offensive smells. Megrim, or a condition midistinguishable from it, may arise also in the course of an ordhiary catarrh, or be mduced by •exposure of the head to a current of cold air, or by malaria. Symptoms and progress. — In the simplest and most common form of megrim, the patient is attacked, more or less suddenly, with dull pain, usually referred to a limited surface immediately over the eye or in the temple. This gradually extends in area, and becomes more intense, but usually still remains limited to one side of the head. It varies in intensity from time to time, is for the most part aching, but is not unfrequently attended with sudden shootings, and generally with throbbing, which is always greatly increased by bodily or mental exertion. It often involves the eye ; and this, together with the scalp, is apt to become hyperaesthetic or tender. The head generally is hot, and the arteries of the affected Tegion manifestly dilated. In many cases the pain affects both sides of 1126 DISEASES OF THE NEEVOUS SYSTEM. the head, although even then it is usually more intense on one side than, the other ; occasionally it attacks the occipital instead of the frontal. region ; and sometimes it becomes generally diffused. From the com- mencement the patient is dull and mdisposed for or incapable of mental or bodily exertion, and with the continuance of the headache these con- ditions increase upon him, and he becomes pale and chilly, and looks. hea%^-, dejected, and miserable. Not uii frequently he has a vague dread, or sense of impending e^il ; and especially he is apt to experience a. general feeling of profound illness, attended vdlh. tremulousness, shivering, and weakness of the limbs. The pulse for the most part is small and weak, and often slower than natm-al. After a variable time a sense of nausea supers^enes, and in a large proportion of cases culmiaates in vomiting, during the attacks of which the headache generally attahis its greatest degree of intensity. After the vomiting has ceased the patient probably goes to sleep, and at the end of some hours awakes in pretty nearly his usual condition of health. In a large number of cases other symptoms are associated with those just considered, and then for the most part precede them. Among the- most interesting of them are disorders of vision. When these occur, they are probably always the earhest in the sequence of events; and they generally vanish with the supervention of headache. They vary in character : — ia some cases certain portions of the retinae become simply insensible, and if the central spots of the eyes be involved, the patient, who probably feels well in all other respects, notices that he cannot see the nib of the pen with which he is writing, or the letters which he is- forming, or that, while distinguishing all other parts of the body, he can- not see the face of the person at whom he is looking. ; in some cases he observes a tremulous, vibratile or rotatory movement in some part or other of the field of vision ; sometimes these tremulous ares or spectra become variously coloured ; double vision sometimes occm's. The patches of retmal anaesthesia, or derangement, appear always to occupy identical parts in both eyes, and are apt to vary in shape from time to time. The colouration of the spectra, when it occurs, is always secondary. Other senses are apt to suffer, but on the whole much less frequently than sight ; and the phenomena referrible to them, when associated witk ocular derangements, always come on later. Occasionally the patient experiences deafness or noises in the ears, or loss or perversion of taste or smell ; but more frequently, perhaps, he is attacked with numbness, passing on may be to complete anaesthesia, of the upper extremity, of the haK of the head and neck and face, and even of the parts within the mouth, all on the same side as the cephalic pain. This loss of sensation is sometimes associated with muscular paralysis. Further the cephalalgia is not unfrequently associated with the presence of distinct nem'algic pams, not only at the back of the head, but in the back and side of the neck, and even in the shoulder and down the arm. It has already been observed that the patient becomes dull and apathetic and mcapable of intellectual exertion ; but psychological MEGEIM. 1127 phenomena of a more remarkable kind are apt to ensue. Sometimes there is marked mental confusion or incoherence of thought, sometimes indeed typical aphasia. Drowsiness is very common : often forming one of the earliest indications of the attack ; sometimes commg on during its progress, and culminating in a more or less prolonged semi-comatose con- dition ; but much more frequently constituting the termination of the attack. Megrim beghis m many different ways. In some cases it supervenes immediately upon exposure to its exciting cause, as when the character- istic headache attacks the sufferer while he is at the theatre, or at a picture gallery, or during exposure to discordant noises or offensive smells, or while he is engaged in some laborious mental occupation. Not unfre- quently it comes on dm'ing the night, the patient waking from time to time with the consciousness of heaviness in the head, and getting up with the attack well-developed ; or it manifests itself when he wakes in the morning, or immediately after rising. In other instances it comes on at various times of the day, without obvious immediate cause. In a large proportion of cases the headache is the first symptom. In many, how- ever, this is preceded by some of the prodromal phenomena above con- sidered : the patient experiences a sense of general illness or of depression or dread ; or he has numbness, or confusion of thought, or extreme drowsi- ness, or other of the physical phenomena which have been enumerated ; or he has some affection of vision. It is curious, as we have already shown, that when these several phenomena, or any of them, manifest themselves, they almost invariably precede the headache. The attack may be limited to any one of these symptoms. The duration of megrim varies for the most part between twelve and twenty-four hom's ; it may, however, last an hour or two only ; and it may be prolonged, but generally by successive relapses, for several days. The subsidence of the attack is generally gradual ; in a large number of cases, it is preceded by vomiting ; and m the great majority (whether vomiting have taken place or not) the patient after a while sinks into a profound sleep, fi-'om which he wakes refreshed, and probably well. During con- valescence he often perspires profusely, and excretes a large quantity of urine. Megrim is essentially a periodical disease, and hi those who are Hable to it not mifrequently comes on with more or less regularity once a week, once a fortnight, or once a month. It not uncommonly, however, occm*s less regularly, and more distinctly in response to certain definite causes to which the patient exposes himself. Moreover, it often ceases for a time mider various circumstances, such as pregnancy, suckling, and chano-e of air or occupation, and occasionally is developed only at long intervals in connection with special causes of ill-health. Pathology. — Megrim has often been regarded as essentially a sym- ptom of disorder of the liver or stomach ; and no doubt affections of these viscera, but more particularly of the stomach, must be regarded as some of its exciting causes. But, on the other hand, the attacks so 1128 DISEASES OF THE NEEVOUS SYSTEM. frequently arise independently of any morbid condition of tlie digestive organs that we are compelled to look elsewhere for its essential seat. It has latterly been referred to disorder of the cerebral circulation due to the influence of the vaso -motor nerves on the vessels of the part supposed to be implicated. Dr. Latham believes that its primary cause is some affection of the vaso-motor nerves, in virtue of which the vessels become contracted and the tissues anasmic ; and that it is to angemia thus pro- duced of the central nervous organs that the defects of vision and other early phenomena are due. And he refers the headache, which is generally if not always attended with manifest dilatation and throbbing of the temporal arteries, to secondary hypertemia. Dr. Liveing, however, points out that even if, as seems not improbable, some of the phenomena are referrible to anaemia and hypersemia, there must still be some ante- cedent cause to which the vaso-motor affection itself is due. And he contends that the phenomena of the disease depend on the irregular accumulation and discharge of nerve-force ; that the immediate ante- cedent of the attack is a condition of unstable equilibrium, and gradually accumulating tension m the parts of the nervous system more particularly concerned ; and that the paroxysm itself may be likened to a storm. He regards the optic thalami and all those parts which lie between these bodies and the roots of the vagi as the seat of disease. Megrim would seem, according to this hypothesis, to have a close pathological relation with epilepsy. The diseases do not, however, pass into one another. Treatment. — In the first place it is important for the patient to avoid those conditions to which his attacks seem to be traceable ; it is especially important also for him to live wholesomely, to avoid gastro -intestinal disturbance, to take plenty of exercise, to inhale the fresh healthy air of the country, and to refrain from too prolonged or intense mental labour, worry, or excitement. Various remedies are employed, reputedly with success, to prevent the occurrence of attacks of megrim : among others, iron, zinc, arsenic, iodide, bromide and chloride of potassium, qumine, strychnia, belladonna, hyoscyamus, and valerian. During the paroxysms nothing is so efficacious as complete rest in the recumbent posture, in a darkened and perfectly quiet room. Belief may often be afforded, how- ever, by the administration of strong tea or coffee, or of caffeine, theine, guarana or croton chloral. Occasionally a full dose of brandy, ammonia, or one of the fixed alkalies benefits the patient. Evaporating lotions, belladonna, or aconite locally applied is often of great service. The aconitia ointment is especially valuable in many cases in warding off or subdumg the headache. But local measures, although they relieve pain, do not prevent or curtail the other phenomena of the attack. The head- ache may sometimes also be soothed by pressure upon the carotid or temporal artery of the affected side. MENIEEE'S DISEASE. 1129 XX. MENIEEE'S DISEASE. (Aural Vertigo.) Definition. — A disease characterised by sudden attacks of vertigo in connection with lesions of the semicircular canals. Causation and patliology. — Experiments performed on the lover animals, in the first instance by Flourens and subsequently by other observers, have distinctly proved that injm-y of the semicircular canals is followed by vertiginous movements, which have some definite relation to the particular canal operated upon. To this subject attention has akeady been directed. It was M. Meniere, however, who first, in the year 1861, recognised and described the phenomena due to disease of these organs in the human being. Many cases have now been recorded in which the group of symptoms presently to be considered has been found associated with impah-ment of hearing ; and in several of them post-mortem exammation has revealed the presence of inflammatory exudation strictly limited to the semicircular canals. There is good reason, however, to beheve that similar effects may be produced indirectly in diseases of the middle ear or other neighbom'ing parts, by the pressure which is apt to be exerted upon the contents of the labyrinth, and through them on the semicircular canals. Hence they may result from catarrh, and complicate ordinary forms of otitis. Symptoms and ]progress. — The specific phenomena of Meniere's disease are sometimes preceded by deafness, earache, and other indications of aural mischief. But in a considerable number of cases they manifest themselves without any such prodromata. The patient is suddenly attacked with noises in his ears, or in one of his ears, and a feeling of vertigo — symptoms which are attended with faintness, pallor, persphation, nausea, and probably actual vomiting. The attack is of short duration, sometimes lasting two or three seconds only ; and usually the recovery ■of the patient from it is for a time complete. The noise, as above stated, is sometimes referred to one ear only, ;Sometimes to both ; but in the latter case it is generally more pronounced on one side than the other. It differs in intensity in different cases, and is variously described as buzzing, hummuig, whistling, or singing, and is likened sometimes to the puffing of a steam-engine, sometimes to a sudden explosion. The sense of vertigo varies in severity and duration ; in some cases there is a mere momentary feeling of giddiness, or a feebler but more prolonged sensation of swimming in the head which resembles that attending sea- sickness ; in some cases the patient feels as if he were suddenly thrown forwards, backwards or laterally, or rotated, and he staggers or falls in the direction which corresponds with his sensation, clutching at neighbourmg objects for support, or actually falling to the ground. The attack is always attended with a sense of anxiety or alarm and faintness. The latter condition may reveal itseK by momentary pallor, praecordial anxiety, and failure of cardiac action, or by all the 1130 DISEASES OP THE NEKVOUS SYSTEM. ordinary signs of well-marked syncope, followed by sweating, and extreme rapidity and feebleness of pulse. A feeling of nausea is probably always- present in a greater or less degree ; but not unfrequently vomiting ensues, and with its occurrence the attack usually comes to a close. The vertiginous seizure, however severe it may be, is never attended with actual loss of consciousness ; and there is never any convulsive movement, paralysis, implication of speech, squinting, sensation which can be likened to the epileptic aura, or indeed any phenomena, beyond those above described as constituting the attack, which in any sense point to the presence of cerebral mischief. Headache even is unfrequent. The fits come on in the first instance at irregular and probably distant intervals ; but they tend gradually to increase in frequency and to approach one another ; and sooner or later, probably, a time arrives when the patient, though still suffering from frequent paroxysms, is never free from some degree of vertigo. The noises in the ear which attend the early attacks of vertigo are not necessarily associated with deafness ; indeed, sometimes hearing is preternaturally acute, and discordant or loud noises are peculiarly painful to the patient. Occasionally the range of audition becomes contracted. At this time also it not unfrequently happens that no affection of hearing is observable between the attacks. But by degrees the noises in the ear become constant, though still undergoing exacerbation when the paroxysms occur ; and the sense of hearing grows gradually more obtuse, until ulti- mately absolute deafness of the affected ear probably ensues. It is curious that, with the supervention of absolute deafness, not only do the paroxysmal attacks generally cease, but with them the continuous sense of giddiness- which had probably also been present. Slight and momentary attacks of giddiness, essentially resembling those above described, are by no means uncommon in connection with various temporary or permanent affections of the middle ear, and are then frequently induced immediately by loud or discordant noises, or by other powerful impressions on the senses. In such cases, however, complete recovery may be anticipated, and the disease seldom takes the course above sketched. Treatment. — It is impossible to lay down rules for the treatment of Meniere's disease. It is important, however, to bearm mind that the ver- tigmous attacks are relieved, though not prevented, by lying down, and in many cases by carefully protecting the patient from all noises and other such influences. Further, it is obvious that when the symptoms depend on the presence of disease in the accessible parts of the ear, treatment directed to these parts should be employed. PAEALYSIS OF THE OCULO-MOTOK NEEVES. 1131 XXI. LOCAL PAEALYSES. A. Paralysis of the Third, Fourth, and Sixth, or Oculo-motor Nerves. Causation. — Paralysis of these nerves is probably always the con- sequence of some lesion involving them either at their orighi or in some part of their course. Among such lesions may be named syphilitic disease of the base of the skull or contiguous parts of the brain ; tubercle, . carcinoma, or other forms of morbid growth, or inflammatory exudation, occupying the same situations ; tumours or accumulations of fluid or blood situated in the superincumbent brain-substance, and causing pressure ; and aneurysms or tumours in the course of the cavernous sinuses. Oculo-motor palsy is common in locomotor ataxy, and is the essence of ophthalmoplegia externa. Symptoms and diagnosis. — La order to determine the situation of lesions causing the various oculo-motor paralyses, and to distinguish the paralyses due to individual nerves, it is essential, on the one hand, to have a clear view of the relations of the oculo-motor nerves at their origin and in the various parts of their course ; and, on the other hand, to have an exact knowledge of the normal actions of the muscles which they supply. Li reference to the anatomical point, it must be borne in mind : that the nuclei of the third and fourth nerves are in close relation with one another m the floor of the iter, and that the sixth arises in common with the facial, in the floor of the fourth ventricle ; that the muscles supplied by these nerves are seven in number, namely, the levator palpebrte superioris, the four recti, and the two obliqui ; and that of these the external rectus is supplied by the sixth alone, the superior oblique by the fourth alone, and all the other muscles by branches of the third. The muscles of the eyeball are six in o number, and arranged in antagonistic pairs. Horizontal sectio.foTleft eye seen from above. which severally rotate the eyeball in OppO- a a, Antero-posterior diameter of eye; 6 6, • j. T !• • T 1 transverse diameter of eve ; r r. fixed axis site directions upon an axis perpendicular of rotation for movements effected by supe- to the plane in which they respectively act, ^Z^^^^^^^^^^^. and passing as nearly as possible through the central point of the globe of the eye. These several pairs are the internal and external recti, the superior and inferior recti, and the superior and inferior obliqui. And the axes of rotation of the eyeball which cor- respond to them (see fig. 105) are (supposing the left eye to be under consideration, and its line of vision to be fixed directly forwards) : — for '^ t 1- , ,'' 1 I _^-' 70° X / . V ^ ^ 1132 DISEASES OF THE NEEVOUS SYSTEM. tlie external and internal recti, a vertical straight line passing through the centre of the eye ; for the superior and inferior recti, a horizontal straight line {t r) passing obliquely through the centre so that its nasal extremity is a little in advance of its temporal extremity, and forming an angle of about 70° with the line of vision ; for the obliqui, another horizontal straight line (o o) passing also obliquely through the centre, but in such a direction that it makes an angle of 85° only with the line of vision — its temporal extremity being just a little beyond the outer margin of the cornea, and its nasal extremity towards the back of the eye, a little in- ternal to the optic disc. It may be assumed as sufficiently accurate for all practical purposes : that the ball of the eye is globular ; that it is lodged in a socket bounded by fat, connective tissue, and membrane, in which it moves as the head of the femur moves m the cotyloid cavity ; that its centre of rotation is the actual centre of the eye ; and farther, as Helmholtz shows, that in consequence of the fixed origins of the oculo-motor muscles, and their broad insertions, the three axes of rotation which have been indicated remain unalterable in their relation to the fixed points of the orbit, no matter how much the line of vision — the line in which the eye is looking — becomes altered. It follows (see fig. 106) from the above considerations : first, that the internal and external recti always cause the cornea to revolve around a vertical axis, to move therefore either in a horizontal equatorial line, or in proportion as it is elevated or depressed below this line in the arcs of smaller and smaller parallel > circles ; second, that the superior and inferior recti always cause the cornea to revolve around the oblique horizontal axis, whose position has already been defined, and hence in the arcs of circles which are parallel to a vertical equatorial .section of the eyeball, Pia. 106. Left eyeball mth iris and ^^de through or near the outer margin of pupil seen from the front. the comea (as the eye looks directly for- o. Anterior pole of axis of rotation for wards) in front, and the imier margin of the obliqui; r, anterior pole of axis of ro- .1. ,^.^ .i.n • -i , i-i tation for superior and inferior recti ; OptlC dlSC belimd, SO that the CircleS tO WlllCh rot'atiorfoTinternIi^and°ex^tern^ these arcs belong become smaller and smaller rJ^°^^' , from the outer to the inner canthus of the eye, ine concentric circles around o and r ■, i ■ n pi •• • , • respectively indicatethe direction and and the Ulfluence 01 the rCCtl m CaUSmg VCrtl- amount of movement of the different , j /• ^i t i parts of the globe due to the action oE cal movemcuts 01 the comea correspondingly ^!S:^^S^^^r^;:^ diminished; third, that the obliqui always m7nts^aw\\f axii°66!'' *^^ "'°^^' ^ausc the comca to revolve around the oblique horizontal axis which has been referred to these muscles, and hence in the arcs of circles which are parallel to a vertical equatorial section of the eyeball, made through or near the inner canthus ; the circles, to which these arcs correspond, commencing in a point a little outside the outer margin of the cornea, become larger and larger PAEALYSIS OF THE OCULO-MOTOK NEEVES. 1133 towards the inner angle of the eye, so that the influence of the oblique muscles upon the cornea varies from the production of simple rotation, when the eye looks outwards, to equatorial amplitude of movement when the eye is directed towards the inner canthus. It follows, further, that while all horizontal consensual movements of the two eyes can be effected by means of the imier and outer recti only, all vertical consensual move- ments require the co-operation of the superior and inferior recti and obHqui. Paralytic affections of the muscles of the eyeball are attended for the most part with squintmg and double vision — the direction and character of the squint bemg different for each muscle affected, and the position of the object, as seen by the squmting eye in relation to that seen by the normal eye, being either internal or external to it, above or below it, or tilted. The existence of double vision is sometimes not recognised by the patient when the axes of his eyes diverge very widely; moreover, the double image tends to merge into one, and the squint to become unap- parent, in proportion as the patient turns his sound eye in the direction towards which the squinting eye inclmes. In testing the eyes with the object of discovering the existence of double vision and the peculiari- ^^^ ^^^ ^^^_ ^^g^ ties it may present, it is generally convenient to place a coloured glass before one of them, in order that the patient may be able to distinguish and indicate by their respective colours the two images which he sees. Assuming the left eye to be affected, the following would seem to be the consequence of paralysis of its several muscles taken singly : — Internal rectus. — Outward squint. Displacement of false image in horizontal Hne, to pa- tient's right. Image not tilted. (See fig. 107.) External rectus. — Liward squint. Displacement of false image in horizontal line, to pa- tient's left. Image not tilted. (See fig. 108.) Superior rec tits . — Downward squint. Displacement of false image upwards. Elevation of pupil above horizontal line ef- fected solely by inferior oblique ; its upward movement, therefore, is in Fig. 109 Fig. 110. Fig. 111. Fig. 112. lu the above diagrams the thick cross represents the??iie image, the thin cross the false image. 1134 DISEASES OF THE NEEVOUS SYSTEM. a curve directed upwards and to the left ; it is ample when the pupil is directed inwards, but, when the pupil is directed outwards, consists in a mere rotation of it upon its axis. Under these circumstances, the false image is tilted to the patient's right. (See fig. 109.) Inferior oblique. — Downward squint. Displacement of false image upwards. Elevation of pupil above horizontal line effected by superior rectus ; its upward movement, therefore, is in a curve, directed upwards and to the right ; it is most ample when the pupil is directed outwards. The false image, when the pupil s above the horizontal line, is tilted to the patient's left. (See fig. 110.) Inferior rectus. — Upward squint. Displacement of false image down- wards. Depression of pupil below horizontal line accompHshed by su- perior oblique. Its downward movement consequently is in a curved hne, directed downwards and to the left, being a mere revolution upon its axis when the eye is directed outwards, but becoming more and more ample as the eye turns to the right. False image, when patient is looMng downwards, tilted to his left. (See fig. 111.) Superior oblique. — Upward squint. Displacement of false image down- wards. Depression of pupil below horizontal line effected by inferior rectus. Its downward movement takes place, therefore, in a curved line directed downwards and to the right, the movement being most ample when the eye is directed outwards, least ample when it looks inwards. When the pupil is below the horizontal Ime, the false image is tilted to the patient's right. (See fig. 112.) It does not generally happen, however, that one muscle only is affected, ■ unless it be the external rectus, or that when two or three muscles are involved they are completely paralysed; and consequently it is often difficult to determine the respective shares which different muscles take in oculo-motor paralysis. Paralysis of the third pair very frequently causes ptosis, together with dilatation and immobihty of the pupil. When the oculo-motor branches of the third nerve are aU implicated, the eye assumes an external squint, and the pupil is commonly directed a httle downwards. Paralysis of the sixth pair is not unfrequently bilateral, probably because, from the long course which these nerves take along the floor of the skull, and from their position between this and the pons, they are peculiarly exposed to pressure and involvement in intra-cranial iii- flammatory and other morbid processes. Treatment. — The treatment of paralysis of the muscles of the eye must be determined by the opinion we form of the nature of the lesion causing it. Iodide of potassium and mercury are indicated in syphilitic cases. Electricity, applied to the muscles, is sometimes serviceable. However it may be explained, patients often recover from these paralyses. B. Paralysis of the Fifth Nerve. Causation. — This, like paralysis of the oculo-motor nerves, may be ■caused by various lesions implicating the nucleus of the nerve or the PAEALYSIS OF THE FIFTH NEEVE. 1135 nerve itself in some part of its course. It is most commonly of syphilitic origin. Symptoms and diagnosis. — The nerve may be implicated wholly or in part, and in the latter case the affection may be limited either to its ophthalmic, to its superior maxillary, or to its inferior maxillary division. When the affection is total, there is complete anaesthesia of all those parts to which the nerve is distributed, and at the same time complete paralysis of all the muscles of mastication which it supplies. The loss of sensation involves the anterior half of one side of the head and face as far back as the ear, mclusive of the conjunctiva, cornea, and eyelids, the mucous membrane of the nose, hps, cheek, gums, and palate, the tongue (excepting in the neighbourhood of the circum vallate papilla), and the external auditory meatus. Consequently the conjunctiva is insensible to all ex- ternal impressions, and hable, therefore, to get irritated and inflamed— its irritation, moreover, is unattended with reflex phenomena ; the sense of smell is impaired, mainly from tendency of the Schneiderian mem- brane to inflame, but partly from loss of power to appreciate impressions made by pungent vapours or gases ; the sense of taste is annulled in the anterior two-thirds of the tongue ; and, partly from the loss of ordinary sensation in one half of the oral mucous membrane, mastication becomes difficult on the correspondhig side, and food tends to collect unknown to the patient between the cheek and gums, or between these and the tongue. The chief muscles supphed by the motor portion of the nerve are the temporal, masseter, and pterygoids. The temporal closes the jaw, and at the same time draws it backwards ; the masseter and internal pterygoid also close the jaw, but tend to draw it forwards ; the external pterygoid co-operates to some extent with the last, but is especially the muscle by which the jaw is thrown forwards. Collectively they close the jaw, and effect the various horizontal movements of trituration. If they be para- lysed, neither the temporal nor the masseter can be felt to harden in contraction as does that of the healthy side, when the teeth are being firmly closed ; when the lower jaw is retracted it is drawn back obliquely with an inclination to the healthy side ; when it is protruded, it is pro- truded obhquely with an inclmation to the paralysed side. The last deformity becomes especially remarkable when the patient opens his mouth wide, for not only is the jaw then displaced in a very high degree towards the paralysed side, but the oral orifice becomes lopsided, and the muscles connected with the affected side of the lower lip appear to act more powerfully than their fellows. The difficulty of masticating on the diseased side is necessarily largely dependent on the weakness of its muscles. We have referred to the tendency which the affected side has to get congested and inflamed. These conditions may supervene in the mucous membrane of the mouth or nose, or in the conjmictiva. It is most com- monly observed, however, in the cornea, which is apt within a few days of -the occurrence of paralysis to become opaque, to ulcerate, and to slough. 1136 DISEASES OF THE NEKVOUS SYSTEM. These nutritive lesions doubtless obey the law which has previously been considered ; that is, they occur not so much when the continuity of the nerve is absolutely destroyed as when the implication of the nerve or of its nucleus is incomplete and irritative. Under the same circumstances, loss of faradic contractility of the paralysed muscles and wasting are Hkely to come on quickly. If the affection of the fifth nerve involve only one of its main branches, the paralytic symptoms will of course be limited to the distribution of that branch. Accordingly, if the ophthalmic division be alone affected, the anffisthesia will occupy the front of the forehead, the upper eyelid, the conjunctiva, and a part of the mucous membrane and integument of the front of the nose ; if the superior maxillary branch, the anaesthesia will involve the cheek, the lower eyelid, and upper lip, together with the side of the nose, a portion of the temple, the interior of the nose, and the mucous membrane of the cheek, upper gums, and palate ; if the inferior maxillary, the lateral part of the head and face, with the ear, the lower lip and gums, the tongue, and the muscles of mastication ; if the motor portion, the muscles of mastication only. Treatment. — If the disease be syphihtic, antisyphilitic remedies are indicated ; but in other varieties of organic disease medicinal treatment can have but little influence. If the affection be hysterical, or due to- inflammation or other removable causes, faradism or galvanism may be serviceable in hastening the restoration both of sensation and of voluntary movement. C. Paralysis of the Portio Dura. {Bell's Paralysis.) Causation. — This may be caused by any lesion implicating the nucleus'- of the seventh nerve in the floor of the fourth ventricle, or involving the nerve in any part of its course thence : either as it passes through the substance of the pons, or between its apparent origin and the internal auditory meatus, or in its passage along the aqueduct of Fallopius, or just after its emergence from the petrous bone. It may be caused : within the skull, by either extravasation of blood, inflammatory mischief, or syphilitic or other growths ; in its passage through the bone, either by fracture, or by morbid growths originating in the bone -sub stance, or in comiection with caries of the internal or middle ear, or in consequence of inflammation attackmg the nerve itself. Externally to the petrous bone, it may be due to injury, as sometimes happens to the infant during delivery by the forceps, or to inflammatory or other lesions of the parotid or other tissues in the vicinity. The most common and interesting cause of Bell's paralysis is inflammation of the nerve within the aqueductus Fallopii — a condition which is readily induced by allowing a draught of cold air to play on the side of the face. Hence not uncommonly it is traceable to a railway journey m which the patient has been sitting facing the engine and next an open window, or results from exposure, while sleeping, of one side of the face to a current of air. Sym])toms and diagnosis. — Inflammatory, or so-called ' rheumatic,' pa- PAEALYSIS OF THE POKTIO DUEA. 1137 ralysis is generally of rapid development, and is not necessarily attended with pain or constitutional disturbance. Yet not unfrequently the draught which causes the paralysis causes also earache, or neuralgic phenomena referrible to the fifth nerve. The symptoms of Bell's palsy are very strik- ing : all the muscles supplied by the seventh of one side are paralysed ; the half of the face, consequently, is without motion and expressionless ; the wrinkles are smoothed away, and the predominant action of the opposite muscles draws the mouth over to that side. When the patient wrinkles his forehead in surprise, the healthy half becomes, through the agency of the occipito-frontalis, transversely furrowed ; when he frowns, the corrugator supercilii contracts the same part into vertical folds ; but in both cases the forehead on the affected side remains perfectly smooth. The orbicularis palpebrarum ceases to act, so that the eye remains open, and the conjunctiva, from the loss of its habitual protection, becomes watery and inflamed. M. Duchenne points out that this condi- tion is sometimes associated with epiphora, and he attributes this circum- stance to the fact that the tensor tarsi is then paralysed as well as the orbicularis itself, and consequently fails to retain the puncta in the posi- tion best adapted for carrying off the lacrymal secretion. The ala of the nose gets flaccid, and the corresponding nostril loses its rotundity. The cheek is motionless, and smooth and limp ; the natural furrow beneath the eye and that descending from the side of the nose become indistinct ; and when the patient coughs, or blows through his mouth, the cheek, owing to paralysis of the buccinator, undergoes momentary distension. The mouth is drawn to the opposite side ; when it is shut, the paralysed half closes less perfectly than the other ; when it is opened, that half opens less completely ; and the more powerfully he exercises his facial muscles, as in laughing and crying, the more extreme does its lateral dis- tortion become. He has lost the power of whistling, and probably that of blowing out a candle ; his utterance is somewhat impaired ; he has difii- culty in retaining fluids in his mouth, especially in the act of drinking ; and food tends to collect between the teeth and the paralysed buccinator. There is no anesthesia. There are some important distinctions between paralysis due to direct implication of the portio dura, and paralysis of the same nerve of hemi- plegic origin. In the first place, in hemiplegia the paralysis rarely involves materially those branches of the portio dura which are distributed to the eyelids and upper half of the face, while in primary affection of the nerve the paralysis is general. In the second place, in hemiplegia not only is there more or less general unilateral palsy, but the motor branch of the fifth pair and the hypoglossal are involved together with the facial ; while, in the other case, the temporal, masseter, and pterygoids still act perfectly, and the movements of the tongue are in no degree compromised. Lastly, in hemiplegia the facial paralysis is rarely absolute even in the parts chiefly affected, and the paralysed muscles retain their bulk and faradic contractility, while in Bell's paralysis the loss of power is usually absolute, and the muscles lose their electrical contractility very rapidly, sometimes 4 D 1138 DISEASES OF THE NEEVOUS SYSTEM. in less than a week. In neither case are the muscles of the eyeball and the levator palpebrse implicated. The phenomena above enumerated are those which most commonly attend Bell's paralysis, and are the only ones which attend it when the lesion causing it is situated below the junction of the portio dura with the Vidian nerve ; but other phenomena are apt to be superadded in proportion as the disease causing paralysis approaches nearer and nearer to the origin of the nerve. If the disease be so situated as to involve the chorda tym- pani and petrosal nerves, the patient is likely to suffer : first, from over- acuteness or painfulness of hearing, which has been attributed to relaxation of the membrana tympani from paralysis of the tensor, but is by Brown- Sequard believed to be due to hyperfesthesia of the auditory nerve depen- dent on involvement of the sympathetic branch supplying its blood-vessels ; second, from dryness of the half of the tongue corresponding to the para- lysed half of the face, and some impairment of taste, owing to implication of the chorda tympani and consequent interference with the salivary secre- tion, and to some obscure influence exerted directly on the tongue ; and, third, from paralysis of the corresponding half of the soft palate, resulting from implication of the petrosal nerves. This paralysis is revealed : partly by the fact that from involvement of the corresponding half of the azygos uvuIeb, the uvula when at rest, and still more when in motion, is so curved that its point is directed away from the paralysed side; and partly by the condition of the corresponding arch of the fauces, which is usually a little lower than its fellow, and, owing to the tonic action of the muscles on the healthy side, is drawn over in that direction. When Bell's paralysis is due to disease situated within the skull various other complications are liable to be associated with it ; and our diagnosis of the seat of the disease will be mainly determined by the nature of these complications. Thus if the disease be within or near the internal meatus, the auditory nerve is likely to be involved and deafness to be pro- duced ; if it implicate the common nucleus of the sixth and portio dura, paralysis of the external rectus will go along with the facial palsy ; and if it be irregular in distribution, or involve any considerable space, various other paralyses, referrible to implication of the nerves originating in the floor of the fourth ventricle, are liable to be present. Occasionally both facial nerves are simultaneously affected, or affected within a short time of one another — a condition which may involve some difficulty of diagnosis. The face then is smooth and expressionless, the eyes open and staring, the lips apart, and the patient is incapable of retaining fluids in the mouth or of pronouncing the labial letters. The prognosis of paralysis of the portio dura will depend on the nature of the lesion to which it is due. That form of the disease which results from exposure to cold for the most part ends favourably, sometimes in a week or two, more frequently after four or five weeks, occasionally only after the lapse of some months. An element in the prognosis is the condi- tion of the ]paralysed muscles as to faradic contractility ; the more com- pletely this has become annulled, the longer will recovery be delayed, and PAEALYSIS OP THE SPINAL NEEVES. 1139 the greater is the fear that the paralysis may he incurahle. M. Duchenne draws attention to the fact that not unfreqnently permanent contraction of the muscles previously paralysed takes place, and that thus consecutive deformities are induced. This happens he says in those cases especially in which, either spasms supervene in the paralysed muscles under the in- fluence of faradism or other forms of excitation, or a rapid return of tonic force takes place in muscles remaining paralysed and irresponsive to fara- dism. The contraction affects sometimes one, sometimes several muscles. When it involves the lesser zygomatic it curves and deepens the naso- labial line and gives an expression of chagrin ; when the greater zygomatic, it elevates the commissure of the mouth and imparts an aspect of gaiety ; when the quadratus menti, it depresses and everts the lip ; when the orbicularis palpebrarum, it causes diminution of the palpebral aperture ; if all the muscles are involved, the side of the face becomes wrinkled, as if by cold. At the same time that the muscles contract, or it may be subsequently, they usually recover their voluntary power ; but that is not always the case, and the contracted muscles may remain permanently paralysed. Treatment. — In the treatment of paralysis of the seventh pair from cold it is generally well (considering the serious results of permanent deformity) at once to adopt active measures ; to apply a few leeches to the mastoid process, and to follow them up by fomentations, poultices, or equivalent applications. Subsequently blisters or other counter-irritants may be resorted to. If recovery do not follow these measures, electricity should be employed. Duchenne thinks it best, in cases where the faradic contractility has wholly disappeared, to delay the use of faradism until after the lapse of two or three weeks. He recommends the employment of a current with rapid intermissions, and that the muscles be directly and in turn excited. He points out that under this treatment the paralysed muscles often regain their tonic power, and the face its symmetry in repose, two or three weeks or more before there is any indication of the return of voluntary power ; and that it is usually in the zygomaticus major that this power first returns — a fact which may be ascertained by making the patient smile. When the muscles begin to contract, he recommends that the intermissions should be few and the sittings short and unfrequent ; and especially he recommends this, if any of the precursory signs of per- manent contraction manifest themselves, in order that such contraction may be prevented. Galvanism also is efficacious in restoring the paralysed muscles. D. Paralysis of the Spinal Nerves. Causation. — Paralysis of these nerves may arise under various condi- tions ; but we propose to refer only to those varieties which M. Duchenne speaks of as paralyses from cold, and in which the paralysis is due to in- flammation of the trunk of the affected nerve. These affections are not uncommon, and may be readily mistaken for. ordinary rheumatism. Symptoms and diagnosis. — The symptoms comprise pain and tender- 4 D 2 1140 DISEASES OF THE NEEVOUS SYSTEM. ness along the affected nerve, and febrile disturbance, together with the various consequences of disease involving mixed nerves : namely, on the one hand, burning or shooting pains in the course of its branches, and hypersesthesia, followed by tingling and numbness ; on the other hand, muscular paralysis, followed by speedy loss of faradic contractility and wasting. The muscular paralysis for the most part comes on later than the sensory symptoms. During the early period of the disease, the tempera- ture of the affected parts is augmented, later on it undergoes manifest diminution. M. Duchenne singles out two forms of this affection for description, one of which he terms 'deltoid rheumatism,' the other 'paralysis of the radial nerve.' Affection of the spinal accessory is also not uncommon. 1. Deltoid rheumatism is essentially inflammation of the circumflex nerve. It is marked by the occurrence of violent neuralgic pains in the deltoid muscle, sometimes coming on in paroxysms, and augmented by any movement of the shoulder. In voluntary movements pain is especially excited in those fibres which are brought into contraction — a circumstance which will help to distinguish deltoid rheumatism from ordinary articular rheumatism. The symptoms may last for a few days only, or be prolonged for months. In many cases convalescence takes place without the occur- rence of complications ; but in some cases, atrophy of the deltoid, or of a part of it, supervenes after the pains have continued for some time ; and when at length, under these circumstances, the pains have subsided, the muscle continues atrophic, although retaining its voluntary and electric contractility. In other cases paralysis, attended with impairment or abolition of faradic contractility, supervenes. 2. Paralysis of the musculo -spiral nerve is sometimes referred to pressure on the nerve, occurring, for example, during sleep, but by M. Duchenne is attributed (like Bell's paralysis) to exposure to cold, especi- ally to exposure of the arm during sleep to a current of cold air, or to cold and damp. It generally comes on suddenly, without pain or tenderness, but with numbness and tingling, extending to the tips of the fingers. The paralytic symptoms have a close resemblance to those of lead-poisoning, and like these, comprise, as an essential feature, dropping of the hand, and incapability of extending the fingers. The differences between them are, as M. Duchenne points out : first, that in paralysis from cold, the paralysed muscles retain their electrical contractility unimpaired, whereas in lead-palsy this quality rapidly diminishes or disappears ; second, that the supinator longus, which never suffers in lead-poisoning, is invariably implicated in the present case. The following, as is shown by M. Du- chenne, is the proof of implication of this muscle: — namely, that when the patient has placed his forearm in the position of semi-flexion and semi- pronation, and attempts to flex it more completely (the attempt being opposed), the long supinator, which in that position is the flexor of the forearm, can be neither seen nor felt to contract. As in lead-palsy the flexor muscles of the forearm and hand and the interossei escape. Paraly- sis of the musculo -spiral nerve from cold is almost always followed sooner LOCAL FUNCTIONAL SPASM AND PAKALYSIS. 1141 or later by recovery. In some cases, however, progressive wasting of the affected muscles comes on ; and occasionally, also, the opposing muscles and the interossei become manifestly enfeebled from want of use. Treatment. — The value of electricity in the treatment of the above forms of paralysis is very great. When the deltoid pains are unattended with fever or local signs of inflammation, M. Duchenne strongly recom- mends the use of cutaneous faradism, effected upon a dry surface, with a feeble and slowly intermittent current. When, however, there is wasting or paralysis, faradism of the muscles or the interrupted galvanic current is especially indicated, both in the case of the deltoid and in that of the muscles of the forearm. In both cases, moreover, frictions, stimulant applications, and blisters are often serviceable. When there is distinct evidence of inflammation, the various forms of electricity are not only inefficacious, but injurious. The ordinary remedies for local inflammation are then called for. XXII. LOCAL FUNCTIONAL SPASM AND PAEALYSIS, WEITEE'S CEAMP, WEY-NECK, HISTEIONIC SPASM, &c. Definition. — The affections here referred to are limited to single muscles, or parts of muscles, or to groups of muscles, and occur only or mainly at the time when certain accustomed specific actions in which they are engaged are in process of performance — the affected muscles appa- rently acting normally mider all other conditions, and in other respects seeming perfectly healthy. Causation. — The causes of these functional derangements are exceed- ingly obscure. They are, however, for the most part induced by the long- continued exercise, in special motor combinations, and the consequent fatigue, of the muscles which afterwards become affected. Symptoms and diagnosis. — The most common of the affections included in the present group are those which are known in this country as ' writer's cramp ' or ' scrivener's palsy,' ' spasmodic torticollis ' or 'wry-neck,' and ' histrionic spasm.' 1. Writer's craoniJ affects, as its names imply, those who are engaged in writing, and more especially those whose avocations compel them to write for many hours a day continuously for long periods of time. It generally commences with a sense of fatigue or pain m certain of the muscles of the hand or forearm, which comes on shortly after the patient has begun to write. This condition mcreases slowly until pain or weari- ness attends all his attempts to write, and compels him to rest for a time or to desist altogether. Sooner or later, and sometimes from the very commencement, some spasm or loss of power, coming on only when the patient is engaged in writmg, seizes certain of the muscles which he is exercising, and renders his handwriting tremulous or jerky, or arrests his operations completely. In the earlier stages of the disease, the patient sometimes resists its influence with more or less success. But its almost 1142 DISEASES OF THE NERVOUS SYSTEM. inevitable tendency is to go on from bad to worse, until at length the use of the pen becomes impossible. In some cases patients have learnt to write with the left hand ; but in many of these, unfortunately, this hand has after a while become affected similarly to the other. The affection is sometimes paralytic, the patient suddenly losing power over certain muscles, and dropping the pen from his hand ; m most cases it is spasmodic, the muscles causing tremulous or choreic movements, or sudden flexion, extension, or rotation. Different muscles are affected in different cases. In some instances they are the extensors and flexors of the index finger ; in some the interossei of the second and third fingers ; in some the muscles of the thumb ; in some the supinatoTs of the hand. Occasionally the muscles of the hand and forearm are all involved. In some cases the spasm or paralysis commences in the deltoid or other muscles of the shoulder ; and in some it extends from the muscles of the hand and arm to those of the head and neck and trmik. As a rule a sense of fatigue or pain accompanies the functional motor disturbance, but occasionally the patient complains of muscular cramp or of neuralgic pains. However extreme the paralysis or spasm becomes, the muscles retain their functional activity for all other movements than those which have induced them ; but there is for the most part distinct loss of muscular power. 2. SiKismodic wry-neck is an affection of adult Hfe, and of either sex. It comes on for the most part insidiously "uith mieasiness or pain in the affected side, and a tendency to jerk the head as though to relieve some feeling of discomfort. By degrees the uneasiness increases, the spasmodic movements become more constant and more violent, and the head is habitually carried on one side. At first the patient can temporarily restrain his spasms by a voluntary effort, and temporarily hold his head erect, or he can counteract the spasmodic contraction of the affected muscles by the voluntary action of the healthy muscles of the opposite side. But after a while the head and neck become permanently twisted, and the clonic spasms which accompany this twisting are beyond even temporary control. The spasm of the muscles of the neck is apt to become associated with similar spasm of the facial muscles or of those of mastication, or of those of the shoulder or arm. In the great majority of cases the spasms cease during sleep, or whenever the head is supported. The muscles which are affected differ in different cases. In some instances they are those which rotate the atlas and skull upon the axis, and the movements of the head are those of simple rotation. Sometimes it is the splenius capitis which suffers ; in which case the head is inclined downwards and backwards towards the affected side, the face at the same time rotating towards the same side, and the skin of the side of the neck being thrown into deep transverse folds. Sometimes it is the clavicular portion of the trapezius which is implicated ; in which case, as in the last, the head is inclined downwards towards the affected side, and thrown somewhat backwards, but the face is rotated towards the opposite side. If the fibres of the trapezius which are attached to the shoulder also are involved, the shoulder will be distinctly elevated. Sometimes the sterno- LOCAL FUNCTIONAL SPASM AND PAEALYSIS. 1143 mastoid suffers ; in wbich case, as when tlie trapezius is contracted, the head is inclined towards the affected side, and the face is rotated towards the opposite shoulder ; but, contrary to what happens in either of the other cases, the head is thro"\vn forwards. Although the several muscles just named may be affected separately, it is more common to find groups of muscles imphcated. But the affected muscles can generally be readily recognised not merely by their effect on the movements of the head, but also by their contraction, rigidity, and spasmodic action. 3. Among examples of other similar conditions we may quote the following, chiefly from M. Ducherme : — A tailor whenever he had made a few stitches suffered from violent rotation of the arm inwards, in conse- quence of contraction of the subscapular muscle. A fencing master, whenever he put himself into the posture of defence, was seized T\'ith rota- tion of the arm inwards and violent extension of the forearm. A turner, whenever he attempted to work the lathe with his foot, suffered from spasmodic contraction of the flexors of the foot upon the leg. A gentleman, who also suffered from writer's cramp, became subject, when he attempted to read, to contraction of the rotator muscles of the head, which carried his head to the right. A hterary man, who had been employed for some years in deciphering manuscripts, suffered after awhile from double vision, coming on a few seconds after he had fixed his eyes intently on any object ; the defect was due to spasmodic contraction of one of the internal recti. A student, who had overworked himself, became the victim of a strange affection which rendered reading impossible, and finally impelled him to commit suicide. As soon as he began to read, he was seized with a painful constriction of the forehead, temples, and eyes, during which the eyebrows were elevated by spasmodic contraction of the frontales, and the eyes closed by the powerful action of the orbiculares palpebrarum. Pianists are liable to the same affection as writers are. Singers occa- sionally become incapable of singing from involvement of the laryngeal muscles ; soldiers of marchuig from implication of the peroneus longus. In some cases the spasms affect the muscles of expression (histrionic spasm), in some the platysma, in some the muscles of mastication, and in some those of respiration. Pathology. — The pathology of these fmictional affections is very obscure. Most writers believe that the primary fault is in the nervous centres ; but Dr. Poore, in his able text-book of electricity, seems to prove conclu- sively that the disease is in many cases due to abuse of the implicated muscles, which ' become tired out, and degenerate mto a condition of chronic fatigue or irritable weakness ; ' and he shows also that, contrary to the general behef, the affected muscles are absolutely weaker than their healthy fellows, and that then- faradic irritabiHty is diminished. Treatment has not usually proved satisfactory. In Duchenne's hands faradism failed absolutely. Dr. Poore, however, has latterly obtained great success by the employment of the continuous current in combination with rhythmical exercise of the enfeebled muscles. His mode of using the current in writer's cramp is as follows : — ' One pole (the positive) is 1144 DISEASES OF THE NEKVOUS SYSTEM. placed, let us say, in the axilla, and the other over the uhiar nerve, just where it leaves the edge of the biceps muscle en route for the olecranon. The strength of the current is short of that which causes muscular con- tractions, but is just sufficient to make the patient conscious of a tingle in the end of the little finger when the circuit is made or broken. The patient is then made to exercise the interossei by separating and approxi- mating the fingers rhythmically.' The nerve to be galvanised and the muscles to be exercised will of course differ in different cases. Liniments and douches may also be employed ; and tonics are generally indicated. But in all cases it is of the highest importance for the patient to abstain in a greater or less degree from all those habitual actions with which the muscular default is especially linked, and never to attempt to overcome it by violent efforts. Eest is essential. XXIII. NEUEALGIA. TIC DOULOUEEUX. SCIATICA. Definition. — By the term neuralgia is meant pain, for the most part paroxysmal, occurring in the course of nerves and in their arete of dis- tribution. Causation. — Neuralgia is the result of numerous different conditions. It may depend on injuries to nerves, due to contusion, laceration, or the impaction of foreign bodies ; on pressure, such as may take place when the bony channels' through which certain nerves pass become contracted from any cause, ^or when nerves are pressed upon by tumours or other adventitious masses ; or on the implication of nerves in disease, as, for example, when they are involved in rheumatic or other inflammations, in syphilitic gummata, or in carcinomatous or other tumours. In some cases it appears to depend upon, or to be connected with, certain con- stitutional conditions, such as the malarial cachexia, anaemia, and hysteria. In a considerable number of cases no cause whatever, local or constitutional, can be discovered. Neuralgic affections are said to be here- ditary. This is no doubt true of specific forms, such as megrim, and pos- sibly of tic, but can scarcely admit of satisfactory proof in respect of the heterogeneous cases, which make up the great bulk of ordinary neuralgife. It need scarcely perhaps be pointed out that neuralgic pains, which are sometimes of extreme intensity, attend a large number of diseases which have already been discussed : among others, tabes dorsalis, spinal caries, and more particularly carcinoma of the vertebra or pelvic organs, certain inflammatory affections of deep-seated parts, such as abscess of the liver, calculous pyelitis, and hip-joint disease, and a large proportion of the cases of zona or herpes zoster. Lastly, it is amportant to bear in mind that the lesion or local con- dition causing neuralgia may exist in the course of the implicated nerve, or in the spinal cord or brain, or (as above pointed out) may occupy some remote part from which it acts indirectly, Symptoms and lorogress . — Neuralgia is characterised essentially by the NEUEALGIA. 1145 occurrence of pain in the course and distribution of some one or more of tlie sensory nerves. The pain varies in character : it may be tinghng, aching, burning, boring, crushing, cutting, stabbing, darting ; it may be continuous, but usually occurs in sudden lightning-like shocks, which come on either singly or in paroxysms made up of a larger or smaller number of such shocks ; and even when it is continuous, it is usually attended with exacerbations presenting more or less of the latter character. The pain varies also in intensity ; in its severest jjaroxysmal form the patient's sufferings are horrible — sometimes he raves and stamps like a madman, sometimes utters half- suppressed groans, sometimes screams aloud, but under any circumstances is so absorbed in the intensity of his sufferings that he appears almost unconscious of everything which is going on about him ; on the other hand, it may consist in nothing more than a little tmgiing, creeping, or burning. This is often the case during the mter-paroxysmal stage of those cases in which there is never entire cessa- tion from pain ; and such sensations often constitute the commencement of each paroxysmal attack. It commonly happens that tenderness or hyperesthesia is associated with neuralgia ; there may be tenderness along the course of the affected nerve ; or there may be general tenderness in the area of its distribution, or spots of special tenderness scattered here and there upon that surface. It is a fact of considerable importance, first established by Valleix, and since confirmed by numerous observers, that in neuralgia there are generally, if not always, specially painful spots, which are more or less characteristic for each nerve that may be mvolved, and are determined mainly by the emergence of the nerve or of some of its branches from a bony canal, or by their passage through some dense fascia. Trousseau insists that one of these painful spots is the spinous process of that portion of the spine from which the painful nerve escapes. The neuralgic paroxysm may often be induced by irritation of the hj^Derassthetic parts, or even by touching them; on the other hand, firm pressure on them may relieve or avert it. Anaesthesia, again, is not unfrequent in connection with neuralgia. Sometimes impairment of tactile sensibility or discrimination goes along with considerable tenderness or hyperesthesia. But absolute loss of sensation in the affected area occasionally supervenes after a time. The sudden darts of intense pain which so commonly attend neuralgia are generally associated -with sudden reflex movements or twitchings of the part affected ; if the toe be attacked, the leg is momentarily drawn up by an uncontrollable impulse ; if the finger, the arm ; if the face (as in ordmary tic douloureux), spasmodic tmtching of the muscles of the pain- ful region occurs. These convulsive movements may vary fi-om mere twitchings of the muscles to spasmodic contractions of considerable force. The above phenomena are apt to be complicated with other local manifestations. In many cases the affected surface becomes congested during the occurrence of the paroxysm ; and not unfrequently obvious dilatation of the arteries and veins both in, and leading to or from, the 1146 DISEASES OF THE NEEVOUS SYSTEM. implicated region takes place, attended with painful throbbing. In con- nection "^^ith congestion, there is apt also to be some tem]Dorary modifica- tion of function m the afi^ected area, such as arrest or increase of secretion, which is especially obvious if the conjunctiva or the mucous membrane of the nose or mouth be the part involved. Further, the various nutritive lesions, especially erythematous and herpetic eruptions, which have previously been referred to affections of the sensory nerves, are all apt to occur in connection with neuralgia. Occasionally also the hair over the affected region turns temporarily or perm.anently white. An interesting feature of neuralgia is the tendency to shift which it presents in many cases. Thus in trifacial neuralgia the paroxysmal attacks not unfrequently wander either from day to day, or it may be at distant intervals, from one branch of the nerve to another branch ; the pain may even pass over to the great occipital nerve or to branches of the cervical or brachial plexus. Another important point connected with neuralgia, and one indeed which has been regarded as inseparable from true neuralgia, is its uni- lateral or unsymmetrical character. This characteristic, however, is not universal, and occasionally both arms or both legs are symmetrically and equally affected. In a large proportion of cases neuralgia is essentially intermittent ; the pains come on in paroxysms lasting probably from a second or two to a minute, rarely longer, which recur every five or ten minutes, day and night, or manifest themselves at longer and more or less irregular intervals. Occasionally they remit for weeks or months together. The general state of health of neuralgic patients presents considerable diversity, yet it is important in reference both to prognosis and to treat- ment to pay attention to this subject. Thus in some cases we find the patient anemic, in some hysterical, in some labouring rnider the conse- quences of old syphilis ; sometimes he is rheumatic, sometimes gouty, sometimes he is suffering from the effects of the malarious poison. But in a considerable number of cases, and these are often the most severe and intractable, no general morbid condition can be discovered beyond that which the persistent neuralgia itself induces. In these cases the disease is not unfrequently mcurable. Neuralgia may attack any of the sensory nerves, as well those supply- ing the viscera as those distributed to the skin. Among the former class may especially be named neuralgia of the heart, stomach, kidneys, uterus and ovaries, testes, and mammEe. Among the latter class the more im- portant probably are trifacial neuralgia or tic douloureux, and sciatica. 1. Tic douloureux, or, as Trousseau terms it, ' epileptiform neuralgia,' is at once the most severe and the most typical variety of neuralgia. It comes on in adult Ufe, and is for the most part of lifelong duration. Its causes are obscure : sometimes it is referred to carious teeth, sometimes to exposure to cold, sometimes to gastro-intestinal irritation, sometimes to old age or failing health or malarious influence. The neuralgic phe- NEUEALGIA. 1147 nomena involve the branches of the fifth nerve of one side. In some cases it is the first division, in some the second, in some the third, occa- sionally the whole nerve ; or it may be that certain portions only of its divisions are involved. The j)ains, moreover, are apt to shift from time to time from one division to another, or from certain fibres to certain other fibres. They vary in character as other neuralgic pains vary ; but usually are burning or shootmg, and occur m sequences of sudden electric-like shocks. They vary also in intensity, from a mere sense of warmth or tingling to paroxysms of the most intense agony. They sometimes come on at rare intervals ; sometimes, on the other hand, occur every few jninutes, night and day, and are then apt to be brought on by any move- ment of the affected parts, by pressure, by sudden shock, or even by a breath of cold air. Consequently, in cases in which the second or third division is involved, the patient finds it impossible to masticate, and almost impossible to take nourishment by the mouth. Under any circum- stances the severity and frequency of the paroxysms are apt to vary from time to time ; and occasionally, even in severe cases, the attacks intermit for comparatively short periods. In aggravated cases the paroxysms of pain are often attended with spasmodic contractions of the muscles of the affected region. Sometimes the patient smacks his lips, or chews, or executes other movements which are apparently voluntary, and are performed with the object of reheving pain. More frequently he rubs his face during the paroxysms vvdth either his hand or a handkerchief, or a pad that he carries in his hand for the purpose. This constant rubbing not uufrequently wears down the hair of the affected side — the whisker, the beard, the hair in the neighbourhood of the temple — which then appears as if kept close shaven ; occasionally it even modifies the form of the side of the face. Further, the frequently repeated spasmodic action of the muscles of the afi^eoted side produces after a while a permanent curiously wrinkled condition of the surface. Tic douloureux, unbearable though it appears to be, does not tend directly or necessarily to shorten hfe. Patients nurse their agony for many years. The only ways in which it can be regarded as inimical to life are by the difliculty which it occasionally opposes to the ingestion of food, and by driving the patient to suicide. 2. Sciatica. — This is one of the most common varieties of neuralgia. It frequently arises from exposure to cold, but may be due to many other causes ; it is occasionally attended or followed by some degree of anaes- thesia, and occasionally, but mainly when due to structural disease, leads to wasting of the muscles. The pain is of true neuralgic character, and is greatly aggravated by movement of the implicated limb, or by pressure. It is in many cases exceedingly persistent and difiicult of cure. Treatment. — In dealing with cases of neuralgia it is always of great importance to ascertain, if possible, the cause on wliich it depends, and then, if it be within our competence, to obviate or remove it. If, for ex- ample, the pain be traceable to the influence of the malarious poison, quinine or arsenic is indicated ; if it be connected with ansemia, iron is 1148 DISEASES OF THE NEEVOUS SYSTEM. probably the best remedy ; if it be a consequence of exposure to cold, of rheumatism or of gout, the treatment suitable for these conditions should be employed ; if it be referrible to syphilis, iodine and mercury are most likely to be serviceable ; and further, if it depend on the existence of some local morbid process compressing or otherwise involving the nerve, our treatment must vary accordingly. But in a large number of cases, no such hints for treatment are af- forded us ; we can then, so far as general treatment is concerned, only deal with them empirically. Among remedies which, under these circum- stances, have been found useful may be enumerated iron, arsenic, quinine in large doses,' oil of turpentine, chloride of ammonium, phosphorus, croton- chloral hydrate, aconite, Indian hemp, belladonna, and opium. Of these, opium, or its alkaloid, morphia, is by far the most valuable. Indeed, the severest cases of tic, and of similar forms of neuralgia in other parts, often find relief only from large and repeated doses of this drug, which may then be given by the mouth, or preferably, by subcutaneous injection. If given by the mouth, it may be necessary at length, having begun with small doses, to administer as much as from twenty to sixty grains of morphia daily. Alcohol is not unfrequently serviceable in re- lieving pain. Cases of the less severe forms of neuralgia are occasionally cured by a few glasses of wine, or by a tumbler of strong brandy and water. Local medication is often very valuable. Of course the several nar- cotics which have been enumerated, especially morphia and atropia, may be injected subcutaneously at the seat of pain. But, besides this, the ap- plication to the surface, or the inunction, of opium, belladonna, or aconite often gives relief. The most valuable of these applications is aconite in the form of the unguentum aconitife. Counter-irritation also is frequently of much benefit, more especially by means of blisters, issues, the actual or galvanic cautery, and acupuncture. Electricity is especially valuable. Duchenne employed cutaneous faradism, rendering the affected surface dry by dusting it with some powder, and then applying to it for a minute or so faradism of considerable strength, and repeating the process from time to time according to circumstances. But the continuous current is much more efficacious. In this case well-wetted sponges must be used, and the current employed must be of no greater intensity than the patient can readily bear ; and, as has before been pointed out, the origin of the affected nerves should be included between the rheophores, of which one should be moved over the painfal region, and especially applied to the painful points. Moreover here, as in the other case, the applications should be of short duration, and frequently repeated. Lastly, division of the affected nerve has often been practised, especially in cases of tic doulou- reux. It cannot be asserted that this procedure ever absolutely cures the neuralgia ; but there is no doubt that it very often effects a temporary cure — a cure lasting occasionally for a few weeks or even for several months. MADNESS. 1149 XXIV. MADNESS. {Insanity.') Definition. By the term iusauity or madness is understood a state of mind in wliich its normal faculties — namely, the feelmgs, the intellect, and the mil — are partially or generally enfeebled, exalted, or deranged ; and in which necessarily the mental disease is reflected in the speech, the actions, and the conduct, and very generally functional disturbances of the organs of sensation, the voluntary muscular system, and the visceral organs are present. The above definition includes many mental conditions which are not ordinarily regarded as madness ; such as the delirium which occurs in febrile and other disorders, and that arising under the influence of alcohol and other toxic agencies ; hysteria, at any rate in many of its phases, and conditions of overpowering passion into which persons presumably healthy occasionally fall ; and those forms of mental aberration, such as general paralysis'of the insane, idiocy, senile dementia, and the hke, which are due directly to obvious organic lesions of the central nervous organs. It seems to us, however, that although some of these forms of mental disturbance or disease are not such as need restraint, or are simply tran- sient conditions, or are mere incidents of grave corporeal disorders, and on many grounds therefore are not madness in the popular acceptation of the word, they are all properly included in the scientific meaning of the term. As is usually done, we shall omit fi'om our description of insanity the dehrium of febrile and other chseases, acute toxic forms of dehrium, ordinary hysteria, and simple outbursts of passion ; but we shall embrace in it paralysis of the insane, idiocy, senile dementia, and msanity due to the development of cerebral tumours. Causation. 1. Predisposing causes. — a. The question of the influence of race or nationality m the causation of madness has been largely discussed. But the subject is a complicated one ; for it necessarily comprises, not merely the simple influence of race, but the collective influence of all those con- ditions which contribute or have contributed to the formation of the national character, such as rehgion, politics, warfare, occupation, habits, intellectual progress, and civilisation. And the general result of inquiries with regard to it has been to show, not that there is any appreciable difference in respect of proneness to insanity among races of men per se, but that insanity is especially apt to become rife during great national or religious crises, and under other conditions of wide-spread emotional ' In wilting this article the authors who have been chiefly consulted, and whose language has here and there been employed, are Griesinger, Marce, Maudsley, and Bucknill and Tuke. 1150 DISEASES OF THE NEEVOUS SYSTEM. excitement ; and that, on the whole, the lower nations are in the scale of education and civilisation the less the frequency of insanity amongst them. h. Hereditary predisposition plays an important part in the production of insanity. According to Dr. Maudsley the proportion of distinctly heredi- tary cases to others is not lower than one-fourth, if not so high as one- half. But, although the general truth of this proposition has been established beyond dispute, it is for many reasons difficult to give it exact numerical expression ; especially it is difficult to decide how far back and how wide amongst direct ancestors and collateral relations such influences may properly be sought. Again, although actual insanity amongst parents or relations is the most frequent cause of hereditary predis]DOsition, there is reason to believe that other neuroses, more espe- cially epilepsy, hysteria, and a suicidal tendency, have a like influence ; that genius and insanity are often distributed in the same family ; and that drunkenness m parents is apt to beget insanity in children. It is said that the frequent intermarriage of close relations tends sooner or later to a like result. Esquirol observed, and his observation has been confirmed, that insanity descends from the mother more frequently than from the father, and to the daughters in larger proportion than to the sons. c. Edu- cation has an undoubted influence in relation to insanity — a judicious traming tending to strengthen minds which have an inherent weakness and proclivity to it, while an injudicious training may sow the seeds of mental disease in those who are free from all original taint. The subject is a wide and important one ; but it is sufficient to remark here that long- continued harshness, cruelty, and repression in early childhood, the per- sistent endeavour to cram the undeveloped mind with abstruse or unsuit- able knowledge, or to instil with terrifying iteration the repulsive dogmas of a narrow Christianity, the foolish and indiscriminate yielding to all the whims, selfish desires, and passions of childhood, may each in its own way exert an evil influence over the future mental welfare of the unfortu- nate victims, d. Social position and occupation are of doubtful efficacy in causing insanity, excepting in so far as the different conditions included under these terms imply exposure to associated influences which are themselves productive of insanity, such as drunkenness and other forms of debauchery, mental strain, emotional disturbance, and the like. e. Sex. There is no sufficient reason for believmg that one sex is more liable to insanity than the other. At the same time the exciting causes of insanity act with different relative frequency in the two cases ; and there are marked differences in the degree in which its several forms prevail among them. Especially it may be noted that general paralysis, which is com- mon in men, is comparatively rare in women. /. No age can be regarded as exempt from liability to insanity. It is rare before puberty ; yet all forms (excepting general paralysis) are occasionally met with during this period of life. It becomes much more common between 16 and 25 ; but arises mainly between 25 and 45 or 50. In women it is apt to come on with marked frequency about the climacteric period. Subsequently the tendency to it declines. In these remarks relating to the influence of MADNESS. 1151 age, idiocy lias been excluded from the one end of tlie scale and senile dementia from the other. 2. The exciting causes of madness are of two kinds, namely the moral or psychical, and the physical. a. Moral causes are generally held to be the most fertile sources of the disease, i. But mere intellectual exertion, however intense or however much prolonged, rarely produces it. ii. And even the expansive passions — ambition, overweening vanity, immoderate joy, and the like — are almost equally inefficacious in this respect ; and, when they cause it, evolve it usually by slow degrees, and, as Dr. Maudsley observes, ' as a gradual development or exaggeration of a particular vice of character,' iii. It is the depressing emotions which are mainly instrumental in causing insanity ; and Pinel was so convinced of the truth of this that the first question he put to a new patient was always, ' Have you suffered vexation, grief, or reverse of fortune ? ' Fierce anger, unrequited love, jealousy, prolonged anxiety, the distress arising from loss of fortune, disappointed ambition, grief at the sudden death of some dear relative or friend, remorse, hatred, fi"ight, religious depression, the sense of being unequal to responsibilities which have been incurred, may be adduced as examples of the kinds of emotion here referred to. The effect of such emotions may be sudden, as when they act by shock ; or slow, in which case either they produce a gradual intensification of peculiarities already present in the patient's character, or they involve a gradual morbid change in one or more of the viscera, to which change, rather than to the emotional disturbance directly, the mental disease is due. h. The i:)hysical causes of machiess. — i. Of these, alcoholic intemper- ance is doubtless the most important. The symptoms of simple inebriation are closely related to those of insanity ; delirium tremens is itself a variety of insanity ; and further, the habit of drmking to excess produces irrita- bility, vacillation, and other mental phenomena which indicate deteriora- tion of mind. But independently of these conditions, partly it may be from the emotional disturbances which are incidental to alcoholism, partly from the direct influence of alcohol in the production of disease (especially induration of the surface of the brain), the abuse of drink is a pregnant cause of insanity. It operates chiefly in men ; and is a prominent cause of general paralysis of the insane. Intemperance in opium, absinthe, Indian hemp, or other narcotics, is also liable to induce insanity, ii. Sexual excesses, and especially self-abuse, are well-recognised exciting causes. Self-abuse is particularly efficacious in this respect, partly from the early age at which it generally commences, partly from the excessive frequency with which it is apt to be indulged in, but mainly, probably, because of the moral distress which a persistence in the habit always occasions, iii. Many affections of the nervous system, general or local, are often associated with insanity, either as its cause, or as the concurrent conse- quence of some obscure morbid state. Insanity often complicates epilepsy ; epilepsy not unfrequently terminates in mental derangement, and more especially in dementia ; and acute maniacal attacks are liable to be asso- 1152 DISEASES OF THE NEEVOUS SYSTEM. ciated with or to replace the epileptic seizure. Not only is a peculiar mental condition closely allied to insanity often present in hysteria, but hysterical patients are liable to attacks of acute mania, and to chronic forms of mania and melancholia. Chronic diseases of the brain or cord in large proportion are attended, sooner or later, by insanity, and more especially by chronic mania or dementia ; among these may be included syphilitic and other cerebral tumours, sclerosis of the nervous centres, and the sequelae of apoplectic effusions, and of injuries to the skull. Many cases also are recorded in which msanity appears to have been induced by disease or injury of nerves, and even by powerful impressions on the organs of special sense, iv. Other local conditions liable to cause insanity are those connected with the female reproductive organs ; the most inter- esting and important of which are related to the puerperal state. It is somewhat rare for insanity to come on durmg pregnancy ; on the other hand, it sometimes disappears on the supervention of pregnancy. It is mainly in connection with parturition that insanity arises. Sometimes there is an acute outbreak of short duration during the very act ; some- times it occurs during the first fortnight after confinement, and is then generally attributable to some inflammatory or septicemic complication ; sometimes it supervenes at a later period, independently of any local or other disease that can be detected, and under such circumstances is apt to be chronic, though for the most part curable, and in the form of melancholia or mania, not unfrequently associated with nymphomania. Outbreaks of insanity occasionally attend the menstrual flow, and are sometimes induced by the suppression of that discharge, v. Many other affections besides those which have been discussed are liable to be com- plicated by, or to cause, insanity ; amongst which may be enumerated diseases of the heart and lungs, diseases of the abdominal organs and kidneys, tuberculosis, gout, chronic anaemia, and suppressed discharges of various kmds. But the most interesting in this respect probably are acute, and especially the acute febrile, diseases. Patients m these cases are sometimes attacked with sudden and furious maniacal excitement, which may last only for a few hours, or a few days ; but not unfrequently the attacks, which are then either melancholic or maniacal, become chronic, and, although generally curable, may need to be treated in an asylum. These outbreaks occur for the most part during the subsidence of the disease, or even during convalescence. They are observed mainly in pneumonia and rheumatism, in enteric and typhus fevers, and in some of the exanthemata. They occur, too, in ague, in which case paroxysms of temporary insanity are apt to replace the ordinary febrile paroxysms. Acute anaemia, such as results from sudden and copious losses of blood, is sometimes attended with an outbreak of acute mania. Symptoms and Progress. A. General description. — In order rightly to understand the pathology of the brain, as that of all other organs, the necessity has long been re- cognised of regarding the morbid structures as mere modifications of the MADNESS. 1153 healthy structures, and to seek m the normal development of the healthy parts the clue to the abnormal development of the parts which are diseased. So, if we would rightly apprehend the pathology of the mind, as that of functional disturbance of other organs besides the brain, we must accept the facts that its abnormal actions are simply modifications of its healthy actions, and that the secret of their evolution is to be learnt from a careful study and comparison with them of the natural ^Dhenomena of the mind. The mind from the moment of birth, at which time it is a blank page, is constantly, through the instrumentality of the organs of sense, re- ceivuig impressions which paint themselves more or less vividly upon it. The impressions or perceptions which are thus made are stored up and remain henceforth the property of the mind, to be utilised by it, to be re- called from time to time voluntarily or involuntarily, to be analysed, com- pared, combined, rearranged, and so to contribute to the formation of new and complex ideas — of a subjective world which reflects but idealises the world without. Intimately associated with the perceptions and ideas which thus throng the mind are the mental qualities which give them their tone or colour, and the purely intellectual functions by whose cold light they are examined and compared. By the former are meant the senses of pleasure and of pain, the moods, the feelmgs, the passions, the moral quahties, which accompany perceptions and ideas, or are called forth by them, and which pervade and leaven them, or put them in special aspects, or endow them with qualities which are not inherent in them, but are the reflexes of the mental conditions whence they are derived. The purely intellectual fmictions comprise memory, reason, and imagmation, the powers by which we recall the perceptions and ideas which are stored up in the mind, by which we analyse, compare, and form judgments, and by which we rearrange our ideas, invent, and create. The springs of action have their sources in the functions which have here been con- sidered. Impressions received in the perceptive centres, and even revived impressions, induce involuntary reflex actions for protective and other purposes. Under the influence of the various moods and passions not only do the features and the general demeanour reveal with more or less accu- racy the dominant emotional condition, but their subject is not un- frequently driven to perform acts, it may be of heroism, it may be of crime, to which reason alone would never have prompted him, or from which it would have restrained him. Above all, presiding over all, is the will, at any rate that higher element of the will, by the exercise of which we give attention to and regulate our mental operations, and which governs, directs, and restrains the more or less wayward and uncertain impulses to action which originate in ordinary reflex conditions or in emotional disturbances. It need scarcely be added that the due relation of the mind to the external world requires, on the one hand, that the organs of sense shall be efficient and in mii.nterrupted connection with the perceptive centres, and, on the other hand, that the motor cell-groups for co-ordinated actions, 4 E . 1154 DISEASES OF THE NEEVOUS SYSTEM. together with the subordinate motor apparatus, shall have their normal relations with the supreme centres of action. In mental disease, or insanity, there is necessarily disturbance of one or more of the functions which have here been enumerated ; and conse- quently we have to consider, as factors of insanity, ' disorders of sensation,' * intellectual disorders,' and ' disorders of movement.' 1. Disorders of sensation. — The sense of illness, or that of well-being ivhen illness is present, may be referred to this head. It is remarkable that in many cases of insanity the patient is quite free from all feeling of bodily ill-health, and on this account wiU often protest against medical treatment. There are other cases, however, notably cases of hypochon- driasis, in which the sense of illness is not only present, but profoundly exaggerated ; and generally when convalescence is in progress the patient suffers from depression, fatigue, and other symptoms which satisfy him that he is iU. Anaesthesia and analgesia are often observed in melanchoHa and dementia, but above all in general paralysis ; and these conditions may be general or limited to certain parts. But, in most lunatics, sensation remains unaltered. There may even be hyperesthesia. The most interestmg sensory disorders, however, are those which are Tmnwn as illusions and hallucinations — the former term signifying the false perception of impressions made upon the organs of sense, the latter term signifying subjective sensory perceptions which ' are projected outwards, and thereby become, apparently, objects and realities.' It is clear that there is a real difference between hallucinations and iUusiona, and yet it is often difficult or impossible to distinguish between them. Thus, in dehrium tremens, when the attendants, articles of furniture, and even ■shadows, are taken for fiends or wild beasts, or muscse volitantes due to disturbance of the retinal circulation are transformed mto beetles, butter- flies, or gold and silver coins, the patient is the victim of illusions ; but when he perceives similar things while nothmg in the world around or in his organs of sense furnishes, so to speak, his mind with an excuse for seeing them, he suffers from hallucinations. Both illusions and halluci- nations may involve any or all of the senses. In the following paragraph, we shall speak of them as if they were identical. Hallucinations of sight are probably more common than those of any ■of the other senses. They are seen, in different cases, by night, by twi- light, or by day; they may be vivid or shadowy; they may be of short duration or persistent, or may come and go ; and they necessarily vary in character — in some instances animals, in some human beings, in some friends long dead, in some devils, in some angels, and in some panoramas crowded with hfe rismg before the patient ; and they are shockmg, terri- fying, or agreeable, according to circumstances. Hallucmations of hearing are rather less common, and on the whole of graver augury, than those of sight. They are especially common in melancholia and chronic mania. The patient generally hears voices, to which he Hstens, with which he converses, which he quarrels with or obeys. These voices sometimes talk nonsense, frequently they upbraid or insult, or utter profane or obscene MADNESS. 1155 language, or revile the sufferer's friends or relations, or tempt or command liini to evil deeds. They often seem as distinct as the real voices which are uttered around him, and appear sometimes to come from articles of furniture or particular spots, sometimes to reach him from a far distance, and maybe by telephonic agency, and sometimes to be internal voices or voices without somad. Occasionally the patient hears discordant marticulate noises, or strains of music. Hallucinations of smell, taste, and common sensation, are not unfrequent. As regards smell and taste the impressions on the perceptive centres are almost always of a disagree- able or offensive kind. Hallucinations of common sensation lead to the belief that animals are crawling over the skin, or that galvanism is being applied, or that frogs, snakes, birds, or the arch-fiend himself is present in the chest, abdomen, or head. They are especially common in relation to the reproductive organs in both sexes. Hallucinations of several senses are often present at the same time ; and, when thus associated, and in any degree concordant, naturally tend to confirm to the patient the objective reality of his false impressions. But, although illusions and hallucinations are amongst the most striking and important indications of insanity, their presence by no means necessarily implies the insanity of the sufferer. Many cases have been recorded (and such cases are not uncommon) in which persons, m all other respects mentally sound, have seen casually, or have been troubled more or less persistently with, hallucinations of sight and even of hearing, but who have been able by reason and observation to satisfy themselves of the unreality of their abnormal sensory impressions. Nor even does it necessarily follow that, because a patient believes in the reality of the phantoms which present themselves to his senses, he is to be regarded as insane. The natural credulity of many persons, the belief in which many have been brought up in the existence of ghosts, in the possibility of the reappearance of the dead, and in the naturalness of supernatural occurrences, and the inaptitude of most persons for scientific investigation, make them ready believers in the objective reality of the phantasms which arise in their perceptive centres, especially if, as is most probable, the hallucinations have some obvious relation to their prevailing sentiments or beliefs. 2. Intellectual diso7"ders. — These comprise perversions of feeling, or of the affective functions, derangement of the intellect or of the ideational functions, and disturbances of the will. a. Esquirol declares ' moral alienation to be the proper characteristic of mental derangement ; ' and says, ' there are madmen in whom it is difficult to find any trace of hallucination, but there are none in whom the passions and moral affections are not perverted or destroyed. I have in this particular met with no exceptions.' The accuracy of the opinions here expressed is generally admitted. The earliest indication of insanity in the great majority of cases is, not the occurrence of hallucinations or perversions of tiie reasoning powers, but some change in the patient's feelings, a sense of sadness, perplexity, restlessness, dissatisfaction, or 4e 2 1156 DISEASES OF THE NEEVOUS SYSTEM. irritability, a feeling of buoyancy, extravagant joy, or recklessness, a condition of dulness, apathy, or utter indifference, which pervades the patient's thoughts, which modifies his relations to the world about him, especially perhaps to particular objects, and which reveals itself more or less obviously in all his actions. The phenomena here referred to are not such as would necessarily strike the casual observer ; for among the many varieties of character presented by those among whom we dwell we not unfrequently meet with some which differ little, if at all, in their actual condition from the abnormal characters of insane persons. The main indications (apart from the supervention of other and more striking evidences of insanity) that such moral conditions are insane, are partly their extravagance, but especially the fact of their coming on in persons in whom an opposite or at any rate different character had formerly pre- vailed. Thus, it is not the fact of a man being in a desponding frame of mind, negiectmg his affairs, and attempting suicide, or of his being a liar, a thief, or grossly indecent, or of his being quarrelsome and revenge- ful and attacking with fury those who thwart him, or of his being reckless in his speculations, and outrageously extravagant in his expendi- ture, which constitutes him insane : for such peculiarities of temper or of conduct are not uncommon in a greater or less degree among such as are altogether free from mental disease, and some at any rate may be deve- loped temporarily mider circumstances which are sufficient to explain their presence. But insanity is manifested when, without adequate cause, the man of hopeful disposition becomes despondent and miser- able ; the truthful, honest, and pure-minded Christian gives himself up to vicious practices ; the amiable and considerate friend becomes quarrel- some and violent in his conduct ; and the cautious and shrewd man of business loses his caution and shrewdness, and enters upon a course of wasteful expenditure and wild speculation. It is under the mfluence of such moral perversion that, without necessary delusion or obvious im- pairment of judgment, hatred, suspicion, jealousy, ungovernable rage, and other passions arise, often directed against near and dear relations and friends, which drive their subjects to acts of violence and murder ; and similarly under its influence that many persons are impelled to theft, arson, drimkenness, and other extravagant foUies or crimes. h. The intellectual functions are probably always to a greater or less extent impaired or perverted in insanity. Often the memory suffers. But in many cases, as for example in monomania, it is, or appears to be, unimpaired. And it is an interesting fact that, although occasionally no doubt patients on recovery from an attack of insanity forget in some degree or even absolutely all that occurred to them during their ill- ness, they do in the large majority of cases retain a fair recollection of their experience, and are slow to forget injuries or kindnesses which they have received at that time. Again, madmen not unfrequently have a vivid recollection of the events of their former lives, while forgetting (perhaps from want of attention) circumstances which have recently occurred ; while, on the other hand, former occurrences are sometimes MADNESS. 1157 blotted out, or become so bazy as bardly to be recognised as belonging to tbeir own experience. Tbese peculiarities attacb especially to cbronic mania and dementia. Li a large number of cases, bowever, it is not so mucb tbat accumulated knowledge is effaced from tbe mind, as tbat tbere is a loss of tbe power of voluntarily recalling it, and tbat it is apt to come up casually and unexpectedly. Occasionally tbe memory appears to be preternaturally active. Tbe faculty of ideation becomes affected, and for tbe most part largely affected, during tbe progress of insanity. In some instances, as in melan- cbolia, conceptions are slowly formed, and ideas present tbemselves slug- gisbly to tbe mind ; m otber cases, as for example in acute mania, tbey are developed tumultuously, and succeed one anotber rapidly, and tbe mind is kept in a constant wbirl. Tbe general cbaracter of tbe patient's ideas is largely determined by bis prevailing mood, or passion ; and bence in melancbolia bis ideas are for tbe most part gloomy and desponding ; in mania, vivacious, bumorous, grotesque. Furtber, tbere is often an obvious connection between tbe prevailing insane ideas, and vivid im- pressions tbat bappened to be made on tbe mind inmiediately before tbe attack. Wben tbe ideas are sluggisb, as tbey are apt to be in dementia and melancbolia, tbey are often persistent, or tend to recur. Tliis per- sistency of certam ideas or certain groups of ideas is especially cbarac- teristic of monomania. Wben, on tbe otber band, tbe ideas flow rapidly, tbey are less tenacious, and, altbougb still largely determined by tbe patient's emotional state, are largely called up by tbe persons, tilings, and occurrences about bim, and by wbatever attracts bis attention for tbe moment. Under tbese conditions, too, tbey are liable to follow one anotber witbout mutual connection, and to become incoberent. Lico- berence, bowever, depends not only upon tumultuousness of ideas, but equally upon failure of ideas and general loss of mental power. It is not necessarily paucity of ideas, or superabundance, or incoberence, or in- appropriateness, or oddity, or fixity of tbem tbat constitutes insanity ; for many sane persons are characterised mentally by some one or more of tbese conditions, and all of us are liable to incoberence of tbougbt and mappropriateness. But bere, as in affective insanity, tbe answer to tbe question as to wbetber a patient is insane or not must depend largely on a comparison between bis present mental condition and tbat wbicb cbaracterised bim formerly. And especially mucb will depend on tbe point of view from wbicb tbe patient regards bis ideas, and on tbe influence wbicb tbey exert over bis conduct. Tbe reasonuig powers are doubtless impaired in all cases of insanity. Tbis is not always at first sigbt apparent ; for many lunatics, especially monomaniacs, argue witb considerable skill, not only on general matters, but even on tbe subject of tbeir delusions, for tbeir belief in wbicb tbey sometimes adduce tbe most plausible reasons ; and otbers, as for example persons sufi'ering from acute mania, converse witb no little brilliancy, making sparkling and witty observations, and being ready witb repartee and sarcasm. In tbe former case, bowever, close observation wiU 1158 DISEASES OF THE NEEVOUS SYSTEM. probably reveal manifest mental weakness, and especially an inability to appreciate or to meet arguments directed against tlieir delusions. And in the latter case the readiness of retort and the vivacity of speech are associated with a total loss of power to pursue any train of reasoning, or even to sustain a connected conversation. But the failure of the reason- ing powers becomes specially apparent when illusions, hallucinations, and vivid ideas take possession of the mind, and are accepted as objective realities or fundamental truths, and form at once the substratum and the motive of the patient's thoughts and actions — when in fact they become delusions and the foundation probably of a superstructure of further delusions. Delusions are often of slow growth, and, though constituting perhaps the most striking phenomena of insanity, for the most part appear secondarily either to the moral disturbance which is generally the earliest symptom of mental disease, or to that phase of insanity which is charac- terised by hallucinations, and by undue slowness, or rapidity, or by per- version of ideas. The melancholic patient presents in the first instance a sense of profound depression ; and it is only subsequently that a definite delusion crystallises as it were out of this general feeling, and becomes the assigned cause of his mental condition. The patient, whose affective state is at first one of gaiety and restlessness, only at a later period acquires the expansive delusion that he is enormously rich, as strong as Hercules, a king of men, or God Almighty. And often, as we have shown, illusions and hallucinations, and it may be added insane ideas, are recognised for a time by the patient at their proper value, and are resisted and wrestled with by him, until probably at length his reason yields at discretion, and becomes their captive. It is of course mainly in dementia that the reasoning power, as well as other mental attributes, fail. c. The varied impulses to action which operate in health are all liable to affection in mental disease. The strong man becomes vacillating, the weak and timid grows obstinate and resolute. It is indeed curious ta observe how, in some cases, the patient seems to lose all power of will, how he apparently loses all capacity not only for directing his thoughts, but to decide for himself whether or not he shall perform even the most trivial action ; while, in others, he seems impelled even against his reason by a stubborn and unbending determination to perform some malicious or wicked deed, or to carry out some absurd design. Careful examination and inquiry will probably show in every case that there is a more or less manifest failure of that higher element of the will, in virtue of which we fix attention upon ideas and trains of thought, com- pare, analyse, and force them into due relation, and by means of which we control and direct the various impulses to action determmed by our perceptions and ideas, and by the moods and passions which alternately sway the mind. It is largely owing to the former of these conditions that the victim of hallucinations of the senses ends by accepting his hallucina- tions as facts, and that so-called ' insane ' ideas become fundamental beliefs. And it is due in great measure to the second of these conditions, that the patient yielding to the uncontrolled impulses of the moment per- MADNESS. 115& forms acts wbicli in a healthy frame of mind his reason would have restrained him fi'om. It often happens that, compelled by impulses, against which haply they may have striven with all their might, patients, not apparently otherwise insane, commit thefts, perform indecent acts in public, set fire to hay-stacks or houses, or give themselves up to bouts of drmking. At the same time it is important to recollect that apparently impulsive insane actions are not necessarily or even principally due to instmctive or moral causes. In a large number of cases, and in many instances too where it is w^hoUy unsuspected, the patient acts under the influence of some delusion : he is ordered by some peremptory voice, by Christ himself, to help himself to his neighbour's breakfast or to pick his pocket ; he puts his hand mto the fire and reduces it to a cinder, in the behef that fire has no influence over him ; he refuses food, because he belongs to the immortals, and does not need it, or because he imagines it is poisoned ; he remains motionless for fear that being made of glass he shall be broken in pieces, or because a false step or even a change of position shall reveal him to those who are seeking his life or cast him headlong down a precipice. d. The destructive tendencies, already referred to in the last para- graph, which are common in madness, but chiefly in that variety of it known as melancholia, form an exceedingly interesting study. They may be suicidal, homicidal, or directed against the lower animals or inanimate objects. And they arise in different ways. In some cases persons un- affected with hallucinations or delusions become the subjects of a more or less uncontrollable impulse to destroy themselves, to kill infants entrusted to their care, or to smash, burn, or otherwise destroy. Thus, even young children commit suicide from simple disgust of life, or on account of some petty disappointment or annoyance, or brutally murder their playmates for no obvious cause ; and many such patients (more especially adults) actully recognise their miserable condition and bewail it, strive for a time, at any rate, more or less successfully against their impulses, and even seek the restraint of a madhouse. In other cases, as for example in the course of epilepsy, patients are suddenly urged by some blind un- governable rage to commit the grossest outrages, to mutilate, to murder, or it maybe to destroy themselves. In other cases, the impulse to suicide or murder is the almost necessary result of the long-continued mental misery from which the patient suffers ; under the influence of his profound depression, percei\ang no other possibility of escape from sorrow, he destroys himself ; or in order to save them from a WTetched future, or to send them to a better world, he takes the lives of those who are dearest to him. But very frequently the determining cause of the patient's action is some hallucination or delusion which dominates his mmd : he kills himself because some voice he dares not disobey tells him to do it ; he makes murderous attacks either to defend himself from those w^hom he supposes to be w^orking him mischief, or to destroy the arch-fiend whom, he believes to be present in human guise, or to save his friends from impending peril. It is important to observe, how^ever, that murder or 1160 DISEASES OF THE NEEVOUS SYSTEM. suicide by the insane is not always due to any destructive desire or impulse ; but that occasionally, for example, a madman will Mil himself in the attempt to prove his immortahty, or his child in the full belief that lie is Christ and will rise the thh'd day. Among destructive impulses must, of course, be included those which impel patients to tear up their clothes and bedclothes, and especially those which incite them to the setting fire to hay-stacks, houses, and the Hke. It must not be forgotten that all melancholic patients, however inoffensive they may seem to be habitually, are liable in a greater or less degree to sudden impulses to MU or destroy. 3. Disorders of movement. — In the remarks just made the performance of combined actions in obedience to the dictates of emotional impulses or of the will were alone under consideration. Under the present heading it is intended simply to call attention to the modes in which muscular actions are executed in madness — to the defects or modifications of move- ments which may be present. It is probably rare to observe entire healthiness of action in those who are insane. In most cases the expres- sion of the features or the movements of the body reveal to the practised eye the patient's mental condition. The wandering look of one, the sullen or suspicious aspect of another, the self-satisfied air of a third, are severally in full accordance with the prevailing emotional condition ; and a similar conformity may be observed between the restlessness of move- ment, the inertness of manner, the obstinate immobility, which are fre- quently met with, and the patient's state of mind. But other muscular phenomena besides these are generally present. In some cases the muscles are rigid, in some relaxed. In some there is apparently excess (temporary, no doubt) of muscular strength, in more there is actual loss of power. Occasionally a condition of catalepsy is present. Further, local paralyses and spasms, such as occur under other cncumstances, are not uncommon here ; among which may be mcluded hemiplegia, paralysis of certain nerves connected with the head and neck and face, epileptic convulsions, convulsive movements of particular parts, chorea-like affec- tions, rhythmical actions, difiiculties of articulation, and nystagmus. As regards the special phenomena of 'general paralysis of the insane,' we shall reserve our observations until we come to the consideration of that disease. 4. In most if not in aU cases of insanity, the several disorders which have just been discussed separately, and may exist alone, become combined in a greater or less degree, and conem- in the development of the special hisane mental phenomena which each patient presents ; and they act and react on one another in such a way that it becomes extremely difficult and often impossible to estimate their several influences upon the patient's thoughts and actions. This difficulty is especially great in the case of dementia, where the perverted mental powers have undergone gradual deterioration, and the motives to action are mainly the satisfaction of the appetites, and the mere shreds of moral and intellectual attributes which survive the sreneral mental wreck. MADNESS. 1161 The remarkable resemblances which exist between dreaming and states of somnambulism artificially induced on the one hand, and insanity on the other, have long been observed. In di'eaming our mental faculties are only partly annulled by sleep. Some are still wakeful, but wakeful in different degrees; and between these all sense of proportion is lost. Sub- ordinate mental phenomena, fitfully or not at all controlled by the higher intellectual powers, attain miwonted importance. Ideas and hallucina- tions, ever varpng and with little interconnection, but determmed to some extent by sensory impressions, and by the thoughts and occupations which preceded sleep, crowd the mind, and are accepted by it as reaHties. There is a total loss of knowledge of our actual relations to the external world, including our relations to time and space. Memory fails to recall in orderly sequence the events of our past lives, even those which have just occurred ; but it brings together confusedly fragments of previous experi- ences, sometimes fragments which had seemed to be utterly forgotten, and blends them into contemporaneous pictures. It even irivents recollec- tions ; and passing thoughts are taken for personal reminiscences of what never occurred to us. The reasoning faculties specially fail. There is little or no power of comparing or analysing the pictures or ideas which present themselves to the mind ; however absurd, however outrageous, iowever impossible they would appear to us if awake, they are accepted as a rule without question and as a matter of com'se by our sleeping minds ; and even though at times we appear to ourselves to reason with acuteness and to argue with force and triumphantly, it is well known that almost always, if on waking our arguments can be recalled to mind, they prove to be disconnected, shallow, and even nonsensical. The moral feelings are also involved in sleep. Sentiments of joy, vanity, pride, and generally of exaltation, are by no means unfrequently excited ; and on the other hand, cunning, hypocrisy, remorse, ungovernable fury, ■cowardice, and horror are common mental phases of the sleepmg state. Further, it may be remarked that at any rate some forms of insanity have a resemblance to dreaming, in the facts of the abeyance of the external senses and of their normal influence over the mind, and of the more or less complete severance between the mental phenomena and the responsive action of the muscles. In connection with this subject it is interestmg to consider, that it is not uncommon for insane persons dm-ing convalescence or after recovery to speak of their past mental condition as though it had been a dream ; that the outbreaks of temporary impulsive insanity which sometimes pre- cede, sometimes replace, but more commonly follow, an attack of epdepsy, and which often impel the patient to deeds of purposeless violence, are apt to pass absolutely from the memory, as a dream often does ; and, further, that if the dreamer were durmg his sleep to act m accordance with his delusions and impulses, as in his dream he believes he does — if the honest man were to pilfer, the wtuous man to commit rape, the losing father to disembowel his child and put it in the dust-bua, if he were to hold audible conversations with his interlocutors, and generally 1162 DISEASES OF THE NEEVOUS SYSTEM. were visibly to play his part in the fantastic and unreal world in which he seems to live — there would be little to distinguish between the condition of the sleeper and that of the lunatic, except perhaps that the lunatic is more or less alive to all that is going on round about him, and that the facts of the external world and his relations to them (it may be falsely seen and falsely interpreted) are mingled with his insane moods, his insane ideas, and his other insane subjective phenomena. B. Special descri'ption. — There are two fundamental divisions of insanity : the one characterised mainly by perversion or disease of the emotions or passions, the other characterised mainly by perversion or disease of the reasoning powers. The former is termed affective insanity f the latter ideational or intellectual insanity. It is not pretended that all lunatics can be placed in one or other of these categories, or, indeed, that affective insanity and ideational insanity ever exist wholly independently of one another ; but it is a fact that in the great majority of cases insanity commences with some change in the feelings, some perversion of the m.oral qualities, some affection of the ]Dassions, which stamps itself on the features and demeanour, and influences the conduct ; and that it is only subsequently that delusions and other distinct evidences of intellectual disease manifest themselves. It is a fact too that the patient may never pass beyond the stage of affective msanity ; and it may be repeated that moral perversion persists as perhaps the most important factor in the constitution of all cases even of ideational insanity. Again, it is now generally acknowledged, as Guislain was the first to establish, that in by far the larger number of cases the earliest indications of insanity consist in a ' state of profound emotional perversion of a depressing and sorroivful character,' and that it is only at a later stage, if at all, that morbid feelings and passions of exaltation show themselves. Although fully admitting the truth of the principles just enunciated, we shall not attempt, any more than other authors have done, to classify the varieties of insanity according to one or other of them ; and while acknowledging most thoroughly that different forms of msanity pass into one another, and that many cases are met with which can only with a certain amount of violence be assigned to any particular division, we shall adopt, in the main, the system of classification which has been accepted — at any rate in principle — by most writers on the subject. Accordingly we shall arrange mental diseases under the following six heads : — 1. Melancholia, madness characterised by mental depression ; 2. Mania, madness characterised by mental exaltation ; 3. Monomania, or partial madness, generally attended with exaltation; 4. Dementia, madness characterised especially by mental weakness ; 5. General paralysis of the insane ; 6. Idiocy, amentia, or congenital mental defect. 1. Melancholia. — The specific character, the fundamental phenomenon, of melancholia is the presence of a profound sense of painful depression — a feelmg of oppression, anxiety, dejection, and gloom. This conclition, indeed, as has already been stated, constitutes the early stage of most MADNESS. 1163 cases of insanity. It may come on without obvious cause, or it may supervene on some bodily illness, or on some mental perturbation or shock. For the most part its onset is gradual ; the patient feels un- happy, irritable, annoyed with himself and all about him ; he loses interest in what formerly gave him pleasure ; everything is a trouble or misery to him. The world is physically unchanged to him, and yet an altered relation between himself and it has arisen which he cannot under- stand, and for which he cannot yet assign a cause. At first he most likely endeavours to conceal the wretchedness he feels ; but soon probably he either mopes, withdraws himself from observation, and neglects his business and his duties, or gives vent to his feelings in irritability of manner and tendency to quarrel, and perhaps displays malice or hatred towards those who should be, and were, dearest to him. The malady may not proceed beyond this point ; but in most cases hallucinations and delusions manifest themselves after a time — hallucinations and delu- sions which correspond closely in character with the patient's affective state. It was formerly believed, and is even now not unfrequently sup- posed, that the delusions of melancholia are the cause of the patient's mental gloom and misery ; but that is not the case. On the contrary, the special delusion or delusions which he manifests crystallise, so to speak, out of his large and vague feeling of depression. Seeking, it may be, for some explanation of his altered state, which probably no one, up to this time, appreciates and deplores more than he himself does, his mind dwells upon some special subject (determined, probably, by his former pursuits or mclinations, or by accidental circumstances), until at length it assumes a predominant influence over him, and becomes transformed into a delusion. This apparent revelation to him of the cause of his mental change is, oddly enough, not unfrequently attended with some diminution of his despondency ; and oddly, too — a circumstance tending to show that the delusion is not the real cause of his condition — the discovered cause is often altogether trivial, and quite inadequate to explain the consequences supposed to flow from it, just as the intense horror or dread which attends nightmare is for the most part altogether disproportionate to the imaginary incidents which seem to cause it. The delusions of melancholia are of the most varied kind. In a large number of cases the patient believes that he has committed some inexpiable crime, that he has done murder if not in deed in thought, that he is a thief, that he has been unchaste, that he has committed the unpardonable sin, that he is a disgrace to his family and to humanity, that he is forsaken of God, and doomed to eternal punishment. In other cases he harbours the delusion that some kind of possession or transformation has taken place in him : he is possessed by the devil or by a legion of devils, or he has been transformed into the evil one ; he has become a dog, a wolf, a toad ; he is made of glass ; he is a mass of corruption ; he exhales offensive odours, which render him an object of disgust ; he is a corpse, or his former self is dead, and that which passes for him is something or someone else. Or his delusions have special reference to other persons : he is an object of general suspicion; 1164 DISEASES OF THE NEEVOUS SYSTEM. everyone is making remarks about liim, or pointing liim ont ; detectives are on the look-out for liim ; spies are constantly dogging his footsteps ; his friends are untrue, or his wife unfaithful ; or dreadful calamities are threatening those who are dearest to him — calamities for which, probably, he is in some way or other answerable, but which he cannot prevent. Or he regards himself as the victim of some person, some power, or some conspiracy : he is being poisoned ; he is subjected to the influence of electricity ; his thoughts and actions are directed in some marvellous way by someone who owes him a grudge, or has acquired midue influence over him ; he is mesmerised or bewitched. It is almost needless to say that hallucinations and illusions are usually associated with the patient's delusions, and then form an integral part of them. There is Httle doubt that the belief so common among melanchohcs, that they are being galvanised, is determined mainly by hallucinations or illusions of common sensation, and that the notion of being made of glass, of being slowly burnt, of being one of the lower animals, of harbouring inside them unholy or loathsome beings, is equally connected with some perversion of the cutaneous or visceral sensibility. The delusion that he is a corpse, that he is bemg poisoned, that he exhales a disgusting odour, may sometimes be referred to affections of the patient's sense of taste or smell. It is in this form of madness especially that the sufferer hears voices which whisper abominable words or sentiments, which revile and upbraid him, which utter calumnies against his friends, which tell him that he is damned, which incite him to acts of violence or crime. Hallucinations of sight also are common ; the patient sees the enemies or fiends that are pursuing him, the judge and jury before whom he is being tried, portents in the heavens, death and destruction around him, hell yawning at his feet. The aspect and demeanour of melancholic patients, though very various, are in accordance with their mental condition. The expression is, according to circumstances, irresolute, sad, suspicious, moody, or con- centrated ; the eyes are cast down, or fixed with an intense look of pain or horror. Generally the patient's movements are languid and feeble, and he remains, perhaps, all day long in one place, and even in one position. Sometimes, under these circumstances, his limbs become rigid, and his muscles may even assume a cataleptic condition ; sometimes, on the other hand, they are flaccid. In many cases the patient is restless, constantly moving about, perhaps hovering around the keeper or the doctor from whom, maybe, he vaguely hopes to obtain relief from his sufferings ; or he takes long walks, and not unfrequently bursts out crying, and wrings his hands in an agony of grief or despair. He bites his nails, plucks out his hair, rubs his skin into holes. Sensibility is often affected in melancholia. There may be more or less general ansesthesia ; or there may be uneasy sensations referred to the limbs or trunk, to the skin or internal organs. Especially, perhaps, the patient suffers from epigastric pain, abnormal feehngs in the head and spine, and diminution of sexual desire. The sleep of melancholies is usually disturbed. For the most part they MADNESS. 1165 sleep little, are troubled with painful dreams, and wake up unrefreslied. They are apt to believe erroneously that they do not sleep at all. The gastro-intestinal functions generally suffer. There is almost always constipation. The appetite often fails ; but sometimes, on the other hand, it is almost insatiable. The refusal to take food, so common in melancholia, does not usually depend on loss of appetite, but rather arises from the fear of being poisoned, the wish to commit suicide, obe- dience to some command, or some other delusion. Nutrition often suffers ; the patient emaciates, his skin becomes harsh and dry, his face assumes a livid or cadaverous hue, which, with the attendant emaciation and modification of expression, imparts a premature aspect of age ; his temperature becomes lowered, his pulse weak and often slow, and his extremities cold and livid. The course of melancholia is for the most part chronic. In some in- stances the patient presents remissions, and much more rarely complete intermissions or lucid intervals of short duration. Occasionally the dis- ease is recurrent, the attacks, which usually resemble one another accu- rately, bemg separated by irregular and comparatively long intervals of sanity. Again, cases are not mifrequently met with (the folie circulaire of Falret) in which insanity presents throughout its course a succession of alternate stages of melancholia and mania. Melancholia of low inten- sity may continue with little change for many years. It has already been pointed out that a melancholic stage precedes most maniacal out- breaks. But this is generally of short duration. Melancholia may leave behind more or less marked traces of mental weakness, and may end in dementia. It has been estimated that somewhat more than half the cases of melancholia get well ultimately, although of these a large pro- portion are liable to relapse ; and that of the remainder, some continue with little change of symptoms, others pass into mental weakness or dementia, and others die. If recovery takes place it is generally gradual, and within six or twelve months from the time of seizure. Should the symptoms extend beyond this limit, recovery is almost hopeless. Death may be due to self-inflicted injuries, to starvation or its consequences, to phthisis or other tubercular affections which are extremely common in this form of insanity, and lastly to pneumonia, or other intercurrent vis- ceral affections. It has been observed that diseases, more especially, perhaps, acute diseases, occurring in the course of melancholia, are apt to have an important influence over it ; sometimes they ameliorate, or even cure, the mental malady ; but in other cases, and probably quite as often, they aggravate it. The above account of melancholia is general, and applies more or less accurately to the greater number of cases that come under observation. But there are several groups of cases which present special characteristics, and require, therefore, separate consideration. a. Hypochondriasis is often not regarded as a form of insanity. But, as Griesinger observes, it is properly a folie raisonnante mdlancholique, a form of melancholia in which there is mental depression, without neces- 1166 DISEASES OF THE NEEVOUS SYSTEM. sary delusion or marked impairment of the reasoning powers, characterised especially by a sense of profound illness, and a tendency to exaggerate the feelings of illness, and to brood over them. Hypochondriacal patients, for the most part, but not necessarily, suffer from uneasiness, pain, or actual illness ; and it is in connection with this mainly that their feelings of profound misery and gloomy foreboding arise. They dwell constantly on then real or supposed maladies ; they examine and discuss mentally every new phenomenon which presents itseK ; they are always looking at the tongue or feeling the pulse, and on the watch for new symptoms ; not merely on altogether insufficient grounds, probably, do they argue them- selves into the behef that they have certain internal diseases which must prove fatal, or render their Hves utterly miserable, but they invent outrageous explanations of obscure groups of symptoms, such as that they have toads or serpents inside, or that their food coagulates within them and foiins a sohd mould of the stomach and bowels, or that they are devoid of these important organs ; they consult medical works and apply to themselves the horrors of which they read ; and their conversation for the most part is a wearisome iteration of their imaginary or exaggerated sufferings. They usually take httle or no mterest in other persons' affahs ; are selfish, querulous and quarrelsome, weak, vacillating, and infirm of purpose ; they have an ah- of sadness or misery, and neglect the duties which devolve upon them. Not unfrequently new maladies arise and replace the old ones ; and they have a tendency to go from phvsician to physician in search of the rehef or cure which does not come. Occasionally actual insane delusions arise, chiefly in connection with their predominant feelings of illness, and the patients become mad beyond all question ; and very commonly, although they reason correctly on all other subjects, then mental powers appear to be clouded and weak in ref^ard to the supposed causes of then maladies. It is not often that hypochondriacs are impelled to murder or even to suicide. Hypochon- driasis is most common in middle-aged and elderly men. As it is often associated with the presence of actual disease, it is always important to institute a careful examination of h}-pochondriacal patients. Eecovery is not unusual imder appropriate treatment. h. Melaiicliolia with stupor or melanclwlia attonita, is a variety of melanchoha which presents a superficial resemblance to dementia, was lono- confounded ■^"ith it, and even now is sometimes difficult to distin- guish from it. In this affection the patient's whole mind appears to be engrossed in one all-absorbing painful delusion ; and, though his senses are open and convey to the sensorium all the impressions they receive, his preoccupied mind takes little or no cognisance of them, and his features and limbs remain alike motionless. The nature of the delusions from which the patient suffers differs of course in different cases ; some- times there is simply a vague sense of impending calamity, sometimes he stands on the brink of an abyss or in the midst of a conflagration, some- times he has committed some great crime and awaits the verdict of the jury and the sentence of the judge, or the day of his damnation has come, MADNESS. 1167 and lieaven and earth are passing away as a scroll. His expression is fixed, and it might even be imagined that he was insensible ; but his face wears a look of intense horror, awe, grief, or anxiety. His limbs are motionless, occasionally flaccid, occasionally rigid, or plastic as in the cataleptic condition. He takes no notice of what is actually going on around him; he does not flinch from ordinary painful impressions, or from noises made close to his ears, or blows aimed at his eyes ; but probably his pupils contract to light, and if a jugful of water be poured on him a sudden inspiration follows. He takes no food, or at any rate requires to be fed ; he passes his evacuations without notice, and if not confined to bed needs to be put to bed and taken out of it, dressed and undressed, hke a patient in a late stage of dementia. Melancholia with stupor may last for a few hours only, or for several days, weeks or months. It sometimes comes on in the course of other forms of insanity, sometimes arises suddenly, especially after a severe mental shock, or in connection with epilepsy. Eecovery from it is often sudden ; and on recovering the patient is apt to express himself as if he had awakened from some fright- ful di-eam— indeed, there is a marked resemblance between this condition and nightmare. c. Melancholia ivith excitement. — Melancholia occasionally puts on the trappings of mania. In this case the bodily activity is much greater than it is m ordinary cases of melancholia ; the patient is excited, restless, rambles about, and wrings his hands, or performs other muscular move- ments ; but withal his frame of mind and his delusions are less variable than they usually are in mania, and present, as is indicative of melan- cholia, a certain degree of monotony. 2. Mania is characterised specially by sentimental exaltation, intel- lectual vivacity and incoherence, and excited muscular action. It may break out suddenly, or come on in the course of certain acute, febrile, and other disorders. But much more commonly its onset is insidious. In this case it is usually ushered in, as melancholia is, with depression ; and, indeed, the beginning of both forms of insanity are in the main identical. After the period of depression has lasted a longer or shorter time, the patient's condition gradually changes ; he becomes restless, dissatisfied, wanders about, roams the streets or fields, or visits friends, with the vain hope of obtainmg reHef from his distressful feelings ; and then by in- sensible gradations his depression and discomfort cease, he becomes lively, loquacious, and boisterous, is readily excited to anger or laughter, is vivacious and varied in his thoughts and language, speaks in a loud tone, entertains an overweening opinion of his bodily and mental powers, and displays increased and incessant muscular activity. During the stao-e of mental depression he often feels ill, and complains of painful or uncom- fortable sensations referred to different parts ; but as the true maniacal condition supervenes such feelings subside, and he seems to himself to be ui the best of health. The most remarkable features of mania are the disturbance of the affective functions which it presents, and the impulse to incessant activity 1168 DISEASES OF THE NEEVOUS SYSTEM. which accompanies this disturbance. The patient's moods are for the most part moods of exaltation, and are not only different in different cases as regards both intensity and character, but are constantly var}dng in the same individual. Sometimes the patient is sad, ill-tempered, angry, suspicious, or ferocious ; more frequently, perhaps, he is gay, jovial, bois- terous, or vam, proud, and arrogant ; or, again, he may be acquisitive, or lasci^'ious, or dommated by other appetites. In accordance vnth these various moods or moral conditions, we observe some patients indulging in frivolous or harmless actions, such as dancing, singing, laughing, shouting; some cm-sing and swearing, using obscene language, tearing and destroy- ing whatever comes in their way, and committing violent and unprovoked assaults ; some collecting and accumulating all kinds of rubbish and filth, or fr'eely displaying their lascivious feelings and even masturbating openly and shamelessly, or eating garbage and even fsecal matter, or giving themselves to drmk. Some of these affective states, and the actions which result fr'om them, are determined by bodily disorders, especially by conditions of the sexual organs ; and not unfrequently, at any rate in the earher stages, the patient is apt to have some consciousness of his abnormal state, and will occasionally try to control or conceal it. The intellectual characteristic of mania is not so much the existence of hallucinations and delusions, though these are usually if not always present, as the incessant tumultuous flow of ideas. In its slightest form this amomits to little more than an mcreased v-ivacity of thought, accom- panied probably by an exaltation of the memory, which manifests itself by unusual brilliancy of conversation, readiness of retort or sarcasm, an aptitude to look at things in new lights, to see misuspected resemblances, and hence to utter witty or humorous or poetical expressions and thoughts, a tendency to speak in rhyme, to discourse with unwonted fluency and eloquence, and to propound startling speculations and theories. In more advanced cases, or in severer forms of mania, this apparent intellectual elevation runs into incoherence ; ideas, still more or less in accordance -uith the patient's affective condition, and still following one another rapidly, have now little or no connection with one another ; there may still be flashes of wit or sarcasm, still fr-agments of eloquence or of versi- fication, still thoughts of exaltation, but they are determined largely by impressions made upon the senses, and pass fr'om the patient's mind as soon as they are uttered or expressed. Illusions, hallucinations, and delusions are all common in mania, and thefr presence largely influences the character of the patient's thoughts, and determmes his speech and actions ; moreover, they themselves are in their origin intimately related to the feehngs which are predominant in the mind. It is osving probably to illusions or hallucmations of the muscular sense that maniacs so often entertain the behef that they are endowed with superhuman strength ; that they can run, or fly, or play at cricket, or perform other athletic exercises vnth marvellous skill. And it is due in some degree to cognate causes that such patients write or recite incoherent nonsense which they regard as poems of surpassing MADNESS. 1169 beauty ; that they boast themselves to be mathematicians, or orators, or singers, such as the world has never before seen ; that they believe them- selves to be in communication or correspondence with statesmen and emjjerors ; that they regard themselves as possessors of untold wealth, and even of the asylum in which they are incarcerated ; and that they hold themselves to be Wellington or Napoleon, the Queen, the brother of Christ, or Christ himself, or, it may be, all three persons of the Trinity in one. It is important, however, to observe that, in mania, the hallucinations and delusions which affect the patient are, like his ideas and moods, fleet- mg and various ; that indi^ddually they do not, as a rule, take any strong hold on the mmd ; and that, in this respect, there is a marked contrast between mania and melancholia, and especially between mania and mono- mania. Sleep is generally impaired in mania. It is often troubled, and, in many cases, sleeplessness may be continued without intermission for weeks or even months. A good nights rest, though in itself a favourable sign, often occurs without the slightest benefit to the mental condition of the patient. The movements of maniacs are in many cases incessant. It is often held that maniacal patients are stronger than they were in health ; but this is for the most part incorrect. Nevertheless it is remarkable how they will sometimes, without any intermission by day or night, and apparently without fatigue, continue for many weeks to execute violent muscular movements. Various sensory phenomena are apt to arise m the course of mania, such as headache, mieasmess at the chest, aches in the limbs, sensations of heat and cold, and the like. Anesthesia, too, is sometimes observed. The appetite is often enormously increased ; but in some cases the desire for food is wholly absent. Sexual feelings are generally increased, and more especially in females ; and reveal themselves by looks and gestures, obscene language, and the like. The menses are generally irregular or absent. There is nothing special to observe about the circulation except that it is often weak, and the pulse somewhat quicker than natural. The face is apt to be congested, and the eyes bloodshot ; but, on the other hand, the hue of the skin is not unfrequently sallow and even cyanotic. Not- withstanding the patient's probably enormous appetite, he usually becomes thin and wrinkled, and looks older than he is. The bowels are apt to be irregular, and especially to be constipated. The temperature of the body is for the most part normal. Occasionally, however, it rises a little, in connection with bodily illness, and especially in those cases in which the patient has httle sleep and passes into a typhoid state. Occasionally, also, there is local increase of temperature in the head. The course of mania varies in different cases. Li some instances it is uniformly progressive ; but much more commonly it is attended with altera nate exacerbations and remissions— the latter being sometimes complete. Complete intermissions sometimes occur periodically. Exacerbations are likely to supervene at the menstrual periods ; but in a large number of. 4 p 1170 DISEASES OF THE NEEVOUS SYSTEM. cases, the variations in the condition of the patient take place, so far as can be ascertained, without obvious cause. We have already referred to the periodical alternations between mania and melancholia, to which condition the name oifolie circulaire has been given. Maniacal outbreaks may vary in duration between a few hours and several months ; but, in most cases, and generally when the attacks are of long standing, they are attended with remissions, and may thus be continued for many years. Becovery from mania is sometimes sudden ; but more commonly it takes place gradually. Occasionally its cessation is connected with the super- vention of some bodily disease, such as diarrhoea or fever. Eecovery generally takes place, if at all, within a year ; but is by no means hope- less even up to the end of the second year. After this, it is rare ; yet cases are occasionally met with in which it has been delayed until after the sixth or seventh year. The terminations of mania, other than the termination in recovery, are, first in chronic mania, second in dementia, and third in death. The last event may be due to simple exhaustion, to the supervention of pneumonia, pleurisy, cerebral congestion, or other diseases, or to injuries accidentally inflicted. It may be added that patients who have once had an attack of mania are very apt to have relapses ; and, again, that, when maniacal patients are suffering from tubercular or other intercurrent diseases, these, however acute their pro- gress, appear to cause but little suffering, and may therefore easily be overlooked. Mania, like melancholia, presents many sub-varieties, characterised by special peculiarities. "We shall refer briefly to a few of them. Delirium tremens, which has been elsewhere described, is manifestly a form of acute mania. The acute delirium of French writers is mania, characterised by suddenness of outbreak ; by ' furious delirium with incessant incoherent chattering, but with the dominant expression of anxiety ; ' by ' vertigo, awkward trembling movements as if the patient were intoxicated;' by sleeplessness, paleness of countenance, dry tongue, and rapid exhaustion. The disease is often attended with fever, lasts from a few days to several weeks, and frequently terminates fatally by collapse. Becurrent or periodic mania is that form of the disease in which the attacks of mania are sepa- rated by considerable intervals of sanity. It is remarkable that here, as in the corresponding variety of melancholia, the successive attacks are almost exact repetitions of those that v/ent before. To the folie circulaire of the French writers we may again call attention. It resembles the last variety of mania, excepting in the fact that the attacks of madness present alternate stages of mental depression and mental exaltation. Mania transitoria is the name given to acute outbreaks, lasting probably for a few hours only. They are sometimes epileptic, sometimes hysterical, sometimes the result of drink, and may arise under various other conditions. Lastly, the so-called mania sine delirio, ov folie raisonnante, must be regarded as one of the varieties, and by no means an unimportant variety, of mania. It is the condition in which the patient presents affective disturbances with corresponding movements or motor impulses ; but in which there is MADNESS. 1171 an absence of delusions and probably of hallucinations. Ic corresponds to the early stage of many cases of ordinary mania, and it may persist without going on to delusive insanity for an indefinite period. In such cases the patient presents some marked change in his moral nature : he becomes light-hearted, volatile, vain, arrogant, quarrelsome ; he neglects his business, or buys and sells or speculates wildly ; he devotes himself to pleasures ; he becomes acquisitive, perhaps steals ; he talks and acts obscenely, and forms immoral connections ; he neglects or ill-uses his wife and children ; he takes to drinking ; he acquires expansive religious notions ; he entertains an exalted view of himself — his mental capacity, his personal appearance, and all that belongs to him. These, or such-like, are the perversions of mind or conduct which he displays, and which are all the more striking that they represent gross exaggerations of his natural characteristics, or are in absolute contradiction to them. Patients thus affected are capable of reasoning, and will probably, if interrogated, assign plausible grounds for their conduct, or invent ready excuses, and will perhaps display shame on the detection of their misdeeds. Although they are for the most part free from hallucinations or delusions, such phenomena are apt to supervene more or less suddenly, and in connection with these, or from other causes, they are always Hable to sudden out- breaks of maniacal fury. This condition may end after a short time in recovery ; it may persist for a length of time with little obvious change ; it may pass into mania or monomania, or it may result in dementia. 3. Monornaniais the term used to designate a form of insanity, specially related to mania, in which the patient, with exalted notions of his own importance, entertains fixed delusions which dominate his thoughts and conduct. It differs from melancholia in the absence of the profomid and persistent depression which characterises that condition ; and from mania in the absence of that wealth of incoherent ideas, and of that restlessness and vivacity of movement which belong to mania, and in the existence in their place of persistent delusions with the power of reasoning and of forming and carrying out enterprises or plans of action. Monomania may take its origin in mania or melancholia ; or it may come on independently, in which case it is usually preceded, as other forms of insanity are, by a stage of melancholy. Here, as m other cases, there is affection of both the moral and the mtellectual side of the mind. Monomaniacs have usually an overweening opinion of their own importance ; they are self- satisfied, vain, haughty, arrogant. One is affable, polite, condescending in his demeanour. Another struts about with an air of insufferable pride, and treats those about him with lofty disdain. Some, especially females, are fond of dress, and deck themselves out fantastically or even show re- markable taste. A few, on the other hand, engrossed in other matters, are slovenly and dirty in their attire and habits. Sometimes they express themselves habitually in pompous or theatrical language. Sometimes they present an air of perfect calm ; their conversation and conduct indicating a supreme tranquil joy. The delusions under which such patients labour are necessarily various, though for the most part of an 4f2 1172 DISEASES OF THE NEEVOUS SYSTEM. exalted character. Iii some cases they look upon themselves as great discoverers : tliey have solved the problem of perpetual motion, have squared the circle, or have invented machmes capable of doing impossi- bilities. In some cases they regard themselves as having extraordinary knowledge, genius, or power : they are wiser than any who have gone before ; they are distinguished generals or statesmen, or royal personages, or great poets ; and they even assume themselves to be specific historical or biblical characters. Not unfrequeDitly they beheve themselves to be benefactors of mankind ; they have revealed conspiracies, and their praises are on everybody's tongue ; or they are apostles or prophets. Occasionally, however, their delusions are of a lower grade : they are objects of suspicion ; they are being constantly tracked ; and people sneeze or cough or make signs which have some mysterious relation to them. ^ Hallucinations and illusions are often associated with the delusions of these patients, and react upon their mental condition. "We have referred to the fact that monomaniacs retain for the most part considerable power of reasoning. In many cases they discuss matters unconnected with their special delusions with perfect intelligence ; and even in relation to their delusions they can usually adduce plausible and even striking arguments ; but that their mental powers are weakened is undoubted. Fnm in their beliefs, they are apt to meet objections with a flat denial or a simple assertion of their claims, arid generally ignore their opponent's arguments. They entertain, in fact, a fmidamental belief which is beyond controversy. Monomaniacs, especially in asylrmis, are often quiet and harmless in their behaviour ; but when thwarted or contradicted, and occasionally even when unprovoked, they are apt to become violent and dangerous, and to exhibit maniacal or ungovernable fury. Monomania seldom ends hi recovery ; and especially rarely if it has existed over six months. It often becomes chronic, and continues with little change for many years. It generally, however, passes sooner or later into dementia. The bodily health is usually good, unless the mono- mania be of a hypochondriacal character. 4. Dementia. — By this is meant, not as in the forms of insanity hitherto considered, a qualitative change or perversion of the mind, but its deterioration or decay. It is the natural termination of all incurable cases of melancholia, mania, and monomania ; it commonly supervenes sooner or later in various forms of cerebral disease, such as epilepsy, sanguineous apoplexy, embolic softening, disseminated sclerosis, and tumours ; and it is apt to come on after long indulgence in drink or mastin'bation, and as one of the accompaniments of old age. Further it occasionally follows, as a primary and acute disease, certain of the acute febrile disorders, and severe mental or bodily shocks. It is interesting, as Griesinger remarks, that the dementia of old age is not unfrequently preceded by a stage of mild maniacal excitement. Perhaps the most remarkable characteristic of dementia, and that by which it contrasts strikingly with the acuter forms of insanity, is the profomid loss which its victims manifest of those moral attributes and sentiments which form so MADNESS. 1173 important a part of the liealthy mental condition, and wliicli by tlieir per- version or intensification constitute the very basis of mania and melan- cholia. The patient is no longer impelled by passion or by feeling ; his acts are not determined by any persistent mood ; he is incapable of intense hate or deep love ; he manifests no interest in those about him, and the loss of friends or relatives, even of those who were dearest to him, affects him little or not at all. It is not meant that there is a total absence of emotions, but they are superficial, they come and go, they exercise no lasting influence, they do not determine the patient's course of action, but they spring momentarily from the impressions made on the senses or the ideas that come to the front. Impairment of the intellect waits upon the moral abeyance. There is always feebleness of the mental powers : memory fails ; the patient probably forgets everything that has occurred during the day, and most that has happened to him during his illness ; but he still calls to mind in a disorderly manner the events of his former life, and the delirious ideas that thronged his mind during his melancholic or maniacal state. He cannot reason ; he is incapable of abstract thought. For the most part the loss of the reasoning power is obvious ; the patient's thoughts and words are incoherent ; he harps upon certain formulae, and does not care or is unable to join in continuous conversation ; and it is a remarkable fact, universally recognised of demented persons, that they are incapable of combining together to form plots, and that large numbers of them collected in a ward may be led and managed by one or two attend- ants like a flock of sheep. In association with the loss of memory and of the reasoning faculty, we find that delirious ideas, hallucinations, and illusions abound. Delusions, however, are rarely developed afresh. Those which are present remain over for the most part from the active stage of madness which preceded dementia ; and they now probably form the centre, so to speak, of the patient's mental operations. They form fimda- mental facts, their reality is indisputable, and the patient's remnant of thought revolves about them, and clings, as it were, to them for support. The existence of hallucinations is shown by the frequency with which demented patients see absent persons and things and visions, and hear voices with which they probably converse audibly. The presence of illu- sions is manifested by the frequency with which they take persons about them for those who are absent or dead ; take pieces of glass and stone for precious stones or gold ; and regard old broken jugs and articles of furni- ture as their children who died long ago. Many of the strange occupa- tions which demented patients delight irf are indicative of the condition here adverted to. Thus, one, as Dr. Maudsley says, 'whose singular movements seem unaccountable, is busy spinning threads out of sunbeams-,' while another ' continues the most violent movement of his arms in order to prevent the motion of the universe or of his own blood from coming to a stand,' and yet another turns about and performs strange antics under the belief that he is absorbing the verdure of the surrounding trees, with the obj ect of utilising it in some mysterious way. The actions of demented patients present remarkable variety, although 1174 DISEASES OF THE NEEVOUS SYSTEM. showing considerable uniformity in the same individual. In some cases they are restless, in constant movement, incessantly chattering, making incoherent but occasionally pertinent remarks upon persons and things, yet having relation to their delusions ; in some they are perpetually making collections of stones, rags, feathers, and other rubbish, in the apparent belief that they are accumulating treasures of great value, or they appropriate their neighbour's food and other articles of property ; in some cases they mope in corners ; in some they pace incessantly back- wards and forwards hke a caged Hon ; m some they adorn themselves fantastically ; in some they sit rocking themselves on a bench all day long. " Li connection with this subject it may be observed that some patients are lascivious m their conduct, and commit masturbation openly ; that, although there is no dominant feeling which guides their conduct, some are apt to smile and laugh, some to cry, some to break out suddenly in fits of violent passion, and some are mischievous or malicious in their general behaviour. Sooner or later they tend to become dirty in their habits and to pass their evacuations without restraint. Patients suffering from dementia for the most part enjoy good bodily health, sleep well, have good appetites, and often become fat. But they have a vacant expression and a look of old age. As regards the duration and termination of the disease, it may be stated that imbeciles and demented persons usually live for many years, remaining at a certain level of iateUigence, or very slowly becoming more and more childish and stupid ; that they rarely, if ever, get well ; and that death is due either to pneumonia, pleurisy, tuberculosis, or other intercurrent disorders, or to attacks of congestive or sangumeous apoplexy or to other brain affec- tions. When the disease is primary and acute, however, recovery is not uncommon. Dementia varies in degree and character. In one form of it, especially as it is occasionally observed after apparent convalescence from an attack of acute mania, the patient becomes so far restored to his normal state that he is able to conduct his business, and to perform the ordinary duties of life ; but his sensibilities are blunted, and he has lost all interest in and ca.pacity for those pursuits and enjoyments which are the evidences and results of culture. He has lost all the freshness and spontaneity, all the higher and holier impulses, all the ideas and sentiments, that rendered him interestmg and sociable ; and is content to pass his hfe automaton- hke within the hmits of a contracted sphere of thought and action. He is physically the same man that he formerly was, and he may seem per- haps to reason as acutely as ever ; he may even appear mentally healthy to those who see him for the first time ; but essentially and to his friends there is a profound change. The greater number of permanent residents in asylums are persons whose dementia follows on mania, melancholia, or monomania, and in whom the delusions or insane ideas of their former condition still survive. They have lost the deep emotions which affected them then ; their mental powers have decayed ; but amid the general wreck of mind their delusions MADNESS. 1175 retain a more or less powerful bold upon tliem, and associated with hallucinations constitute the prominent parts of their mind and determine their actions. It is such patients that one sees performing all kinds of strange antics : pohshing the floor with their saliva, taking the altitude of the absent sun with closed eye, directing magnetic currents, adorning themselves with fantastic ornaments, collecting rags and sticks, sitting perpetually dumb because they are God the Father, who speaks only through His Son, remaining fixed in one position because they are made of glass or wood, or beheving that they contain strange monsters in their interior. In another group of cases there is a still greater loss of the mental faculties. But for the fragments of delusions and ideas that, so to speak, play upon its surface, the mmd is a blank. The memory is almost in abeyance ; they forget everything of the recent past, and most of what happened in their previous lives ; often they have lost all idea of their own identity, and have absolutely forgotten their own names. Objects about them make the usual impressions on the organs of sense ; but the impressions are scarcely, if at all, taken cognisance of by the mind. There is often more or less insensibihty to pain. No new ideas are developed. All capacity for real sensibility or passion is of course absent ; but the patient nevertheless is apt either to present a miiform joyous aspect, or he is disposed to cry, to show malice, or to be mischievous. Such patients are generally in constant movement, restless, and frequently pass a large portion of their time in chattering, laughing, or singing. Not unfrequently there are evidences of paralytic weakness of the hmbs. In yet another group of cases, and this constitutes the last stage of dementia, the patient's intellect is almost entirely annulled ; and his life is mainly vegetative. He takes no notice of what is going on about him, or of what happens to his own person ; fitfuUy perhaps he utters a few sounds, it may be a few words, and gleams of emotion play across his vacant and meaningless features ; he performs a few monotonous move- ments, or remains m one posture hour after hour, or if set walking con- tinues to walk until his progress is arrested by force ; he requires to be fed, to be dressed and imdi-essed, to be put to bed and to be taken out of it, and to have all his wants attended to like a baby. Nutrition m this as in the other cases may remain miimpaired. 5. General paralysis.— This is a well-marked form of insanity, for- merly confounded with mania, but clearly distmguished fi-om it mthe first instance by MM. Bayle and Calmeil, and now universally recognised as a specific disease. It differs from other forms of insanity, anatomically m the fact that the syraptoms depend directly on chronic inflammation of the grey surface of the brain, and cUnically in the association with mental alienation of progressive paralysis of all the voluntary muscles. General paralysis occurs much more frequently in men than in women. It is rarely if ever met with in persons under 20 ; and most connnonly makes its appearance between the ages of 35 and 45. Its causes are various and often obscure. One of the most important is long-continued 1176 DISEASES OF THE NEEVOUS SYSTEM. alcoholic intemperance. It is also attributed to venereal excesses, over- work, anxiety, mental shock, and physical injuries. It usually commences with a prodromal period of uncertain duratiori,, but which may last for several months, in which, as in the early periods of other forms of insanity, the moral or affective nature of the patient becomes more or less profoundly modified. He becomes restless and irritable, and disposed to take offence and be violent ; he makes a show, maybe, of still attending to his duties, but he gives himself up to de- bauchery, he lies, he speculates, he cheats or steals, and becomes a cause of deep anxiety to his friends. Sooner or later the actual invasion of the disease takes place. This, according to M. Falret, may show itself in four different ways, in two of which the physical symptoms predominate, in two the psychical : — a. In the congestive variety, the patient is suddenly attacked with an epileptic or apoplectic fit, which differs in nothing from the similar seizures which attend so many chronic affections of the brain. From this after a few hours or a few days he recovers, when it is probably ob- served that he presents maniacal excitement with grandiose delirium, or that there is some little impairment of memory and intellect together with slight difficulty of speech and trembling of the lips. Not unfre- quently there is progressive improvement in the patient's condition until another fit leads to aggravation of his symptoms. Occasionally the initial congestive attack shows itself, not in an actual fit, but in an outbreak of mania attended with hallucinations and delirious ideas. h. In the paralytic variety, symptoms of paralysis precede all others, and probably attain a high degree of development before the obvious indications of mental alienation declare themselves. The patient under such circumstances himself observes that he is gradually losing muscular power, and that he cannot take the amount of exercise, or do the amount of work, that he formerly could do. He observes that his legs tremble, and. that he has difficulty in ascending a hill or going upstairs ; that his arms and hands are tremulous, and that he caimot write or perform other manual operations with his former dexterity ; and further that his lips tremble when he speaks, and that his enunciation is imperfect. The paralytic phenomena gradually increase upon him ; and ere long — it may be after a few weeks or a few months — the symptoms of cerebral excite- ment or alienation, which may have been gradually and imperceptibly creeping on even from the beginning, become clearly developed. The paralysis presents very striking features. It is generally first observable in the lips and tongue, and then extends with more or less uniformity of progress until it iiivolves all the voluntary muscles. It is characterised by the association of tremulous movements (developed only when the patient exercises his muscles) with loss of power. The lips tremble at the moment of attempted utterance. So soon as the patient endeavours to open them a little hesitation or hitch in their movement, or distinct trembling, as though the patient were about to sob, may be observed. This appearance is generally regarded as of fatal omen. The tremor MADNESS. 1177 varies in degree, and may involve other parts besides the Hps. Some- times, indeed, the whole face, and even the orbiculares palpebrarmn are thrown into muscular ripples when the patient speaks ; and the jaws themselves may chatter as in the cold stage of an ague fit. The tongue trembles similarly when protruded. The effect of these movements on speech is remarkable. In some cases the patient simplj'' hesitates a little ; in some he slurs his words, or draAvls them, or utters them in a mono- tone, or speaks as though he was scanning. Sometimes his speech is so tremulous that it can scarcely be understood ; sometimes the pre- liminary movements of his lips and tongue are so prolonged and violent that he finds it impossible to get his words out. Not unfrequently he stammers or blunders in the use of words. The difiiculty of speech is usually greatest when he is being watched or when he is nervous. The legs and arms are for the most part afl^ected simultaneously ; but some- times the arms suffer earlier than the legs, and conversely ; and occa- sionally the paralysis commences in the hemiplegic form. No doubt the loss of power is generally observed earliest in the legs ; they become weak and tremble in use ; the patient has difficulty in walking ; he cannot readily rise from his seat ; he walks bent forward with his legs apart, and takes short quick steps, and often has a tendency to run ; he is easily thro'wn off the balance, and especially has a tendency to totter when suddenly checked in his onward progress, or made to turn. The arms also get weak and tremulous ; and consequently the handwriting becomes shaky ; and the patient soon has to give up writing, and any other manual labour, especially such labour as requires delicacy of touch — engraving, painting, playing musical instruments, and the like. The paralytic symp- toms are not altogether unlike those which attend disseminated sclerosis ; and occasionally the affection of the legs is that of ordinary locomotor ataxy, including loss of patellar reflex. Among the paralytic symptoms must be included inequality in the pupils, and loss of action of the irides under the influence of light. Generally some degree of impairment of sensibility accompanies the motor paralysis. c. The expansive variety, which commences with exaltation of mind and delirious ideas of an expansive kind, is the commonest variety of general paralysis. In this, paralysis comes on some little time after the insane symptoms have existed ; and it may remain doubtful for a time whether or not the case is really one of the disease under consideration. The prodromal symptoms, which are mainly those of so-called ' moral insanity,' gradually undergo further development. Patients, who have hitherto been in a capricious frame of mind that has excited the uneasi- ness of their friends, become more restless, more excitable, more violent and wayward than they were. They talk, write, compose incessantly ; and are constantly entertaining new projects. But at the same time there is a manifest failure of memory, especially in relation to things which have just happened. Their bodily activity is for the most part remarkable ; they are always on the move, sometimes actively engaged in trivial mat- ters, sometimes restlessly hurrying about from place to place, sometimes 1178 DISEASES OP THE NEEVOUS SYSTEM. going on journeys and disappearing for a time witliout giving any intima- tion to those about them as to their proceedings. They are apt to do all kinds of outrageous things, to indulge in venereal excesses, to give them- selves up to drinking, to steal, to undress in public places, to come to a dinner-party in dressmg-gown and slippers, to spend money extravagantly, and to make valuable presents to persons who have no claim upon them, to speculate wildly, and to manifest alternately boisterou s gaiety, reckless audacity, and sudden anger. Up to this point there may have been no true maniacal delirium. But ere long the grandiose notions and delusions which are so characteristic of this affection manifest themselves. These usually have relation to money and wealth. The patient, who perhaps is in receipt of a small precarious income, at first believes that his income is assured to him and double or treble of what it really is ; and by rapid strides he assumes that he is worth thousands, millions, millions of millions, that all the gold in the world is his. Or he enters upon imaginary specula- tions, buys up all the railways in England, all the railways ui the world, and bestows salaries of hundreds of thousands a yea r on any casual ac- quaintance. Or he has a house of gold, surrounded by trees of gold and precious stones ; he has extensive possessions, a county, a country, the whole universe. In connection with the idea of wealth, arise ideas of glory, honour, and power. Such patients become distinguished soldiers, generals, emperors ; they are great statesmen, poets, or philosophers ; they are brothers of Christ, Christ himself, or the Almighty ; they are hundreds of feet high ; their strength is enormous ; they can create giants and worlds ; they can cure the sick, and raise the dead. Their notions, too, are often fantastic as well as exalted ; they have several rows of natural gold teeth ; they have an unfailing growth of hair, which they can spin out of their heads as silkworms spin silk from their tails ; they live on minced whales, stuffed elephants, and ostrich's eggs. The delirious fancies of general paralytic patients are always associated with more or less dementia. Their delusions are not systematised ; and their actions are not necessarily in conformity with their delusions ; moreover their delusions are variable, and are mmgled in the most grotesque way with the circumstances of their daily life. Thus the man who believes that he is worth millions, and is ready to bestow thousands, will gladly accept a few shillings, will talk reasonably about his daily earnings, will beg piteously for a little tobacco. He who believes himself to be Christ will talk perhaps ration- ally on his private affairs, and be ready, if such has been his occupation, to polish your boots or sweep your chimney. The patient who is an em- peror or king will tell you that his wife is a washerwoman and his children attend a charity school. The characteristic paralytic phenomena always appear sooner or later in this case — generally as soon as distinct delusions manifest themselves — and rapidly progress from bad to worse. d. The melancholic variety is rarer than the last, and in striking contrast with it. In this the patient is low-spirited and miserable ; he thinks he is ruined or dishonoured, he has committed unpardonable MADNESS. 1179 crimes, lie is doomed to death, or to eternal pmiisliment. His con- dition, indeed, is much like that of an ordinary melanchohc patient, ex- cepting that here, as in the last case, the symptoms are more variable, the delusions are less persistent, and occasional gleams of high spirits or gran- diose delirium flash across his mind and reveal themselves in his aspect and behaviour. Occasionally the depression of spirits assumes a hypo- chondriacal character ; the patient has uncomfortable feelings within him which become connected with some fantastic belief, such as that he has no inside, that he can neither swallow, defaecate, nor pass water, and so on. This melanchohc condition may last throughout the whole period of the patient's illness ; or it may be replaced, sooner or later, by the ordinary form of exalted delusions. When it persists, it generally implies that the patient's illness is of a specially grave character, and that it will terminate rapidly in death — a result which is often accelerated by his refusal to take food, by malnutrition, and by the appearance of bed-sores. In this case, as in the last, the sjnnptoms of paralysis more or less speedily comphcate the patient's malady and stamp its real nature. It must not be forgotten that, however the disease begins, sooner or later, if not from the very first, mental ahenation and muscular paralysis become associated, and thenceforward run their downward course together. Nor must it be forgotten that, although cases are frequently met with in which the mental phenomena precede the symptoms referrible to the muscular system, and cases are occasionally met with in which muscular weakness appears to forestall insanity, in a very large proportion of cases the commencement of the two conditions is simultaneous. When the disease is fuUy established, the special traces of the several varieties of origin are, for the most part, lost ; the paralysis has become considerable, and the mind, though still presenting delirious conceptions of an exalted or, more rarely, of a depressed character, has sunk deeper into incoherence and dementia. The tremors of the lips and tongue, and the paralysis of the muscles of mastication and deglutition have advanced, so that the patient has great defect of articulation, perhaps cannot articulate, and has difficulty in chewing and swallowing; he probably cannot, without assistance, get upstairs or into his bed ; he walks with difficulty across his room ; he has lost the power of dressing himself, and even, maybe, of carrying food to his mouth. There is impairment of co-ordination as well as weakness. Sometimes his muscles become contracted. His mental condition is that of dementia ; he has lost nearly all notion of time, space, and locality ; he has almost or entirely forgotten his father, mother, wife, and nearest relations ; he shuffles about listlessly ; he undresses himself at unsuitable times and places ; he gets into his neighbour's bed, and appro- priates his neighbour's food ; he collects all kinds of rubbish . He is gene- rally quiet and manageable, but occasionally presents sudden outbreaks of maniacal violence ; and his mind is still, in a greater or less degree, the seat of delusions relating to riches and grandeur, or more rarely to such as are of a sad or painful nature. In the last stage of general paralysis the patient has lost the power of 1180 DISEASES OF THE NEEVOUS SYSTEM. locomotion, and is confined to bed or to a chair ; the power of speech is annulled ; he can no longer feed himself ; he passes his evacuations incontinently into his bed or trousers ; and his mind is sunk into the lowest depths of dementia ; he knows no one, probably gives no indication of his wants, and passes his time in fumbling with his fingers, pulling to pieces his clothes or bed-linen, and uttering from time to time incoherent noises or cries. There are two or three points in connection with the history of general paralysis which must not be omitted from our description. As regards the sensory organs, we have already pointed out that even early in the disease there is usually manifest impairment of common sensation. This anaesthesia becomes more pronounced as the malady progresses, until at length the patient takes no notice when he is pinched, pricked, or otherwise injured. It is curious, however, that he occasionally suffers from paroxysms of extreme hyperaesthesia. The other organs of sense for the most part remain unaffected ; but smell and taste occasionally diminish in acuteness or become lost. The digestive organs usually act well ; the appetite is unimpaired, and often sooner or later becomes ravenous ; at this time, too, the patient crams his food into his mouth and swallows it with little attempt at mastication. As a consequence, general paralytics are usually well-nourished and even become fat. In the last stage, however, emaciation may take place, bed-sores form, and diarrhoea, pneumonia, or tuberculosis supervene, (jrinding of the teeth, convulsive actions of groups of muscles, and the copious exudation of sebaceous matter over the skin, are characteristic phenomena. The progress of general paralysis is for the most part uniformly from bad to worse, and the patient, as a rule, dies within three years of the first accession of symptoms. But remissions are not rare, and occasionally the disease becomes arrested in its progress. A few cases of recovery have been recorded. The causes of death are various. In some cases, the patient dies of simple exhaustion, accelerated by bed-sores and other complications. In some cases, his death is due to asphyxia, resulting from the impaction of a bolus of food at the top of the larynx. The most interesting causes of death, however, are the apoplectiform seiztires to which such patients are always liable. These are identical with those which occasionally usher in the disease. They occur at any period of its coujse, but more espe- cially towards its termination, and recur from time to time. They in- variably aggravate the patient's condition. They are ushered in with excitement and elevation of temperature ; by which occurrences their advent may often be predicted. Their symptoms are, coma coming on sometimes suddenly, sometimes gradually, not infrequently convulsions or hemiplegia, and elevation of temperature to 103°, 104°, or more. The attacks are not unlike those due to uraemic poisoning, and correspond pretty accurately to what was formerly called serous apoplexy. 6. Idiocy is a form of mental weakness which dates from birth, or comes on shortly after birth, at any rate before the mental faculties have MADNESS. 1181 reached their full development. It differs, therefore, from dementia, especially in the fact that the mind presents few or none of those insane reminiscences which are so common in dementia, and tend to give to each case distinctive features. Moreover hallucinations, illusions, and insane ideas or delusions are by no means necessarily, or even generally, present. The causes of idiocy are various. Generally it depends directly on some anatomical defect, arising during intra-uterine development, or coming on shortly after birth. It may be due to injuries inflicted on the brain or its coverings. Occasionally it is the result of convulsions or epilepsy of early life, of over-forcing of the mind, of fright, or of other powerful mental impressions, or it is a sequela of some serious illness, such as one of the infectious fevers. It is often referrible to inheritance : thus, it is not uncommon among the children of parents who are close relations ; it is often observed in families where other malformations, insanity, epilepsy, or tendency to scrofulous disease, prevails ; and it is a frequent consequence of drunkeness of father or mother. Like goitre, it is also the product of certain localities. Idiocy, like dementia, varies from mere feebleness of intellect to a condition in which the mind is almost wholly absent. In the latter case, the patient is apathetic, with a dull, vacant, fatuous aspect ; he requires to be fed, clothed, and attended to in all particulars ; he cannot speak, mumbles inarticulately, or grunts from time to time without obvious cause, or when he feels the pangs of hunger ; he takes no notice of any- one or anything ; he has no affections, and remembers nothing ; he remains still, or performs various monotonous, meaningless movements ; his sense of feeling is imperfect, his smell and taste are defective, and his hearing is obtuse ; his tongue is often enlarged, and his incisor teeth protrude. His body is probably imperfectly developed, or deformed, and certain of his muscles, or all of them, are shrunken, rigid or paralysed. Choreic and epileptic convulsions are not infrequent. The sexual organs are usually undeveloped, though occasionally masturbation is practised. In the highest class of cases there is simple imbecility. The patient is often well-developed and well-grown ; his nutritive functions are perfect ; but he is restless and volatile, capricious in temper, clumsy in his actions, slow in the acquisition of speech, imperfect of memory and difficult to teach, awkward and inapt in the amusements and games in which his playmates delight, incapable of application or of continuous thought, and given to indulge his appetites ; he is often spiteful. Between these extremes innumerable varieties exist. But they may be roughly arranged in two classes : namely, first, those who are dull and apathetic, and for the most part deformed ; and, second, those who are restless and excit- able, who readily respond to impressions made upon the senses, and who laugh, cry, scream, gesticulate, clap their hands, get into mischief, and at times give way to outbreaks of uncontrollable anger or fury. Idiots have been divided by Esquirol into three classes : namely, idiots who can use short words and phrases ; idiots who can only utter monosyllables and certain cries ; and idiots who are unable even to express themselves in 1182 DISEASES OF THE NEEVOUS SYSTEM. monosyllables. Epilepsy is a common complication of idiocy. It is a cm'ious circumstance, but one scarcely to be wondered at when one con- siders the variety of anatomical and other defects onwbich idiocy depends, that idiots not infrequently present special talents which prima facie might appear incompatible with the presence of idiocy. Thus there are some actual, and even extreme, idiots, who manifest a real talent for the performance of music, some who have a marvellous power of drawing and painting, some who show remarkable ingenuity and skill m making models of ships or houses, some who possess an astonishing memory for dates or poetry, and some even who can perform mental calculations of considerable difficulty. Idiots, with the exception perhaps of cretms, rarely attain an advanced age. Education has a considerable influence over their condition. Most of them are capable of having the faculties they possess improved by judicious traming ; and it is interesting to see in well-conducted asylums how happy and useful in a way, and intelligent within certain limits, patients become, who mider other circumstances would have been dirty and spitefu , and incapable of any occupation or amusement, and perhaps given to filthy habits. On the other hand it is worthy of observation how much an idiot may retrograde under adverse conditions, how rapidly the loss of eyesight or of hearing, coming on accidentally, may reduce an idiot of the higher class to the lowest depths of mental degradation. C. Madness arising under special physical conditions of system. — The subject we are now about to consider is one of great practical, and of no less scientific, importance. It is the relation between certam physio- logical and pathological conditions of the organism, and the quality of the insanity with which (supposing insanity to arise) they are severally likely to be associated. Alienists recognise more or less distinct differences in the characters of insanity, according as it appears in early life, in association with child- bu'th, in women at the climacteric period, and in old age. They recog- nise obvious distinctions in insanity as it presents itseK in connection respectively with hysteria, epilepsy, and self-abuse. Alcoholic insanity, and that referred to constitutional syphiHs, again, severally display cha- xacteristic peculiarities. There are also special features in the madness which occasionally breaks out suddenly in the course of acute febrile disorders. The list might easily be extended. It is not our object, nor have we space, to consider the subject at any length. In regard to some of the more important of the above varieties of insanity we have already said elsewhere (under the heads of hysteria, epilepsy, and cerebral txmiours for example) all that we deem it necessary to say. In regard to others, such as that associated with syphilis, and those of youth, old age, and the cessation of the menses, the distinctive features, though doubtless real, are not sufficiently striking to be disposed of in a few simple paragraphs ; and on that account mainly we pass them by. The foUowmg, however, are weU-marked and easily recognisable types. 1. Alcoholic insanity. — We have already shown that delirium tremens MADNESS. 1183 (whicli lias been described at length) is a form of acute mania. But besides this, persons who are given to drink are liable to chronic madness. Two varieties are met with. In the first the symptoms are not unlike those of delirium tremens, and come on much in the same way. They also strikingly resemble those of general paralysis of the insane. Thus, the patient has hallucinations and delusions which are often grandiose, together with muscular tremors and debility. The chief distinctions between them are, that in alcoholic insanity the delusions and halluci- nations tend to be persistent, there is usually marked sleeplessness, the pupils are regular, and the patient as a rule recovers pretty rapidly under treatment. The other variety is simply dementia. It is allowable to refer here to the condition known as Dipsomania, wherein patients have a violent craving for drink, which is not constant, but comes on in paroxysms at irregular and sometimes long intervals. The paroxysms continue for days, sometimes for weeks ; and during them the sufferer, not for the pleasures of the table or of society, but simply to satisfy his ungovernable propensity, drinks without ceasing until irritability of stomach or sheer helplessness brings his debauch to an end. 2. Puerperal insanity. — Madness not unfrequently becomes developed in connection with the puerperal state. Three varieties may be distin- guished, according as it is connected with gestation, with child-birth, or with lactation. The first variety is commonly characterised by disHke to the husband, and refusal to take food. If it comes on during the first month or two of pregnancy it usually disappears about the fourth month ; if later, not until after delivery ; and in either case is not benefited by premature delivery. The second variety presents certain differences according as it appears durmg the first few days after delivery, or after the lapse of fourteen days and later. In the first case the patient is usually maniacal, in the second melancholic. But in either she nearly always passes, prior to recovery, into a state of partial dementia, and her physical health improves long before her mind improves. The third variety is apparently due to the exhaustion arising from lactation. It is mostly melancholic, or attended with feelings of suspicion. 3. Insanity of self-abuse. — In this the patient usually begins by be- coming weak-minded and vacillatmg ; incapable of application ; a burden to himself and others ; hypochondriacally concerned about his health ; solitary in his habits ; avoiding society ; utterly selfish, and withal not mifrequently conceited and suspicious. As the malady progresses he suffers largely from hallucinations, especially of sight and hearing ; he has delusions which are to a great extent delusions of self-exaltation ; and he is mider influences — he is looked at, remarks are made about him, he is mesmerised, galvanised, or bewitched. Further, he often complains of his head ; he has feelmgs there which he explains oddly ; his brain is rotten, or is being peeled as though it were an onion, or his thoughts break in bubbles at the surface. In some cases the patients are impulsive, and make sudden onslaughts on those about them. 4. Insanity of febrile disorders. — In the course of pneumonia, rheuma- 1184 DISEASES OF THE NEEVOUS SYSTEM. tism and other inflammatory affections, and in connection with some of the specific febrile diseases (not unfrequently during convalescence) patients are attacked with maniacal symptoms. These are often deve- loped with sudden violence. As a rule, however, the mania soon passes into dementia, and sooner or later the patient recovers. But here, as in the madness of parturition, the bodily health improves before the mental health is re-established. D. Prognosis of insanity. — Idiocy is, of course, incurable, although, as we have pointed out, such powers of mind as the sufferer possesses may often, by careful education, be improved in no inconsiderable degree. It has no necessary influence in shortening the duration of life, although as a matter of fact, owing to various causes which need not be specified, idiots as a rule die early. General paralysis of the insane, notwithstand- ing occasional cases of recovery or arrest, may also be regarded as practi- cally incurable. We have already adverted to the fact that intermissions and periods of partial amendment are not uncommon in this disease, but as an almost universal fact general paralytics die within three years of the first appearance of symptoms. A large number die within the first year. Dementia, the result of advancing age, or of organic disease of the brain, may generally be regarded as incurable ; although cases of dementia due to syphilitic disease of the brain occasionally recover, temporarily at any rate, under appropriate treatment. The dementia, again, which follows upon chronic melancholia, mania, and monomania is incurable. It is important to observe, however, that demented patients often Hve for years fairly healthy in body, and with little, or rather, perhaps, very slow deterioration of their mental state. Primary dementia — dementia due to moral shock, or to acute systemic disease — is much more hopeful, as also is the partial dementia which follows upon puerperal madness, or upon the mania of febrile disorders. Indeed, in these cases the patient gene- rally recovers. Of the three varieties of insanity — melancholia, mania, and monomania — mania is the most liable to recovery ; monomania the least liable. At the same time there are considerations which modify for cer- tain cases the general applicability of this rule. For example, insanity of sudden onset is usually more curable than that which has come on insidi- ously ; insanity which has already lasted for some time with no improve- ment is less hopeful than insanity of recent occurrence ; cases in which mania and melancholia alternate [folic circulaire), and cases of recurrent insanity, are specially gloomy as to their prospects of ultimate recovery. Again, melancholia with the fixed delusion that the sufferer is the victim of some external agency, or in which under some such mental influence he has homicidal tendencies, is of ill omen. Insanity traceable to here- ditary predisposition presents on the whole a less favourable prospect than insanity where no such original taint can be traced. When insanity has been brought on or aggravated by sexual excesses, and especially by self- abuse (excepting in the earliest stage of the disease), and especially when insanity is associated with epileptic fits, the chances of recovery are very faint. Madness arising in young persons, or occurring in those who are MADNESS. 1185 suffering from some curable bodily disorder, or developed in hysterical or puerperal females, is to a very large extent curable. It need hardly be added, that the prospects of life in insanity are largely dependent on the conditions of health associated with the mental disease ; that, as has already been pointed out, tuberculosis is exceedingly common and fatal amongst insane patients ; that intercurrent diseases of various kinds are apt to carry them off ; that they are exposed to many accidental (suicidal or other) causes of death ; and lastly, that occasionally in acute forms of insanity, attended with absence of sleep, death from simple exhaustion ensues in the course of two or three weeks. Pathology and Morbid Anatomy. It is in this department of the study of insanity that our knowledge is least advanced — a fact due not to any want of skill or labour, or of admir- able investigators, but to the inherent difficulty of the inquiry. We are acquainted, no doubt, with many facts which directly or indirectly throw light upon the subject. We know, for example, that it is the gray surface of the brain which is the supreme organ of all mental operations, and that in order that this shall act efficiently it is essential that the nerve-cells of the part shall be healthy in themselves and shall retain their due communication with one another, that their vascular supply as well for nourishment as for the removal of effete matters shall be sufficient, that they shall not be exposed to mechanical pressure or other like injurious influences, and that they shall not be acted on by poisonous matters. And we know, as the basis of these conclusions and as confirming them, that symptoms, differing little if at all from those of the several varieties of msanity which we have considered, may be caused by inflammation of the meninges or substance of the brain, by tumours affecting the same parts, by effusions of blood, by injuries or softening involving the super- ficies of the brain, by anaemia due to loss of blood, by the circulation of poisonous matters retained in the blood — such as carbonic acid, bile and urea — and by the direct action of poisons absorbed from the stomach, especially alcohol, opium, and belladonna. In true insanity, however, (excluding general paralysis and idiocy, which, for reasons presently to be stated, stand in a different position, and may be regarded as distinct from it), no lesions of suflicient constancy or importance to explain the mental phenomena of the disease have ever been detected. It is not by any means that no pathological changes are discoverable in the brains of persons who have died insane. On the contrary, manifest lesions are of constant occurrence ; amongst which may be enumerated, congestion, opacity, and adhesion of the visceral arachnoid and pia mater, thickening of the ependyma of the ventricles, excess of serum in the sub-arachnoid tissue, wasting of the brain, increased density and abnormal firmness of the brain-tissue, atheromatous and earthy changes in the arteries at the base, small aneurysms in the substance of the brain, evidences of the transudation of blood furnished by the presence of pigment, etc., in the course of the smaller vessels, increase of the cerebral connective tissue 4 G 1186 DISEASES OF THE NEEVOUS SYSTEM. with tlie appearance of fatty molecules and corpora amylacea, atrophy of the brain-cells with pigmentation or loss of pigment, patches of sclerosis scattered here and there, extravasations of blood, abscesses and tumours. But such lesions or alterations of structure are most of them found even more frequently in the brains of persons who have never been insane, who perhaps have presented no cerebral symptoms whatever, and who Jiave died of other than cerebral diseases. The fact is that, in patients who die of acute insanity or of insanity in the early stage, Httle or no change of any importance is discoverable. In many such cases the brain appears to be absolutely healthy ; and, in those which present abnormal appearances, these are either simple anaemia, or more commonly conges- tion, pervading the pia mater, gray matter, and centrum ovale. But even when congestion is discovered, it is doubtful what relation it bears to the patient's symptoms; whether, in fact, it is their cause or their conse- quence. It is m the brains of patients who have died of insanity of many years' duration, and especially in the brains of such as have long been demented, and whose death is probably due to some intercurrent disorder, that the morbid changes above enumerated are almost, exclusively found. The changes most commonly met with under such circumstances are those indicative of degeneration — namely, atrophy of the brain and of its essential elements, increase of the connective tissue, adhesion and opacity of the meninges, and thickening of the small vessels, with the appearance along them of corpora amylacea, fatty matter, blood-pigment, and other evidences of sanguineous exudation. It is not, however, surprismg that the post-mortem phenomena of insanity are so vague, not to say trivial. The gravity of the symptoms of disease depend, as a rule, less on the nature of the disease than on the relative importance of the organ which it implicates. And, as we well know, so-called ' functional ' disorders of the dynamical elements of the iiervous centres, or disorders which depend upon molecular changes or alterations of relation which have hitherto escaped the eye, and which in themselves are often transitory and of little moment, are always attended with much more serious symptoms than similar disorders of less important parts, or even than gross diseases implicating the white substance of the brain. We need only refer m illustration to the phenomena of tetanus and poisoning by strychnia ; to those of hysteria, chorea, and epilepsy ; and to those arising from opium, alcohol, and other substances which act as poisons to the brain. In the same sense we may regard insanity as a functional affection of the gray matter of the surface of the brain, charac- terised by either exaltation, diminution, or perversion of function, and presenting subordinate differences which depend partly on the degree of functional modification present, partly on the particular are® of the brain-surface which are chiefly, or it may be solely, implicated. That insanity does not necessarily involve any profound pathological change in the texture of the brain is proved by the frequency with which rapid recovery takes place, even when the mental disturbance has been of a very aggravated kind and long maintained. At the same time there can be no MADNESS. 1187 doubt that insanity of long duration leads to gradual structural changes in the brain-substance, and that the supervention of such changes influ- ences the patient's condition disastrously, and renders his restoration to mental health impossible. Among the lesions to which insane patients are liable we may take this opportunity of advertmg to one, licBinatoma auris, not, however, on accomit of its mtrmsic importance, but because it is common m insanity, and characteristic of it. This, which is an effusion of blood between the cartilage and the perichondrium, and leads to much thickening and de- formity of the organ, occurs in all varieties of insanity; and its occurrence is generally looked upon as of ill-omen. It has been at tributed to violence mtentional or accidental, on the part of attendants ; but there is no doubt that it occurs independently of this cause. The remarks above made do not apply to general paralysis of the insane, or to most cases of idiocy, in both of which morbid conditions are usually found amply sufficient to explain the clinical phenomena mani- fested during Kfe. It is now fully established that general paralysis of the insane is due directly to a kind of chronic or slow mflammation commenc- ing in the gray matter of the surface of the brain, and either remainuig Limited to this, or involving also other parts of the brain, and even the spinal cord. The morbid changes referred to differ Httle, if at all, in their essential features from the sclerosis which forms the pathological basis of tabes dorsalis, and other varieties of chronic spmal disease. The pia mater and surface of the brain become hypersemic, and the pia mater and arachnoid thickened and unduly adherent to each other and to the brain ; the neurogHa and its corpuscles undergo abnormal development ; the walls of the smaller blood-vessels partake in this change, and become thickened and incorporated with the hypertrophied connective tissue around ; the nerve-cells in the gray matter atrophy, and after a time tend to disappear ; and accompanying these changes are evidences of old exudation of blood along the vessels, with fatty disintegration, and the appearance of corpora amylacea among the diseased tissues. The process is a progressive one ; and it is almost needless to say that, in the changes occurrmg in the gray matter of the hemispheres, we have a sufficient explanation alike of the mental excitement leading on to dementia, and of the paretic trembling going on to muscular paralysis, which in associa- tion characterise the disease. It is obvious, too, to those who are at all acquainted with these affections, that there is a clinical relationship be- tween general paralysis on the one hand, and tabes dorsalis, disseminated sclerosis, and bulbar paralysis on the other; and that many of the paralytic symptoms of general paralysis resemble those of one or other of these affections, and, at any rate, may in some cases be referred to con- current sclerosis of the cord, medulla oblongata, and other parts of the central nervous organs. In most cases of idiocy, excepting those due to early epilepsy, severe mental shock and other functional conditions operating after birth, there is ample explanation in the anatomical characters of the skull and brain 4g2 1188 DISEASES OF THE NEEVOUS SYSTEM. of the mental feebleness whicli is present. In some cases the brain, and consequently the skull, are unusually, and it may be, very remarkably small. In many cases the brain is imperfectly developed : the corpus callosum, or some other important part of it, is incomplete or absent ; the posterior lobes do not cover the cerebellum ; one side or part of the brain or cerebellum is atrophied ; or the convolutions are few in number and simple, as they are in some of the lower animals. Sometimes the cHild is born with congenital hydrocephalus ; or a portion of the brain, or an offset of its membranes, protrudes through a hole m the parietes of the skull. In some instances, as in cretinism, the idiocy appears to depend primarily on premature ossification of the bones at the base of the skull, and consequent interference with the due development of the brain. Sclerosis is frequently met with. Occasionally undue enlargement of the brain, without other visible change, has been observed in idiots. But even in cases of congenital idiocy it sometimes happens that no apparent defect of the central nervous organs or of their envelopes can be detected. Treatment. The treatment of insanity may be considered under two heads, namely, the moral and the therapeutical. 1. Of these the moral treatment is by far the most important. It is obvious that, putting out of the question our duties to the lunatic's friends and to the public, it is for his own benefit that we should protect him from the consequences of his violence or folly; and that just as it is salu- tary to restrain a wayward child, or a sane man's ungovernable temper, so it is salutary to the madman to put a check upon his caprices or his passions. It is from another point of view important that maniacs who are in any way dangerous or mischievous should be restrained from yield- ing to their msane instincts or impulses. Our first object, in fact, in the treatment of insanity should be to remove the patient from the surromid- ings and associations in the midst of which his insanity arose. How this shall be best effected must depend on the nature of the case, and on the pecuniary circumstances and social position of the patient. But in all cases this removal should be accompanied by restraint. In some instances the patient, with a suitable attendant or keeper, may be allowed to travel. Change of scene, change of associations, the moral pressure which is brought to bear upon him, and the inability mider which he now labours of giving play to his insane tendencies and actions, are valuable items in his treatment, and collectively often effect a cure. In some instances, where travelling is for any reason undesirable, or is forbidden by pecuniary considerations, removal in company of a skilled medical attendant to some country house or seaside place is indicated. The cases which are best treated in either of these ways are those of the several forms of insanity in their early stages, and those cases in which insanity has been caused, or is kept up, by indulgence m masturbation, drunkenness, or other vicious habits. Hysterical patients also are generally best treated away from asylums. The cases for which private treatment is especially unsuitable MADNESS. 1189 are those of \ioleut mania, those of melancholia with suicidal or murderous propensities, those presenting persistent hallucinations of hearing and suspicion, those in which the patient habitually refuses food, and those in which the association with epilepsy tends to provoke sudden explosions of dangerous delirium. For most lunatics an asylum is the most suitable means of restraint and treatment ; for many, because the cost of providing for their separate care is beyond the means of those who are responsible for them ; and for more, because from the special characters of their malady they are best and safest treated in association with other patients, and under the rules and regulations of a well-ordered establishment. It is, no doubt, true that many patients resent incarceration, and experience a real grief and pam in being separated from their friends, and put into the society of others hke themselves ; but, as a matter of fact, the creation of a real cause of emotion, by takhig the patient out of his unsubstantial sorrows, is not unfrequently of benefit to him ; and, on the other hand, it is astonishing how soon such patients reconcile themselves to their altered circumstances. Most lunatics accept their new position as a matter of course, and Tvithout any evidence of mental suffering being awakened by it. The advantages of an asylum are obvious. The patient is deprived of the power of tyrannising over the members of his household, or those who are subordinate to him ; he cannot spend money lavishly or speculate, or indulge in debauchery, or commit acts of violence on himself or others ; he is spared the irritating opposition or weak submission to his will of those about him ; he is fed regularly and wholesomely, and compelled to keep good hours ; the obvious madness of some of his companions not improbably impresses him, and the recognition of their condition may even have a beneficial effect upon his own. Moreover patients in asylums are, accordmg to their conditions and tastes, encouraged to spend their time in a mixture of work and recreation which has been carefully thought out and prepared for them. Further, there is usually an ascendmg scale of treatment, in virtue of which patients as they improve receive more indulgence, and are regarded more and more as sane persons. In asylums, again, the facilities for treating troublesome and violent patients are much greater than they are in lodgings or even at home. In the above remarks it has been assumed that the cases under treatment are curable. For incurable ^Datients, especially those suffering from chronic mania, demen- tia, or general paralysis, and for many idiots, an asylum is clearly the most appropriate place of residence. It may be added that it is not generally wise to irritate patients by opposition, or even to argue with monomaniacs on the subject of their delusions. At the same time it is well that they should see that you do not acquiesce m them. 2. The therajjeutical treatment of insanity, on the whole, is of little specific value. And especially chronic madness, of whatever kind, rarely requires it. In insanity, however, as in other cases, possibly even more than in other cases, it is of course important to treat any bodily affection which may arise. Lmiatics are not infrequently feeble and anaemic. Under such circumstances iron and quinine or other tonics are clearly 1190 DISEASES OF THE NEEVOUS SYSTEM. called for. Tuberculosis, pneumonia, pleurisy, and other diseases are very apt to come on in the course of insanity, and to give but slight indications of their presence. It is needless to say that such maladies ought not to be overlooked, and that they demand special treatment. If the stomach or bowels be deranged, if gout or rheumatism be present, if there be uterine or ovarian disorder, if pains or aches be complained of, these several affections should be attended to. And, again, if the patient's insanity have arisen from drink or self-abuse, special therapeutic treatment will probably be desirable. Many systems of treatment of insanity have been advocated at different times. Blood-letting, hot and cold bathing, counter-irritation, purging , and narcotism, comprise the chief of those to which recourse has been had. At the present time, however, none of them is regarded as of specific value ; and they are severally used in moderation only as occasion requires. General blood-lettmg has fallen into disuse ; but occasionally the application of the cupping-glasses or of leeches for the relief of cerebral congestion seems to be useful. Even this modified form of blood-letting, however, is seldom employed. Baths, no doubt, are important agents. Warm baths, continued for some hours, are often useful in calmmg excitement. Cold baths and shower-baths, applied for not more than a minute or two at a time, are frequently beneficial in the treatment both of melancholia and of mania. Cold to the head, combined with the immersion of the body in a warm bath, is a specially valuable method of reducing excitement and pro- moting sleep. Counter-irritants to the head or nape of the neck, more especially to the head, are said to be of service mainly in chronic cases. Active systematic purging has almost fallen into desuetude. It is important, however, and necessary in many cases, to keep the bowels regulated. Narcotics are indispensable in the treatment of insanity ; but they should not be recklessly employed, for they are capable of much harm as well as of much benefit. Of these opium is by far the most valuable. The cases in which it is specially serviceable are those of commencing insanity, when the patient is sleepless^ and irritable and hypersesthetic ; those in which mania is subsiding ; melancholic cases ; and cases of insanity due to alcoholism, or exliaustion. Among other narcotics or sedatives which are, or have been, employed may be enumerated, chloral hydrate, hyoscyamus, conium, digitalis, and bromide of potassium. The bromide of potassium is frequently given in combination with some one of the others, and appears often to be of service. To narcotics generally, with the exception of opium, at any rate to narcotics habitually given, Dr. Maudsley entertains serious objections. When insane patients refuse food it becomes necessary to feed them periodically by means of the stomach-pump. MADNESS. 1191 Legal management of lunatics. 1. Places for the legal custody of lunatics. — Patients are received into the county and borough asylums, registered hospitals, licensed houses or single charge. In the last case (that in which the proprietor receives only one patient at a time) a licence is not required. To obtain a licence to receive Imiatics application must be made, in the metropolitan district to the Commissioners in Lunacy, in extra-metropohtan districts to the County Quarter Sessions. The county and borough asylums are provided for the reception of paupers ; but occasionally and under special circum- stances non-pauper patients are admitted into them. Bethlehem Hospital receives patients of the educated middle classes who are miable to pay anything. St. Luke's admits such as are able to pay in part for their maintenance ; and there are several other registered hospitals scattered about England in which patients are taken charge of at a cost of a pound a week upwards. Licensed houses are mainly for the reception of paying patients, but some of them admit paupers. 2. Private lunatics. — No lunatic may be kept for profit unless he be under certificates. For the reception of a patient, whether into single charge, a licensed house or registered hospital, an order for his reception (with a statement appended) and two medical certificates are required. The order should be signed if possible by a near relative ; but this is not essential. It holds good for one calendar month from its date ; and the person who signs it must have seen the patient within one month of signing. Each medical certificate must be signed by some duly qualified practitioner, who is also in actual practice ; and his examination of the patient must be made apart from any other medical man. The certificate comprises two parts : first, the part containing the facts indicating insanity observed by the medical man himself ; and, second, the part containing the facts indicating insanity communicated by others. It is absolutely necessary for the signer of the certificate to state facts which he has himseK observed ; but in many cases these are so slight, while those observed by others are so grave, that the more weighty part of the cer- tificate is comprised in the second part. In every case in which quoted facts are recorded, the name of the informant should be given. A certificate, if mcorrect, may in most cases be amended withm fourteen days of the reception of the patient. If, as occasionally happens, there is only one medical man available, his sole certificate, accompanied by a written explanation of the reasons for there being only one, will be accepted ; but in this case the patient must be recertified by two medical men within three clear days after admission. A certificate holds good only for seven clear days from the time at which the examination to which it relates was made ; so that it must be signed and the patient must be received within that period. For the 1192 DISEASES OF THE NEEVOUS SYSTEM. reception of a patient in England, he must be examined and his cer- tifieates signed in England ; and similarly with respect to Scotland and Ireland. The same person may not sign both the order and one of the medical certificates. Xor may a medical man sign any certificate for the reception of a patient the order for whom is signed by his own father, brother, son, partner or assistant. Neither may he sign it if he be connected with the institution to which the patient is to be sent, or if he be interested in it in any way, or if his father, brother, son, partner or assistant be thus connected or interested. And lastly, no two medical men who are in partnership may certify for the same patient. The medical certificates need not be made on the printed statutory forms (see p. 1193) pro-\-ided they be made on verbaUy correct copies of them. A patient once mider certificates can be moved from one hcensed house or registered hospital to another, or to or from single charge, by means of an order of transfer. But he cannot be thus moved from one of these to an asylum, or conversely. For this purpose he must be recertified. ^Yithin twenty-four hours of a patient being taken charge of mider certificates, notice thereof must be sent to the commissioners, together with exact copies of the order, statement, and certificates under which he has been received ; and, within seven clear days, an additional state- ment as to the patient's mental and bodily condition, signed by the medical superintendent or ■sdsitor, must be transmitted to them. Letters from patients must either be kept for the inspection of the commissioners, or be sent to their destination. A patient m single charge must be visited once a fortnight by a medical man, unconnected with the proprietor of the house in which he is staying, and who has not signed one of the patient's certificates ; and he must leave, in a book kept for the purpose, a written statement of the patient's condition and treatment and any other details that may occur to him. The commissioners visit every certified lunatic at least once a year. If a patient escape from legal custody, and remain within the juris- diction, he may, at any time during the fourteen days immediately follow- ing his escape, be recaptm-ed and detamed on the old certificates, after which tune fi-esh certificates are required. But if he have escaped fi'om England to Scotland or Ireland, or conversely, he can only be reconsigned to an asylum on fresh certificates. Whenever such escape takes place, notice thereof must be at once forwarded to the commissioners. Notice must also be sent to them on the discharge of a patient or on his recovery. If death occur, the fact must be notified to the commissioners, to the coroner, and to the person who signed the order for admission. Leave of absence for patients who are under certificates must be obtained from the commissioners. 3. Lunatics wandering at large or not under proper care. — Lunatics under certain circumstances may be dealt with summarily. If any person MADNESS. 1193 00 us ^ '-I S CD rJ2 6 ^ !=! ^ o o '3 >i •1-1 -4-= &J3 >t3 c3 .2 i c3 SO r5S CZ2 rd eg ^ § 0) I' ,a •?s -l-= O 05 (N 55i 8 ^s: I c ^ I i ■75 S-.r»'5-2 i nS ^^■^^i <£ t" -r = ^ o si P ^ fl ^ 2 2 2 Q SS . o ;-• -4-3 w . C) c S s?= <^i be ?: t; ci o ts i o e gcj fl -*J /^ CJ Jh M M *H ^ _. m 'r-| ::::=«■" s" -i-= 9 ?= i^ < s P «:i S » c .-^ ■^. ,„^o„„oi ' It IS some time since so succinct and withal to produce a good and trustworthy manual.' Lancet. ' Dr. Edis may be congratulated on having pro- duced a most readable and trustworthy guide to the diseases of women. The work is up to date, coinplete an account of the diseases of women has appeared as Dr. Edis's manual. Its order and clearness are remarkable. The book will be wel- come as well on account of its intrinsic merits, as because it will fill a place in gynaecological litera- and is evidently that of one who has specially ] ture which was empty.' London Medical Record. A HANDBOOK of OPHTHALMIC SCIENCE and PRACTICE. Illustrated by numerous Woodcuts and Chromo-lithogi'ajihs of Microscopic Drawings of Diseases of the Fundus and of other parts of the Eye. By Henry Jcler, F.R.C.S., Junior Ophthahnio Surgeon, St. Mary's Hospital ; Senior Assistant-Surgeon, Royal Westminster Ophthalmic Hospital ; late Clinical Assistant, Moorfields ; Demonstrator of Anatomy, St. Mary's Hospital, London. Svo. 18s. CLINICAL MANUAL for the STUDY of MEDICAL CASES. Edited by James FiNLATSON, M.D., Physician and Lecturer on Clinical Medicine in the Glasgow Western Infirmary, &c. With Special Chapters hy Prof. Gairdn'ER on the Physiognomy of Disease ; Prof. Stephenson on Disorders of the Female Organs ; Dr. Alexander Robertson on Insanity; Dr. Samson Gemmeil on Physical Diagnosis; Dr. Joseph Coats on Laryngoscopy, and also on the Method of Performing Post-Mortem Examinations. The rest of the book, on the Examination of Medical Cases and on the Symptoms of Disorder in the Various Systems, is by Dr. Finlatson. With numerous Illustrations. Crown Svo. 12s. 6d. LEGAL MEDICINE. Part II. Contents : Legitimacy and Paternity — Pregnancy ■ — Abortion — Rape — Indecent Exposure— Sodomy — Bestiality — Live Birth — Infanticide — As- phyxia—Drowning — Hanging— Strangulation— Suffocation. By Charles Meymott Tidy,M.B., F.C.S., Ma=ter of Surgery; Professor of Chemistry and of Forensic Medicine at the London Hospital ; Offioial Analyst to the Home OflBce ; Medical Officer of Health for Islington ; late Deputy Medical Officer of Health and Public Analyst for the City of London, &lc. Now ready, royal Svo. 21s. *** Part I. including Evidence — The Signs of Death— The Post-mortem — Sex — Monstrosities — Hermaphrodism— Expectation of Life— Presumption of Death and Survivorship- Heat and Cold — Bums— Lightning Explosions — Starvation. With Illustrations. Royal 8vo. 25s. The ELEMENTS of PHYSIOLOGICAL and PATHOLOGICAL CHEMISTRY. A Handbook for Medical Students and Practitioners. Containins- a General Account of Nutrition, Foods, and Digestion, and the Chemistry of the Tissues, Organs, Secretions and Excretions of the Body in Health and in Disease. Together with the Methods for Preparing or Separating their Chief Constituents, as also for their Examination in Detail, and an Outline Syllabus of a Practical Course of Instruction for Students. By T. Cran.stocn L'hap.les, M.D., P.C.S.. M.S., &.C., Lecturer on Practical Physiology, St. Thomas's Hospital, London ; late Medical Registrar, St. Thomas's Hospital; and formerly Assistant- Professor and Demonstrator of Chemistry and Chemical Physics, Queen's College, Belfast, Sic, &c. With 38 Woodcut Illustrations and 1 Chromo- lithograph. Demy 8vo. 21s. London : SMITH, ELDER, & CO., 15 Waterloo Place. SMITH, ELDER, k CO.'S PUBLICATIONS. A GUIDE to THERAPEUTICS. By Robert Faequhabson-, M.P., M.D. Edin. P.R.C.P. Lond., late Lecturer on Materia Medica at St. Mary's Hospital Medical School, &c. Third Edition. Crown 8vo. Is. 6d. An EPITOME of THERAPEUTICS. Being a Comprehensive Summary of the Treatment of Diseases as recommended by the leading British, American, and Continental Physicians. By W. Domett Stone, M.D., F.R.C.S., Honorary Member of the CoUepe of Physicians of Sweden, Physician to the "Westminster General Dispensary ; Editor of the ' Half- yearly Abstract of the Medical Sciences.' Crown 8vo. 8.s. 6d. COMMENTARY on the BRITISH PHARMACOPCEIA. By Walter George Smith, M.D., Fellow and Censor Kinp and Queen's College of Physicians in Ireland ; Examiner in Materia Medica, Q.U.I. ; Assistant -Physician to the Adelaide Hospital. Crown 8vo. 12*. Gd. OCULAR THERAPEUTICS. By L. de Weckbr, Professor of Clinical Ophthal- mology, Paris. Translated and Edited by Litton Porbks, M.A., M.D., F.E.G.S., late Clinical Assistant, Eoyal London Opthalmic Hospital. With Illustrations. Demy Svo. 16s. A TREATISE on THERAPEUTICS. Comprising Materia Medica and Toxicology, with Especial Reference to the Application of the Physiological Action of Drugs to Clinical Medicine. By H. C. "Wood, jun., M.D. New Edition, Enlarged. 8fo. 14s. DISEASES of the NERVOUS SYSTEM, their Prevalence and Pathology. By Julius Althaus, M.D., M.R.C.P. Lond., Senior Physician to the Hospital for Epilepsy and Paralysis, Regent's Park ; Fellow of the Royal Medical and Chirurgical Society, Statistical Society, and the Medical Society of London ; Member of the Clinical Society ; Corresponding Member of the Societe d'Hydrologie Medicale de Paris ; of the Electro-Therapeutical Society of New York ; &c. &c. Demy Svo. 12s. The LOCALISATION of CEREBRAL DISEASE. By David Ferrier, M.D., F.R.S., Assistant Physician to King's College Hospital, Professor of Forensic Medicine, King's College. With numerous Illustrations. Svo. 7s. 6d. A PRACTICAL TREATISE on the DISEASES of the HEART and GREAT VESSELS, including the Principles of their Physical Diagnosis. By Walter Hayle Walshe, M.D. Fourth Edition, thoroughly revised and greatly enlarged. Demy Svo. 16s. A PRACTICAL TREATISE on DISEASES of the LUNGS, including the Principles of Physical Diagnosis and Notes on Climate. By Walter Hayle Walshe, M.D. Fourth Edition, revised and much enlarged. Demy Svo. 16s. On FUNCTIONAL DERANGEMENTS of the LIVER. By C. Muhchison, M.D., LL.D., F.R.S., Physician and Lecturer on Medicine, St. Thomas's Hospital, and formerly on the Medical Staff of H.M.'s Bengal Army. Second Edition. Crown Svo. 5s. AUSCULTATION and PERCUSSION, together with the other Methods of Physical Examination of the Chest. By Samuel G-ee, M.D. With Illustrations. Third Edition. Fcp. Svo. 6s. A. TEXT-BOOK of ELECTRICITY in MEDICINE and SURGERY, for the Use of Students and Practitioners. By George Vivian Poobe, M.D. Lond., M.R.C.P., &c. ; Assistant-Physician to University College Hospital ; Senior Physician to the Royal Infirmary for Children and Women. Crown Svo. 8s. 6d. SKIN DISEASES ; including their Definitions, Symptoms, Diagnosis, Prognosis, Morbid Anatomy, and Treatment. A Manual for Students and Practitioners. By Malcolm Morris, Surgeon to the Skin Department, St. Mary's Hospital, and Lecturer on Dermatology in the Medical School. With Illustrations. Crown Svo. 7s. 6d. HOUSEHOLD MEDICINE : containing a Familiar Description of Diseases, their Nature, Causes a'ld Symptoms, the most approved Methods of Treatment, the Properties and Uses of Remedies, &c., and Rules for the Management of the Sick Room. Expressly adapted for Family Use. By JoHx Gardiner, M.D. Eleventh Edition, with numerous Illustrations. Demy Svo. 12s. 6rf. A MANUAL of DIET in HEALTH and DISEASE. By Thomas King Chambers, M.D. Oxon., F.R.C.P. Lond. ; Honorai-y Physician to H.R.H. the Prince of Wales ; Consulting Physician to St. Mary's and the Lock Hospitals ; Lecturer on Medicine at St. Mary's School ; Corresponding Fellow of the Academy of Medicine, New York, &c. Second Edition. Crown Svo. 10s. Qd. London : SMITH, ELDER, & 00., 15 Waterloo Place. SMITH, ELDER, & CO.'S PUBLICATIONS. QUAIN and WILSON'S ANATOMICAL PLATES. 201 Plates. 2 vols. Eoyal folio, half-bound in morocco, or Five Pai-ts bound in cloth. Price coloured, £10. 10s. ILLUSTEATIONS of DISSECTIONS. In a Series of Original Coloured Plates the Size of Life, representing the Dissection of the Human Body. By Q. V. Ellis and G. H. Ford. Imperial folio. 2 vols, half -bound in morocco, £6. 6s, May also be had in parts, separately. Parts 1 to 2S, '3s. 6d. each ; Part 29, 5s. DEMONSTEATIONS of ANATOMY; being a Guide to the Knowledge of the Human Body by Dissection. By George Viner Ellis, Emeritus Professor of University College, London. Ninth Edition, Revised. With 248 Engravings on Wood. Small 8vo. 12s. Gd. A DIEECTOEY for the DISSECTION of the HUMAN EODY. By John Cleland, M.D., P.E.S., Professor of Anatomy in the University of G-lasgow. Second Edition- Fcp. 8vo. 3s. ed. SUEGrEEY : its Principles and Practice. By Teviotht Holmes, M.A., Cantab., F.E.C.S., Surgeon to St. George's Hospital. Fourth Edition. With upwards of 400 Illustrations. Eoyal 8vo. SOs. A SYSTEM of SUEGEEY : Pathological, Diagnostic, Therapeutic, and Operative. By Samuel D. Gross, M.D., LL.D., D.C.L. Oxon. Fifth Edition, greatly Enlarged and thoroughly Eevised, with upwards of 1,400 Illustrations. 2 vols. Svo. £3. 10^. ANTISEPTIC SUEGEEY: its Principles, Practice, History, and Eesults. By W. Watson Cheyne, M.B., F.E.C.S., Assistant-Surgeon to King's College Hospital, and Demon- strator of Surgical Pathology in King's College. With 145 Illustrations. Svo. 21*. 'In the volume before ns Mr. Cheyne has I Mr. Lister's results and views have hitherto made a very valuable addition to surgical litera- been published only f ragmentarily in journals and ture. The intimate professional relations of Mr. transactions of learned societies, Mr. Cheyne's Cheyne witli Professor Lister give a special | book affords a trustworthy and complete state- importance and value to this work ; for while 1 ment of them.' — Lancet. A MANUAL of DENTAL SUEGEEY and PATHOLOGY. By Alfred Coleman, L.E.C.P., F.E.C.S. Exam., L.D.S., &c. ; Senior Dental Surgeon and Lecturer on Dental Surgery to St. Bartholomew's and the Dental Hospital of London; Member of Board of Examiners in Dental Surgery, Eoyal College of Surgeons ; late President Odontological Society of Great Britain. With 388 Illustrations. Crown Svo. I2s. 6d. ' It is always satisfactory to come across a ! subjects on which he has especially worked, nor manual written by an author thoroughly ac- to minimise in importance others to which he has quainted with his subject, and with a just sense j given less attention. The manual is well- balanced, of proportion, not disposed to magnify unim- clear, simple, and exact, and is an excellent stu- portant details because they happen to include | dent's book.' — London Medical Record. HUMAN MOEPHOLOGY: a Treatise on Practical and Applied Anatomy. By Henry Albert Eeeves, F.E.C.S.B., formerly Demonstrator of Anatomy at the London and at the Middlesex Hospital Medical Colleges, and Lecturer on Anatomy at the London School of Medicine for Women ; Surgeon, and formerly Pathologist, to the Hospital for Women ; Surgeon to the Royal Orthopsedic Hospital ; Surgeon to the East London Children's Hospital ; Assistant Surgeon and Teacher of Practical Surgery at the London Hospital; Consulting Surgeon to the Westminster General Dispensary ; formerly Assistant-Surgeon to the Central London Oph- thalmic Hospital ; and Surgeon in co-charge of the Aural Department and Surgical Eegistrai at the London Hospital, &c. Now ready, with 564 Illustrations, Svo. price 25s. Vol. 1. Contents : The Limes and the Perinjeum. ELEMENTS of HUMAN PHYSIOLOGY. By Dr. L. Hermann, Professor of Physiology in the University of Zurich. Second Edition. Entirely recast from the Sixth German Edition, with very copious additions, and many additional Woodcuts, by Arthur Gamgee, M.D., F.E.S., Brackenbury Professor of Physiology in Owen's College, Manchester, and Examiner in Physiology in the University of Edinburgh. Demy Svo. 16*. 'London: SMITH, ELDER, & CO., 15 Waterloo Place. SMITH, ELDER, & CO.'S PUBLICATIONS. ^ ATL.IS of HISTOLOGY. By E. Klein, M.D., F.R.S., Lecturer on Histology at St. Bartholomew's Hospital Medical School, and Noble Smith, P.Pl.C.S. Edin. L.R.C.P. Lond., &c. Surgeon to the All Saints' Children's Hospital ; Senior Sargeon and Surgeon to the Orthopaedic Department of the Farringdon Dispensary ; Orthopffidic Surgeon to the British Home for Incurables. A complete representation of the llicroscopic Structure of Simple and Compound Tissues of Man and the higher Animals, in carefully executed coloured engravings, with Explanatory Text of the Figures, and a concise account of the hitherto ascertained facts in Histology. Eoy al 4to., with 48 coloured plates, bound in half -leather, price £4. 4s. ; or in 13 parte, price 6s. each. A MANUAL of PATHOLOGICAL HISTOLOGY. By Coexil and Eantiee. Translated by authority from the Xew and Re-written French Edition, with the original Illus- trations. Vol. I. Histology of the Tissues. Demy 8vo. price 21s. Vol. II. Special Pathological Histology. Lesions of the Organs, Part I. With 12.5 Illustrations. Demy 8vo. 12^. 'An admirable exposition of all that is known • ' We may safely recommend the work as the respecting the morbid histology of the tis-sues ! foremost text-book of its class, and we are certain and organs of the human body. ... We should , that it will now be widely studied by many to be glad to see it in the hands tf all medical whom the original was a closed book.'^ students, and of all those who wish to keep themselves informed of the present state of pathology.'— LoxDox Medicai. Record. ' We can heartily recommend the book to all who are interested in the study of pathological histology.'— Glasgow Medical Jotjenai-. The DESCEIPTIVE ATLAS of ANATOAIY. A Eepresentation of the -Anatomy of the Human Body. In 92 Royal 4to. Plates, containing -550 Illustrations. Introducing Heitzmanx's Figures, considerably modified, and with many Original Drawings from Xatme. By KoBLE Smith, F.R.C.S. Edin. L.R.C.P.'Lond., Surgeon to the All Saints' Children's Hospital, Senior Surgeon and Surgeon to the Orthopsedic Department of the Farringdon Dispensary, and Orthopajdic Surgeon to the British Home for Incurables. Bound in half-leather, 2os. LA^■CET. ' There can be no doubt that this manual is by a very long way the best in the English language, and we can heartily recommend it as a text-book.' BlRMLN"GHAM MEDICAL REVIEW. ' Certauily one of the most remarkable publi- cations of the day. The great advantage which it presents is that all the attacliments of bones, the arteries, veins, &c., are copiously lettered and described in situ ; and the arteries and veins are cr,lom-ed. The book is one of great utiUty and merit, and reflects credit on the ai-tist and also on those who have produced it.' British Medical Journal. 'The plan of this work is most excellent, and to one who is tmable to keep his anatomical knowledge always ready at demand, but who reqnu"es occasionally to refer to particular points, it will prove an invaluable aid. Instead of a letterpress description, with letters or figures to aid in identifying the various processes of bone, or muscles, or blood-vessels, these structures are labelled in situ.' —GhxSGOvr Medical Jourxai,. An INDEX of SUEGEEY. Being a Concise Classification of the Main Facts and Theories of Surgery, for the Tse of Senior Students and others. By C. B. Keetlet, F.R.C.S., Surgeon to the West London Hospital, aiid to the Surgical Aid Society. Second Edition. Crown 8vo. 10s. M. ' Will prove truly valuable, and wiU, we trust, for many vears be kept up to the imperious de- mands of" surgical progress. The system of arrangement is just what the system m such a publication should ever be, purely alphabetical, and the text is written in as elegant and intel- ligible English as can be expected in condensa- tions and abridgments.' British Medical Joursai. ' Mr. Keetley's work fills a gap that has long existed in the educational literature of surgery. Previous attempts have been made to produce a book of the same chai-acter, btit, compared with the " Index," they have all been crude and in- effectual. We heartily congratulate ilr. Keetley on his performance, and as heartily thank him for conferring a real boon on medical students by this much needed and excellently executed aid to the study of surgery.' - Medical Xews. The SUEGEEY'" of DEFOEMITIES. A Manual for Students and Practitioners. By IsToble SinTH F.R.C.S. Edin., L.E.C.P. Lond., Surgeon to the AU Saints' Cliildren's Hospital, Senior Surgeon and Surge on to the Orthoisedic Department of the Farringdon Dispensary, and Orthopfedic Surgeon to the British Home for Incurables. With 118 Illustrations. Crown 8vo. 105. M. ' This is a sound practical guide to the treat- j ment of bodilv deformities, based evidently upon | personal ob.=efvation and experience _. . We can cordiallv recommend the work as a guide to j busv practitioners, who will find iii it iust what they want, clearly set forth and illustrated.' LosDox Medical Record. 'The woodcuts show very practically the i i:oints which they are intended to illustrate, | and materially help the reader. We can re- commend this as one of the most practical, useful, and able handbooks of Orthopaedic Surgery. It is one which will 'be alike popular and useful with practitioners and students, and establishes for its author a high position in the department of science and practice which his handbook illustrates.' British Medicax Journal. London: SMITH, ELDEK, & CO., 15 Waterloo Place. \.0 Date Due ' . :B'ti >V\e.o